dmacres/mimiciii-hospitalcourse-meta · Datasets at Hugging Face

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53,541	184,226	In summary, Ms is an 80 year-old woman with chronic systolic congestive heart failure, presenting with shortness of breath. . # Acute on chronic systolic congestive heart failure: History and presentation consistent with CHF exacerbation - LVEF 20%, BNP 26,000 on admission, lung exam with crackles, CXR w left pleural effusion/congestion. Unclear etiology of CHF exacerbation, possibly from upper respiratory infection vs uncontrolled hypertension (a few SBPs in 140s-150s). Dietary indiscretion and medication non-compliance are likely not causes given patient is presenting from Rehab. Cardiac ischemia ruled out with negative biomarkers. Pt was diuresed w furosemide 80mg IV at first for a goal of -1L/24hrs, then with furosemide with HCTZ 30 minutes prior, as pt stopped responding to furosemide only. Total net -2L in 2 days. Pt improved clinically. PICC line placement was deferred to Rehab. Was transferred back to Rehab on losartan, metoprolol, furosemide, HCTZ. She will need electrolytes checked every other day in the future to monitor. . # Shortness of breath: Pt required BiPAP on admission, transitioned to Venti mask within hours. Successfully weaned to O2 by NC with diuresis. Distress treated with morphine PRN. Now on 2L NC. . # Pneumonia: After diuresis, patient developed worsening productive cough and fevers. CXR notable for likely right lower lobe infiltrate. After discussion with family, decision was made to treat with oral levofloxacin but not to aggressively pursue blood cultures or intravenous access for antibiotics, which had been difficult. Pt is to continue to take levofloxacin through . . # Atrial fibrillation: Patient had a brief of atrial fibrillation with rapid ventricular rate that was controlled with beta blocker and returned to sinus after 4 hours. The decision was made not to anticoagulate with warfarin given that this was likely precipitated by her acute illness and she was already on Plavix and full-dose aspirin. . # CAD: History of MI in . Will continued aspirin, Lopressor, and losartan. . # Peripheral Vascular Disease: S/p bypass. Continued aspirin. Restarted Plavix per discussion with PCP. . # CVA: Patient with right-sided hemiparesis, right facial droop, expressive aphasia. Continued aspirations and fall precautions, as well as supportive measures. . # Hypertension: Lopressor and losartan were continued. . # Diabetes: Type 2 on insulin. Continued standing insulin in addition to sliding scale. . # Parkinson's disease: Continued carbidopa levodopa TID. As per family, pt's condition is progressively worse. She is often more lethargic. Has been refusing meds in hospital, but eventually took them with family. . # Depression: continued sertraline and bupropion. . # Goals of care: On admission, patient was DNR/DNI. After discussion with her family, the decision was made to not aggressively pursue infectious work-up for fever, but rather empiric tx for now with levo. Pt is to be discharge to the .	TITLE: Cardiology Physician Note History of Present Illness Date: Initial visit Events / History of present illness: -improved resp status -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg HCTZ 30minutes before with good result; will continue this now -changed losartan to -repeat CXR showed resolution of possible infiltrate on prior film Medications Unchanged Physical Exam BP: 125 / 47 mmHg HR: 65 bpm RR: 28 insp/min Tmax C last 24 hours: 37.4 C Tmax F last 24 hours: 99.4 F T current C: 36.2 C T current F: 97.2 F O2 sat: 93 % on Supplemental oxygen: 3L NC Previous day: Intake: 300 mL Output: 1,582 mL Fluid balance: -1,282 mL Today: Output: 480 mL Fluid balance: -480 mL VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti mask Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Jugular veins: Not visible) Respiratory: (Effort: WNL), (Auscultation: crackles at bases) Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass: No), (Hepatosplenomegaly: No) Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle strength and tone: right upper extremity flexed. patient was tachypnenic, tachycardic and hypertensive- CXR showed bilateral infiltrates- EKG showed LBBB w/ lateral depressions- Patient was transferred to CCU on mask ventilation for further management Heart failure (CHF), Systolic, Acute on Chronic Assessment: Recd pt wl hr 100 afib. Did receive ntg in EW for hypertension. #Hypertension: continue lopressor and losartan . #Hypertension: continue lopressor and losartan . ), (Dorsalis pedis artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+), (Edema: Right: 0, Left: 0) Skin: ( WNL) Labs ABG: 7.40 / 49 / 128 / / 4 Values as of 01:00 PM Tests ECG: (Date: ), NSR, LVH, LBBB, st depressions V4-V6. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. Date of service: Initial visit, Cardiology service: CCU Presenting complaint: Dyspnea History of present illness: 80 y.o. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. # Depression: - continue sertraline and bupropion FEN: pureed diet, diabetic consistent carbohydrate ACCESS: PIV's; consider PICC line upon discharge for easier administration of furosemide PROPHYLAXIS: -DVT ppx with heparin sub q, pneumoboots -Pain managment with tylenol, morphine -Bowel regimen colace, senna milk of magnesia CODE: DNR/DNI DISPO: call out to floor later today if stable ------ Protected Section ------ Cardiology Teaching Physician Note On this day I saw, examined and was physically present with the resident / fellow for the key portions of the services provided. Heart failure (CHF), Systolic, Acute on Chronic Assessment: Hemodynamically stable- lung sounds w/ bibasilar crackles. The previously present marked perivascular haze has regressed and in the accessible lung fields of the right hemithorax. In the left hemithorax, a previously described pleural density that obliterates the diaphragmatic contour remains and probably has increased somewhat with major portions layering posteriorly with patient in semi-upright position. FINDINGS: There is interval development of a right-sided, mild-to-moderate pleural effusion, and slight interval decrease in moderate-to-severe left- sided pleural effusions. There is interval decrease definition of the right cardiac border. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. TITLE: Cardiology Physician Note History of Present Illness Date: Initial visit Events / History of present illness: -improved resp status -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg HCTZ 30minutes before with good result; will continue this now -changed losartan to -repeat CXR showed resolution of possible infiltrate on prior film Medications Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 , bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan 50 PO BID, Carbidopa levodopa Physical Exam BP: 125 / 47 mmHg HR: 65 bpm RR: 28 insp/min Tmax C last 24 hours: 37.4 C Tmax F last 24 hours: 99.4 F T current C: 36.2 C T current F: 97.2 F O2 sat: 93 % on Supplemental oxygen: 3L NC Previous day: Intake: 300 mL Output: 1,582 mL Fluid balance: -1,282 mL Today: Output: 480 mL Fluid balance: -480 mL VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti mask Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Jugular veins: Not visible) Respiratory: (Effort: WNL), (Auscultation: crackles at bases) Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass: No), (Hepatosplenomegaly: No) Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle strength and tone: right upper extremity flexed.	49	[ { "category": "Respiratory ", "chartdate": "2177-02-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 435592, "text": "Demographics\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n To ICU from ED\n 11:45\n Transport was without incident.\n Bedside Procedures:\n ABG puncture (13:00)\n Comments: Pt placed on NIV at 8:35a in ER secondary to increased SOB\n with RR 40\ns. Pt tolerated well\n with improved RR 25-30. ABG done\n once pt was transported to unit\n results - 7.40/49/128/31/4 on PSV\n with 50% FiO2. Pt taken off NIV and placed on 50% Venti-mask. Pt\n tolerating well with sats 98-100%. Pt\ns breathing seems more\n comfortable.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435645, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- ABG done- successfully weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-45cc/hr- no respiratory distress.\n Plan:\n monitor I&O- ? lasix dose tonight- trend cardiac enzymes- resume\n cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435823, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436200, "text": "80 yr old Rehab patient w/ significant PMH for chronic systolic\n CHF (EF 20%) who presented to EW w/ SOB. patient was tachypnenic,\n tachycardic and hypertensive- CXR showed bilateral infiltrates- EKG\n showed LBBB w/ lateral depressions- Patient was transferred to CCU on\n mask ventilation for further management\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Rec\nd pt wl hr 100 afib. Spontaneously converted to NSR w/ no vea. BP\n 90-110/.\n Action:\n Lopressor dose held at 0800, but administered at 10am. HCTZ 12.5mg f/b\n 80mg po lasix.\n Response:\n HR 80\ns nsr w/ no vea. u/o 30-60cc/hr\n Plan:\n Cont meds as above monitoring I/o\ns, possible decrease in lasix dose if\n pt overdiureses.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436204, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHFw/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR,\n however pt noted to be in afib for approx 2 hrs. Pt spontaneously\n converted.\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID -\n GU\n u/o 30-60cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance. Pt is aspiration\n risk. Taking nectar thickened liquids. Meds have been crushed and put\n in pudding or applesauce.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436137, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435945, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS +bibasilar crackles, diuresing well to additional lasix/ hctz. Cont\n w/ conjested cough, sats dropping <90% on 2L nc, RR> 30.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont to encourage c&db, ? chest pt if tol. ? PICC placement here or @\n NH.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436119, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435939, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz .\n Conts w/ conjested cough, given nebs w/ good effect. Increased 02 to 3L\n nc to maintain sats >92%. No c/o HA, sugars covered by RISS. CXR pa/lat\n showed resolution of RLL infiltrate.\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435940, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n HEADACHE\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435944, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS +bibasilar crackles, diuresing well to additional lasix/ hctz. Cont\n w/ conjested cough, sats dropping <90% on 2L nc, RR> 30.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont to encourage c&db, ? chest pt if tol\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436115, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated. Cont standing insulin & sliding scale.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436112, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435938, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz .\n Conts w/ conjested cough, given nebs w/ good effect. Increased 02 to 3L\n nc to maintain sats >92%\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436051, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- - EKG showed LBBB w/\n lateral depressions- She was Rx w/ 80mg ivp lasix @ nursing home prior\n to transport. In EW tx w/ Ntg and placed on Bipap- Patient was\n transferred to CCU on mask ventilation for further management. Able to\n wean off BIPAP almost immediately and eventually weaned to 2LNC.,\n maintaining sats >95%. ON Tuesday AM pt was given additional Diuresis\n and goal was to add HCTZ and increase Lasix to provide better\n diuresis. PT has frequent admits for failure, Lives at Rehab,\n Plan is for pt to get PICC so she can be treated In the nursing home.\n We are treating her by increasing her antihypertensive, additional\n lasix was given yesterday with HCTZ PT responded to lasix after several\n doses, she is down over 2 liters by weight, she has good/fair urine\n output and has been incontinent around the Foley as well. CXR PA and\n Lateral was done yesterday that showed Improved CHF, as well as and\n left pleural effusion, Atrovent Nebs were also started for wheezing.\n Pt has been stable today but lethargic, thought to be R/T Parkinsons\n and pt refusing her meds. We did have problems with her taking meds\n today but with help of family pt did eventually take them. She sleep\n most of today, but was awake and alert in the afternoon, fed herself\n lunch, visited with son. She sounded wheezy this morning, did respond\n to atrovent, HCTZ and lasix ~ 350 cc. She was apparently incontinent\n last night of urine. She had two IV infiltrate today with D5W, warm\n compress to left arm, area looks ok, somewhat swollen elevated on\n pillows. IV team placed a 22 right hand, pt has VERY poor access and is\n planned for PICC line in future at rehab ( they place piccs\n there). Team is aware, we are hydrating pt with D5 to treat\n hypernatremia and we are checking lytes at 6 PM. Pt did rec KCL\n replacement. She continues to have high glucose, She only likes to eat\n pudding, milk, apple juice.\n Has decreased appetite lately per son. She gets SS and 70/30\n Plan is to continue med regime of HCTZ, Lasix, follow I/o weight.\n Offer PO free water hydrate with D5, and follow lytes NA, U/O\n ? Dc to rehab from CCU.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435585, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435641, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- ABG done- successfully weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr- no respiratory distress.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435886, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n ------ Protected Section ------\n Rec\nd hctz, followed 30minutes later w 80mg iv lasix at 6pm. Has begun\n to diurese. Congested cough. Rr mid 20s to 30s. sats >95% on 2l nc. c/o\n HA, rec\nd 650mg Tylenol. Poor appetite. Ate pudding, refused\n potato,. Bs 190, covered per ss. Family visited and updated.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:25 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436110, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions.\n" }, { "category": "Physician ", "chartdate": "2177-02-10 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 435569, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Dyspnea\n History of present illness: 80 y.o. female with pmh significant for\n chronic systolic congestive heart failure, LVEF 20%, presenting to ED\n from nursing home after waking this morning acutely short of breath.\n The on-call physician at the nursing home gave the patient lasix 80mg\n IV, albuterol, and morphine prior to transfer. No foley was placed,\n however, upon arival to ED the patient's sheets were soaked with\n urine. In ED, patient was tachypneic with RR in 40's and had Oxygen\n saturaiton of 88% on NRB. BNP was 26,000, CXR showed bilateral\n infiltrates. She was also hypertensive with BP 160/100 and tachycardic\n to 120's. EKG showed LBBB with lateral depressions. She was given\n nitroglycerin and placed on Bipap. She responded with O2 saturation\n of 98%, respiratory rate of 16, and her blood pressure and heart rate\n decreased to 110/60 and 60-70's respectively. Her ekg changes returned\n to baseline. Attempts were made to wean her form Bipap to NRB and\n venti mask, and were unsuccessful secondary to O2 desaturation and\n tachypnea.\n .\n The patient has had multiple CHF exacerbations recently, which have all\n been handled at rehab. Per the patient's PCP, has been\n decompensating somewhat with diminished PO intake. The patient had an\n episode of shortness of breath at Rehab on which reoslved\n with lasix 90mg IV and morphine. She was \"Do Not hospitalize\" status 1\n week ago, however, given the difficulty of treating her CHF\n exacerbations overnight without doctors on , it was decided to\n revoke the \"DNH\" status for the purposes of transferring the patient to\n the hospital in the event that an exacerbation would occur overnight\n and no MD's were avaliable to push IV lasix.\n .\n Review of symptoms is answered by her son. has expressive\n aphasia.\n .\n review of systems is notable for absence of fever, chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Past medical history: HTN\n DM type 2 insulin-dependent\n PVD (s/p bypass)\n CAD (s/p MI in )\n h/o stroke (in w/ residual complete R sided hemiparesis,\n dysphagia, expressive aphasia)\n CHF (LVEF 20-25%)\n Depression\n Intraductal papillary mucinous tumor found on CT \n Parkinson's disease\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus, Hypertension\n CAD Risk Factors Absent\n Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: No)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Current medications: Aspirin 325 mg PO daily\n Cholecalciferol (Vitamin D3) 1000 units PO daily\n Senna 8.6 mg PO BID\n Calcium Carbonate 500 mg (1,250 mg) PO daily\n Sertraline 50 mg PO daily\n Carbidopa-Levodopa 25-100 mg Tablet. One tablet PO daily\n Omeprazole 20 mg Capsule, Delayed Release(E.C.) PO BID\n Bisacodyl 10 mg Tablet, Delayed Release PO BID\n Metoprolol Tartrate 50 mg PO BID\n Losartan 50 mg PO Daily\n Bupropion 100 mg Tablet Sustained Release PO QAM\n Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension\n Sig: Sixteen (16) units Subcutaneous qAM: Please continue\n sliding scale coverage as directed.\n Furosemide 80 mg Tablet PO Daily\n Milk of magnesia\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n SOB\n Cardiovascular ROS Signs and Symptoms Absent\n Chest pain, Edema\n Cardiovascular ROS Details: Review of symptoms is answered by her son.\n has expressive aphasia.\n .\n review of systems is notable for absence of fever, chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Review of Systems\n Organ system ROS normal\n Constitutional, Gastrointestinal, Genitourinary\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis\n Physical Exam\n Date and time of exam: \n General appearance: on BiPap. Breathing comfortably responsive to\n voice. overweight. Right upper extremity flexed.\n Vital signs: per R.N.\n BP right arm:\n 120/60 / mmHg\n HR: 65 bpm\n RR: 16 insp/min\n O2 sat: 100 % on Supplemental oxygen: 50%\n Vital sign details: Vent: CPAP PEEP 6, FiO2 50%, Frequency 20, TV 290\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n ABG: 7.40 / 49 / 128 / / 4 Values as of 01:00 PM\n Tests\n ECG: (Date: ), NSR, LVH, LBBB, st depressions V4-V6.\n Echocardiogram: (Date: ), : The left atrium and right\n atrium are normal in cavity size. Left ventricular wall thicknesses and\n cavity size are normal. There is moderate to severe global left\n ventricular hypokinesis (LVEF = 20-25 %). No masses or thrombi are seen\n in the left ventricle. The right ventricular cavity is mildly dilated\n with moderate global free wall hypokinesis. The aortic valve leaflets\n (3) are mildly thickened but aortic stenosis is not present. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n Moderate (2+) mitral regurgitation is seen. The pulmonary artery\n systolic pressure could not be determined. There is no pericardial\n effusion.\n IMPRESSION: Severe global left ventricular systolic dysfunction c/w\n diffuse process (multivessel CAD, toxin, metablolic, etc.). Right\n ventricular cavity enlargement with free wall hypokinesis. Moderate\n mitral regurgitation.\n Assessment and Plan\n ASSESSMENT AND PLAN\n 80 year old woman with pmh significant for chronic systolic congestive\n heart failure, presenting with shortness of breath.\n .\n # Acute on Chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, BNP 26,000 on\n admission. Lung exam with crackles. Unclear etiology, dietary\n indescretion and medicaiton non-compliance are likely not causes given\n patient is presenting from rehab. Possible upper respiratory\n infection, possible worsening valvular disease. Uncontrolled\n hypertension is also a possibility. Ischemia is also a possibility.\n -diurese with lasix 40mg IV\n -trend cardiac enzymes\n -goal I/O neg 1L\n -continue metoprolol\n -continue losartan\n -will place PICC, to allow easier lasix administration while at \n rehab.\n .\n #Respiratory Status: Patient is breathing comfortablky on CPAP, PEEP\n 5Oxygen saturation 98% on FiO2 50%. Per report in ED, attempts at\n weaning off CPAP to venti mask were unsuccessful secondary to marked\n tachypnea to 40's. recent ABG with adequate oxygenation, and CO2 49.\n need to increase pressure support.\n -trend ABG\n -wean off Bipap\n .\n #CAD: History of MI in . Will continue aspirin, lopressor, and\n losartan.\n .\n #Peripheral Vascular Disease: S/p bypass. will continue aspirin. Will\n restart plavix per discussion with PCP.\n .\n #CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia. Will continue with aggressive bowel regimen, soft\n diet.\n .\n #Hypertension: continue lopressor and losartan\n .\n #Diabetes: Type 2 on insulin. will continue standing insulin in\n addition to sliding scale.\n .\n #Parkinson's disease: Continue carbidopa levodopa TID.\n .\n #Depression:continue sertraline and bupropion\n .\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: CCU\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435632, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr- no respiratory distress.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435714, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to tnsport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%.\n Headache\n Assessment:\n Pt w/ expressive aphasia. Found to be restless & motioning w/ L arm to\n forehead indicating c/o headache. ? Received ntg in EW.\n Action:\n Given apap 650mg po.\n Response:\n After approx 1hr restlessness & gesturing stopped, back to sleep.\n Plan:\n Cont to monitor for s/s HA.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n While c/o headache, RR ^30s, BP^ 150s, HR 112.\n Action:\n Given 80 ivp lasix.\n Response:\n RR down into 20s, BPs 120s, HR 70s. Voided approx 700cc over 6hr period\n Plan:\n Cont to monitor for potential flash.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436225, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 49.1 kg\n Daily weight:\n 46.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Nsaids\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CAD s/p MI - CHF (EF20-25%)- family hx of\n sudden cardiac death- h/o stroke w/ residual complete R sided\n hemiparesis- PVD s/p bypass- dysphagia, (expressive aphasia)-\n depression- intraductal papillary mucinous tumor found on CT -\n parkinson's disease.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:92\n D:55\n Temperature:\n 101.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 31 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 845 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 05:00 AM\n Potassium:\n 3.6 mEq/L\n 05:00 AM\n Chloride:\n 100 mEq/L\n 05:00 AM\n CO2:\n 31 mEq/L\n 05:00 AM\n BUN:\n 30 mg/dL\n 05:00 AM\n Creatinine:\n 1.0 mg/dL\n 05:00 AM\n Glucose:\n 112 mg/dL\n 05:00 AM\n Hematocrit:\n 33.0 %\n 05:00 AM\n Finger Stick Glucose:\n 188\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 625\n Transferred to: 323\n Date & time of Transfer: 1530 pM\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435706, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n HEADACHE\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n 80 year old woman with pmh significant for chronic systolic congestive\n heart failure, presenting with shortness of breath.\n .\n # Acute on Chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, BNP 26,000 on\n admission. Lung exam with crackles. Unclear etiology, dietary\n indescretion and medicaiton non-compliance are likely not causes given\n patient is presenting from rehab. Possible upper respiratory\n infection, possible worsening valvular disease. Uncontrolled\n hypertension is also a possibility. Ischemia is also a possibility.\n -diurese with lasix 40mg IV\n -trend cardiac enzymes\n -goal I/O neg 1L\n -continue metoprolol\n -continue losartan\n -will place PICC, to allow easier lasix administration while at \n rehab.\n .\n #Respiratory Status: Patient is breathing comfortablky on CPAP, PEEP\n 5Oxygen saturation 98% on FiO2 50%. Per report in ED, attempts at\n weaning off CPAP to venti mask were unsuccessful secondary to marked\n tachypnea to 40's. recent ABG with adequate oxygenation, and CO2 49.\n need to increase pressure support.\n -trend ABG\n -wean off Bipap\n .\n #CAD: History of MI in . Will continue aspirin, lopressor, and\n losartan.\n .\n #Peripheral Vascular Disease: S/p bypass. will continue aspirin. Will\n restart plavix per discussion with PCP.\n .\n #CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia. Will continue with aggressive bowel regimen, soft\n diet.\n .\n #Hypertension: continue lopressor and losartan\n .\n #Diabetes: Type 2 on insulin. will continue standing insulin in\n addition to sliding scale.\n .\n #Parkinson's disease: Continue carbidopa levodopa TID.\n .\n #Depression:continue sertraline and bupropion\n .\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: CCU\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436043, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436222, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 49.1 kg\n Daily weight:\n 46.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Nsaids\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CAD s/p MI - CHF (EF20-25%)- family hx of\n sudden cardiac death- h/o stroke w/ residual complete R sided\n hemiparesis- PVD s/p bypass- dysphagia, (expressive aphasia)-\n depression- intraductal papillary mucinous tumor found on CT -\n parkinson's disease.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:92\n D:55\n Temperature:\n 101.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 31 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 845 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 05:00 AM\n Potassium:\n 3.6 mEq/L\n 05:00 AM\n Chloride:\n 100 mEq/L\n 05:00 AM\n CO2:\n 31 mEq/L\n 05:00 AM\n BUN:\n 30 mg/dL\n 05:00 AM\n Creatinine:\n 1.0 mg/dL\n 05:00 AM\n Glucose:\n 112 mg/dL\n 05:00 AM\n Hematocrit:\n 33.0 %\n 05:00 AM\n Finger Stick Glucose:\n 188\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 625\n Transferred to: 323\n Date & time of Transfer: 1530 pM\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435627, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436217, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435772, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435774, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:41 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435674, "text": "Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435675, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435676, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to tnsport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%.\n Headache\n Assessment:\n Pt w/ expressive aphasia. Found to be restless & motioning w/ L arm to\n forehead indicating c/o headache. Did receive ntg in EW for\n hypertension.\n Action:\n Given apap 650mg po.\n Response:\n After approx 1hr restlessness & gesturing stopped, resumed sleeping.\n Plan:\n Cont to monitor for s/s HA.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n While c/o headache, RR ^30s, BP^ 150s, HR 112.\n Action:\n Given 80 ivp lasix.\n Response:\n RR down into 20s, BPs 120s, HR 70s. Voided 200cc over 1hr period\n Plan:\n Cont to monitor potential flash PE\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436138, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n ------ Protected Section ------\n Approx 0545 pt went into Afib w/ RVR in 140s-150s, BPs remained stable.\n HO made aware, ordered one time dose of po lopressor 50mg. Dose given @\n 0620, results pending.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:52 ------\n" }, { "category": "Physician ", "chartdate": "2177-02-13 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 436160, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - refusing meds in AM, but finally\n took them with family at bedsite\n - difficult IV access, has 1 PIV, plan for PICC at Rehab\n - 700cc of D5W for hypernatremia, Na 149 --> 146 --> 145; fluids\n stopped once glucose was elevated\n - diuresing: lasix 80mg PO BID and HCTZ 12.5mg \n - at 6 AM went into afib, rate to 120s, metoprolol 50mg given\n Medications\n Unchanged\n Physical Exam\n BP: 119 / 57 mmHg\n HR: 107 bpm\n Tmax C last 24 hours: 37.8 C\n Tmax F last 24 hours: F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 % on Supplemental oxygen: 3L NC\n Previous day:\n Weight: 46.5 kg\n Intake: 1,250 mL\n Output: 1,175 mL\n Fluid balance: 75 mL\n Today:\n Output: 640 mL\n Fluid balance: -640 mL\n VS: BP (88-129)/(40-77), HR(97-120s), RR 25, O2 Sat 95-98% on 3L NC\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), Auscultation: no crackles, but some\n bronchial breath sounds\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 287\n 11.1\n 112\n 1.0\n 31\n 3.6\n 30\n 100\n 145\n 33.0\n 13.1\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n 05:59 PM\n 05:00 AM\n WBC\n 13.4\n 7.8\n 13.1\n Hgb\n 11.2\n 10.1\n 11.1\n Hct (Serum)\n 32.6\n 29.4\n 33.0\n Plt\n \n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n 146\n 145\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n 4.3\n 3.6\n Cl\n 103\n 105\n 106\n 103\n 100\n HCO3\n 31\n 30\n 30\n 31\n 33\n 30\n 31\n BUN\n 33\n 32\n 32\n 32\n 30\n Creatinine\n 1.1\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 192\n 161\n 108\n 258\n 112\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 31 / Values as of 05:00 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam now without crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on lasix with HCTZ before doses\n - lasix 80 PO BID and HCTZ 12.2mg PO BID 30min prior.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n # Afib: new onset, started this AM, HR to 120s, asymptomatic\n - may need to increase BB for rate control\n .\n #Hypernatremia: Likely from restricted access to free water. Improved\n now after 700 D5W + oral water.\n -monitor lytes\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.1 this morning AM, differential pending. Tmax\n 100. No clear sign of infection., possible PNA?.\n - f/u diff\n - monitor for signs of infection\n -consider abx for CAP\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-13 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 436176, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - refusing meds in AM, but finally\n took them with family at bedsite\n - difficult IV access, has 1 PIV, plan for PICC at Rehab\n - 700cc of D5W for hypernatremia, Na 149 --> 146 --> 145; fluids\n stopped once glucose was elevated\n - diuresing: lasix 80mg PO BID and HCTZ 12.5mg \n - at 6 AM went into afib, rate to 120s, metoprolol 50mg given\n Medications\n Unchanged\n Physical Exam\n BP: 119 / 57 mmHg\n HR: 107 bpm\n Tmax C last 24 hours: 37.8 C\n Tmax F last 24 hours: F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 % on Supplemental oxygen: 3L NC\n Previous day:\n Weight: 46.5 kg\n Intake: 1,250 mL\n Output: 1,175 mL\n Fluid balance: 75 mL\n Today:\n Output: 640 mL\n Fluid balance: -640 mL\n VS: BP (88-129)/(40-77), HR(97-120s), RR 25, O2 Sat 95-98% on 3L NC\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), Auscultation: no crackles, but some\n bronchial breath sounds\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 287\n 11.1\n 112\n 1.0\n 31\n 3.6\n 30\n 100\n 145\n 33.0\n 13.1\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n 05:59 PM\n 05:00 AM\n WBC\n 13.4\n 7.8\n 13.1\n Hgb\n 11.2\n 10.1\n 11.1\n Hct (Serum)\n 32.6\n 29.4\n 33.0\n Plt\n \n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n 146\n 145\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n 4.3\n 3.6\n Cl\n 103\n 105\n 106\n 103\n 100\n HCO3\n 31\n 30\n 30\n 31\n 33\n 30\n 31\n BUN\n 33\n 32\n 32\n 32\n 30\n Creatinine\n 1.1\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 192\n 161\n 108\n 258\n 112\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 31 / Values as of 05:00 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam now without crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on lasix with HCTZ before doses\n - lasix 80 PO BID and HCTZ 12.2mg PO BID 30min prior.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n # Afib: new onset, started this AM, HR to 120s, asymptomatic; converted\n spontaneously.\n - continue aspirin 325\n - may need to increase BB for rate control\n - no need for anticoagulation now\n .\n #Hypernatremia: Likely from restricted access to free water. Improved\n now after 700 D5W + oral water.\n - encourage PO free water intake\n - check Na every other day\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n - check CXR\n # Leukocytosis: WBC 13.1 this morning AM, differential pending. Tmax\n 100. No clear sign of infection., possible PNA?.\n - f/u diff\n - monitor for signs of infection\n -consider abx for CAP\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: transfer back to Rehab (likely today)\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435970, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 ,\n bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan\n 50 PO BID, Carbidopa levodopa\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - diuresis switched to lasix 80 PO BID and HCTZ 25mg PO BID.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n #Hypernatremia: Likely from restricted access to free water. Will give\n D5W 1000cc.\n -D5W 1000cc.\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435972, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 ,\n bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan\n 50 PO BID, Carbidopa levodopa\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - diuresis switched to lasix 80 PO BID and HCTZ 25mg PO BID.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n #Hypernatremia: Likely from restricted access to free water. Will give\n D5W 1000cc.\n -D5W 1000cc.\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:39 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436088, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n" }, { "category": "Echo", "chartdate": "2177-02-11 00:00:00.000", "description": "Report", "row_id": 87849, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Valvular heart disease.\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 129/58\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 09:50\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic;\nanterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic;\nlateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR. LV inflow pattern c/w restrictive filling abnormality, with elevated LA\npressure.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thicknesses are normal. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is severely\ndepressed (LVEF= 20-25 %) with inferior, anteroseptal and apical\nakinesis/severe hypokinesis and hypokinesis elsewhere. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests a restrictive filling abnormality, with\nelevated left atrial pressure. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056222, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with severe CHF p/w resp distress\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with severe congestive heart failure, now presents\n with respiratory distress. Evaluate for acute cardiopulmonary process.\n\n TECHNIQUE: Chest radiograph, portable upright AP view only.\n\n COMPARISON: Chest radiograph on .\n\n FINDINGS: The study is limited by motion and patient's rotation to the left.\n Allowing these limitations, the enlarged cardiac silhouette is unchanged.\n Aortic tortuosity with vascular calification is unchanged. There is mild\n perihilar haziness and pulmonary vasculature prominence, also unchanged,\n compatible with mild CHF. There is interval decrease definition of the right\n cardiac border. The left hemidiaphragm is silhouetted out, consistent with\n left pleural effusion. The right effusion is slightly decreased. There is\n non-specific opacity seen in the right upper lung. There is no pneumothorax.\n There are underlying degenerative changes seen in the thoracolumbar spines.\n\n IMPRESSION:\n 1. Mild congestive heart failure.\n 2. Non-specific new opacity in the left upper lung. Recommend repeat PA &\n lateral views after diuresis to further assess as this study is technicall\n limited.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056939, "text": " 11:47 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with leukocytosis. Please r/o PNA\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:14 PM\n Interval development of mild-to-moderate right pleural effusion and slight\n interval decrease in moderate-to-severe left pleural effusion. Bibasilar\n atelectasis. Pleural effusions and atelectasis limit detection of pneumonia\n within the lower lung fields.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 80-year-old female with leukocytosis. Please\n evaluate for pneumonia.\n\n EXAMINATION: PA and lateral chest radiographs.\n\n COMPARISONS: Comparison to PA and lateral chest radiographs from .\n\n FINDINGS: There is interval development of a right-sided, mild-to-moderate\n pleural effusion, and slight interval decrease in moderate-to-severe left-\n sided pleural effusions. There is persistent bibasilar atelectasis.\n Evaluation of the lower lung fields for pneumonia is limited secondary to hazy\n increased opacification from pleural effusions and atelectasis. The upper\n lung zones are clear with no signs of pneumonia. The cardiomediastinal\n contours are stable with moderate cardiomegaly. The visualized osseous\n structures are unchanged.\n\n IMPRESSION: Interval development of mild-to-moderate right pleural effusion,\n and slight interval decrease in moderate-to-severe left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2177-02-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056940, "text": ", M. 11:47 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with leukocytosis. Please r/o PNA\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n PFI REPORT\n Interval development of mild-to-moderate right pleural effusion and slight\n interval decrease in moderate-to-severe left pleural effusion. Bibasilar\n atelectasis. Pleural effusions and atelectasis limit detection of pneumonia\n within the lower lung fields.\n\n" }, { "category": "Radiology", "chartdate": "2177-02-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056551, "text": " 3:15 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 6:45 PM\n Pulmonary vascular congestion improved since yesterday, sizable left-sided\n pleural effusion persists.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: CHF exacerbation. Evaluate for infiltrates.\n\n FINDINGS: The patient's condition required examination in sitting upright\n position with AP frontal and lateral view. Analysis is performed in direct\n comparison with a preceding AP single chest view obtained during the preceding\n day. Heart size remains significantly enlarged. The previously present\n marked perivascular haze has regressed and in the accessible lung fields of\n the right hemithorax. The vascular pattern is now unremarkable and no\n evidence of pleural effusion is present in the right lateral sinus. No acute\n infiltrates are present. In the left hemithorax, a previously described\n pleural density that obliterates the diaphragmatic contour remains and\n probably has increased somewhat with major portions layering posteriorly with\n patient in semi-upright position. There is no evidence of pneumothorax on\n either side. The lateral view suffers from the non-elevated arms, but one can\n identify and confirm the rather prominent left-sided pleural effusion reaching\n posteriorly up to the level of the fifth thoracic vertebra. A right-sided\n pleural effusion is rather limited and only mildly blunts the posterior\n pleural sinus.\n\n IMPRESSION: Regression of pulmonary vascular congestion during the last one\n day interval. Sizable left-sided pleural effusion persists. No evidence of\n pneumothorax or new localized infiltrates. As shown earlier, there is a\n moderately compressed vertebral body at level T12.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056552, "text": ", M. 3:15 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Pulmonary vascular congestion improved since yesterday, sizable left-sided\n pleural effusion persists.\n\n\n" }, { "category": "ECG", "chartdate": "2177-02-13 00:00:00.000", "description": "Report", "row_id": 220869, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. Possible\nleft ventricular hypertrophy. Diffuse non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of multiple\nabnormalities as previously noted persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2177-02-12 00:00:00.000", "description": "Report", "row_id": 220870, "text": "Sinus rhythm\nConsider left atrial abnormality\nModest intraventricular conduction delay mat be incomplete left bundle branch\nblock\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of , rate faster, but otherwise probably no\nsignificant change\n\n" }, { "category": "ECG", "chartdate": "2177-02-10 00:00:00.000", "description": "Report", "row_id": 220871, "text": "Sinus rhythm\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to hypertrophy\nSince previous tracing of the same date, heart rate slower\n\n" }, { "category": "ECG", "chartdate": "2177-02-10 00:00:00.000", "description": "Report", "row_id": 220872, "text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , heart rate faster\n\n" } ]
6,713	135,319	1. Diabetic ketoacidosis - The patient came in in florid diabetic ketoacidosis with a pH of 6.98 and a bicarbonate of 5. She was aggressively treated with 4 liters of normal saline and insulin. Her potassium was also elevated at 6.7. She was continued on an insulin drip with 1/2 normal saline and kept NPO. Her glucose responded relatively quickly dropping below 200 into the 100s. Her anion gap also corrected relatively rapidly and the patient did well from this standpoint. Attempts were then made to normalize the patient's sugars which varied widely from low sugars on Glargine 12 and insulin sliding scale to high sugars on Glargine 8 and a regular insulin sliding scale. The acidosis associated with her diabetic ketoacidosis once corrected remained corrected and the patient did not again have an anion gap. Fluid repletion continued through her stay and by approximately the fourth day the patient was beginning to take p.o. well. The day before admission the patient was eating a full diabetic diet. 2. Cardiac - During the course of the stay the patient ruled in for a non-ST elevation myocardial infarction with troponins in the range of .4 to .5 and creatinine kinases in the range of 300. The patient was effectively asymptomatic, however, her mental status was confused during this time. The patient was treated with conservative medical management, receiving Aspirin and beta blocker. The patient had an echocardiogram during the admission which showed preservation of left ventricular function with an ejection fraction greater than 55%. Plan was to start the patient on a statin drug, either at the end of this admission or as an outpatient for its cardioprotective effects. The patient had a total cholesterol during admission of 106, however, this can be artificially low around the time of a myocardial infarction. 3. Abdominal pain - On day #2 of admission, the patient complained of some abdominal pain and had an increased amylase and lipase. The patient underwent abdominal computerized tomography scan which showed no evidence of colitis, bilateral pleural effusions or uterine fibroids. The patient's increased amylase and lipase resolved fairly rapidly. The patient did not continue to have any abdominal pain. 4. Change in mental status - Initially the patient was quite confused and disoriented, oriented only to her name. Her mental status slowly improved over the course of the admission. She had a head computerized tomography scan that was negative for acute process. Her B12 and Folate levels were both normal. RPR was negative. Because of the patient's persistent change in mental status, the patient underwent a lumbar puncture during the admission. The results were consistent with an aseptic meningitis with cerebrospinal fluid showing 59 white blood cells, 9 red blood cells, protein 53 and glucose of 121. Cryptococcal antigen was negative, RPR was negative, herpes PCR was negative, fungal culture negative, blood culture negative, and urine cultures were negative. A neurology consult was obtained and this will be discussed below. The patient's mental status continued to improve. She was able to passive swallow on evaluation, and her mental status changes were felt simply related to severe extent of her illness. She did have an myocardial infarction of the head and cervical spine which was also negative for an intracranial process. 5. Bilateral proximal arm weakness - The patient began to complain of this as her mental status improved and she literally could not move her upper arms very much, several days after admission. On further investigation it was determined that this was a longstanding problem for the patient and as she recovered from the illness she actually regained strength and decreased pain in her upper arms. Neurology was consulted for this problem as she did receive a head computerized tomography scan and computerized tomography scan of the spine. Computerized tomography scan of the head showed reversible posterior encephalopathy possibly secondary to hypertension but no masses, no midline shift. Magnetic resonance imaging scan of the spine showed cervical spondylosis C5-C6 and C6-C7 with some narrowing of the spinal canal but no epidural abscess or other intraspinal process. At the time of this dictation, it was suggested that the patient follow up with Neurosurgery for the pain and the findings either as she remains in-house or as an outpatient. 6. Hypertension - The patient came in an extensive hypertensive regimen including Lisinopril, Hydrochlorothiazide, Diovan and Atenolol. The patient was treated in the hospital with Metoprolol 275 t.i.d. She was started on Losartan 100 initially. An ACE inhibitor was not used because of the patient's allergy to Univasc. Her regimen will likely change before discharge, but she did continue to be hypertensive to the 180s/approximately 80 to 90. 7. Glaucoma - After several days off of treatment, the patient was continued on a home glaucoma regimen. 8. Anemia - The patient's hematocrit did drop below 28 and the patient received 1 unit of packed red blood cells to good affect increasing her hematocrit to 34. The patient will have her hematocrit monitored for the remainder of her stay and should continue receiving her B12 shots. This dictation will be addended with the patient's discharge information at time of discharge. , M.D. Dictated By: MEDQUIST36 D: 14:37 T: 14:45 JOB#:	Physiologic mitral regurgitation is seen (withinnormal limits). Sinus tachycardiaSupraventricular extrasystolesST junctional depression is nonspecificSince previous tracing, sinus tachycardia, atrial premature complexes, and STdepression is present CT HEAD WITHOUT IV CONTRAST: The ventricles, basal cisterns and sulci are mildly prominent throughout, consistent with age appropriate involutional changes. BS clear decreased in bases bilaterally.GI: Please guiac all stool, -BM, +BS. INDWELLING FOLEY IN PLACE; PATENT WITH LG. tx with 2 gms ceftriaxone and flagyl.NEURO-was disoriented and incoherent upon arrival to EW-perked up with some care and is now oriented to person, answering simple questons.IV ACCESS-has #18 L antecube, #18 L wrist.a-stable DKAPadmit to MICU B for monitoring, care LS CLEAR TO DIMINISHED BILAT. Maint fluid of D5.45NS stopped. Sinus rhythm.Minor nonspecific lateral ST-T wave changesSince previous tracing of the same date: atrial ectopy not seen and ST-T wavechanges are decreased SOFT, NTND WITH +BS NOTED. The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. AND ORDERED FOR DOSE CEFTRIAXONE; AWAITING ID APPROVAL.C/V- HR 70S', NSR WITH NO ECTOPY NOTED. Slight pain in RUQ, my have an abd CT in near future.GU: Pt has f/c with marginal to adequate u/o. Pt reciving K phos currently. BP pt slightly hyertensive 140-160's sys. NGT INSERTED AND MED WITH ZOFRAN. ON ASPIRATION PRECAUTIONS FOR ALTERED MENTAL STATUS YEST. At C7-T1 and inferiorly to T4-5 disc degenerative changes are identified. NGT DC'D YEST. Con't to monitor MS. At times able to converse and other times completely lethergic.Cardiac: Pt in SR HR 80-90 no ectopy. 99.3 ORALLY. Been taking BG from ear lobes, I think the result from the edematous fingertips is skewed.Access: PT has PIV x3.Next labs, CK, lytes and PTT at 2230, con't to monitor MS. NGT PLACED TO LIS AND THE ZOFRAN HELPED WITH THE NAUSEA.NEURO: PT HAS BEEN INTERMITTENTLY ALERT AND ORIENTED X2. FINDINGS: AP supine view is compared to semi-upright view dated . There is mildmitral annular calcification. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 62Weight (lb): 138BSA (m2): 1.63 m2BP (mm Hg): 194/81HR (bpm): 76Status: InpatientDate/Time: at 10:12Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). Pt on q1 Hr BG, done via ear since pt very edematous.ID: Pt con't to have white count, LP done today, along wiht CT of abd. GIVEN X1 DOSE VANCO. Meds changed to IV for aspiration risk.GU: Pt has f/c with good u/o. MICU Nursing Progress NoteNeuro: Pt lethergic, arousible to voice, oriented x2 at times. FINDINGS: At the craniocervical junction and C2-3 and C3-4 mild degenerative changes are noted. T1 axial and coronal images were obtained following gadolinium. ON IVF D5 1/2NS @ 75/HR.RESP- ON 2L NC. PERIPHERAL PULSES PALPABLE. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The heart and mediastinum are within normal limits. LP YEST. Anion gap closed. BP 120-130 systolic. At C6-7 diffuse disc bulge and posterior ridging is identified with mild bilateral foraminal narrowing. Glargine @ HS. Well-defined radiopaque densities seen at the proximal humerus are unchanged from . 8:41 PM MR W& W/O CONTRAST Clip # Reason: r/o disk dz or epidural abscess ? MICU Nursing Progress NoteNeuro: Pt remains pleasently confused. NEGATIVE.SKIN - GROSSLY INTACT.SOCIAL - PTS. Soft-tissue changes are identified in the right maxillary and ethmoid sinuses. WITH TMAX. The uterus is otherwise unremarkable. Mild to moderate bilateral foraminal narrowing seen. TECHNIQUE: T1, T2 inversion recovery sagittal and gradient echo axial images were obtained following Gadolinium. Bilateral pleural effusions. Of concern is pt's persistent weakness of UE's, ?MRI. DID R/I FOR MI. Pt waxes and wanes in MS. Pt currently difficult to arouse, arouses to voice. Pt ruling in MI, EKG done, given and started on lopressor q4 for HR control, HR in low 80's is acceptable. STATUS AND CONT. NGT dc'd during a period of alertness, unable to place another NGT. NIBP 130'S-170'S/40'S-60'S. BP 185/66 @ 1200, so Labetolol IV started @ 1mg/hr. Uterine fibroids. IMPRESSION: Mild CHF cannot be excluded. IMPRESSION: 1. CT ABD. +MAE, THOUGH MINIMAL RUE. Pt is an aspiration risk!GI: Pt c/o LUQ pain, Abd soft distended, tenderness with palpation. Bowel sounds present, no stool since 1200.Endo: Initially receiving Insulin @ .5u/hr, D/C'd @ 1200. AND ONE THIS AM PER TEAM; RESULTS PENDING. NOTABLE FOR WBCS IN TUBE #1 & #4. MICU B Nursing Progress Note (0700-1100)Pt. bp has been 80-100/.RESP-wearing O2 2-3L nasal cannula.RR 28-30, unlabored.F/E- is on 5th litre of NS.voided 700 ccs in EW.please see labs in carevue.mucous membranes are dry.ENDO-sugar was 850 upon admit to the EW.was tx with 10u ivp insulin then started on a drip at 7u/hr. AMTS. CT of abd negative. Poor access for venapuncture. However, mild CHF cannot be excluded. UPDATED ON PT. ALERT AND ORIENTED X PERSON AND TIME T/O EVE., CONFUSED WITH PLACE. Patient is status post cholecystectomy. Urine yellow/clear.Plan: Called out to floor. UE weak bilat, to go to MRI this pm for spine and head scans.CV: HR stable 75-88NSR without ectopy, increasing to 108 with talking. Pts cardiac enzymes peaked, heparin stopped.Resp: Pt on 2L via NC, O2 sat 100%. However, FS @ 1400 292 and @ 1600 403. Pt must remain flat X multiple hours due to LP.Cardiac: Pt in SR occ Sinus arrythmia.	17	[ { "category": "Radiology", "chartdate": "2140-09-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 797563, "text": " 1:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above\n r/o bleed in setting of falls\n REASON FOR THIS EXAMINATION:\n change in mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 4:46 AM\n no bleed; no major CVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change and fall.\n\n COMPARISON: \n\n TECHNIQUE: Noncontrast axial images were obtained from the skull base to the\n vertex.\n\n CT HEAD WITHOUT IV CONTRAST: The ventricles, basal cisterns and sulci are\n mildly prominent throughout, consistent with age appropriate involutional\n changes. There is no mass effect, shift of normally midline structures, intra\n or extra-axial hemorrhage, or hydrocephalus. /white matter differentiation\n is preserved. There is mild low attenuation changes within the\n periventricular white matter, consistent with chronic microvascular\n infarctions. The osseous structures, paranasal sinuses and soft tissues are\n unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or edema.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797564, "text": " 2:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hyperglycemic coma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above\n r/o infiltrate\n REASON FOR THIS EXAMINATION:\n hyperglycemic coma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoglycemic coma.\n\n COMPARISON: .\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiomediastinal and hilar contours are\n unremarkable. The lungs are clear without focal opacities or effusions. The\n soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 797690, "text": " 9:34 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: ABDOMINAL PAIN, LOW GRADE FEVER, ELEVATED AMYLASE, R/O MESENTERIC ISCHEMIA\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with abdominal pain, low grade fever, mental status changes,\n elevated amylase and leukocytosis (24)\n REASON FOR THIS EXAMINATION:\n r/o mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Abdominal pain and fever.\n\n TECHNIQUE: CT of the abdomen and pelvis with contrast. 150 cc of Optiray were\n used for this examination. Optiray was used due to patient request.\n\n There are no prior studies for comparison.\n\n FINDINGS\n\n CT OF THE ABDOMEN WITH CONTRAST:\n There are bilateral pleural effusions in the lung bases. The liver, spleen,\n adrenals, kidneys, pancreas, and intra- abdominal vessels are unremarkable in\n appearance. Patient is status post cholecystectomy. Small and large bowels are\n normal in appearance. There is no evidence of bowel dilation. There is no fat\n stranding or fluid within the mesentery or surrounding the bowel. There is no\n mesenteric or retroperitoneal lymphadenopathy. There is no free air or free\n fluid within the abdomen. An NG tube is visualized within the stomach.\n\n CT OF THE PELVIS WITH CONTRAST:\n A Foley catheter is present within the bladder. The bladder, rectum, and\n sigmoid are otherwise unremarkable in appearance. There are fibroids within\n the uterus. The uterus is otherwise unremarkable. There is no free fluid or\n lymphadenopathy within the pelvis.\n\n The osseous structures are unremarkable.\n\n\n IMPRESSION:\n 1. No evidence of ischemic colitis.\n 2. Bilateral pleural effusions.\n 3. Uterine fibroids.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-10 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 798011, "text": " 12:07 PM\n HUMERUS (AP & LAT) RIGHT; SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHTClip # \n Reason: assess for trauma, fracture\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with dka, aseptic meningitis, s/p fall\n REASON FOR THIS EXAMINATION:\n assess for trauma, fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with aseptic meningitis.\n\n FINDINGS: There is no fracture or dislocation. Well-defined radiopaque\n densities seen at the proximal humerus are unchanged from . These are\n probably soft tissue calcifications.\n\n IMPRESSION: No fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-09 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 797955, "text": " 8:41 PM\n MR W& W/O CONTRAST Clip # \n Reason: r/o disk dz or epidural abscess ?? not sure if contrast need\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with MS changes w/ CSF pleocytosis w/ mildly elevated glucose\n & nrml protein now w/ UE weakness\n REASON FOR THIS EXAMINATION:\n r/o disk dz or epidural abscess ?? not sure if contrast needed???\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with mental status changes and CSF pleocystosis with\n mildly elevated glucose, r/o epidural abscess.\n\n TECHNIQUE: T1, T2 inversion recovery sagittal and gradient echo axial images\n were obtained following Gadolinium. There are no prior similar examinations\n for comparison.\n\n FINDINGS: At the craniocervical junction and C2-3 and C3-4 mild degenerative\n changes are noted. At C4-5 mild disc bulging and a broad based right sided\n disc herniation seen slightly indenting the thecal sac. At C5-6 diffuse disc\n bulging and posterior ridging is seen with mild narrowing of the spinal canal\n and indentation on the thecal sac. Mild to moderate bilateral foraminal\n narrowing seen. At C6-7 diffuse disc bulge and posterior ridging is\n identified with mild bilateral foraminal narrowing.\n\n At C7-T1 and inferiorly to T4-5 disc degenerative changes are identified. The\n spinal cord shows normal intrinsic signal.\n\n Following Gadolinium no evidence of abnormal intraspinal enhancement or\n evidence of epidural abscess is identified. No evidence of discitis or\n osteomyelitis is seen in the cervical and upper thoracic region. Prevertebral\n soft tissues are well maintained.\n\n IMPRESSION: Changes of cervical spondylosis with mild spinal canal narrowing\n at C5-6 and C6-7 with foraminal changes as above. No evidence of epidural\n abscess or abnormal intraspinal enhancement.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-09 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 797956, "text": " 8:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for evidence of encephalopathy\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with MS changes w/ CSF pleocytosis w/ mildly elevated glucose\n & nrml protein now w/ UE weakness\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of encephalopathy\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with mental status changes, rule out\n encephalopathy.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and susceptibility axial\n images of the brain were obtained before gadolinium. T1 axial and coronal\n images were obtained following gadolinium. Comparison was made with the\n previous MRI study of .\n\n FINDINGS: There are foci of T2 hyperintensity in bilateral posteroparietal\n and supero-occipital regions in the subcortical region extending to the\n cortex. These findings are new since the previous MRI study. Mild changes of\n small vessel disease are identified. No evidence of midline shift, mass\n effect or hydrocephalus is seen. No evidence of abnormal parenchymal,\n vascular or meningeal enhancement seen following the administration of\n gadolinium. Soft-tissue changes are identified in the right maxillary and\n ethmoid sinuses. Soft-tissue changes are also seen in both sphenoid sinuses.\n\n IMPRESSION: Foci of T2 hyperintensity in the subcortical and cortical region\n of parieto-occipital lobes could be secondary to posterior reversible\n encephalopathy from hypertension. Clinical correlation recommended. Further\n evaluation with a follow-up and diffusion-weighted images is recommended.\n Findings were discussed with Dr. at the time of interpretation\n of this study on at 11:30AM.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797748, "text": " 9:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above r/o infiltrate\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n FINDINGS: AP supine view is compared to semi-upright view dated .\n The heart and mediastinum are within normal limits. The pulmonary vessels\n appear more prominent since the prior study, which may be appropriate for\n supine positioning. However, mild CHF cannot be excluded. There is no focal\n consolidation or pleural effusion. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION: Mild CHF cannot be excluded.\n\n" }, { "category": "Echo", "chartdate": "2140-09-09 00:00:00.000", "description": "Report", "row_id": 64154, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 138\nBSA (m2): 1.63 m2\nBP (mm Hg): 194/81\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 10:12\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\nnormal limits). The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-07 00:00:00.000", "description": "Report", "row_id": 1351046, "text": "NURSING PROGRESS NOTE:\nAT BEGINING OF SHIFT PT VOMITING SM AMT'S OF THICK GREEN BILIOUS LOOKING MATERIAL. PT GAGGING AND WRETCHING. NGT INSERTED AND MED WITH ZOFRAN. NGT PLACED TO LIS AND THE ZOFRAN HELPED WITH THE NAUSEA.\nNEURO: PT HAS BEEN INTERMITTENTLY ALERT AND ORIENTED X2. AT ONE POINT PT'S EYES WERE GLAZED OVER AND UNABLE TO RESPOND VERBALLY OR UNABLE TO RESPOND TO SIMPLE COMMANDS. AFTER AWHILE PT BECAME MORE RESPONSIVE BUT WAS VERY CONFUSED. PT TALKING RAGTIME ALL .\nBLOOD SUGARS HAVE BEEN CHECKED EVERY HOUR AND INSULIN DRIP TITRATED ACCORDINGLY. SEE FLOWSHEET FOR DATA.\nPTT AT 2230 150, HEPARIN DRIP TURNED OFF FOR 1HR AND RESTARTED AT 450UNITS. WILL RECHECK PTT IN AM.\nCV: PT'S HR IN HIGH 80'S WITH NO ECTOPY, PT GIVEN AN EXTRA DOSE OF LOPRESSOR, HR IN 70'S-80'S ALL NIGHT.\nPT C/O INTERMITTENT ABD PAIN THROUGHOUT THE NIGHT. WBC ELEVATED AND AMYLASE RISING, PT TO HAVE ABD CT SCAN WITH CONTRAST, HAS NOT BEEN DONE AS OF YET.\nIV FLUID HAS BEEN RUNNING AT 300CC/HR ALL . KPHOS FINISHED AND PHOS CAME UP SLIGHTLY BUT K CAME BACK TOO HIGH. IV FLUID CONT WITHOUT K.\nFOLEY CATH PATENT AND DRAINING SM AMT;S OF CLEAR YELLOW URINE..\nPT IS NPO, HYPOACTIVE BOWEL SOUNDS, NO STOOL AT THIS TIME.\nBROTHER NOTIFIED LAST THAT PT A BLOOD TRANSFUSION DUE TO LOW HCT. BROTHER GAVE CONSENT AT THAT TIME BUT CALLED BACK AT O500 AND\nTOOK BACK THE ORDER BECAUSE HE FELT HE SHOULD COME IN AND SEE HER AND TO SEE THAT SHE IS REALY CONFUSED AND UNABLE TO MAKE THIS DECISION HERSELF.\nPT IS AT THIS TIME.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-07 00:00:00.000", "description": "Report", "row_id": 1351047, "text": "MICU Nursing Progress Note\nNeuro: Pt remains pleasently confused. Pt OOB with great difficulty to chair. Pt waxes and wanes in MS. Pt currently difficult to arouse, arouses to voice. Pt must remain flat X multiple hours due to LP.\n\nCardiac: Pt in SR occ Sinus arrythmia. Pt on lopressor IV changed to PO and changed back to IV. BP pt slightly hyertensive 140-160's sys. Pts cardiac enzymes peaked, heparin stopped.\n\nResp: Pt on 2L via NC, O2 sat 100%. BS clear decreased in the bases. Pt is an aspiration risk!\n\nGI: Pt c/o LUQ pain, Abd soft distended, tenderness with palpation. Pt given 900cc baricat, via NGT. CT of abd negative. Pt had episodes of nausea. NGT dc'd during a period of alertness, unable to place another NGT. Meds changed to IV for aspiration risk.\n\nGU: Pt has f/c with good u/o. yellow in color and clear. Pt on D5 1/2 NS at 50cc/hr.\n\nEndo: Pt currently on 2U/hr of insulin, team does not want insulin turned off, please adjust IVF to maintain BG between 100-120. Pt on q1 Hr BG, done via ear since pt very edematous.\n\nID: Pt con't to have white count, LP done today, along wiht CT of abd. No head CT at this time for MS. cx drawn. No source of infection at this time. 2 sets of BS to be drawn with next sets of labs.\n\nLabs: Pt due for pm labs at 2100, with 2100 labs please send first set of BC, with am labs please draw the second set of BC.\n\nAccess: Pt has PIV x2. Poor access for venapuncture.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 1351044, "text": "pmicu nursing brief admit note\nmrs is an 84 yo woman admitted to the pmicu this am from the EW with DKA. her family called EMS because pt was having a change in her mental status, fell several times and felt \"off balance\".she does not have air conditioning in her apt.? if she's been compliant with her insulin.\nbrief review of systems\nCV-HR came down from 120's st to ~110 with IVF administration. bp has been 80-100/.\nRESP-wearing O2 2-3L nasal cannula.RR 28-30, unlabored.\nF/E- is on 5th litre of NS.voided 700 ccs in EW.please see labs in carevue.mucous membranes are dry.\nENDO-sugar was 850 upon admit to the EW.was tx with 10u ivp insulin then started on a drip at 7u/hr. last fingerstick=485.\nGI-abd is soft, nontender, positive bowel sounds.had some nausea and vomitting at home and in EW- tx with 10 mgs reglan with relief.\nID-2 sets blood cultures, urine sent from EW. tx with 2 gms ceftriaxone and flagyl.\nNEURO-was disoriented and incoherent upon arrival to EW-perked up with some care and is now oriented to person, answering simple questons.\nIV ACCESS-has #18 L antecube, #18 L wrist.\na-stable DKA\nP_admit to MICU B for monitoring, care\n" }, { "category": "Nursing/other", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 1351045, "text": "MICU Nursing Progress Note\nNeuro: Pt lethergic, arousible to voice, oriented x2 at times. Con't to monitor MS. At times able to converse and other times completely lethergic.\n\nCardiac: Pt in SR HR 80-90 no ectopy. BP 120-130 systolic. Pt ruling in MI, EKG done, given and started on lopressor q4 for HR control, HR in low 80's is acceptable. Heparin started at 750u/hr with 3700u bolus. Next PTT is 2300. goal PTT is 50-80.\n\nResp: Pt on 2L via NC. O2 sat 100%. BS clear decreased in bases bilaterally.\n\nGI: Please guiac all stool, -BM, +BS. Slight pain in RUQ, my have an abd CT in near future.\n\nGU: Pt has f/c with marginal to adequate u/o. Pt on D5 1/2 NS with 20mEq K at 300 cc/hr, after the L hanging, change to D5 con't at 300cc/hr.\n\nEndo: Pt on insulin gtt currently at 8u/hr. BG q1 hr, goal is <150. Anion gap closed. Lytes being repleated. Pt reciving K phos currently. Been taking BG from ear lobes, I think the result from the edematous fingertips is skewed.\n\nAccess: PT has PIV x3.\n\nNext labs, CK, lytes and PTT at 2230, con't to monitor MS.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351048, "text": "MICU-B NPN 1900-0700\nNEURO - PT. ALERT AND ORIENTED X PERSON AND TIME T/O EVE., CONFUSED WITH PLACE. VERY PLEASANT. +MAE, THOUGH MINIMAL RUE. C/O PAIN WITH MOVEMENT OF RUE, NO BRUISING NOTED. LP YEST. NOTABLE FOR WBCS IN TUBE #1 & #4. ?VIRAL MENINGITIS. GIVEN X1 DOSE VANCO. AND ORDERED FOR DOSE CEFTRIAXONE; AWAITING ID APPROVAL.\n\nC/V- HR 70S', NSR WITH NO ECTOPY NOTED. NIBP 130'S-170'S/40'S-60'S. CONT. ON Q4 HR. 10 MG. LOPRESSOR. PT. DID R/I FOR MI. PERIPHERAL PULSES PALPABLE. ON IVF D5 1/2NS @ 75/HR.\n\nRESP- ON 2L NC. O2SATS. 98-100% RR TEENS-20'S. LS CLEAR TO DIMINISHED BILAT. BASES. PRODUCTIVE COUGH NOTED; WILL SWALLOW OR SPIT OUT.\n\nGI/GU - PT. NGT DC'D YEST. ON ASPIRATION PRECAUTIONS FOR ALTERED MENTAL STATUS YEST. ABD. SOFT, NTND WITH +BS NOTED. NO STOOL THIS SHIFT. INDWELLING FOLEY IN PLACE; PATENT WITH LG. AMTS. LIGHT, YELLOW URINE OUT OVER/.\n\nENDO - REMAINS ON INSULIN GTT. @ 1U/HR T/O SHIFT PER TEAM. FS CHANGED TO Q2/HR; ALL WITHIN GOAL RANGE 100-200.\n\nID - PT. WITH TMAX. 99.3 ORALLY. WBC 15.5 THIS A.M. DOWN FROM 25.4 YEST. X2 SETS BLOOD CXS. SENT. ONE LAST EVE. AND ONE THIS AM PER TEAM; RESULTS PENDING. CT ABD. YEST. NEGATIVE.\n\nSKIN - GROSSLY INTACT.\n\nSOCIAL - PTS. SISTER AND CALLED OVER/. UPDATED ON PT. STATUS AND CONT. PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351049, "text": "MICU B Nursing Progress Note (0700-1100)_\n\nPt. awake, alert and interactive. She has started taking clear liqs and tolerating them well. Insulin gtt has been decreased from 1U/hr to .5U/hr after fingerstick of 89. Continues on D5.45NS at 75cc/hr. Insulin requirements to be re-evaluated later in the day...to be converted to sliding scale as her po intake increases. Of concern is pt's persistent weakness of UE's, ?MRI.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351050, "text": "Nursing Progress Note 1200-1900\nReview of Systems:\n\nNeuro: Pt remains pleasant and cooperative but intermit confused. A&O X 3. UE weak bilat, to go to MRI this pm for spine and head scans.\n\nCV: HR stable 75-88NSR without ectopy, increasing to 108 with talking. BP 185/66 @ 1200, so Labetolol IV started @ 1mg/hr. After 1hr, bolused with 5mg and rate increased to 2mg/hr. No sig change in BP. At 1600 Labetolol D/C'd and pt given Lopressor 37.5mg crushed in applesauce. BP presently 167/66. Afebrile.\n\nResp: Pt has remained on NC @ 2l, sating @ 97% with RR 25-30 and easy. HOB up 30 degrees. Lungs clear, diminished bilat.\n\nGI: Eating erratically, difficulty with swallowing foods/liqs. Able to swallow Lopressor in custard @ 1600. Maint fluid of D5.45NS stopped. Bowel sounds present, no stool since 1200.\n\nEndo: Initially receiving Insulin @ .5u/hr, D/C'd @ 1200. Given 2uReg/1uHumalog insulin per SS before lunch when FS 251. However, FS @ 1400 292 and @ 1600 403. Sliding scale adjusted and pt received 12uReg @ 1600.\n\nGU: Good urine output per carevue. Presently -100ml for 24hrs. Urine yellow/clear.\n\nPlan: Called out to floor. Reassess BP to adjust Lopressor dose. FS Q2hr, with insulin per SS. Glargine @ HS. MRI to help assess neuro status.\n\n\n" }, { "category": "ECG", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 123155, "text": "Sinus rhythm.\nMinor nonspecific lateral ST-T wave changes\nSince previous tracing of the same date: atrial ectopy not seen and ST-T wave\nchanges are decreased\n\n" }, { "category": "ECG", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 123156, "text": "Sinus tachycardia\nSupraventricular extrasystoles\nST junctional depression is nonspecific\nSince previous tracing, sinus tachycardia, atrial premature complexes, and ST\ndepression is present\n\n" } ]
4,474	106,798	Patient was admitted to the on , and underwent an aortic valve replacement with #25 valve. The patient also underwent coronary artery bypass grafting from the saphenous vein graft to the right coronary artery. The procedure was performed without complications, and the patient was as is routine, transferred to the Cardiac Surgery Intensive Care Unit while intubated. The patient was extubated awhile after arriving to the Intensive Care Unit. At the time, the patient was alert and moving all extremities. His blood gases were good and appeared in no distress. Within a few minutes after being extubated, however, the patient decompensated and became apneic with a decrease in his oxygen saturations. The patient required reintubation and was evaluated by the Neurology service. Following evaluation, the patient's event was believed to be secondary to respiratory arrest contributed by the need to be supine with his groin line as well as his previously undiagnosed history of sleep apnea. Patient showed no neurological deficits after the reintubation and quickly returned to baseline neurologic function. No immediate imaging was deemed necessary. A bronchoscopy was performed revealing minimal mucus and essentially clear airways. Patient underwent hemodialysis on postoperative day #1. Patient was ultimately extubated on postoperative day #2 without event. On postoperative day two, the patient underwent another session of hemodialysis, and was noted to have frequent premature atrial contractions subsequently changing to atrial fibrillation at a rate of 140. The patient was bolused with amiodarone and started on a drip. The patient returned to sinus rhythm shortly after. The patient remained on Levophed drip. The patient had been empirically started on levofloxacin antibiotic regiment for possible pneumonia given some thick copious mucus. This patient was afebrile and had a normal white count. Over the following few days, the patient had brief episodes of atrial fibrillation, though revert to sinus rhythm with amiodarone boluses. A Heparin drip was started and plans were made for anticoagulation with Coumadin. The patient remained on a Levophed drip to support his blood pressure with goal systolic blood pressures in the 90s-100s. Patient was ultimately weaned off of his Levophed on postoperative day #7. His systolic blood pressure remained low mainly in the 90s, but the patient seemed to tolerate this well. The patient was transferred out of the ICU on postoperative day #8. The patient remained on hemodialysis and ultrafiltration to try and offload some of the volume the patient had gained intraoperatively. Patient was ultimately started on Coumadin on . Within three days, the patient's INR was 2.5 following doses of 2 mg, 2 mg, and 1 mg. Patient completed a 14-day course of levofloxacin and was started on clindamycin for some lower extremity erythema. Patient was noted to have small Stage II decubitus ulcer on , and wound care consult was requested with the recommendation made for Duoderm gel and thin Duoderm wafer dressings to the wound as well as frequent positioning changes. Patient had remained in normal sinus rhythm with no further episodes of atrial fibrillation since transferred from the Intensive Care Unit. He was on amiodarone by mouth. By postoperative day 20, the patient was deemed ready for discharge to rehab facility. But by the time of discharge, the patient's pain was well controlled and his respiratory status was stable. His estimated dry weight was 87 kg, and on the day prior to discharge, had a predialysis weight of 94.1 kg. Four kg of fluid was taken off that day. Patient had been seen by Physical Therapy while in house and on ambulation remained somewhat unsteady and weak, requiring the assist of two people for safe ambulation. The patient's sternal incision was healing well with Steri-Strips in place. Patient also had some left lower extremity incisions, which appeared to be healing well with a few small blisters. A transthoracic echocardiogram had been performed on approximately to confirm the absence of thrombus in the patient's heart. The transthoracic echocardiogram revealed no such thrombus, and the decision was made to cease further anticoagulation on the patient and his Coumadin was discontinued. The benefits and risks of further Coumadin therapy had been reviewed, and further treatment was deemed unnecessary given that the patient had been in normal sinus rhythm for much of his hospitalization and that his atrial fibrillation could have been attributed to his significant fluid overload immediately after the surgery.	Lobulated, somewhat cystic-appearing collection of fluid in close continuity with the left glenohumeral joint. There is opacification in the retrocardiac region obscurring the hemidiapragm which may be postoperative in nature. There has been a right nephrectomy. There is a new patchy opacity at the right base adjacent to the hemidiaprhagm and acute infiltrate can't be excluded. There is calcification of the aortic knuckle. There issevere mitral annular calcification. Ground glass opacity in right upper lobe of uncertain chronicity. FINDINGS: MR WITH CONTRAST: There is abnormal intermediate and high signal involving the subcutaneous soft tissues of the anterior and lateral right , representing nonspecific soft tissue edema. IMPRESSION: The patient has been extubated. IMPRESSION: Noncompressible right lower extremity vessels. Probable residual LV decompinsation with bilateral pleural effusions, larger on the left. Mild (1+) mitralregurgitation is seen.4. IMPRESSION: Satisfactory post-operative findings on AP single chest view. There is evidence of left lower lobe collapse/consolidation, associated with a moderate sized left pleural effusion. There is mild mitral stenosis. There is mild mitral stenosis. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. There are bilateral pleural effusions with lower lobe atelectasis. The lungs are grossly clear with the exception of some ground glass opacity toward the right lung apex which may represent early or resolving infectious or inflammatory focus. Aorta is calcified and unfolded. MILD RESP ACIDOSIS INITIALLY-RESOLVED AFTER VENT CHANGES. There is again evidence of the recent CABG and AVR surgery. MRI OF THE RIGHT ANKLE WO/W IV CONTRAST: In the lateral aspect of the talar dome there is a subchondral area of high T2 signal with associated loss of the articular cartilage. Septalhypokinesis is present.2. Incompletely imaged at the inferior most aspect of the coronal images is a round lesion within the calcaneus that is high signal on STIR sequences and is isointense to muscle on T1W images. FINDINGS: Doppler evaluation was performed of the right lower extremity arterial system. A moderate sized left pleural effusion is present. expiratory wheezes c/ activity. + dopp pp bilat. Wean Neo gtt as bp tolerates. Encourage respitory hygeine. pp by dopplerresp: LS clear with dim bases. CONT ON PO AMIODORONE. heparin gtt for afib. Clinda and levo given. Pulm: remains vented with abg's per . right leg dressing changed, eschar intact, small amt serosang drainage. Bp 80's off neo gtt. ABG-sl alk- with pO2 71 on RA-Placed on 2l nc. cont abx. PAIN RELIEF AFTER 1 PERCOCET X 2. d/c a-line. rle dsg changed->silvadine &dsd applied.resp: lungs clear but diminished in bases. Tolerating po's. Last BM .Endo: Glucose 100-WNL.Incisions: Sternum-healing-C/D-OTA. Wean Levo if BP tolerates. anuric. CI 2.33-2.95. Started Linezolid per id. R calf- erythema-wound debrided. converted to a-fib rate 100's to 120's--bolused c/ amio c/ improvement in hr. change rle dsg . GU: Hemodialysis M/W/F, right av fistula with +T/B. passing flattus no bm.gu: aneuric. bedrest d/t femoral line->t&r q2h. PLAN TO HAVE DIALYSIS THIS AM... 100, tylenol given at beginning of shift, PP+ via doppler.RESP: Lungs clear, diminished at bases, resp. Pedal pulses are dopplerable.RESP: Lungs clear w/ diminished bases. Instituted Msra precautions. later converted back to nsr. Awaiting MRI.Resp: Lungs ess CTA except crackles L base. ?D/C SWAN TODAY AND GET OOB. W/ REMINDERS. levo gtt weaned to keep MAP > 60. svo2 69-72. L thigh with dry eschar-no erythema-OTA. pt into afib ~ 0945 am (pt became slighlty hypotensive with afib -> SBP in the 80's. ?dc femoral aline in am. Resite IV line. R: As above. bs q6h. breath sounds clear bilat, decreased at lll. Change RLL . MONITOR PTT. afebrile. Pt currently on norepi at 0.34mcg/kg/min with sbp 104/48 (65). ORIGINAL STERNAL DRSG , REMOVED.A/P: UNEVENTFUL NOC. Dialysis as ordered. gtt., able to wean down to .28, CI/CO WNL, SV02 62-67, occassional PVC's and PAC's noted, low grade temp. asymptomatic. + BOWEL SOUNDS.GU: ANURIC,?DIALYSIS TOMORROW. SINCE OR YET.G.U./RENAL: BUN/CR IMPROVED AFTER HD. d/c to . 1st degree AVB. 1st degree AVB. Pt. Compared to the previous tracing the mechanism is once again probably sinuswith first degree A-V block, rate 74. gtt., SV02 60-70, CI/CO WNL, continues on amio.gtt, PP+, afebrile.RESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. , COMPRESSIONS GIVEN FOR APPROX. PATIENT'SS K AT APPROX. RESPIRATORY CALLED FOR EXTUBATION, GIVEN THE OK BY TO EXTUBATE. Amio gtt started and second bolus given. NEURO GROSSLY INTACT.CV: LEVO WEANED OFF POST DIALYSIS. GIVEN 2MORE AMPS D50 AFTER INTIAL AMP, PLAN TO CHECK 630 AM.. K PENDING THIS AM. Probable sinus rhythm with first degree A-V delay and left atrial abnormality.Prolonged QTc interval. Probable sinus rhythm with first degree AV delay and left atrial abnormalityLow voltageLeft axis deviationRight bundle branch block and left anterior fascicular blockConsider prior anterolateral myocardial infarctDiffuse ST-T wave changes with prolonged Q-Tc interval - cannot exclude in partmetabolic/drug effectand/or ischemiaClinical correlation is suggestedSince previous tracing of , QRS voltage decreased and further ST-T wavechanges seen Sinus rhythmFirst degree A-V blockMarked left axis deviationRBBB with left anterior fascicular blockPossible old anterior infarctLateral T wave changes are nonspecificLow QRS voltages in precordial leadsNo change from previous PULSES DOPPLERABLE. GI NPO NGT DRAINING APPROX. Probable junctional rhythm, rate 68, with associated right bundle-branchblock/left anterior hemiblock. Percocet x 1 for pain control. GROIN LINES PATENT.RESP: LUNG SOUNDS CLEAR TO DIM AT BASES EPISODES OF WHEEZING C/ ACTIVITY. Levo gtt infusing. PASSING FLATTUS NO BM.GU: ANEURIC. Normal sinus rhythmMarked left axis deviationRBBB with left anterior fascicular blockLow QRS voltages in precordial leadsOld anterior myocardial infarctSince last ECG, no significant change 10SEC, , ANESTHESIA HAD BEEN CALLED TO BEDSIDE, CALLED TO BEDSIDE, BEGAN CAPTURING WITH SBP, INTUBATED WITHOUT DIFFICULTY, PROPOFOL 10CC GIVEN PER ANETHESIA FOR INTUBATION LEVO WEANED TO .3MCG/KG/MIND/T SBP 170'S. Potassium down to 3.9. CONTINUE C/ CURRENT PLAN OF CARE. BG WNL.SKIN: Dsgs CDI. CA/MAG WNL THIS AM. Air leak heard with cuff deflated ptior to extubation,labile BP @ time will continue to follow.	48	[ { "category": "Radiology", "chartdate": "2133-04-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 819089, "text": " 8:03 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with severe AS, CAD. For AVR/CABG. put Dr. \n as ordering MD.\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Aortic stenosis, coronary artery disease. AVR/CABG. R/O CHF.\n\n PA AND LATERAL CHEST: The views were obtained on the stretcher. Comparison is\n made to previous films from taken supine. There is again evidence of\n the recent CABG and AVR surgery. The heart again shows fairly marked\n enlargement, predominantly left ventricular. Aorta is calcified and unfolded.\n The pulmonary vessels show moderate upper zone redistribution. There is\n evidence of left lower lobe collapse/consolidation, associated with a moderate\n sized left pleural effusion. There is also evidence of a right sided effusion\n posteriorly. Allowing for postural differences these findings show slight\n improvement since the prior study.\n\n IMPRESSION:\n\n 1. Status post CABG/AVR surgery.\n 2. Probable residual LV decompinsation with bilateral pleural effusions,\n larger on the left.\n 3. Left lower lobe collapse/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 817988, "text": " 9:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Asses ETT placement\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr re intubated for resp distress\n\n REASON FOR THIS EXAMINATION:\n Asses ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE DATED .\n\n INDICATION: Assess position of ET tube.\n\n COMPARISON: at 5:55.\n\n FINDINGS: The heart is enlarged. There is widending of the mediastinum,\n unchanged from prior examinations. There is calcification of the aortic\n knuckle. The lungs are expanded and clear.\n\n The tips of the ET tube and Swan-Ganz catheter are in satisfactory position.\n There has been interval uncurling of the Swan-Ganz.\n\n IMPRESSION: Line positions as described. Otherwise no significant from prior\n examination.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-30 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 820130, "text": " 3:35 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: s/p AVR/CABG w/new onset calf tenderness-r/o DVT\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR/CABG w/new onset calf tenderness-r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG and AVR with bilateral calf tenderness.\n\n FINDINGS: Duplex and color Doppler demonstrate no DVT from the common femoral\n through to the proximal tibial veins bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 817961, "text": " 3:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW\n\n INDICATION: History of bypass surgery and aortic valve replacement, follow up\n examination.\n\n FINDINGS: AP single view obtained with patient in supine position\n demonstrates EGT in place terminating in the trachea approximately 4 cm above\n the carina. NG tube has been passed reaching far below the diaphragm. A\n Swan-Ganz catheter approaching from below curves in the right atrium but\n reaches the area of the main pulmonary artery. No evidence of pneumothorax.\n Metallic structures of a porcine aortic valve prosthesis in place. Moderate\n post-operative mediastinal widening is seen and perivascular haze exists\n without evidence of edema or new parenchymal infiltrates. The lateral pleural\n sinuses are free.\n\n IMPRESSION: Satisfactory post-operative findings on AP single chest view.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-01 00:00:00.000", "description": "RP TIB/FIB (AP & LAT) RIGHT PORT", "row_id": 820206, "text": " 12:11 PM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: r/o necrotizing fascitis\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with s/p AVR/CABG, with worsening leg wound\n REASON FOR THIS EXAMINATION:\n r/o necrotizing fascitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infected leg wound, evaluate.\n\n TECHNIQUE: Two views of the right tibia and fibula.\n\n No comparisons.\n\n FINDINGS: There are surgical clips overlying the soft tissues of the left\n medial thigh. There is soft tissue swelling in the upper thigh, no definite\n evidence of subcutaneous air. There are extensive vascular calcifications.\n There is an ill-defined lucency overlying the navicular and possibly the\n middle cuneiform.\n\n IMPRESSION:\n 1. Soft tissue swelling in the proximal thigh, no definite evidence of\n subcutaneous air.\n 2. Ill-defined lucency overlying the dorsum of the navicular bone, dedicated\n foot views are recommended for better characterization. Differential\n diagnosis includes osteomyelitis or degenerative changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 818155, "text": " 12:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr re intubated for resp distress\n\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 64-year-old man with CABG and AVR now reintubated for respiratory\n distress.\n\n AP SUPINE PORTABLE CHEST: at 1 p.m.: Compared to prior portable\n chest two days ago, the endotracheal tube has been pulled. The pulmonary\n artery catheter is unchanged. There is still marked widening of the superior\n mediastinum. Some of this may be due to supine positioning, but mediastinal\n hematoma cannot be entirely excluded. There is opacification in the\n retrocardiac region obscurring the hemidiapragm which may be postoperative in\n nature. In addition, there is patchy density at the right base which is new.\n\n IMPRESSION: The patient has been extubated. There is widened mediastinum and\n mediastinal hematoma can't be entirely excluded. There is a new patchy\n opacity at the right base adjacent to the hemidiaprhagm and acute infiltrate\n can't be excluded. Postoperative changes at the left base. The overall\n opacity of the chest is increased raising the question of congestive heart\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 819678, "text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pleural effusion\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with severe AS, CAD. For AVR/CABG. put Dr. \n as ordering MD.\n REASON FOR THIS EXAMINATION:\n assess for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Severe AS and CAD.\n\n PA AND LATERAL CHEST: When compared to the prior films of , cardiac size\n appears to have decreased. Some cardiac enlargement, however, is still\n present. The aorta remains calcified and unfolded.\n\n The right lung field is clear. A moderate sized left pleural effusion is\n present. Significantly altered in size since the prior chest x-ray.\n\n IMPRESSION: Decreasing cardiac size, left effusion. No significant failure.\n\n" }, { "category": "Echo", "chartdate": "2133-04-27 00:00:00.000", "description": "Report", "row_id": 70856, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/p AVR with 25 mm perimount Pericardial AVR.\nHeight: (in) 68\nWeight (lb): 200\nBSA (m2): 2.05 m2\nBP (mm Hg): 126/68\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 15:09\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: An aortic valve prosthesis is present.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nsevere mitral annular calcification. There is mild mitral stenosis. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function very difficult to asses but is probably normal. Septal\nhypokinesis is present.\n2. An aortic valve prosthesis is present.\n3. The mitral valve leaflets are moderately thickened. There is severe mitral\nannular calcification. There is mild mitral stenosis. Mild (1+) mitral\nregurgitation is seen.\n4. There is no pericardial effusion.\n5. Compared with the findings of the prior study (tape reviewed) of ,\nthe prosthetic aortic valve is new.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-07 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 820850, "text": " 8:10 AM\n ART EXT (REST ONLY) Clip # \n Reason: RLE full non-invasive studies please.\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with nonhealing saphenectomy wound s/p CABG, AVR.\n REASON FOR THIS EXAMINATION:\n RLE full non-invasive studies please.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with nonhealing saphenectomy site.\n\n FINDINGS: Doppler evaluation was performed of the right lower extremity\n arterial system. Doppler tracings are triphasic at all levels from the\n femoral to the dorsalis pedis artery. Ankle brachial index is falsely\n elevated due to noncompressible vessels. Pulse volume recordings are\n maintained to the ankle and show drop off of the metatarsal where they are\n approximately 7 mm.\n\n IMPRESSION: Noncompressible right lower extremity vessels. Mild flow deficit\n to the right forefoot.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-05 00:00:00.000", "description": "R MR ANKLE W&W/O CONTRAST RIGHT", "row_id": 820618, "text": " 10:00 AM\n MR ANKLE W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: r/o lateral malleolar osteo\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M, dialysis dependent PKD, POD #21 s/p CABG/AVR complaining of pain at\n , vein harvest incision somewhat macerated, no gross purulence or\n erythema. Afebrile but with WBC increased 10.4 to 13.2.\n REASON FOR THIS EXAMINATION:\n r/o lateral malleolar osteo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG, complaining of pain at at the site of vein harvest\n incision, no erythema or secretions, elevated white blood cells.\n\n TECHNIQUE: Axial, coronal, and sagittal images of the right ankle were\n obtained without and with IV contrast.\n\n Comparison with prior x-rays from .\n\n MRI OF THE RIGHT ANKLE WO/W IV CONTRAST: In the lateral aspect of the talar\n dome there is a subchondral area of high T2 signal with associated loss of the\n articular cartilage. There are multiple well-defined rounded lesions in\n multiple bones which have high T2 signal and are consistent with erosions. The\n largest ones are seen in the distal fibula, in the anterior aspect of the\n calcaneus and in the cuboid bone. The navicular bone is fragmented, there is\n joint space narrowing at the joint space between the navicular and the\n cuneiform with associated subchondral marrow edema. There is diffuse edema in\n the subcutaneous soft tissues without evidence of focal collections. There is\n no fluid within the joint space. The visualized tendons and ligaments about\n the ankle joint are preserved. There is generalized muscle edema.\n\n IMPRESSION:\n 1) Diffuse subcutaneous and muscle edema without evidence of focal\n collections.\n\n 2) Multiple large erosions in the distal fibula, calcaneus, and tarsal bones,\n differential diagnosis includes synovitis related to trauma, inflammatory\n arthropathy, gout and less likely amyloid.\n\n 3) Fragmentation and degenerative changes in the articulation between the\n navicular and the cuneiform could be related to neuropathic changes.\n\n 4) Osteochondral defect in the talar dome.\n\n The findings were discussed with Dr. at the time of the exam.\n (Over)\n\n 10:00 AM\n MR ANKLE W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: r/o lateral malleolar osteo\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2133-05-02 00:00:00.000", "description": "R MR CALF W&W/O CONTRAST RIGHT", "row_id": 820337, "text": " 8:11 PM\n MR W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: C/O PAIN @ RIGHT , VEIN HARVEST INCISION SOMEWHAT MACERATED. PT. IS AFEBRILE BUT W/ INCREASED WBC.\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M, dialysis dependent PKD, POD #21 s/p CABG/AVR complaining of pain at\n , vein harvest incision somewhat macerated, no gross purulence or erythema.\n Afebrile but with WBC increased 10.4 to 13.2.\n REASON FOR THIS EXAMINATION:\n Evaluate for deep infection along vein harvest incision. Note allergy to\n iodinated contrast \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P right lesser saphenous vein harvest. Complaining of right \n cellulitis at vein harvest site.\n\n TECHNIQUE: MR examination of the right was performed utilizing the\n following sequences: axial and coronal T1W images and T2W IR images, and\n axial PD weighted images with fat saturation following the IV administration\n of Gadolinium. Comparison is made to the radiographs obtained .\n\n FINDINGS:\n MR WITH CONTRAST: There is abnormal intermediate and high signal\n involving the subcutaneous soft tissues of the anterior and lateral right\n , representing nonspecific soft tissue edema. No fluid collection is\n demonstrated. No abscess is seen. There is abnormal, non-specific,\n intermediate signal involving the anterior cortex of the anterior tibia\n which is of uncertain etiology but which may reflect the presence of local\n hyperemia. No frank fracture line is identified.\n\n There is a round, well-circumscribed, lesion in the distal fibula metaphysis,\n measuring 15 mm. This lesion demonstrates uniform high signal on STIR\n sequences and is isointense to muscle on T1W images. Following Gadolinium,\n uniform high signal is seen on fat saturated proton density weighted images. A\n tract exiting through the anterior medial cortex of the distal fibula and\n communicating with the joint space is demonstrated. The signal within the\n lesion on post contrast imaging is isointense to enhancing joint fluid.\n\n Incompletely imaged at the inferior most aspect of the coronal images is a\n round lesion within the calcaneus that is high signal on STIR sequences and is\n isointense to muscle on T1W images.\n\n Several tiny foci of susceptibility artifact along the anterior and medial\n are consistent with the patient's history of surgery.\n\n There is a moderate ankle joint effusion.\n\n IMPRESSION:\n\n Cellulitis involving the soft tissues of the anterior and medial .\n Underlying signal abnormality in the anterior tibial cortex may represent\n (Over)\n\n 8:11 PM\n MR W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: C/O PAIN @ RIGHT , VEIN HARVEST INCISION SOMEWHAT MACERATED. PT. IS AFEBRILE BUT W/ INCREASED WBC.\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n reactive edema or local hyperemia. The finding is nonspecific, however, and\n infection is not excluded.\n\n Lesions within the lateral malleolus and calcaneus. These lesions are not\n well evaluated on this study, which was tailored to examine the . Further\n evaluation with contrast enhanced MR examination of the ankle is recommended.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 820899, "text": " 3:13 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVALUATE FOR POSSIBLE STERNAL COLLECTION\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with\n REASON FOR THIS EXAMINATION:\n r/o sternal collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for sternal infection. Postop 26 days from CABG.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast chest CT.\n\n FINDINGS: There is soft tissue and fluid attenuation surrounding the sternum\n and in the retrosternal space, but with no discernible fluid collection. There\n is leftward displacement of the most superior sternal wire. The sternum\n itself demonstrates rarefaction of bone with a moth-eaten permeative\n appearance which may be seen in the setting of osteomyelitis. There is\n extensive coronary and vascular calcification. There is no adenopathy. There\n is a small pericardial effusion. There is a lower right paratracheal lymph\n node which measures just under 1 cm. The upper abdomen reveals the presence\n of numerous low-density lesions within the liver and numerous cystic lesions\n and calcifications in the left kidney. There has been a right nephrectomy.\n The gallbladder is somewhat distended and contains several calcified stones\n towards the gallbladder neck. Two similar calcifications are noted in the\n region of the pancreatic head, perhaps representing common duct stones.\n Clinical correlation is suggested.\n\n There are bilateral pleural effusions with lower lobe atelectasis. The lungs\n are grossly clear with the exception of some ground glass opacity toward the\n right lung apex which may represent early or resolving infectious or\n inflammatory focus. The bones reveal, in addition to findings suspicious for\n sternal osteomyelitis, multiple bilateral anterior rib fractures. Has this\n patient had chest compressions?\n\n IMPRESSION:\n 1. Findings concerning for sternal osteomyelitis with adjacent peristernal\n infection/inflammation. This could be confirmed with either gallium or\n Indium-111 labeled white blood cell sanning. 2. Gallstones and probable\n choledocholithiasis. There is no definite biliary dilatation but correlation\n with liver function tests and clinical symptoms is suggested.\n 3. Numerous hepatic cysts and multicystic left kidney with multiple\n calcifications. Does this patient have polycystic kidney disease?\n 4. Large bilateral pleural effusions with atelectasis.\n 5. Ground glass opacity in right upper lobe of uncertain chronicity. If\n acute, this may be due to an early or resolving infection. If chronic,\n bronchoalveolar cell carcinoma would be a consideration. In the absence of\n infectious symptoms, a 3- month- old followup CT could be considered to insure\n (Over)\n\n 3:13 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVALUATE FOR POSSIBLE STERNAL COLLECTION\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n resolution.\n 6. Lobulated, somewhat cystic-appearing collection of fluid in close\n continuity with the left glenohumeral joint. This may represent a\n proliferative synovial process. Consider left shoulder MRI for further\n evaluation without and with gadolinium.\n 7. Multiple anterior rib fractures. Has this patient had chest compressions?\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320231, "text": "Resp Care\n\nFrom OR pt placed on full vent support of 800/10/100/5. Original abg slightly acidotic and rr increased to 12. Fio2 decreased to 50%\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320232, "text": "admission note\nPT FROM OR S/P CABG X 1 & #25 TISSUE AVR. SEDATED ON PROPOFOL AND HIGH DOSE LEVO GTT. ALSO AVP REPORTEDLY FOR PROLONGED PR.\n\nCV: LABILE SBP 70'S-130'S TX W/ 2L LR AND LEVO TITRATION. BP STABLE NOW THAT REVERSED, PROPOFOL AWAKE AND PROPOFOL OFF. SVO2 60'S-70'S W/ GD C.I.(SEE FLOW SHEET). SVO2 DID DROP TO 57% AFTER TURNING FOR BATH BUT RECOVERED SLOWLY. MINIMAL DRNG VIA SINGLE MED CT. 2ND U PRBC INFUSING FOR HCT 25. ALL LINES IN R FEM DUE TO OCCLUDED PROX VESSELS(SEE HX). RUA AVF W/ FAINT THRILL.\n\nNEURO: , FOLLOWING COMMANDS AND NODDING HEAD APPROPRIATELY TO QUESTIONS. REFUSING PAIN MED ;ACKNOWLEDGED THAT PAIN IS MINIMAL.\n\nRESP: MILD EXP WHEEZES INITIALLY. MILD RESP ACIDOSIS INITIALLY-RESOLVED AFTER VENT CHANGES. CURRENTLY EXCELLENT VT'S ON 10 IPS, 5 PEEP. FIO1 .50; SPO2 99%.\n\nG.I.: SM AMT BILIOUS DRNG VIA OGT.\n\nG.U./RENAL: NO FOLEY-DOES NOT MAKE URINE. CREAT=5, K+4.9. CA+2 REPLETED. PLAN FOR HD TOMORROW VIA AVF.\n\nSKIN: INTACT. DRSGS DRY. HAS BILAT LE ACES.\n\nSOCIAL: HAS LG FAMILY. WIFE TO BE SPOKESPERSON. ALL IN TO VISIT.\n\nA/P: BP STABILIZING. BEGINNING TO WEAN LEVO. NEURO INTACT. TOLERATING INITIAL VENT WEAN. PLAN TO EXTUBATE IF BP STABLE AND WEAN PROGRESSING WELL. WILL BE DIFFICULT TO RAISE HEAD DUE TO GROIN LINES. CHECK CXR. MONITOR LYTES AND HCT. HD TOMORROW. ASSESS FOR PAIN.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-13 00:00:00.000", "description": "Report", "row_id": 1320244, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative with care.\n\nCV: Junctional rthyem with rate of 63-66, BP tolerating well, continues on low dose levo., able to slowly wean, CI/CO WNL, Sv02 60-68, PP+, afebrile, A pacing wires not sensing and capturing 100%, switched over to V side for higher mA's, currently pacer turned to off.\n\nRESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. 100%, using IS, nonproductive cough.\n\nGI: Obese, BS+, taking sips of water.\n\nGU: Hemo. patient, to be dialyzed today, + bruit on RUE AVG but no palpable thrill.\n\nPAIN: no c/o pain.\n\nPLAN: Continue to monitor CV and RESP status, wean levo. as tolerated, wean 02, pulmonary toilet, increase activity once femerol lines out, continue to monitor electrolytes, increase po intake.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-13 00:00:00.000", "description": "Report", "row_id": 1320245, "text": "D: Please see data, MD notes/orders. Neuro: A&O x3 CV: Afib with hr 17eens-120s. Sbp 90's. CO/CI stable wnl. Pulm: 02 at 2L n/c, sats 98-100%. Lungs clear, decr at bases. GU: Dialized this am, see notes. Required levo titration to keep map >60. Pt recieved one unit prbc for hct 29.4. GI: Abd obese, bs+, pt taking fair po intake. Skin: Surfaces intact, peripheral pulses palpable. Soc: Wife/children visiting in two's q 1-2hrs. Access: Peripheral access unobtainable, pt remains with femoral cco swanganz/art line. Comfort: Has intermitent soreness at sternotomy site, mostly with turns. P: Monitor hr/rythm for now, titrate levo gtt down as bp tolerates. D/c art line when levo gtt off, change line to tlc over wire to allow pt to increase activity level. Prn pain meds, note response to same. Keep family updated on plan of care. R: Levo currently at 0.04mcg/kg/min with map of 61. Pt medicated for pain with one percocet x2 today with good effect. Questions from family answered satisfactorily.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-14 00:00:00.000", "description": "Report", "row_id": 1320246, "text": "UPDATE\nCV: ACCEL JUNCTIONAL HR IN 70'S. CONT ON PO AMIODORONE. IV HEPARIN GTT STARTED LAST EVE. PTT THIS A.M. 35 ON 700U/HR->UP TO 800U. LEVO INCREASED SL TO MAINTAIN MAP 60 OR>. C.I. CONSISTENTLY >2.5, SVO2 LOW-MID 70'S.\n\nRESP: USING I.S. W/ REMINDERS. C&R THICK, YELLLOW SPUTUM THIS A.M. SPO2 HIGH 90'S ON RA.\n\nNEURO: INTACT. PAIN RELIEF AFTER 1 PERCOCET X 2. SLEPT WELL ON&OFF.\n\nG.I.: THIRSTY-DRINKING LIQS O/N. NO B.M. SINCE OR YET.\n\nG.U./RENAL: BUN/CR IMPROVED AFTER HD. OTHER LYTES WNL. I&O +200 BY MN. PT STATES ARMS STILL FEEL HEAVY DUE TO FLUID.\n\nSKIN: INTACT. ORIGINAL STERNAL DRSG , REMOVED.\n\nA/P: UNEVENTFUL NOC. ?D/C SWAN TODAY AND GET OOB. REMAINS DEPENDANT ON PRESSOR FOR BP. CONT PULM TOILET. ENC NUTRITION. MONITOR PTT. PAIN MED PRN.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-12 00:00:00.000", "description": "Report", "row_id": 1320243, "text": "NEURO: INTACT.\nCARDIAC: MP JUNCTIONAL, ABLE TO WEAN LEVO TO .08M/K/M. KEEPING MAP ^ 6O. CO/CI ACCEPTABLE, SVO2 55-60+. AMIODORONE GTT DECREASED TO .5M/M.\nRESP: CPT Q 4, COUGHING RAISING THICK WHITE. CS COARSE DIMINISHED IN BASES.\nGI: ATTEMPTING TO EAT, POOR APPETITE. + BOWEL SOUNDS.\nGU: ANURIC,?DIALYSIS TOMORROW. BRUIT PRESENT.\nENDO: FOLLOWING PROTOCOL, NO NEED FOR TX.\nPAIN: MEDICATED WITH PERCOCET WITH RELIEF.\nFAMILY IN.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-05-04 00:00:00.000", "description": "Report", "row_id": 1320259, "text": "PATIENT WITH QUIET NIGHT, SLEEPING IN 2-3HR INTERVALS, THEN REPOSITIONED.. NO C/O PAIN TO LOWER EXTREMITY. SB P 80'S THRU THE NIGHT, AFEBRILE ,1ST DEGREE AVB NO ECTOPY..NO O2, BILATERAL BS CLEAR.PLAN TO DRAW AMLABS AFTER DSG CHANGE AT 6AM.. PATIENT ON LINEZOLID/LEVAQUIN FOR LEG WOUND..\n" }, { "category": "Nursing/other", "chartdate": "2133-05-04 00:00:00.000", "description": "Report", "row_id": 1320260, "text": "PATIENT'S WOUND IMPROVING PER CT SERVICE, SIVADENE DSG APPLIED. WILL RELAY TO RN COMING ON IN REGARDS TO EVALUATING DUODERM /COOCCYX DSG FOLLOWED BY RN... PATIENT BATHED, ORAL CARE DONE. PLAN TO GET OOB TO CHAIR IN AM, PLAN TO ENCOURAGE PATIENT TO TAKE PAIN PILL PRIOR OOB TO CHAIR. PLAN TO HAVE DIALYSIS THIS AM...\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320238, "text": "CSRU NOTE:\n\nNEURO: , , follows commands, able to communicate by mouthing words and nodding head to questions.\n\nCV: Apaced at rate of 88, underlying rythem accelerated junctional with subsequent decrease in BP, continues on levo. gtt., able to wean down to .28, CI/CO WNL, SV02 62-67, occassional PVC's and PAC's noted, low grade temp. 100, tylenol given at beginning of shift, PP+ via doppler.\n\nRESP: Lungs clear, diminished at bases, resp. alkalosis (see flowsheet), on Fi02 40%, PEEP 5, PS 5, 02 sat. 100%, suctioned for small to moderate amounts of thick tan secretions, sputum culture sent.\n\nGI: Obese, BS hypo, OGT in place, placement verified.\n\nGU: ESRD, on hemodialysis M,W,F. AVF to RUE, + bruit, (-) thrill, nonfunctional AVF to LUE.\n\nPAIN: Medicated with MS04 for incisional pain with good relief.\n\nENDO: RISS per unit protocol.\n\nPLAN: ? extubate today, HD today for fluid removal?, continue to monitor hemodynamics, continue to wean levo. if BP tolerates, pain management, monitor electrolytes.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320237, "text": "D: Please see data, MD notes/progess notes. Neuro: , following commands, communicating by mouthing words/gesturing. Mae with equal strength. CV: Pt initially asynchronously av paced at rate of 92. During hemodyalisis had bursts of afib and pacer was put on standby for brief period and then av pacing was resumed. Pacer was placed on pause after dialysis with junctional rythm noted. SBP in mid to high 80's at that time with pressors onboard. Pacing mode changed to asynchronous atrial pacing with improved sbp. Pt currently on norepi at 0.34mcg/kg/min with sbp 104/48 (65). Co/Ci stable. T max 101.7 with bc sent x2. Pulm: remains vented with abg's per . Lungs coarse, decr at bases. 02sats >95%. GU: Anuric, hemodialized today for hyperkalemia. Post dialysis K 4.5. Pt needed volume repletion for sustained hypotension not responsive to pressor support. See dialysis notes. GI: Abd obese, bs+, ogt to lws draining small amounts bile. Skin: surfaces intact, extremities w/d. All dressings per . Endo: Has not needed insulin coverage. Soc: Has many children/wife who have visited briefly each hour and were updated on pt condition/plan of care. Consults: Seen by neuro today as follow up from events last night, ?ing obstructive sleep apnea after obtaining hx from pts wife. P: Notify team of change in neuro status, ativan/mso4 prn. CV: titrate levo other pressors to keep map >60, monitor for further rythm changes.Continue vent support, ?extubation in am. Possible hemodialysis tomorrow to take off fluid as tolerated. Support family, clarify info prn. R: As above.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-01 00:00:00.000", "description": "Report", "row_id": 1320254, "text": "shift update:\n\nneuro: a&o x3. mae. turned & repositioned in bed. c/o numbness in rle when elevated on more than one pillow. denies pain.\n\ncardiac: 1st degree av block. hr 60-70's. sbp remains low 70-100's. asymptomatic. + dopp pp bilat. rle dsg changed->silvadine &dsd applied.\n\nresp: lungs clear but diminished in bases. sat's 99-100% on ra.\n\ngi/gu: +bs. tolerated po's for breakfast but at lunch pt c/o having congestion when eating. denied n/v & difficulty swallowing. food present in sputum. no uop. no hd today.\n\nendo: no ssri required per protocol.\n\nskin: duoderm changed to decub on coccyx. several small open areas noted. scant ss drainage.\n\nsocial: family into visit.\n\nplan: mri. cont abx. monitor hr/rhythm/bp. bedrest d/t femoral line->t&r q2h. bs q6h. monitor skin for further breakdown. change rle dsg .\n" }, { "category": "Nursing/other", "chartdate": "2133-05-02 00:00:00.000", "description": "Report", "row_id": 1320255, "text": "1900-0700\n\nC/O of right leg pain \"aching\" med with percoet with relief and elevated on pillow\nNeuro-intact\nCV-SBP 70's-90's Ct team aware pt asymptomatic CSM doppler pulses cap refill>3\nResp-LS clear dim at bases RA\nGI-renal diet/BS WNL\nGU-CRF hemodialysis ?sat/or sunday\nID-awaiting MRI of right leg ?fluid collection Positve BC +cocci pairs cluster cont on ABX afebrile\nskin-right leg incision site black areas tender to touch silvaden drsg to \nPlan-MRI/HD/ cont ABX and maintain pts comfort\n" }, { "category": "Nursing/other", "chartdate": "2133-05-02 00:00:00.000", "description": "Report", "row_id": 1320256, "text": "NEURO: A+Ox3, following commands. Medicated w/ 2 percocet tabs for pain.\n\nCV: Started on neo gtt post HD d/t sbp 60-80's asymtomatic. Notified . Maintained in 90's. 1st degree AVB. No ectopy. Pedal pulses are dopplerable.\n\nRESP: Lungs clear w/ diminished bases. Spo2 >96% 2L Np.\n\nRENAL: 500cc off via dialysis.\n\nID: Tmax 100. Instituted Msra precautions. Started Linezolid per id. VSS. No anaphylactic rxn.\n\nGI: Tolerating solids.\n\nSKIN: RLE eschar tissue intact. No drainage. DSD changed @ 1800. Last changed @0600.\n\nA/P Monitor for allergic rxn to Linezolid. Wean Neo gtt as bp tolerates. Drsg @ 0600.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-03 00:00:00.000", "description": "Report", "row_id": 1320257, "text": "ekg sr, first degree avb, no ectopy, rate 60s. sbp > 90 most of night, able to wean neo to 0.4 mcg, did not tolerate decrease to 0.2 mcg. anuric. afebrile. breath sounds clear bilat, decreased at lll. deep breathes well, occ nonproductive cough. maintaining spo2 94-99% on room air. abd soft, bowel sounds present, drinking small amts, no stool tonight. feet warm, palp pulses bilat. right leg dressing changed, eschar intact, small amt serosang drainage. chest and l leg incisions dry and intact. admitted to r leg discomfort at 0500, but wanted only tylenol. after dressing change was more uncomfortable and accepted 1 tylenol. and oriented, cooperative, sleeps when undisturbed.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-03 00:00:00.000", "description": "Report", "row_id": 1320258, "text": "A+OX3, pleasant, cooperative. Bp 80's off neo gtt. 1st degree AVB. No ectopy. Lungs are clear diminished bases. Tolerating po's. Small formed brn bm today. Dopplerable pedal pulses. Change RLL . Small amt serous drainage. Wound still necrotic w/ small areas of slough. Silvadine cream applied. DSD applied. A/P Stable. Contact precautions. . Keep leg elevated.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-16 00:00:00.000", "description": "Report", "row_id": 1320251, "text": "D: Neuro: A&O, intermitent incisional pain. Emotional day, recieved news that his 86yr old mother died this morning. CV: SR converted to afib with rate 106-120s this afternoon. BP remained stable, converted back to sr at 1600. Amiodorone bolus/increased po dose per med sheets. Levo gtt currently off, sbp 98-100/40's. Pulm: RA sats 96-97%. Lungs clear, exertional expiratory wheezes noted. GU: Hemodialysis M/W/F, right av fistula with +T/B. GI: Abd obese, bs+, passing flatus, no stool. Skin: Surfaces intact, bilateral leg incision dressings d&i. Pedal pulses weak but palpable. Act: 00B in chair for several hours today, tolerated well. Soc: Very supportive family, children/wife in for short visits every 1-2hrs. P: Attempt to keep levo gtt off, keep sbp>85. ?dc femoral aline in am. Encourage respitory hygeine. Dialysis as ordered. Increase act as tolerated, reconsult PT when pt able to ambulate. Offer emotional support for pt loss. R: As above, pt back in bed, sleeping in naps, no pain voiced. Pt able to speak with his brother on the phone re: loss of mother, wife will contact priest to come visit pt.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-17 00:00:00.000", "description": "Report", "row_id": 1320252, "text": "focus: status update\nneuro: and oriented x3 mae on command. perl. mildly anxious awaiting dialysis. perl.\n\ncv: nsr c/ no ectopyfor most of the noc. converted to a-fib rate 100's to 120's--bolused c/ amio c/ improvement in hr. later converted back to nsr. levo off ? d/c a-line. hep cont at 1100 c/ ptt within range.\n\nresp: lung sounds clear at top fields dim at bases. expiratory wheezes c/ activity. sats 97 to 100 ra.\n\ngi: tolerting po intake and fluid. abd obese c/ active bowel sounds. passing flattus no bm.\n\ngu: aneuric. pt to be dialyzed today.\n\nendo: riss.\n\npain: medicated c/ percocet c/ improved level of discomfort.\n\nsocial: family called for update on pt's status.\n\nplan: ? d/c to . to be dialyzed today.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-01 00:00:00.000", "description": "Report", "row_id": 1320253, "text": "Nursing Admission Note:\n\nPt is 64yo ESRD pt who underwent CABGX1/AVR on , now readdmitted to CSRU r/t hypotension assoc with c/o R leg pain and ?infection-monitor for sepsis.-Ruled out for DVT by US. Has R calf erythema, wound debrided on 2- Pt seen by plastics and ID.\n\nNeuro: and oriented X3. MAE. C/o feeling weak and tired.\nCV: HR-60-70's SR with 1st degree AV block. SBP 70-90/30-40's by cuff on L arm. Dr aware- Pedal pulses palp- 1+ ankle edema.\nID: BC X2 drawn-on via L fem arterial stick and 1 from R TLCL. Clinda and levo given. Attempted to place R fem line -unable- Will attempt again in am-If able to get further IV access will dc R TL and culture tip. Awaiting MRI.\nResp: Lungs ess CTA except crackles L base. Cough dry-non prod. ABG-sl alk- with pO2 71 on RA-Placed on 2l nc. O2 sats 98-100%.\nGU: Last HD -Renal to see this am-DNV.\nGI: NPO, Abd soft, NT, ND with +BS. Last BM .\nEndo: Glucose 100-WNL.\nIncisions: Sternum-healing-C/D-OTA. L thigh with dry eschar-no erythema-OTA. R calf- erythema-wound debrided. Betadine and DSD applied.\nComfort: Medicated with Percocet 1 X2 for R calf intermittent throbbing pain with good effect.\nActivity: On bedrest r/t low BP-leg.\nA: Low BP and R leg infection-Rule out sepsis\nP: ID following-Clinda and levo as ordered., Awaiting MRI. Renal following for HD-assess volume status. Resite IV line. BC pending.-Follow labs.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-14 00:00:00.000", "description": "Report", "row_id": 1320247, "text": "7am-7pm update\nNeuro: Pt and orientated x 3. MAE and able to follow commands.\n\nCV: pt initally in NSR, no ectopy. pt into afib ~ 0945 am (pt became slighlty hypotensive with afib -> SBP in the 80's. requiring increase in levo gtt). afib treated 150 mg amio bolus IV and pt remains on amio PO BID. pt on heparin gtt this am -> heparin gtt turned to off for line change. heparin gtt for afib. goal to keep PTT 40-60. pt continues on levo gtt. levo gtt weaned to keep MAP > 60. svo2 69-72. CI 2.33-2.95. PA line dc'd this afternoon. pp by doppler\n\nresp: LS clear with dim bases. becomes SOB/wheezing with activity. pt remains on room air. o2 sats 97-100%.\n\ngi/gu: pt with + bs. tolerting cardiac diet. no urine output\n\nrenal: HD yesterday. no HD today. lytes WNL\n\ncomfort: percocet for pain control.\n\nplan: wean levo gtt to keep MAP > 60, ? HD tomorrow, restart heparin gtt this evening at 900 u/hr, goal to keep PTT 40-60. monitor lytes/bs, pain control\ncomfort:\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-15 00:00:00.000", "description": "Report", "row_id": 1320248, "text": "Pt. flat in bed with slight reverse t- and hob @ 15 degrees until 2300 due to right fem. line oozing since line changed. Dsg changed and heparin resumed @ 2200. 900u/hr. Medicated for incisional pain with percocet. Sleeping in naps. Becoming slightly sob and wheezy with linen changes but improved when left alone. No o2; sao2 >95%.\nBP stable on current dose of Levophed.\nplan: hemodialysis today. Wean Levo if BP tolerates. OOB to chair. Continue pulm hygeine and advance diet as tol.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-15 00:00:00.000", "description": "Report", "row_id": 1320249, "text": " A:\n\nNeuro: and oriented x 3,mae, following commands correctly, oob to chair with slide board, hoya back to bed and tolerated well.\n\nCardiac: nsr in the 70's no ectopy, on levo gtt and weaning off, dopplerable pedial pulses, skin warm dry and intact, a-febrile, continues heparin gtt for old a/f.\n\nResp: lungs dim in bases, no o2 ra sats are 100%, is using i/s and is coughing and deep breathing.\n\nSkin: chest with staples is cdi, abd with old ct dsd's are cdi, bilat legs with dsd's that are draining a moderate amount of serosang drainage.\n\nGi/gu: tolerating po's abd soft and obese, good bowel sounds, is a hd pt and dnv, awaiting for dialisis later today.\n\nPlan: wean levo, monitor ptt's, monitor bp's durring dialisis, increase activity, encourage to cough and deep breath, monitor leg dsd's and change as needed.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-16 00:00:00.000", "description": "Report", "row_id": 1320250, "text": "FOCUS: STATUS UPDATE\nNEURO: AND ORIENTED X3, MAE ON COMMAND. PERL. NEURO GROSSLY INTACT.\n\nCV: LEVO WEANED OFF POST DIALYSIS. HEP INCREASED TO 1100 U/H TO MAINTAIN GOAL OF 50 TO 70. NSR C/ NO ECTOPY. PULSES DOPPLERABLE. GROIN LINES PATENT.\n\nRESP: LUNG SOUNDS CLEAR TO DIM AT BASES EPISODES OF WHEEZING C/ ACTIVITY. SATS 98 TO 100 RA.\n\nGI: AND OBESE C/ ACTIVE BOWEL SOUNDS. ABD SOFT AND NOT TENDER TO PALPATION. PASSING FLATTUS NO BM.\n\nGU: ANEURIC. DIALYZED 2L\n\nENDO: RISS.\n\nSOCIAL: FAMILY VISITED AND WIFE CALLED FOR UPDATE\n\nPLAN: ? D/C TO FLOOR. CONTINUE C/ CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320233, "text": "PATIENT'SS K AT APPROX. 6.5 TREATED WITH 10U REGULAR INSULIN IV, 1AMP D50, ALSO NABICARB IV AS WELL. APPROX. 10MIN AFTER TREATMENT. RESPIRATORY CALLED FOR EXTUBATION, GIVEN THE OK BY TO EXTUBATE. PATIENT MAE STRONG, ABG GOOD. HOB ELEVATED APPROX. 10DEGREES, BED IN REVERSE TRENDELBERG. PATIENT EXTUBATED TO 50% SHOVEL MASK, INTIALLY RESPONDING TO RN/RESP THERAPIST, BUT WITHIN A FEW MINUTES DECOMPENSATED, AMBU ON 100%, DROPPING SBP, PLACED IN REVERSED TRENDELBERG, INCREASED LEVOPHED TO.4 FROM .33, , NP PRESSURE. , COMPRESSIONS GIVEN FOR APPROX. 10SEC, , ANESTHESIA HAD BEEN CALLED TO BEDSIDE, CALLED TO BEDSIDE, BEGAN CAPTURING WITH SBP, INTUBATED WITHOUT DIFFICULTY, PROPOFOL 10CC GIVEN PER ANETHESIA FOR INTUBATION LEVO WEANED TO .3MCG/KG/MIND/T SBP 170'S. NEURO CALLED TO EVALUATE APPROX. 30MIN AFTER INTUBATION PATIENT AWAKE APPROPRIATELY RESPONDING TO NEUROLOGIST QUESTIONS MAE STRONGLY TO COMMAND. PLAN TO EVALUATE NEURO STATUS THRU THE NIGHT. SEDATED ON LOW DOSE PROPOFOL AT 10MCG/KG/MIN. GIVEN AMG MSO4 AT 2245 FOR INCISIONAL DISCOMFORT. K 5.4 AFTER INTERVENTIONS WITH MEDS WILL FOLLOW CLOSELY. BS DOWN TO 122, WILL RECHECK AT 2300, IF ELEVATED STILL PLAN TO START INSULIN DRIP , POSTTRANSFUSION HCT AT 31.. ICA 1.1 GIVEN 2GMCAGLUCONATE IV. SVO2 RECAL AT 69%.. DISCUSSED PATIENT'S STATUS WITH FAMILY. ALL FAMILY MEMBERS INTO VISIT PRIOR TO GOING HOME, FATHER RESPONSIVE TO FAMILY..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320234, "text": "AFTER PATIENT REINTUBATED, BRONCHSCOPY DONE AT BEDSIDE, SMALL PLUG REMOVED FROM AIRWAY, OTHERWISE ALL LOOKS GOOD. PATIENT CONTINUES TO MAE TOCOMMAND, WHEN ASKED, RESTING COMFORTABLE ON LOW DOSE PROPOFOL. K ELEVATED AGAIN, GIVEN 10UREGULAR INSULIN IV, ALSO 1/2D50GIVEN. PLAN TO WEAN TO FIO2 40%..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320235, "text": "AFTER INSULIN GIVEN, BS CHECKED 75, GIVEN AMP D50 AGAIN. APPROX. 1HR LATER K ELEVATED AT 5.9 GIVEN 10U REGUALR INSULIN IV, 1 AMP D50 GIVEN AS WELL.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320236, "text": "AFTER INSULIN TO LOWER K BS HAS BEEN LOW RECEIVED 2AMPS D50 SEE FLOW SHEET PLAN TO CHECK BS AT 630 AM..PATIEN AVPACED THRU THE NIGHT AT 91, GOOD CI/SVO2 IN THE 69% RANGE, SBP SUPPORTED ON LEVOPHED .35-.4MCG/KG/MIN. RESP WEANED DOWN TO 40% WITH ABG PENDING THIS BS CLEAR BILATRELLY, NIL SECRETIONS, MINIMAL CT DRAINAGE FROM MEDIASTINAL CT..GU NO URINE MADE BASELINE. GI NPO NGT DRAINING APPROX. 150CC BILIOUS DRAINAGE, ABDOMEN DISTENDED.. K ELEVATED TREATED WITH INSULIN/DEXTROSE/BICARB. BS LOW AFTER INSULIN GIVEN. GIVEN 2MORE AMPS D50 AFTER INTIAL AMP, PLAN TO CHECK 630 AM.. K PENDING THIS AM. CA/MAG WNL THIS AM. NEURO PATIENT THIS AM DURING , TO COMMAND MOUTHING HIS NEEDS, ABLE TO LIFT ARMS.. I/D ON CLINDAMYCIN X 6DOSES, LEVOFLOXCIN NEEDS I/D APPROVAL THIS AN DRUG DUE AT 9AM!!!?? WEAN TO EXTUBATE THIS AM.??ACCESS IV.??/HEMODIALYSIS?? THIS AM. CONTINUE TO SUPPORT FAMILY DURING PATIENT'S ICU STAY..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320239, "text": "Resp Care\n\nPt stable on current settings. Acid base relationship adequate with good oxygenation. RSBI 61 ? wean attempt this am. Suctioning sm to mod thick tan sputum.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320240, "text": "Patient extubated and placed on 70% open face mask. ,coop HR 76,BP 112/47,sat 100%. Air leak heard with cuff deflated ptior to extubation,labile BP @ time will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320241, "text": "7a-7p\nCV: Apaced in morning with AAI 88, underlying rhythm switching between junctional and NSR 70s. Levo gtt infusing. Pacing wires began to not capture 100%, attempted to pace on v-side using higher ma's but still did not capture 100%. Pacer turned off. CI was >2 and SVO2 >60%. Frequent PACs started during dialysis, amiodarone bolus given with result of fewer PACs. Rhythm changed to afib with rate of 140. BP slightly lower but MAP still >60. Amio gtt started and second bolus given. Magnesium given. HR dropped to low 100s. Had to increase levo gtt slightly. Lopressor 5mg IV given. Pt later converted to junctional rhythm 60-70s. Attempted to apaced again, but still will not capture 100% and rhythm becoming more irregular with the intermittent pacing. Low grade temp.\n\nPULM: Weaned and extubated without difficulty. Pt was placed in reverse t- with HOB 30 degrees, and cuff leak checked before extubation. Currently on 4L/NC with 100% sats. Lungs clear. CTs draining very small amounts serosanginous fluid, no airleak.\n\nNEURO: Oriented. Percocet x 1 for pain control. Family in to visit several times during day.\n\nGU: Bilaral nephrectomies in past.\n\nGI: Bowel sounds present, NG tube was d/c'd after swallowing clears OK.\n\nRENAL: Hemodialysis done today, did not remove any fluid. Potassium down to 3.9. BG WNL.\n\nSKIN: Dsgs CDI.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-12 00:00:00.000", "description": "Report", "row_id": 1320242, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative with care.\n\nCV: Continues in junctional rthym at 63, BP stable and able to slowly wean levo. gtt., SV02 60-70, CI/CO WNL, continues on amio.gtt, PP+, afebrile.\n\nRESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. 100%, chest PT done, +cough but unable to expectorate any sputum, CT to 20 cm suction with scant drainage, pt. is a mouth breather.\n\nGI: Obese, BS+, tolerating sips of clears.\n\nGU: Hemo. patient, last dialyzed yesterday, no fluid removed, AVG to RUE with +bruit, but no palpable thrill.\n\nPAIN: Medicated with Percocets for incisional pain with good effect.\n\n\nPLAN: Pulmonary toilet, wean levo. as BP tolerates, continue to monitor CV and RESP. status, monitor electrolytes, pain management.\n" }, { "category": "ECG", "chartdate": "2133-04-30 00:00:00.000", "description": "Report", "row_id": 159592, "text": "Normal sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nLow QRS voltages in precordial leads\nOld anterior myocardial infarct\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2133-04-27 00:00:00.000", "description": "Report", "row_id": 159824, "text": "Probable sinus rhythm with first degree A-V delay and left atrial abnormality.\nProlonged QTc interval. Right bundle-branch block. Left axis deviation - left\nanterior fascicular block. Generalized low voltage. Consider prior\nanterolateral myocardial infarction. Clinical correlation is also suggested for\nmetabolic/drug effect and/or ischemia. Since the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2133-04-26 00:00:00.000", "description": "Report", "row_id": 159825, "text": "Sinus rhythm\nFirst degree A-V block\nMarked left axis deviation\nRBBB with left anterior fascicular block\nPossible old anterior infarct\nLateral T wave changes are nonspecific\nLow QRS voltages in precordial leads\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2133-04-21 00:00:00.000", "description": "Report", "row_id": 159826, "text": "Probable sinus rhythm with first degree AV delay and left atrial abnormality\nLow voltage\nLeft axis deviation\nRight bundle branch block and left anterior fascicular block\nConsider prior anterolateral myocardial infarct\nDiffuse ST-T wave changes with prolonged Q-Tc interval - cannot exclude in part\nmetabolic/drug effectand/or ischemia\nClinical correlation is suggested\nSince previous tracing of , QRS voltage decreased and further ST-T wave\nchanges seen\n\n" }, { "category": "ECG", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 159827, "text": "Compared to the previous tracing the mechanism is once again probably sinus\nwith first degree A-V block, rate 74. Otherwise, no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 159828, "text": "Probable junctional rhythm, rate 68, with associated right bundle-branch\nblock/left anterior hemiblock. Possible old anteroseptal and lateral wall\ninfarction. Compared to the previous tracing of the mechanism is now\njunctional accelerated rhythm rather than sinus with first degree A-V block.\nTRACING #1\n\n" } ]
69,024	179,797	#vfib arrest - Pt developed post-operative anterior Q wave myocardial infarction on in setting of stopping aspirin followed by ventricular fibrillation arrest. He was defibrillated x5. Pt was pulseless for 20 minutes then got pulse back. Received 5 shocks first of which for vfib at 5:30 pm got 150j then got 1mg of epi for bradycardia 39-42, second shock at 5:39 with BP 102/63, received 300g amiodarone then in VF, shocks at 5:48, 5:49, 5:50 with pulse back at 120 with BP of 90/60 got 150 g lidocaine. His EKG (anterior Q waves)and TTE (akinesis of the anteroseptal segments, apical walls) were consistent with proximal LAD territory infarction stent thrombosis after stopping aspirin. Pt arrived at 18 hours after the event and was therefore out of the window for cooling or thrombolytics. Pt was started on a heparin drip and a lidocaine drip as his vfib arrest was in the setting of acute ischemia. Lidocaine was stopped on . Lactate was only 1.2 on transfer. EP was consulted and and pt was sent home with a lifevest per their recommendations with plan for repeat echo in roughly 1 month for re-assessment of EF and consideration of AICD. Pt had full return of neurologic function and was found to be an alert/oriented lively conversationalist. Also without any focal neurologic deficits on neuro exam. . # - In the PACU at following sphincterotomy pt c/o chest pain was found to have hyperacute T waves in V3-V6 and ~ depressions in I and II, and cardiac enzymes showed CK of 4270, CKMB of 610 and Tn-XX of 136. Pt then experienced Vfib arrest, see above, and was intubated/stabilized overnight and EKG on showed Q waves in V1-V5. Pt was transferred to where MB on presentation was >500 and troponin 11.21, enzymes subsequently trended down. Pt had been started on plavix at , which was continued along with aspirin, heparin gtt and atorvastatin 80. Pt's last documented cath was from and showed: left main: normal no disease. LAD: 85% proximal stenosis along with mild long mid area of disease, post stenosis. large diag branch noted within the ostia of 60% stenosis. Lcirc: normal vessel without disease. results of PCI: reduction of the initial 85% severe proximal/LAD stenosis to 0% and a reduction of the initial 60% ostial diagonal branch stenosis to less than 20%. Cath was performed at on which showed: 50% flow through stent, (likely thrombus that migrated distally) TIMI 3 flow, no intervention, no other lesions. Pt was sent home on crestor as he stated atorvastatin "did not work for him" in the past (likely was referring to myalgias). Also home with metoprolol, aspirin/plavix, lisinopril, and spironolactone. . #CHF - ECHO after vfib arrest/ showed: severely depresssed left ventricular systolic function with regional wall motion abnormalities. Moderate pulmonary artery systolic hypertension. EF 15-20%. prior to admission pts last TTEwas at hospital , showed: compared to study of no significant changes. left atrium borderline enlarge, normal LV fn, normal wall motion. Trace AI, trace MR, trace TR. LVEF 55%. Pt had been taking lasix 40 daily and metolazone 5mg m/w/f at home. On admission, pt was persistently tachycardic, likely as compensation for impaired contractility. Pt was aggressively diuresed with good resolution in respiratory status and cxr findings of improvement in pulmonary edema. Given his marked apical akinesis of LV with EF of 15-20% pt was sent home with warfarin lifelong anticoagulation, and bridged with enoxaparin. . #respiratory status - pt was intubated in setting of vib arrest, extubated on at without issues. Remained with O2 requirement (NC sufficient to maintain appropriate sats). Evidence of pulmonary edema on CXR secondary to , Vfib arrest responsible for decreased EF to 15-20%. hypoxia/dyspnea resolved with aggressive diuresis, see CHF above. . #hypotension - transferred on levophed for low blood pressures, likely cardiac injury s/p stent thrombosis. Pt was also on propofol for sedation while on ventilator and this was likely contributingg. Levophed was quickly weaned without issue. Propofol was changed to fentanyl/midazolam which were also weaned the day after transfer. . #fever/leukocytosis - on transfer pt was found to have dark cloudy urine. He had received 1g CTX on at OSH for WBC of 15 and concern for UTI. UA at OSH was cloudy, trace ketones, large blood, neg nit and leuks WBC RBC 4+ bacteria. Although cultures and UA were negative at , CTX was continued for 7 day course as these studies had been done after pt had received his first dose. WBC trended down to normal limits. It was also felt that /vfib arrest was contributing somewhat to leukocytosis. . #Atrial fibrillation - pt was newly with atrial fibrillation s/p Vfib arrest/. He was successfully cardioverted on . # (Cr of 1 --> 1.5): in setting of vfib arrest/ pt had an elevated creatinine to 1.5 on transfer from baseline 1.0. With extubation, pressor weaning, and diuresis creatinine quickly went back to baseline. . #transaminitis - LFTs considerably elevated with ALT of 131 AST 565 LD 1381 (alkphos 57, tbili 0.4). These elevations were felt to be poor perfusion during vfib arrest. LFTs trended down and on discharge ALT was 64 and AST was down to 150. Pt without jaundice,n/v/abd pain. . #tobacco use - pt longtime and current smoker. Was extensively counseled on the risks of smoking and was maintained on a nicotene patch throughout hospital stay. . #s/p sphincterotomy - contact at OSH who did the procedure to get recs for dressing. Pt was monitored closely as he was being anticoagulation but no signs of significant bleeding and remained hemodynamically stable.	Anterior ST segment elevation myocardial infarctionpattern, age indeterminate. Stable left basilar atelectasis with a possible small left pleural effusion. A right internal jugular central line ends in the upper SVC. A right internal jugular central line ends in the upper SVC. Right internal jugular catheter ends in the mid SVC. Trivial mitral regurgitation is seen. RV function depressed.AORTA: Normal aortic diameter at the sinus level. Trace aortic regurgitation is seen. FINDINGS: The endotracheal tube ends approximately 1.7 cm from the carina. Anteroseptal myocardial infarction, age indeterminate.Borderline low voltage. Endotracheal tube 1.7 cm from the carina. Hypokinesis of the basal and mid inferoseptal, anteriorand anterolateral walls. Anteroseptal myocardial infarction of indeterminate age. Non-specific inferiorST-T wave changes. Anterior wall myocardial infarction, age indeterminate withST segment elevations in the anterior precordial leads. Anterior ST segment elevation myocardial infarction, ageindeterminate. Anteroseptal wall myocardial infarction,age indeterminate. Q waves in leads V1-V5 with ST segment elevation.Anteroseptal myocardial infarction of indeterminate age. Mild [1+] TR. Low limb and precordial QRS voltage. FINDINGS: A right internal jugular central line overlies the SVC and ends at the level of the carina, approximately in the mid SVC. Compared to the previoustracing of the rhythm is now atrial flutter. Moderate pulmonaryartery systolic hypertension.Dr. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. A small left pleural effusion is likely present. FINDINGS: In comparison with the study of , the endotracheal tube has been removed. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Sinus rhythm. Sinus rhythm. Sinus rhythm. Noprevious tracing available for comparison. The patient appears to be in sinusrhythm. The cardiomediastinal silhouette is mildly enlarged and unchanged from the prior radiograph. Right IJ catheter tip remains in the upper portion of the SVC. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Improvement in left basilar atelectasis. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -akinetic; basal inferoseptal - hypo; mid inferoseptal - hypo; basalanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;septal apex- akinetic; lateral apex - akinetic; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size. Mild pulmonary edema. Mild pulmonary edema. The cardiac silhouette is mildly enlarged. The cardiac silhouette is moderately enlarged and unchanged. Endotracheal tube is too low and at the level of the carina pointing towards the main stem bronchus. There ismoderate pulmonary artery systolic hypertension. Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. ST segment elevation in the anteriorprecordial leads. Left hemidiaphragm is not well seen, consistent with small effusion and atelectasis. Trivial MR. (<140ms) transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There is mild pulmonary edema. Evaluate endotracheal tube. Generalized lowvoltage. A clip in the right upper lobe is noted. Compared to the previous tracing of nochange.TRACING #1 Suboptimalimage quality - poor suprasternal views. Compared totracing #2 the rhythm is now sinus.TRACING #3 ST segment elevation in leads V1-V4 with Q waves.ST segment depression seen in the inferior limb leads may be reciprocalchanges. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. FINDINGS: The endotracheal tube ends 3.5 cm from the carina. Mild enlargement of the cardiac silhouette with probable worsening of pulmonary vascular congestion. Atrial flutter with 3:1 conduction. A small amount of atelectasis persists. An endotracheal tube is too low and approximately 5 mm from the carina pointing towards the right main stem bronchus. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. ETT pulled back 3 cm. Endotracheal tube 3.5 cm from the carina. A small amount of left basilar atelectasis is unchanged. Reassess placement of ETT. There is no pericardialeffusion.IMPRESSION: Severely depresssed left ventricular systolic function withregional wall motion abnormalities as described above. Since the previous tracing of the rate is now slower. STEMI.Height: (in) 66Weight (lb): 242BSA (m2): 2.17 m2BP (mm Hg): 127/75HR (bpm): 100Status: InpatientDate/Time: at 15:08Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: OptisonTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LVsystolic dysfunction. Atrial flutter with 4:1 conduction. No AS. Bilateral perivascular haze reflects engorgement of the pulmonary vasculature with mild pulmonary edema. There is severe regional left ventricular systolicdysfunction with akinesis of the anteroseptal segments, apical walls (withrelative preservation of the apical inferior segment), and true apex(?near-aneurysmal). Chest radiograph at 1215. Compared to the previous tracing ST segmentelevations are slightly more prominent.TRACING #3 The left heart border is somewhat obscured, most likely due to underlying atelectasis, although an early or small pneumonia cannot be excluded. There is no right pleural effusion. A small left pleural effusion may be present, but is not definitely seen. ST segmentelevation is similar in appearance.TRACING #2 The mitral valveleaflets are mildly thickened. Rightward axis. Mild pulmonary edema is unchanged from the prior radiograph. 3. 3. 3. Left ventricular wall thicknesses andcavity size are normal. Left basilar hazy opacification is likely atelectasis, although early pneumonia cannot be excluded. Clinical correlation is suggested. ST segment elevation isslightly more prominent. 2. 2. 2. No LV mass/thrombus. COMPARISONS: Chest radiograph at 1320. Compared to tracing #1 conduction is now 4:1. No definite pleural effusions are seen. 1:22 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Reassess placement of ETT. ST segment elevation in leads V2-V5, cannot exclude ongoinginjury patern. REASON FOR THIS EXAMINATION: Reassess placement of ETT. The opacification at the left base has improved suggesting it was likely atelectasis. Compared to the previous tracing no change.TRACING #4 PATIENT/TEST INFORMATION:Indication: V-fib arrest. FINAL REPORT INDICATION: Status post STEMI and Vfib arrest.	14	[ { "category": "Radiology", "chartdate": "2163-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223639, "text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, pulmonary edema\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with large STEMI perioperatively, new onset CHF EF 15%\n REASON FOR THIS EXAMINATION:\n interval change, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MI with new onset of CHF.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has\n been removed. The patient has taken a much better inspiration. Mild\n enlargement of the cardiac silhouette with probable worsening of pulmonary\n vascular congestion. Left hemidiaphragm is not well seen, consistent with\n small effusion and atelectasis.\n\n Right IJ catheter tip remains in the upper portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223547, "text": " 1:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Reassess placement of ETT.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD s/p STEMI and VF arrest, now intubated. ETT pulled\n back 3 cm. Reassess placement of ETT.\n REASON FOR THIS EXAMINATION:\n Reassess placement of ETT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post STEMI and Vfib arrest. Evaluate endotracheal tube.\n\n COMPARISONS: Chest radiograph, at 12:15.\n\n FINDINGS: The endotracheal tube ends approximately 1.7 cm from the carina. A\n right internal jugular central line ends in the upper SVC. The opacification\n at the left base has improved suggesting it was likely atelectasis. A small\n amount of atelectasis persists. There is mild pulmonary edema. No definite\n pleural effusions are seen. The cardiomediastinal silhouette is mildly\n enlarged and unchanged from the prior radiograph. A feeding tube is in place\n within the stomach.\n\n IMPRESSION:\n 1. Endotracheal tube 1.7 cm from the carina.\n 2. Improvement in left basilar atelectasis.\n 3. Mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223555, "text": " 1:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p vfib arrest check for ETT plcment\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p vfib arrest\n REASON FOR THIS EXAMINATION:\n s/p vfib arrest check for ETT plcment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube placement, status post V-fib arrest.\n\n COMPARISONS: Chest radiograph at 1320. Chest radiograph\n at 1215.\n\n FINDINGS: The endotracheal tube ends 3.5 cm from the carina. A right\n internal jugular central line ends in the upper SVC. Mild pulmonary edema is\n unchanged from the prior radiograph. A small amount of left basilar\n atelectasis is unchanged. A small left pleural effusion may be present, but\n is not definitely seen. There is no right pleural effusion. There is no\n consolidation or pneumothorax. The cardiac silhouette is moderately enlarged\n and unchanged. A feeding tube is seen within the stomach.\n\n IMPRESSION:\n 1. Endotracheal tube 3.5 cm from the carina.\n 2. Mild pulmonary edema.\n 3. Stable left basilar atelectasis with a possible small left pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223536, "text": " 12:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pna, ards\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p vfib arrest, cardiogenic shock\n REASON FOR THIS EXAMINATION:\n please eval for pna, ards\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post V-fib arrest.\n\n COMPARISONS: None.\n\n FINDINGS: A right internal jugular central line overlies the SVC and ends at\n the level of the carina, approximately in the mid SVC. An endotracheal tube\n is too low and approximately 5 mm from the carina pointing towards the right\n main stem bronchus. A clip in the right upper lobe is noted. A feeding tube\n is seen within the stomach with the tip out of the field of view. Bilateral\n perivascular haze reflects engorgement of the pulmonary vasculature with mild\n pulmonary edema. The left heart border is somewhat obscured, most likely due\n to underlying atelectasis, although an early or small pneumonia cannot be\n excluded. A small left pleural effusion is likely present. There is no\n pleural effusion on the right. There is no pneumothorax. The cardiac\n silhouette is mildly enlarged.\n\n IMPRESSION:\n 1. Endotracheal tube is too low and at the level of the carina pointing\n towards the main stem bronchus.\n 2. Right internal jugular catheter ends in the mid SVC. No pneumothorax.\n 3. Left basilar hazy opacification is likely atelectasis, although early\n pneumonia cannot be excluded.\n\n The endotracheal tube position was discussed with the ICU team at 1:30 pm on\n by Dr. .\n\n" }, { "category": "Echo", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 93708, "text": "PATIENT/TEST INFORMATION:\nIndication: V-fib arrest. STEMI.\nHeight: (in) 66\nWeight (lb): 242\nBSA (m2): 2.17 m2\nBP (mm Hg): 127/75\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -\nakinetic; basal inferoseptal - hypo; mid inferoseptal - hypo; basal\nanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;\nseptal apex- akinetic; lateral apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. \n(<140ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. The patient appears to be in sinus\nrhythm. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is severe regional left ventricular systolic\ndysfunction with akinesis of the anteroseptal segments, apical walls (with\nrelative preservation of the apical inferior segment), and true apex\n(?near-aneurysmal). Hypokinesis of the basal and mid inferoseptal, anterior\nand anterolateral walls. No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size is normal with depressed free wall\ncontractility. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Severely depresssed left ventricular systolic function with\nregional wall motion abnormalities as described above. Moderate pulmonary\nartery systolic hypertension.\n\nDr. notified of the results by phone on at 6:25 p.m.\n\n\n" }, { "category": "ECG", "chartdate": "2163-12-20 00:00:00.000", "description": "Report", "row_id": 243759, "text": "Sinus rhythm. Rightward axis. Q waves in leads V1-V5 with ST segment elevation.\nAnteroseptal myocardial infarction of indeterminate age. Generalized low\nvoltage. Since the previous tracing of the rate is now slower.\n\n" }, { "category": "ECG", "chartdate": "2163-12-18 00:00:00.000", "description": "Report", "row_id": 243760, "text": "Sinus tachycardia. Anterior wall myocardial infarction, age indeterminate with\nST segment elevations in the anterior precordial leads. Non-specific inferior\nST-T wave changes. Low limb and precordial QRS voltage. Compared to\ntracing #2 the rhythm is now sinus.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-12-18 00:00:00.000", "description": "Report", "row_id": 243981, "text": "Atrial flutter with 4:1 conduction. ST segment elevation in the anterior\nprecordial leads. Compared to tracing #1 conduction is now 4:1. ST segment\nelevation is similar in appearance.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-12-17 00:00:00.000", "description": "Report", "row_id": 243982, "text": "Atrial flutter with 3:1 conduction. Anteroseptal wall myocardial infarction,\nage indeterminate. ST segment elevation in leads V2-V5, cannot exclude ongoing\ninjury patern. Clinical correlation is suggested. Compared to the previous\ntracing of the rhythm is now atrial flutter. ST segment elevation is\nslightly more prominent. The other findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-12-16 00:00:00.000", "description": "Report", "row_id": 243983, "text": "Sinus tachycardia. Anterior ST segment elevation myocardial infarction, age\nindeterminate. Compared to the previous tracing no change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2163-12-16 00:00:00.000", "description": "Report", "row_id": 243984, "text": "Sinus tachycardia. Anterior ST segment elevation myocardial infarction\npattern, age indeterminate. Compared to the previous tracing ST segment\nelevations are slightly more prominent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243985, "text": "Sinus tachycardia. ST segment elevation in leads V1-V4 with Q waves.\nST segment depression seen in the inferior limb leads may be reciprocal\nchanges. Compared to the previous tracing the rate is increased and ST-T wave\nchanges are new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243986, "text": "Sinus rhythm. Anteroseptal myocardial infarction, age indeterminate.\nBorderline low voltage. Compared to the previous tracing of no\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243987, "text": "Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age. No\nprevious tracing available for comparison.\n\n" } ]
24,105	142,549	Admitted on and underwent minimally invasive mitral valve repair with Dr. . Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Extubated that evening and started on amiodarone for brief non-sustained runs of SVT/VT. Swan removed on POD #1 and transferred to the floor to begin increasing his activity level. Chest tubes removed on POD #2 with slight right apical pneumothorax present, but asymptomatic. He made excellent progress on the floor and was cleared for discharge to home with VNA on POD #3.	Normal descending aorta diameter. IMPRESSION: Unchanged right pneumothorax and bilateral bibasilar discoid atelectasis. hypotension (SBP 80 mm Hg) and tachycardia(HR 110 bpm) there is with a posteriorly directed MR jet of moderateintesity and a maximalleft ventricular outflow tract gradient calculated to be70-80 mm Hg.With fluid boluses/HR and after load control the improved to Chordal only. Normal ascendingaorta diameter. Linear atelectasis overlies left hilum. There is no pericardial effusion.P2 segment of the mitral valve shows flail segment with anteriorly directed MRjet of severe intensity./PL ratio less than 1.5 and C- distance= 2.78cmMitral annulus diameter in the IC plane= 3.1 cm.POST CPB:Preserved biventricular systolic functionAnnuloplasty ring in mitral position.Posterior leaflet has been resected.There is chordal with any associated mitral regurgitation or significantleft ventricular outflow gradient at a SBP of 130 mm Hg and HR of 75 bpm..With provocative maneuvers, e.g. Mildmitral annular calcification. FINDINGS: There has been interval placement of an endotracheal tube, NG tube, and right-sided chest tube, which remain in satisfactory position. Additional Amiodarone bolus given and drip kept at 1mg. Severe (4+) MR. Eccentric MR jet.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. REASON FOR THIS EXAMINATION: r/o PTX, effusion. The small right apical pneumothorax, right subcutaneous emphysema partially overlying the right lower lung, the bilateral, more on the right, bibasilar discoid atelectasis are unchanged. Chest tube is present in right apical region. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is a small right apical pneumothorax (10%). Myxomatous mitral valveleaflets. The IVC is normal in diameterwith appropriate phasic respirator variation.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Sinus rhythmST-T wave configuartion suggests in part early repolarization pattern/normalvariant but clinical correlation is suggestedSince previous tracing of , early precordial QRS transition and T waveless prominent R/O PTX. IMPRESSION: Small right apical pneumothorax (10%). Comparison is made to the prior chest x-ray dated . 2:42 PM CHEST (PA & LAT) Clip # Reason: RT SIDED CHEST TUBE. Mitral valve prolapse.Status: InpatientDate/Time: at 10:49Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Pre CPB TEE performed to assess the mitral valve and placement of monitoringlines.Coronary Sinus canula and PA vent line placed under TEE guidance into theCoronary sinus and Pulmonary artery.Aortic perfusion wire placed under TEE guidance.Venous access cannula wire and venous cannnula positoned in the right atrimunder TEE guidance.LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Focal calcifications in aortic root. Overall normal LVEF (>55%).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. The ascending,transverse and descending thoracic aorta are normal in diameter and free ofatherosclerotic plaque. d/c swan if VEA continues. NP IN REGARDS TO 2ND AMIO BOLUS.. GU GREAT U/O. Linear and discoid atelectases are present at both lung bases, and there are probable small bilateral pleural effusions. Cutaneous and anterior mediastinal emphysema is noted in the lateral view. There is bibasilar atelectasis. Left ventricular wall thicknesses and cavity size arenormal. Neo started to keep SBP >100 in view of echo results "SAMS" when BP too low.Pulm: breath sounds dim at bases. ON KEFZOL . 1645 PATIENT WITH INCREASED MULTIFOCAL ECTOPY K INFUSING , APPROX. Bibasilar atelectasis. The right chest tube remains in place. Keep BSP > 100 up to 130.Encourage ADL's as tol. continues to have ventricular ectopy with one 24 beat run VT at 0120. Patchy atelectasis is seen at the lung bases. Neuro: Pt. The semi-rounded opacity projecting just lateral to the left of the spine most probably represents an inserted new mitral valve. Mitral valve disease. The endotracheal tube, nasogastric tube, and the Swan-Ganz catheter has been removed. There is partial mitral leafletflail. The previously identified mild congestive heart failure has been resolved. CT's now to water seal. IMPRESSION: 1. Severe (4+) mitral regurgitation is seen. Respiratory Care Note: received patient this shift s/p mrr and on ventilatory support. PATIENT/TEST INFORMATION:Indication: Left ventricular function. The cardiomediastinal contours are stable. COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared to previous study of yesterday. Rightventricular chamber size and free wall motion are normal. 10:15 AM CHEST (PORTABLE AP) Clip # Reason: r/o PTX, effusion. 's BP sagging to 90's after extubation. PATIENT ON PROPOFOL SR IN THE 80'S, PER ANESTHESIA D/T "" KEEP SBP GREATER THAN 100, WITH HR 80-80'S. Pt. No atheroma in descendingaorta.AORTIC VALVE: Normal aortic valve leaflets (3). SPO2 100%. Overall left ventricular systolic function is normal (LVEF>55%). The TEE probe was passedwith assistance from the anesthesioology staff using a laryngoscope.Conclusions:PRE-BYPASS: The left atrium is elongated. A cuff leak was noted prior to extubation. The mitralvalve leaflets are mildly thickened. palp pp.Plan: ? The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation.	9	[ { "category": "Nursing/other", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 1576788, "text": "PATIENT ON PROPOFOL SR IN THE 80'S, PER ANESTHESIA D/T \"\" KEEP SBP GREATER THAN 100, WITH HR 80-80'S. PATIENT HAS RECEIVED TOTAL OF 4000CCLR , BUT DESPITE THE VOLUME IS STILL NEGATIVE!! HCT SENT AT 1900 PLAN TO TRANSFUSE IF 30 OR LESS. PRESENTLY PROPOFOL AT 40MCG/KG/MIN WITH NEO AT .5MCG/KG/MIN. RSP AT 40% PLAN TO CHANGE TO SIMV AND EVENTUALLY CPAP ONCE MORE AWAKE. REVERSED AT 1845, MAE TO COMMAND AT 1900. AT APPROX. 1645 PATIENT WITH INCREASED MULTIFOCAL ECTOPY K INFUSING , APPROX. 20 BEAT RUN OF VT , BOLUSED WITH 150 MG AMIODARONE DRIP STARTED ON AMIODARONE DRIP AT 1MG/MIN, K/CA/MAG ALL REPLETED. K AT THIS TIME WAS 3.5. SINCE VT CONTINUES TO HAVE COUPLETS AS WELL AS MULTIFOCAL PVC, PLAN TO ?? NP IN REGARDS TO 2ND AMIO BOLUS.. GU GREAT U/O. GI OGT TO LCS, DRAINING BROWN TO BLOODY SECRETIONS, ON CARAFATE/RANITIDINE. PATIENT SEADTED WITH 2MG MORPHINE X2 , AS WELL RECEIVING TOTAL OF 25MG DEMEROL IV FOR SHIVERING. ON INSULIN DRIP SEE FLOW SHEET FOLLOWING CSRU INSULIN PROTOCOL. ON KEFZOL . PLAN TO DISCUSS WITH NP IN REGARDS TO MOTRIN ORDER. WIFE SEE PATIENT ALONG WITH MOTHER.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 1576789, "text": "Respiratory Care Note:\n received patient this shift s/p mrr and on ventilatory support. patient weaned and extubated to a 50% cool mist face tent. A cuff leak was noted prior to extubation. Patient able to vocalize and raise blood tinged sputum post extubation. SPO2 100%. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-08 00:00:00.000", "description": "Report", "row_id": 1576790, "text": "Neuro: Pt. extubated last evening. He was completely appropriate and alert.\nCV: Pt. continues to have ventricular ectopy with one 24 beat run VT at 0120. All electrolytes repleted. Additional Amiodarone bolus given and drip kept at 1mg. Pt.'s BP sagging to 90's after extubation. Neo started to keep SBP >100 in view of echo results \"SAMS\" when BP too low.\nPulm: breath sounds dim at bases. Otherwise clear. O2 weaned to cannula.\n\nGI/GU: taking ice chips without n/v. HUO continues to be > 100cc/hr and up to 450cc for earlier hours. K+ repleted.\n\nEndo: insulin drip off when BS in the 80's.SSRI started at BS 129.\n\nSkin: right lateral chest wall dsg d&i. palp pp.\n\nPlan: ? d/c swan if VEA continues. Keep BSP > 100 up to 130.\nEncourage ADL's as tol. Pain management prn.\n" }, { "category": "Echo", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 67896, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Mitral valve prolapse.\nStatus: Inpatient\nDate/Time: at 10:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPre CPB TEE performed to assess the mitral valve and placement of monitoring\nlines.\nCoronary Sinus canula and PA vent line placed under TEE guidance into the\nCoronary sinus and Pulmonary artery.\nAortic perfusion wire placed under TEE guidance.\nVenous access cannula wire and venous cannnula positoned in the right atrim\nunder TEE guidance.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler. The IVC is normal in diameter\nwith appropriate phasic respirator variation.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Focal calcifications in aortic root. Normal ascending\naorta diameter. Normal descending aorta diameter. No atheroma in descending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve\nleaflets. Elongated mitral valve leaflets. Partial mitral leaflet flail. Mild\nmitral annular calcification. Severe (4+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope.\n\nConclusions:\nPRE-BYPASS: The left atrium is elongated. No atrial septal defect is seen by\n2D or color Doppler. Left ventricular wall thicknesses and cavity size are\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. The mitral valve leaflets are myxomatous.\nThe mitral valve leaflets are elongated. There is partial mitral leaflet\nflail. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet\nis eccentric. There is no pericardial effusion.\nP2 segment of the mitral valve shows flail segment with anteriorly directed MR\njet of severe intensity.\n/PL ratio less than 1.5 and C- distance= 2.78cm\nMitral annulus diameter in the IC plane= 3.1 cm.\n\nPOST CPB:\nPreserved biventricular systolic function\nAnnuloplasty ring in mitral position.\nPosterior leaflet has been resected.\nThere is chordal with any associated mitral regurgitation or significant\nleft ventricular outflow gradient at a SBP of 130 mm Hg and HR of 75 bpm..\nWith provocative maneuvers, e.g. hypotension (SBP 80 mm Hg) and tachycardia\n(HR 110 bpm) there is with a posteriorly directed MR jet of moderate\nintesity and a maximalleft ventricular outflow tract gradient calculated to be\n70-80 mm Hg.\nWith fluid boluses/HR and after load control the improved to Chordal \nonly.\n\n\n" }, { "category": "ECG", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 149285, "text": "Sinus rhythm\nST-T wave configuartion suggests in part early repolarization pattern/normal\nvariant but clinical correlation is suggested\nSince previous tracing of , early precordial QRS transition and T wave\nless prominent\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 913479, "text": " 6:30 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct d/c\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe MR, plans for MVR\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of pneumothorax after discontinuation of\n the right chest tube.\n\n PA and lateral upright chest radiograph compared to the previous film from the\n same day made at 13:49 a.m.\n\n The small right apical pneumothorax, right subcutaneous emphysema partially\n overlying the right lower lung, the bilateral, more on the right, bibasilar\n discoid atelectasis are unchanged. The lung volumes are relatively low. The\n heart size is top normal and stable, the mediastinal width is unchanged as\n well. The semi-rounded opacity projecting just lateral to the left of the\n spine most probably represents an inserted new mitral valve.\n\n IMPRESSION: Unchanged right pneumothorax and bilateral bibasilar discoid\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 913442, "text": " 2:42 PM\n CHEST (PA & LAT) Clip # \n Reason: RT SIDED CHEST TUBE. R/O PTX.\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe MR, plans for MVR\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n HISTORY: Mitral regurgitation with mitral valve repair and pneumothorax.\n\n Chest tube is present in right apical region. There has been no significant\n change in the size of the small right pneumothorax. Linear and discoid\n atelectases are present at both lung bases, and there are probable small\n bilateral pleural effusions. Linear atelectasis overlies left hilum.\n Cutaneous and anterior mediastinal emphysema is noted in the lateral view.\n\n IMPRESSION: No significant change in size of small right pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 913145, "text": " 3:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, tamponade, Pulmonary edema, pneumothorax\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MV Repair\n REASON FOR THIS EXAMINATION:\n Pleural effusion, tamponade, Pulmonary edema, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair.\n\n Comparison is made to the prior chest x-ray dated .\n\n FINDINGS: There has been interval placement of an endotracheal tube, NG tube,\n and right-sided chest tube, which remain in satisfactory position. There has\n also been placement of a right internal jugular catheter through which a Swan-\n Ganz catheter has been advanced. The tip of the catheter is not well seen due\n to motion artifact, probably in the outflow tract. There is bibasilar\n atelectasis. The cardiomediastinal contours are stable. There is no pleural\n effusion. No pneumothorax is identified.\n\n IMPRESSION:\n 1. Bibasilar atelectasis.\n 2. Interval placement of Swan-Ganz catheter with the tip not well seen due to\n motion artifact. A repeat film will be recommended to confirm position.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 913233, "text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, effusion.\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MV repair. CT's now to water seal.\n REASON FOR THIS EXAMINATION:\n r/o PTX, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE:\n\n INDICATION: 45-year-old man status post MV repair.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n to previous study of yesterday.\n\n The right chest tube remains in place. There is a small right apical\n pneumothorax (10%). Patchy atelectasis is seen at the lung bases. There is\n continued cardiomegaly. The previously identified mild congestive heart\n failure has been resolved.\n\n The endotracheal tube, nasogastric tube, and the Swan-Ganz catheter has been\n removed.\n\n IMPRESSION: Small right apical pneumothorax (10%).\n\n\n" } ]
65,689	143,433	73M with h/o CVA on coumadin, CAD s/p DES->LCx , s/p L renal artery stent , infrarenal AAA s/p repair admitted with forearm, chest, and tooth pain (prior anginal equivalent) who went to cardiac catheterization for NSTEMI, s/p PCI complicated by mid vessel RCA dissection, followed by STEMI (distal RCA + RPL, felt to be secondary to dissection). . # NSTEMI and STEMI: The patient was admitted to the floor and his cardiac enzymes were trended peaking at 0.08 from <0.01 on admission. He was taken to cardiac catheterization, which revealed a RCA thrombus thought to be the culprit lesion that was treated with one DES. This was complicated by a distal RCA dissection requiring three overlaping BMS distal to and overlapping with the DES as well as one proximal BMS and overlapping with the DES with the final result being TIMI-3 flow. Bedside TTE was performed and was notable for the absence of pericardial effusion with normal wall motion. He was started on plavix 75mg, which he will take 75mg for one week and then change to 75mg daily. He was continued on aspirin 325mg daily. He was maintained on an integrillin drip for 18hours post catheterization. He was started on rosuvastatin, as he had a history of poor tolerance to other statins. He was pain-free until afternoon at which time he developed chest pressure, arm pain, and teeth pain. At that point he was noted to have ST-elevations in inferior leads and CODE STEMI was called. He was brought immediately to the cath lab at which time angiography showed occlusion of the RPL off the mid-distal RCA felt to be due to his prior dissection. The proximal PCA appeared patent. Given the dissection flap, a wire could not be passed into the vessel and no intervention was performed. He was chest pain free several hours later and remained so throughout the remainder of his hospital stay. Follow-up echocardiogram showed basal/midlateral akinesis/hypokinesis (although technically sub-optimal) that was new from priors. . # HISTORY OF CVA: Given his history of recent stroke, thought to be embolic, he was maintained on systemic anticoagulation with coumadin. Heparin was initiated while his INR was subtherapeutic. In consultation with his outpatient neurologist the goal INR is 1.8 to 2.5. The patient was discharge home with Lovenox injections twice daily until he began therapeutic again on his Coumadin. . # ATRIAL TACHYCARDIA: He was monitored on telemetry during the course of his hospitalization. He was primarily in sinus rhythm with a rate in the 80s although he did have asymptomatic episodes of atrial tachycardia to the 110s. His metoprolol dose was increased to 37.5mg q8hr. . # HAND CELLULITIS: This was thought to be due to an infiltrated IV site. There was a pustule that was lanced with culture growing MSSA. He was started on Keflex + Bactrim with plans for a 7 day course (Bactrim D/C'd once sensitivities available). He remained afebrile with a normal white count and site clinically improved prior to discharge. . # HYPERTENSION: He was continued on losartan and metoprolol. As above, metoprolol dose increased to 37.5 tid. Losartan held for ARF. . # ACUTE RENAL FAILURE: Creatinine trended up from baseline 1.2 -> 1.4 after cath . It rose again from 1.4 -> 1.6 after second cardiac cath. This was felt to be due to potential contrast nephropathy as he received substantial contrast load for both procedures. was held with some improvement in his renal function. Creatinine at baseline for this patient is 1.1-1.2 and 1.4 upon discharge. . # HYPERLIPIDEMIA: He was initially continued on niacin and cholestyramine. This was changed to rosuvastatin 10mg daily, however he developed myalgias and he was changed back to home cholestyramine.	Noaortic regurgitation is seen. There is moderatesymmetric left ventricular hypertrophy. There is amild resting left ventricular outflow tract obstruction. Mild regionalLV systolic dysfunction. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Consider left ventricular hypertrophy by voltagein lead aVL. Resting bradycardia (HR<60bpm).Conclusions:The left atrium and right atrium are normal in cavity size. The patientappears to be in sinus rhythm. PATIENT/TEST INFORMATION:Indication: Evaluate for pericardial effusion/ s/p coronary perforation, hypotensionHeight: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 123/90HR (bpm): 116Status: InpatientDate/Time: at 15:11Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Small LV cavity. Ectopic atrial tachycardia. Since the previous tracing of ST-T waveabnormalities are both prominent.TRACING #1 Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Myocardial infarction.Height: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 140/107HR (bpm): 58Status: InpatientDate/Time: at 09:58Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Moderate symmetric LVH. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow patternc/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , regional wallmotion abnormality is now detected but studies are technically suboptimal forcomparison. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Compared to the previous tracing of therehas been further evolution of the findings of acute infero-posterolateralmyocardial infarction. The left ventricular cavity size isnormal. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Sinus rhythm with slowing of the rate as compared with prior tracingof . The left ventricular inflow patternsuggests impaired relaxation. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus bradycardia. Sinus bradycardia. There is further evolution of the findings of acuteinfero-posterolateral myocardial infarction. ST-T waveflattening in lead I with downsloping ST segment depression in lead aVL. Inferoposterolateral myocardial infarction with ST-T waveconfiguration suggesting acute/recent/in evolution process. Mild resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: No pericardial effusion.Conclusions:Focused study to exclude effusion: The left ventricular cavity is unusuallysmall. The mitral valve appears structurally normalwith trivial mitral regurgitation. Ectopic atrial rhythm. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The estimated pulmonary artery systolic pressureis normal. Earlyprecordial R wave transition. Tamponade.Height: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 161/102HR (bpm): 114Status: InpatientDate/Time: at 19:10Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Clinical correlation is suggested.TRACING #3 The aortic valveleaflets (3) are mildly thickened. ST segment elevation in leads II, III and aVF. The rate has increased and the findings are consistent withactive inferoposterior and lateral myocardial infarction. Followup andclinical correlation are suggested.TRACING #1 Since the previous tracing of ST-T wavechanges are less prominent.TRACING #4 Since the previous tracing of same date probably nosignificant change.TRACING #3 Left ventricular systolic function is hyperdynamic (EF>75%). Suboptimal image quality - patient unable to cooperate. Followup and clinical correlation are suggested.TRACING #2 No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. There is mild regional left ventricular systolic dysfunction withprobable basal to mid lateral akinesis/hypokinesis (LVEF ?45-50%) but viewsare technically suboptimal for assessment of regional wall motion. Right ventricularchamber size and free wall motion are normal. Normal LV cavity size. Compared to the previous tracing of voltage inleads I and aVL is now more prominent. Rightventricular chamber size and free wall motion are normal. Emergencystudy performed by the cardiology fellow on call. There is no significant pericardial effusion.Dr. Results were personallyreviewed with the MD caring for the patient.Conclusions:Very limited study. Since the previous tracing of same date there isprobably no significant change.TRACING #2 These findings are new as compared with priortracing of . Hyperdynamic LVEF >75%. No AS. There is no aortic valve stenosis. There is no pericardialeffusion.	11	[ { "category": "Echo", "chartdate": "2190-06-08 00:00:00.000", "description": "Report", "row_id": 93464, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 140/107\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 09:58\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mild regional\nLV systolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\nappears to be in sinus rhythm. Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is moderate\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. There is mild regional left ventricular systolic dysfunction with\nprobable basal to mid lateral akinesis/hypokinesis (LVEF ?45-50%) but views\nare technically suboptimal for assessment of regional wall motion. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The left ventricular inflow pattern\nsuggests impaired relaxation. The estimated pulmonary artery systolic pressure\nis normal. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , regional wall\nmotion abnormality is now detected but studies are technically suboptimal for\ncomparison.\n\n\n" }, { "category": "Echo", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 93503, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade.\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 161/102\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 19:10\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Emergency\nstudy performed by the cardiology fellow on call. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nVery limited study. There is no significant pericardial effusion.\n\nDr. was notified in person of the results on at 7 p.m.\n\n\n" }, { "category": "Echo", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 93504, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for pericardial effusion/ s/p coronary perforation, hypotension\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 123/90\nHR (bpm): 116\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%. Mild resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nFocused study to exclude effusion: The left ventricular cavity is unusually\nsmall. Left ventricular systolic function is hyperdynamic (EF>75%). There is a\nmild resting left ventricular outflow tract obstruction. Right ventricular\nchamber size and free wall motion are normal. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2190-06-05 00:00:00.000", "description": "Report", "row_id": 244067, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration suggesting acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of ST-T wave\nchanges are less prominent.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244068, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of same date probably no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244069, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of same date there is\nprobably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244070, "text": "Sinus bradycardia. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of ST-T wave\nabnormalities are both prominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-06-02 00:00:00.000", "description": "Report", "row_id": 244071, "text": "Sinus rhythm with slowing of the rate as compared with prior tracing\nof . There is further evolution of the findings of acute\ninfero-posterolateral myocardial infarction. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 244072, "text": "Ectopic atrial tachycardia. Compared to the previous tracing of there\nhas been further evolution of the findings of acute infero-posterolateral\nmyocardial infarction. Followup and clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 244073, "text": "Ectopic atrial rhythm. ST segment elevation in leads II, III and aVF. ST-T wave\nflattening in lead I with downsloping ST segment depression in lead aVL. Early\nprecordial R wave transition. These findings are new as compared with prior\ntracing of . The rate has increased and the findings are consistent with\nactive inferoposterior and lateral myocardial infarction. Followup and\nclinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 244294, "text": "Sinus bradycardia. Consider left ventricular hypertrophy by voltage\nin lead aVL. Compared to the previous tracing of voltage in\nleads I and aVL is now more prominent.\n\n" } ]
52,593	148,720	66 y/o male s/p segment III resection with Dr on who was discharged to rehab facility and now returns with abdominal incision wound infection. His other concerns are fluid overload and acute on chronic renal failure. He was initially admitted to 10 but was transferred to the SICU for worsening respiratory status, however he did not require intubation. Legionella culture was negative. Bubble study was negative for intracardiac shunt A wound VAC was placed to the abdominal incision after completely opening the incision and Vancomycin was started x 3 days. Blood cultures were negative. Right leg cellulitis was noted on admission and this improved with the Vancomycin. LENIs were obtained and negative for DVT. He was seen in consult by Nephrology and Hepatology. Per both their recommendations Midodrine and octreotide were added as was Rifaxamin. With mild volume expansion, the ARF appeared to be resolving and all diuretics continued to be held. On he underwent paracentesis for increasing abdominal pain. Ultrasound did indicate the presence of ascites. 1.7 liters of fluid was removed and the WBC was 955 with 79% polys. No organisms were seen on gram stain and the fluid culture was reported as no growth. He was started on Zosyn (6 days total) and the Vancomycin was added back in and dosed per trough levels. Nutrition consult was obtained and TPN was initiated via newly placed PICC line. He was transfused 2 units RBCs on HD 7 for Hct 28.2 which dropped 4% from previous day in setting of paracentesis. Hct remained stable thereafter. On a repeat paracentesis was performed and the WBC was now elevated to 3925 with 70% polys. As this occured while on Zosyn, the antibiotic was changed to Meropenem, this was per ID recommendation who was also consulted. Renal consult service was recommending the initiation of hemodialysis as his creatinine which initially decreased to 3.3 by HD 5 was increasing daily in the ensuing days. The patient was transferred to the medical service on with the hepatobiliary (West 1 team) following abdominal wound and VAC changes. On , the patient was in respiratory distress with tachypnea and sat-ing at 95% on 5 liters of oxygen. This was secondary to fluid overload secondary to liver and renal failure. Paracentesis with ultrasound was attempted at the bedside, but very little fluid could be removed. Fluid was sent for fungal cultures. To date, all blood, peritoneal, and urine cultures have been negative. Hemodialysis line was placed by IR in anticipation of hemodialysis for fluid overload. Hemodialysis did not provide any relief of respiratory symptoms and the patient remained in a great deal of pain with respiratory distress. Goals of care were discussed with the patient, his family, and the PCP (Dr. , as well as the attending of record, Dr. . The patient was made DNR/DNI on . Clinical status continued to deteriorate on . On , the family decided on comfort measures only and all medications/treatments were discontinued. Mr. at 15:42 on .	IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. HR 100-110 sinus tach & sbp 120-130 Action: Gentle IV hydration @ 75 cc/hour. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. The aortic valve leaflets are mildlythickened (?#). There is a mildresting left ventricular outflow tract obstruction. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg). Moderate mitral annularcalcification. PROCEDURE: Placement of temporary hemodialysis catheter via the right IJ access. Mild restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (?#). A spot in the right upper quadrant was marked and prepped and draped in the usual sterile fashion. Drainage now serosang fluid. Drainage now serosang fluid. FINDINGS: As compared to the previous radiograph, the course of the right-sided PICC line is unchanged. FINAL REPORT CHEST RADIOGRAPH. Impaired Skin Integrity Assessment: Patients abdominal dressing oozing moderate amounts serous fluid. Impaired Skin Integrity Assessment: Patients abdominal dressing oozing moderate amounts serous fluid. Newly inserted central venous access line, the course is normal, the tip projects over the right atrium and should probably be pulled back by 3-4 cm. Assess for fluid collection or abscess. There is stable appearance of the anterior abdominal wound with wound VAC in place. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Diagnostic paracentesis requested for today please. The right side of the neck was prepared and draped in the usual sterile fashion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right IJ was accessed with a micropuncture needle under ultrasound guidance. A 0.018 wire was then placed through the needle into the right IJ. (Over) 1:58 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Assess for fluid collection/abscess, eveidence of SBP Admitting Diagnosis: RENAL FAILURE FINAL REPORT (Cont) OR THERAPEUTIC; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # Reason: please do paracentesis. No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. A request was made to place a temporary hemodialysis catheter. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The dilators were removed. HR 100-110 sinus tach & sbp 100-120. HR 100-110 sinus tach & sbp 100-120. Poor R waveprogression, probably a normal variant. There are coronary artery calcifications. There is diverticulosis. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Action: Transplant team aware, vac dressing placed by Dr. . Action: Transplant team aware, vac dressing placed by Dr. . TECHNIQUE: CT through the abdomen and pelvis was performed after administration of oral contrast only. There is diffuse mesenteric stranding. A small incision was made over the needle and then the needle was removed.	31	[ { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688931, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 132.4 kg\n Daily weight:\n 132.1 kg\n Allergies/Reactions:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Precautions: None\n PMH: COPD\n CV-PMH:\n Additional history: HCV, cirrhosis, HCC, hepatocellular CA, (s/p liver\n resection ), osteroarthritis, COPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:71\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 2,056 mL\n 24h total out:\n 924 mL\n Pertinent Lab Results:\n Sodium:\n 131 mEq/L\n 02:58 PM\n Potassium:\n 5.4 mEq/L\n 02:58 PM\n Chloride:\n 96 mEq/L\n 02:58 PM\n CO2:\n 26 mEq/L\n 02:58 PM\n BUN:\n 55 mg/dL\n 02:58 PM\n Creatinine:\n 3.6 mg/dL\n 02:58 PM\n Glucose:\n 121 mg/dL\n 02:58 PM\n Hematocrit:\n 29.7 %\n 03:12 AM\n Finger Stick Glucose:\n 131\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: None\n Transferred from: SICU B\n Transferred to: 10\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688865, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill.\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Response:\n U/o remained stable\n Per\n No Vanco dose due today. Dose/Trough due prior dose\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688866, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688861, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688863, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous\n Foley to gravity w/ adequate u/o >30cc/hr\n BLE w/ generalized edema. Lasix d/c\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2151-07-07 00:00:00.000", "description": "Generic Note", "row_id": 688843, "text": "TITLE:\n Clinical Nutrition:\n 65 y.o. M s/p segment 3 resection for HCC readmitted from rehab\n with hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring. Patient started on calorie counts today . Patient\n reports a poor appetite and refused supplements at this time. Will\n follow up with calorie counts and po intake.\n #\n" }, { "category": "Physician ", "chartdate": "2151-07-07 00:00:00.000", "description": "Intensivist Note", "row_id": 688841, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n cellulitis\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy, obesity, osteoarthritis, COPD\n Current medications:\n 3. 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Bisacodyl\n 7. Docusate Sodium 8. Fluticasone-Salmeterol Diskus (250/50) 9. 10.\n Ipratropium Bromide Neb 11. Multivitamins 12. Senna 13. Sodium Chloride\n 0.9% Flush 14. Sodium Chloride 0.9% Flush 15. Thiamine 16. Vancomycin\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.1\nC (96.9\n HR: 106 (99 - 125) bpm\n BP: 120/59(73) {104/45(61) - 146/99(111)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132.1 kg (admission): 132.4 kg\n Total In:\n 2,515 mL\n 478 mL\n PO:\n 590 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,925 mL\n 358 mL\n Blood products:\n Total out:\n 945 mL\n 175 mL\n Urine:\n 945 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,570 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: R LE cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 155 K/uL\n 9.9 g/dL\n 111 mg/dL\n 3.9 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 97 mEq/L\n 132 mEq/L\n 29.7 %\n 10.5 K/uL\n [image002.jpg]\n 02:46 AM\n 05:57 PM\n 03:12 AM\n WBC\n 12.1\n 10.5\n Hct\n 29.7\n 29.7\n Plt\n 145\n 155\n Creatinine\n 4.1\n 3.9\n 3.9\n Glucose\n 89\n 146\n 111\n Other labs: PT / PTT / INR:19.8/33.2/1.8, ALT / AST:34/51, Alk-Phos / T\n bili:65/2.1, Amylase / Lipase:, Albumin:2.4 g/dL, Ca:8.0 mg/dL,\n Mg:2.0 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN INTEGRITY,\n ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neuro: oriented, interactive\n CVS: Stable, goal MAPS >60\n Pulm: for COPD Advair; albuterol atrovent neb q4, autoset CPAP,\n pulmonary following\n GI:reg diet, bowel regimen\n FEN: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: ATN (from lasix) vs HRS: elevated BUN/Cr reflecting decreased\n intravascular volume, pre-renal failure, nephro following, consider\n adding midodrine or octreotide, U/O 20-100, LOS +2.6L\n Heme: boots for proph, autoanticoagulation given liver disease\n Endo: cosyntropin stress test, cortisol 15.8 > 22.0 (> 3hrs later), ?\n adrenal insufficiency\n ID: had vanco on floor for cellulitis, F/U AM trough\n TLD:PIV, foley, PICC requested\n Wounds: abd w/ vac dressing, RLE with cellulitis\n Imaging: CXR P\n Prophylaxis: boots\n Consults: transplant \n Code: full\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:01 PM\n 22 Gauge - 03:15 AM\n Prophylaxis:\n DVT: Boots\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688907, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688908, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688909, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n Borderline po\ns. Carlorie Count\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n Continue Calorie Count.\n Transfer to 10\n" }, { "category": "Rehab Services", "chartdate": "2151-07-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 688825, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt. is 65 y.o. male\n s/p liver resection for HCC, re-admitted from rehab with wound\n infection, SOB, LE cellulitis and hyponatremia.\n Past Medical / Surgical History: Chronic HCV, cirrhosis, HCC,\n hepatocellular CA s/p resectiion, peripheral neuropathy, obesity, OA,\n COPD,\n Medications: Vancoymycin, Albuterol, Thiamine\n Radiology: CXR: No significant interval change from earlier same day.\n Lungs remains clear.\n No large effusion and no pneumothorax. Cardiomediastinal contour is\n unchanged, as is elevation of the right hemidiaphragm.\n LE US: no evidence of DVT\n Labs:\n 29.7\n 9.9\n 155\n 10.5\n [image002.jpg]\n Other labs:\n Activity Orders: As tolerated\n Social / Occupational History: Lives alone. Family involved in care. +\n tobacco hx, +ETOH\n Living Environment: 3 STE, 1 level home\n Prior Functional Status / Activity Level: At rehab PTA, assistance with\n all ADLs\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3 impulsive at\n times\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 103\n 115/69\n 19\n 92 on 3L\n Sit\n /\n Activity\n 118\n /\n 85-92 on 4L\n Stand\n /\n Recovery\n 102\n 115/64\n 18\n 94 on 3L\n Total distance walked:\n Minutes:\n Pulmonary Status: BS dimished at bases\n Integumentary / Vascular: Abd vac attached, Foley catheter, L UE PIV,\n Telemetry, R Lower leg cellulitis\n Sensory Integrity: pt. reports sensation grossly intact to LT in LEs.\n Pain / Limiting Symptoms: no c/o pain\n Posture: obese\n Range of Motion\n Muscle Performance\n bilat. UEs/LEs: WLF throughout\n bilat. UEs/LEs: > throughout\n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. amb 200 ft pushing w/c with CGA, desatting to\n 85-88 % on 4L.\n Rolling:\n Received in sitting\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n Stand-pivot\n\n\n x\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n Pushing w/c\n\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: no LOB during ambulation\n Education / Communication: Pt. edu re: Role of PT, , d/c plan to\n home, RN comm re: pt. status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Transfers, Impaired\n Clinical impression / Prognosis: Pt. is 66 y.o. male s/p liver\n resection, admitted from rehab with wound infection, SOB, cellulitis,\n that p/w above impairments associated with pulmonary pump\n dysfunction/deconditioning. Pt. appears to be functioning close to his\n baseline and anticipate that pt. will progress towards d/c home in \n PT visits. Will f/u as appropriate to progress mobility, and endurance.\n Goals\n Time frame: 1 week\n 1.\n supine to sit indep.\n 2.\n sit to stand indep.\n 3.\n Amb 300 ft with RW indep\n 4.\n Maintain SpO2 > 92 % on 2L\n 5.\n Verbalize understandin of Role of PT\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: x/wk\n bed mobility, transfers, gait-training with RW, stairs, endurance\n training\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face time: 9:30-10:17 am\n Nsg recs: Amb with RW x/day\n" }, { "category": "Physician ", "chartdate": "2151-07-06 00:00:00.000", "description": "Intensivist Note", "row_id": 688507, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n SOB\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy , obesity, osteoarthritis , COPD\n PSH: Segement III Liver resection\n : Ascorbic acid 500\" , Keflex 500\"\" , Heparin SQ ''' , Dilaudid PRN\n Vac change , Advair diskus 1\" , Thiamine 100' , MVI , Zinc 220'\n ,Atrovent PRN , senna , Serax 15 PRN HS , Ambien 5' , Dilaudid PRN\n All: iodine, peanuts\n Current medications:\n 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Cosyntropin\n 7. Fluticasone-Salmeterol Diskus (250/50)\n 8. Ipratropium Bromide Neb 9. Multivitamins 10. Senna 11. Sodium\n Chloride 0.9% Flush 12. Sodium Chloride 0.9% Flush\n 13. Thiamine\n 24 Hour Events:\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 106 (96 - 118) bpm\n BP: 110/69(78) {102/50(62) - 138/69(78)} mmHg\n RR: 22 (16 - 26) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 920 mL\n 449 mL\n PO:\n 120 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 800 mL\n 329 mL\n Blood products:\n Total out:\n 140 mL\n 190 mL\n Urine:\n 140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 259 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), wet sounds bilat\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: cellulitis right leg, marked\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN\n INTEGRITY, ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neurologic: oriented, interactive\n Cardiovascular: Stable, goal MAPS >60\n Pulmonary: for COPD continue salmeterol + fluticasone; ipratropium +\n albuterol neb prn\n Gastrointestinal / Abdomen: reg diet\n Nutrition: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: elevated BUN/Cr , ?pre-renal failure, FENa 0.3%\n Hematology: boots for proph, autoanticoagulation given hx of liver\n disease\n Endocrine: F/U corsyntropin stress test as pt has low Na and elevated\n K, question adrenal insuficiency\n Infectious Disease: Check cultures, had vanco on floor for cellulitis,\n F/U AM trough\n Lines / Tubes / Drains: PIV, foley\n Wounds: leg, abd vac\n Imaging:\n Fluids:\n Consults: transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 08:01 PM\n 20 Gauge - 08:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2151-07-07 00:00:00.000", "description": "Intensivist Note", "row_id": 688751, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n cellulitis\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy, obesity, osteoarthritis, COPD\n Current medications:\n 3. 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Bisacodyl\n 7. Docusate Sodium\n 8. Fluticasone-Salmeterol Diskus (250/50) 9. 10. Ipratropium Bromide\n Neb 11. Multivitamins 12. Senna\n 13. Sodium Chloride 0.9% Flush 14. Sodium Chloride 0.9% Flush 15.\n Thiamine 16. Vancomycin\n 24 Hour Events:\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.1\nC (96.9\n HR: 106 (99 - 125) bpm\n BP: 120/59(73) {104/45(61) - 146/99(111)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132.1 kg (admission): 132.4 kg\n Total In:\n 2,515 mL\n 478 mL\n PO:\n 590 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,925 mL\n 358 mL\n Blood products:\n Total out:\n 945 mL\n 175 mL\n Urine:\n 945 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,570 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: R LE cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 155 K/uL\n 9.9 g/dL\n 111 mg/dL\n 3.9 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 97 mEq/L\n 132 mEq/L\n 29.7 %\n 10.5 K/uL\n [image002.jpg]\n 02:46 AM\n 05:57 PM\n 03:12 AM\n WBC\n 12.1\n 10.5\n Hct\n 29.7\n 29.7\n Plt\n 145\n 155\n Creatinine\n 4.1\n 3.9\n 3.9\n Glucose\n 89\n 146\n 111\n Other labs: PT / PTT / INR:19.8/33.2/1.8, ALT / AST:34/51, Alk-Phos / T\n bili:65/2.1, Amylase / Lipase:, Albumin:2.4 g/dL, Ca:8.0 mg/dL,\n Mg:2.0 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN INTEGRITY,\n ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neuro: oriented, interactive\n CVS: Stable, goal MAPS >60\n Pulm: for COPD Advair; albuterol atrovent neb q4, autoset CPAP,\n pulmonary following\n GI:reg diet, bowel regimen\n FEN: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: ATN (from lasix) vs HRS: elevated BUN/Cr reflecting decreased\n intravascular volume, pre-renal failure, nephro following, consider\n adding midodrine or octreotide, U/O 20-100, LOS +2.6L\n Heme: boots for proph, autoanticoagulation given liver disease\n Endo: cosyntropin stress test, cortisol 15.8 > 22.0 (> 3hrs later), ?\n adrenal insufficiency\n ID: had vanco on floor for cellulitis, F/U AM trough\n TLD:PIV, foley, PICC requested\n Wounds: abd w/ vac dressing, RLE with cellulitis\n Imaging: CXR P\n Prophylaxis: boots\n Consults: transplant \n Code: full\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:01 PM\n 22 Gauge - 03:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2151-07-06 00:00:00.000", "description": "Intensivist Note", "row_id": 688593, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n SOB\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy , obesity, osteoarthritis , COPD\n PSH: Segement III Liver resection\n : Ascorbic acid 500\" , Keflex 500\"\" , Heparin SQ ''' , Dilaudid PRN\n Vac change , Advair diskus 1\" , Thiamine 100' , MVI , Zinc 220'\n ,Atrovent PRN , senna , Serax 15 PRN HS , Ambien 5' , Dilaudid PRN\n All: iodine, peanuts\n Current medications:\n 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Cosyntropin\n 7. Fluticasone-Salmeterol Diskus (250/50) 8. Ipratropium Bromide Neb\n 9. Multivitamins 10. Senna 11. Sodium Chloride 0.9% Flush 12. Sodium\n Chloride 0.9% Flush 13. Thiamine\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 106 (96 - 118) bpm\n BP: 110/69(78) {102/50(62) - 138/69(78)} mmHg\n RR: 22 (16 - 26) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 920 mL\n 449 mL\n PO:\n 120 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 800 mL\n 329 mL\n Blood products:\n Total out:\n 140 mL\n 190 mL\n Urine:\n 140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 259 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), wet sounds bilat\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: cellulitis right leg, marked\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN\n INTEGRITY, ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neurologic: oriented, interactive\n Cardiovascular: Stable, goal MAPS >60\n Pulmonary: for COPD continue salmeterol + fluticasone; ipratropium +\n albuterol neb prn\n Gastrointestinal / Abdomen: reg diet\n Nutrition: MVI, thiamine, regular diet, NS @75 ml/hr\n Renal: elevated BUN/Cr , ?pre-renal failure, FENa 0.3%. Consult\n nephrology and discuss albumen\n Hematology: boots for proph, autoanticoagulation given hx of liver\n disease\n Endocrine: F/U corsyntropin stress test as pt has low Na and elevated\n K, question adrenal insuficiency\n Infectious Disease: Check cultures, had vanco on floor for cellulitis,\n F/U AM trough\n Lines / Tubes / Drains: PIV, foley\n Wounds: leg, abd vac\n Consults: transplant\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n 22 Gauge - 08:01 PM\n 20 Gauge - 08:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688682, "text": "Constipation (Obstipation, FOS)\n Assessment:\n c/o constipation..passing flatus\n Action:\n Digital exam for hard stool..given ducolax supp..fleets\n enema..disimpacted & ss enema given\n Response:\n Mod amt hard formed stool\n Plan:\n Continue with good bowel regiment..increase activity as tol..PT consult\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Placed on ofm @ fio2 100%\n Action:\n Sat\ns >95% when sitting up\n Response:\n Does drop sat\ns when flat or with exertion\n Plan:\n Continue with good pulmonary toilet..encourage deep breathing &\n coughing..increase activity as tol..oob as much as pt can tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat remains elevated but adequate huo\n Action:\n Urine lytes sent ..renal consult\n Response:\n No increase in renal failure\n Plan:\n Will try to remove fluid ? Lasix or albumin at this time awaiting renal\n consult suggestions..continue to follow huo\ns closely\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688737, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Breathing unlabored @ rest. Dyspneic with any activity. Sp02 mid 90\n on 5 L nasal cannula. Lung sounds clear but diminished.\n Action:\n Resp status monitored.\n Response:\n Unchanged overnight.\n Plan:\n CXR this am. Encourage pulmonary hygiene.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient making adequate hourly urine (> 20 cc/hour). HR 100-110 sinus\n tach & sbp 120-130\n Action:\n Gentle IV hydration @ 75 cc/hour.\n Response:\n Unchanged overnight.\n Plan:\n Awaiting AM labs. Patient to have renal ultrasound this AM.\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688547, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted to SICU from FA 10 due to recent increase in\n creatinine & worsening resp status. Patient s/p liver rsx .\n Patient arrived approx 7:30, oriented and appropriate. SOB with any\n activity, but otherwise unlabored. Lung sounds clear but diminished.\n Spo2 high 90\ns with NRB. Patient making borderline hourly urine 30-40\n cc. HR 100-110 sinus tach & sbp 100-120.\n Action:\n Fluid bolus given over 2 hours and IV maint fluid given. NRB changed\n to nasal cannula 5 liters.\n Response:\n Resp status remains unchanged. All vitals stable. AM creat still 4.1,\n patient continues to make urine. Patient slept minimally overnight.\n Remains oriented x3, but now occasionally making confused statements.\n Plan:\n ? Transfer back to Fa 10 today.\n Impaired Skin Integrity\n Assessment:\n Patient\ns abdominal dressing oozing moderate amounts serous fluid.\n Afebrile. No complaints abdominal/wound pain. Wound tissue pink,\n granulating.\n Action:\n Transplant team aware, vac dressing placed by Dr. . Drainage\n now serosang fluid.\n Response:\n Skin otherwise intact. Wound vac functioning well. Patient has area\n of cellulitis on RLE, no change since admission.\n Plan:\n Continue to monitor closely.\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688546, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted to SICU from FA 10 due to recent increase in\n creatinine & worsening resp status. Patient s/p liver rsx .\n Patient arrived approx 7:30, oriented and appropriate. SOB with any\n activity, but otherwise unlabored. Lung sounds clear but diminished.\n Spo2 high 90\ns with NRB. Patient making borderline hourly urine 30-40\n cc. HR 100-110 sinus tach & sbp 100-120.\n Action:\n Fluid bolus given over 2 hours and IV maint fluid given. NRB changed\n to nasal cannula 5 liters.\n Response:\n Resp status remains unchanged. All vitals stable. AM creat still 4.1,\n patient continues to make urine.\n Plan:\n Continue to follow closely.\n Impaired Skin Integrity\n Assessment:\n Patient\ns abdominal dressing oozing moderate amounts serous fluid.\n Afebrile. No complaints abdominal/wound pain. Wound tissue pink,\n granulating.\n Action:\n Transplant team aware, vac dressing placed by Dr. . Drainage\n now serosang fluid.\n Response:\n Skin otherwise intact. Wound vac functioning well.\n Plan:\n" }, { "category": "Echo", "chartdate": "2151-07-06 00:00:00.000", "description": "Report", "row_id": 98179, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. BUBBLE STUDY, respiratory failure.\nHeight: (in) 67\nWeight (lb): 290\nBSA (m2): 2.37 m2\nBP (mm Hg): 108/62\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 13:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient did not cooperate with the entirety of the study; therefore images\nwere incomplete.\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF >75%. TDI E/e' >15, suggesting PCWP>18mmHg. Mild resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No valvular AS. The\nincreased transaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). There is a mild\nresting left ventricular outflow tract obstruction. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are mildly\nthickened (?#). There is no valvular aortic stenosis. The increased\ntransaortic velocity is likely related to high cardiac output. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\ntricuspid valve leaflets are mildly thickened. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Hyperdynamic left ventricular function.\nNo intracardiac shunting by bubble study.\n\nCompared with the report of the prior study (images unavailable for review) of\n, no major change is evident.\n\n\n" }, { "category": "ECG", "chartdate": "2151-07-16 00:00:00.000", "description": "Report", "row_id": 277316, "text": "Sinus tachycardia with intermittent ventricular premature beats. Poor R wave\nprogression, probably a normal variant. Non-specific lateral ST-T wave\nchanges. Compared to the previous tracing of the overall rate has\ndecreased. The other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2151-07-09 00:00:00.000", "description": "Report", "row_id": 277317, "text": "Sinus tachycardia. Poor R wave progression. Non-specific low amplitude\nT waves. Low QRS voltage in the precordial leads. Compared to the previous\ntracing of T wave flattening is slightly more pronounced, especially\nin lead I.\n\n" }, { "category": "ECG", "chartdate": "2151-07-08 00:00:00.000", "description": "Report", "row_id": 277318, "text": "Sinus tachycardia. Poor R wave progression. Low QRS voltage in the precordial\nleads. Compared to the previous tracing of ventricular rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2151-07-05 00:00:00.000", "description": "Report", "row_id": 277319, "text": "Sinus tachycardia. Low QRS voltage in the precordial leads. Compared to the\nprevious tracing of there is no significant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-07-05 00:00:00.000", "description": "Report", "row_id": 277320, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2151-07-14 00:00:00.000", "description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)", "row_id": 1090883, "text": " 2:56 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: please do paracentesis. send fluid for gram stain, culture,\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with HCC s/p liver resection readmitted with incision\n cellulitis and worsening HRS\n REASON FOR THIS EXAMINATION:\n please do paracentesis. send fluid for gram stain, culture, cell count\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED PARACENTESIS\n\n COMPARISON: None.\n\n HISTORY: 66-year-old male with HCC status post liver resection with worsening\n ascites.\n\n FINDINGS/PROCEDURE: After the risks, benefits and alternative to the\n procedure were explained to the patient, written informed consent was\n obtained. Preprocedure timeout was performed using three patient identifiers.\n A spot in the right upper quadrant was marked and prepped and draped in the\n usual sterile fashion. Local anesthesia was obtained using buffered lidocaine\n solution 1%. Subsequently, a 5 French catheter was advanced into the\n pocket of ascites. 600 cc of clear yellow-brown fluid was obtained. Small\n amount of samples were sent to the laboratory as requested.\n\n There were no immediate post-procedure complications.\n\n The attending physician, . , was present and supervising\n throughout the entire procedure.\n\n IMPRESSION: Successful ultrasound-guided diagnostic and therapeutic\n paracentesis yielding 600 cc of clear yellow brownish fluid. Small amount of\n sample was sent to the laboratory as requested.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1091213, "text": " 4:24 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : Where is the line?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with dyspnea and question line location\n REASON FOR THIS EXAMINATION:\n Where is the line?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Line placement.\n\n COMPARISON: , 8:10 a.m.\n\n FINDINGS: As compared to the previous radiograph, the course of the\n right-sided PICC line is unchanged. Newly inserted central venous access\n line, the course is normal, the tip projects over the right atrium and should\n probably be pulled back by 3-4 cm. There is no evidence of complications such\n as pneumothorax. Otherwise, the radiograph is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-12 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1090551, "text": " 1:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Assess for fluid collection/abscess, eveidence of SBP\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with increasing WBC, + paracentesis\n REASON FOR THIS EXAMINATION:\n Assess for fluid collection/abscess, eveidence of SBP\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old man with increasing white blood count and suspicion of\n spontaneous bacterial peritonitis. Assess for fluid collection or abscess.\n\n COMPARISON: .\n\n TECHNIQUE: CT through the abdomen and pelvis was performed after\n administration of oral contrast only. The patient could not receive IV\n contrast due to elevated creatinine. Multiplanar reformats were performed.\n\n FINDINGS:\n\n ABDOMEN: There is increasing consolidation with air bronchograms in the right\n lower lobe, suspicious for pneumonia. There are coronary artery\n calcifications. The liver is shrunken and nodular, consistent with cirrhosis.\n There is an increasing amount of free flowing ascites in the abdomen and\n pelvis, compared to prior, but no focal fluid collection to suggest discrete\n abscess. The pancreas, spleen, and adrenal glands are unremarkable. There are\n two 1.0 cm stones in the lower pole of the left kidney. The right kidney\n appears normal. There is diffuse mesenteric stranding. The bowel loops are\n of normal caliber.\n\n PELVIS: Again seen is slightly increasing pelvic ascites. There is stable\n appearance of the anterior abdominal wound with wound VAC in place. There is\n no abscess in this location. There is diverticulosis. There are degenerative\n changes in the spine.\n\n IMPRESSION:\n\n 1. Increasing ascites without discrete focal fluid collection to suggest\n abscess.\n\n 2. Changes in the liver consistent with cirrhosis.\n\n 3. Increasing right lower lobe consolidation suspicious for pneumonia.\n\n 4. Two 1 cm nonobstructing left kidney stones.\n\n 5. Diverticulosis.\n\n\n (Over)\n\n 1:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Assess for fluid collection/abscess, eveidence of SBP\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 1091207, "text": " 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ******************************* CPT Codes *****************************\n NON-TUNNELED US GUID FOR VAS. ACCESS \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESLD, hepatorenal syndrome, volume overload leading to\n dyspnea who needs initiation of HD for fluid removal\n REASON FOR THIS EXAMINATION:\n Please place a temporary HD catheter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 7:52 PM\n PFI: Placement of temporary hemodialysis catheter via the right IJ access\n with tip of the catheter in the right atrium and the catheter is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 66-year-old man with endstage liver\n disease, hepatorenal syndrome, volume overload, leading to dyspnea, who needs\n initiation of hemodialysis for fluid removal. A request was made to place a\n temporary hemodialysis catheter.\n\n OPERATORS: Dr. and Dr. , the attending\n radiologist who was present and supervised during whole procedure.\n\n PROCEDURE: Placement of temporary hemodialysis catheter via the right IJ\n access.\n\n ANESTHESIA: Lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After the risks and the benefits of procedure as well\n as local anesthesia were explained, informed consent was obtained. The\n patient was brought to the angiographic suite and placed on the stretcher. The\n head of the stretcher was raised in 45 degree to relieve the shortness of\n breath. The right side of the neck was prepared and draped in the usual\n sterile fashion. The right IJ was accessed with a micropuncture needle under\n ultrasound guidance. Hard copies of ultrasound were stored. A 0.018 wire was\n then placed through the needle into the right IJ. A small incision was made\n over the needle and then the needle was removed. A micropuncture sheath was\n then placed over the wire into the right IJ. The wire and the inner stiffener\n of the sheath were removed. A 0.035 wire was then placed through the\n sheath into the right IJ. The sheath was then removed. A 12 French and a 14\n French soft tissue dilators were sequentially used to dilate the soft tissue\n entrance into the right IJ. The dilators were removed. A 14 French, 15-cm\n AngioDynamics temporary hemodialysis catheter was then placed over the wire\n into the right IJ. The final position of the tip of the catheter was in the\n right atrium which was confirmed by a bedside chest x-ray. Both ports of\n catheter were aspirated and flushed easily. Both ports were capped. The\n catheter was sutured to skin and a sterile dressing was applied.\n\n The patient tolerated the procedure well, and there were no immediate\n (Over)\n\n 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n complications.\n\n IMPRESSION: Placement of a temporary hemodialysis catheter via the right IJ\n access with the tip of the catheter in the right atrium and the catheter is\n ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 1091208, "text": ", C. MED FA10 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESLD, hepatorenal syndrome, volume overload leading to\n dyspnea who needs initiation of HD for fluid removal\n REASON FOR THIS EXAMINATION:\n Please place a temporary HD catheter\n ______________________________________________________________________________\n PFI REPORT\n PFI: Placement of temporary hemodialysis catheter via the right IJ access\n with tip of the catheter in the right atrium and the catheter is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-08 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1090009, "text": " 2:32 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place double lumen PICC\n Admitting Diagnosis: RENAL FAILURE\n ***************************** CPT Codes *****************************\n PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man needing access and TPN\n REASON FOR THIS EXAMINATION:\n place double lumen PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for TPN and IV access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure under supervision of Dr.\n .\n\n TECHNIQUE: Using sterile technique and local anesthesia, the basilic vein was\n punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a dual lumen PICC line measuring 38 cm in length was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied. The patient tolerated\n the procedure well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double-lumen PICC line placement via the right basilic venous approach. Final\n internal length is 38 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-11 00:00:00.000", "description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US", "row_id": 1090380, "text": " 9:38 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Diagnostic paracentesis requested for today please.\n Admitting Diagnosis: RENAL FAILURE\n ***************************** CPT Codes *****************************\n PARACENTESIS DIAG. OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ascites, ?SBP\n REASON FOR THIS EXAMINATION:\n Diagnostic paracentesis requested for today please.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 66-year-old male with ascites and abdominal pain, to\n assess for possible subacute bacterial peritonitis. Preliminary scans reveal\n moderate volume of ascites, particularly in the right flank.\n\n After obtaining written informed consent and performing a timeout procedure\n with three patient identifiers, an appropriate site in the right upper\n quadrant/right flank was selected for paracentesis. Under sterile conditions\n with local anesthesia (1% Xylocaine), a 5 French catheter was placed into\n the fluid and specimens were obtained for requested laboratory tests,\n including cell count and differential and culture. The catheter was then\n connected to vacuum bottles and 1.7 liters of fluid was removed without\n difficulty. There were no complications during the procedure.\n\n CONCLUSION: Successful ultrasound-guided paracentesis.\n\n\n" } ]
16,576	145,108	A/P: 85 yo female with h/o CHF, HTN and AFib who presents with CHF exacerbation. 1. CHF: Pt with echo in with EF>55%. Likely diastolic component of HF. Dose of diuretics recently adjusted by PCP as thought she was overdiuresed and now has had increased fluid overload. Started with iv lasix at 40mg IV bid with minimal response however good response with 80mg iv bid. Discussed mgmt with daily weights and adjust lasix dose based on this and may have to decrease ace/BB dose to tolerate excess diuresis. Also as vague left sided chest pain with clinical heart failure out of proportion to echo, re-reviewed nuclear stress in with attending and findings concerning for reversible defect of anterior wall and taken to catheterization to evaluate for ischemia contributing to worsening episodesof heart failure. Was continued on atenolol and lisinopril while in house, but following catheterization while on integrillin patient developed hematemesis and was transferred to ccu. She was also hypotensive after further diuresis in cath lab. She was monitored in the ccu and her blood pressures improved as diuresis was held. Her hematocrits remained stable and was transferred back to floor. Her diurretics were held with goal to keep her euvolemic. Then as blood pressure improved, she was restarted on low dose ace and changed to coreg from atenolol for heart failure. She was continued on asprin for life and plavix for 9months for recently placed stent. At time of discharge she was euvolemic with a weight of 81.3kgs. She will monitor her weights at rehab. She was started on 80mg lasix qd with goal to keep her weight stable within 1-2kg of 81.3kg. Her blood pressures should be monitored closely with adjustments in her lasix regemin. She was continued on oxygen and this can be continued to followed and titrated off as tolerated. Her CXRs confirmed cardiomegaly and bilateral pleural effusions. Her dyspnea was stable with ambulation, but will require continued physical therapy. If her weight increased by more than 2kg her lasix should be increased to twice a day and if she loses more than 2kg then her lasix dose should be halved. * 2. CAD: stable no previously known heart disease but after re-review of nuclear stress, pt went to cardiac cath as above and had a stent to her distal left circumflex. For which she will continue asprin for life and plavix for 9months at least. * 3. Afib: stable as she is s/p ablation with pacer and maintained on amiodarone, temporarily bridged with heparin during her stay and then restarted on her wafarin with good result. Her goal INR , but came in supratherapeutic INR and coumadin was held intiitally and for her catheterization. She is also continued on her beta-blocker with good rate control. * 3. HTN: stable after episode of hypotension after overdiuresis on floor and during catheterization. Slowly as her volume status improved, she was started on low dose lisinopril instead of enalapril and coreg instead of atenolol because of her heart failue. Even as she was re-started on lasix her blood pressure remained stable. * 4. Acute on chronic renal failure: her creatinine was 1.5 at baseline, the source of her chronic renal failure was unclear and she had bilateral renal ultrasounds with dopplers to assess for flow across renal arteries as she has a pacer and an MRA is not possible. Renal ultrasound was inconclusive for hypertensive nephropathy vs renal artery stenosis. During her catheterization, unfortunately her renal arteries were not assessed. Following catheterization she did have a slight creatinine bump which may have been secondary to contrast nephropathy, exacerbated by overdiuresis or ATN secondary to transient hypotension. However, by time of discharge her creatinine was 1.2 and stable even on ace and lasix. * 5. Hematemesis: patient developed hematemesis and melanotic stools following integrillin infusion post-stent. She was transfused and her hematocrit remained stable and she was eventually taken for EGD and colonoscopy with results as above. She was started on twice a day protonix, four times a day sucralfate and will plan to re-EGD in 3weeks. Her dysphagia improved and her diet is slowly being advanced as she tolerates. Her pain is improving as well with treatment. She also had a speech and swallow eval which assessed her swallow function to be normal and felt that her dysphagia was consistent with esophageal source as by EGD. Per nutrition they reccommended more frequent, smaller meals with Boost supplements. Of note her CMV IgM ws negative and IgG was posotive consitent with prior exposure to CMV. Her H.pylori serologies are still pending at time af discharge and is return positive she should be started on treatement for H.pylori. * 6. Pseudomonas bronchitis: patient continued to have productive cough, but negative chest xray, her sputum was sent and showed pan-sensitive pseudomonas and staph aureus. She was started on vanc/cipro/ceftaz empirically and then transitioned to cipro for discharge to complete 2week course which will be completed on .	BS: slight expiratory wheez RUL, which cleared with the RX. follow hct in am, fluid boluses as needed if bp drops. Prev BS's pnd. has pneumoboots on.ms- dtr interprets (pt speaks ). dtr pt's stent card and info brochure.a- s/p cath w/rising creatinine. pt to turn side to side, ?oob when bp staying up. Compared to the previous tracing of nodiagnostic interim change. Conitnue to monitor resp status and nebs tx. Pulses palpable.Resp: Pt LS coarse with exp wheezes noted at bases and at times throughout, neb tx given. APPEARS MORE COMFORTABLE SINCE TREATMENT.GI: ABD SOFT, + BOWEL SOUNDS NO BM OVERNIGHT. GIVEN ALB/ATR NEBS X3. GIVEN ALB/ATR NEB WITH SOME RELIEF FORM SOB. ccu npno-id- t max 99.2. c+s sputum shows pseudomonas and staph aureus coag pos. WILL NEED MED FOR CONSTIPATION.ID: AFEBRILE WBC 13.3 CONT ON LEVAQUIN PO.A: RESP DISTRESS, CONGESTED. C/O RIGHT LOWER ABD PAIN. DENIES CHEST PAIN, C/O INTERMITTENT ABDOMINAL CRAMPINESS, STATES FEELS LIKE SHE NEEDS TO MOVE BOWELSO. NT SUCTIONING DONE. extremities edematous except for r arm. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATAID: TEMP 98.9 -99.6 PO, CONTINUES ON LEVO - WBC 13RESP: SPUTUM FROM YESTERDAY 3+ GM NEG RODS - LUNGS COARSE W/EXP WHEEZES, DENIES SOB, RECEIVING ALBUTEROL NEBS, SATS ON R/A 89% - 92%, SATS ON 2L NC 95-98%; CONTINUES TO HAVE INTERMITTENT CONGESTED COUGH, LOOSE, MOSTLY NON-PRODUCTIVE, RECEIVED DELSYM X1, TYLENOL #3 X1CV: HR 60 AV PACED, BP REMAINS 70-80'S/SYSTOLIC - HCT 27.7 RECEIVED 1 UNIT PRBC'S - BP TO 90'S THEN DRIFTED BACK TO 70'S, 2ND UNIT HUNG AND INFUSING SLOWLY OVER 4 HOURSGI: ABDOMEN SOFT, INTERMITTENT CRAMPING DIET NPO TO CLEARS, TOLERATING SIPS H2O THUS FAR, NO STOOL BUT OCCAS STATES SHE FEELS CONSTIPATEDGU: FOLEY IN PLACE DRAINING CLEAR AMBER URINE IN SM AMTS DESPITE 2 U PRBC'S, BUN/CR RISING POST CATH AND WITH LOW BPNEURO/MS: A+O X3, SLEEPING IN NAPS THIS AFTERNOON, NO ISSUES W/ANXIETY THIS SHIFTSOCIAL: GRANDDAUGHTER IN MOST OF DAY, NOW DAUGHTER IN W/PT, FAMILY VERY INVOLVED IN CARE, UPDATED FREQUENTLY REGARDING PT CONDITIONA: REMAINS HYPOTENSIVE - ? urine lytes sent.po4 5.7, on tums.gi- abd soft w/bowel sounds. BECAME TRANSIENTLY HYPOTENSIVE SBP 60 (RESOLVED WITHOUT TREATMENT). neb rxs prn, none given.gu- creat up to 3.3. u/o inmproved to 15-23cc/hr. NURSING PROEGRESS NOTE 7P-7ANEURO: PT. Pt denies SOB, RR 12-21 O2 sats 93-99. pneumonia.p- follow resp status, creat. also s/b gi. a+o according to dtr. COOL NEB FOR 02 TO HELP LOOSEN SECRETIONS. S/P CVA ? Pt speaking, understands and speaks minimal English.CV: Pt HR 60 AV paced, NBP 71-87/32-38, MAPs 46-54, HO aware. assisted/encouraged to turn side to side with skin care q2-3hrs, does not stay far over on side hwever after repositioned. Tylenol with codeine given x 1.GU: Pt with poor u/o 6-35 cc/hr anber urine, HO aware, no increase in u/o see with fluid boluses. cooperative and pleasant.access- i iv leaking, 1 clotted off, unable to flush. Regular A-V sequential pacingSequence error: V2,V3 omittedPacemaker rhythm - no further analysisNo change from previous RIGHT GROIN C&D. ?swallowing eval. LUNGS WITH RALES IN UPPER AIRWAYS. A-V sequential paced rhythmNo change from previous A-V sequential paced rhythmNo change from previous A-V sequential paced rhythmNo change from previous S/P STENT PLACEMENT.P: MED FOR CONSTIPATION. ANXIOUS AT TIMES.CV: BP 64-78, GIVEN FLUID BOLUS 250 CC WITH MODERATE EFFECT. No dizziness, BP stable.Resp: sats 97% on 2L NC, LS with scattered rhonchi, congested cough, strong but not expectorating.ID: sputum with pseudomonas as well as staph auereous coag (+), placed on MRSA contact precautions. CCU NPN 7p-7aS: "Okay...Thank you. HCT 29.1GI: ABD SOFT HYPOACTIVE BOWEL SOUNDS, ATTEMPTED BM BUT NO RESULTS. send clot w/next bld draw. GIVEN TESSALON PERLESAND TYLENOL#3 FOR C/O HEADACHE AND GENERLIZED BODY PAIN. O2 SOURCE CHANGED TO COOL NEB 70% TO HELP LOOSE SECRETIONS. GIVEN LASIX 60 MG IVP WITH FAIR RESPONSE.A: S/P STENT TO LCX, POST PROCEEDURE CHEST DISCOMFORT WITH BLOODY EMESIS.P: FOLLOW HCT, LASIX IF NEEDED. MONITOR I/O. Attempted BM on commode without success.Soc: daughter, grandson in. c/o feeling of something stuck in esophagus. k-3.8, replaced with 40meq po x1. BUN/creat cont to rise from yesterday. "O: Please see careview for VS and additional data. Respiratory Care:The RN graciuosly said she will do NEBs today becauce of the high level of of RT activity elsewhere. AT TIMES DIFICULT TO COMMUNICATE WITH PT. DENIES C/O CP.RESP: C/O "UNABLE TO CATCH MY BREATH". Pt contines with non productive congested sounding cough. hct 31.2. no chest pain.resp- on 2l n/c sat 94-98. l/s coarse, few scat wheezes in am, none this pm. See careview for full assessment data, VS, and transfer note.pt alert and oriented times three. FOLLOW HCT. ETIOLOGY HYPOVOLEMIA VS INFECTION VS OTHER ETIOLOGYP: MONITOR BP - CONSIDER TRANSFUSION INSTEAD OF FURTHER FLUID BOLUSES W/HCT < 30, CONTINUE TYLENOL #3 FOR PLEURITIC TYPE CHEST PAIN/COUGH,CONT SUPPORT PT AND FAMILY. GIVEN DELSYM COUGH SYRUP WITH SOME RELIEF FROM COUGH.GU: URINE OUTPUT POOR. UO ~40cc/hr after fluid. A few minutes after the morphine pt states she feels much better. Updated by RN/MD.A/P: pt s/p cath with stent x2, worsening renal function post cath, choking episode, with hemoptysis, hypotension, now with MRSA, pseudomonas in sputum. Pt denies CP/SOB. CARDIAC VS GI. CCU NURSING 0700-1900 S/P CATH/STENTS. bp improved. FOLLOW LYTES. C/O MIDSTERNAL CHEST DISCOMFORT ? BUN 43 (was 33), creat 3.3 (was 2.7).Neuro: Pt denies pain, family at bedside for translation.GI: Pt abd soft, +BS x 4 no stool this shift. DAUGHTER IN ALL NOC. no bm.skin- butocks reddened, no breakdown. prob. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATAID: TEMP TO 101R - BC X2, SPUTUM SENT, WBC'S TO 15 FROM 5, LEVO IV STARTED, TYLENOL GIVENCV: PT CONTINUED TO C/O CHEST PAIN AS ABOVE THIS AM, STATS MSO4 DID NOT HELP - AM CPK FLAT, RECEIVED TYLENOL #3 1 TAB THEN REPEATED X1 AFTER PT TOLERATED IT WELL AND SYMPTOMS IMPROVED, PT SLEEPING THROUGHOUT AFTERNOON, WHEN WAKENED, A+O, DENIES FURTHER PAIN; HR REMAINS AV PACED AT 60, BP REMAINS LOW AT 75-107/30'S-60, RECEIVING MULTIPLE BOLUSES NS AND D5NS AT 100/HR, RESPONDING TO BOLUSES BRIEFLT THEN DECREASING TO 70'S AGAIN, PT BASELINE HYPERTENSIVE, W/BP 70/ PT W/O COMPLAINTS AND MENTATING WELL, BP CHECKED BY AUSCULTATION AND NBP BILATERALLY - ALL CORRELATE; NEGATIVE PULSUS PER CARDS FELLOWHEME: NO FURTHER WRETCHING OR HEMOPTYSIS; SERIAL HCTS 31.2 - 30.1 - 29.0, NO OBVIOUS SOURCE OF BLEEDING, NO ABDOMINAL PAIN OR BACK PAINRESP: LUNGS COARSE W/EXP WHEEZES, FREQUENT CONGESTED COUGHING IN AM - RECEIVED TYLNOL #3/TENSILLON PEARL THIS AM - NOW W/O COUGH WHILE ASLEEP, O2 AT 4L NC, SATS 96-100%, RR 12-14, RECEIVING Q 6HR NEBS W/GOOD RESULTSGI: GI FOLLOWING, CONTINUING PPI/NPO, NO STOOLGU: FOLEY DRAINING CLEAR YELLOW URINE ~ 20CC/HR, + 1750CC THUS FAR TODAYSOCIAL: DAUGHTER, GRANDDAUGHTER IN THROUGHOUT DAY, VERY ATTENTIVE TO PT, ASKING NUMEROUS QUESTIONS, RN ALSO SPOKE W/GRANDSON FROM STATE, ALL UPDATED REGARDING CONDITION AND PLAN OF CAREA: T SPIKE/^ WBC, CONGESTED COUGH, HX FOR POTENTIAL ASP PNEUMONIA NO EVIDENCE OF BLEED - HCT DECREASING W/^ FLUID INTAKE REMAINS HYPOTENSIVE - ?	20	[ { "category": "ECG", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 300940, "text": "A-V sequentially paced rhythm with capture. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 300941, "text": "A-V sequentially paced rhythm. Compared to the previous tracing of no\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300942, "text": "Regular A-V sequential pacing\nSequence error: V2,V3 omitted\nPacemaker rhythm - no further analysis\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300943, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300944, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 300945, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 300946, "text": "Regular A-V sequential pacing\nPacemaker rhythm - no further analysis\nSince previous tracing of same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 300947, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 300948, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479174, "text": "ccu npn\no-id- t max 99.2. c+s sputum shows pseudomonas and staph aureus coag pos. . pnd for staph aureus.\ncv- hr 60, 100%av paced, bp rarely 70s in early am, then 80s-low 90s, up to 108/ this pm. re'd 1 fluid bolus 500cc n/s in am over 1hr. k-3.8, replaced with 40meq po x1. hct 31.2. no chest pain.\nresp- on 2l n/c sat 94-98. l/s coarse, few scat wheezes in am, none this pm. no sob. neb rxs prn, none given.\ngu- creat up to 3.3. u/o inmproved to 15-23cc/hr. urine lytes sent.\npo4 5.7, on tums.\ngi- abd soft w/bowel sounds. taking meds ok, liquids ok. c/o heartburn/pain when tried to eat solids, unable to eat, ho informed. also s/b gi. no bm.\nskin- butocks reddened, no breakdown. has ecchymosis on r side from fall at home prior to admit and on arms esp. left. extremities edematous except for r arm. assisted/encouraged to turn side to side with skin care q2-3hrs, does not stay far over on side hwever after repositioned. has pneumoboots on.\nms- dtr interprets (pt speaks ). a+o according to dtr. cooperative and pleasant.\naccess- i iv leaking, 1 clotted off, unable to flush. ivs restarted x2 r hand and r lower arm, #20s, patent.\nsocial/teaching- dtr in all day, updated on pt's condition and plan, understands. dtr pt's stent card and info brochure.\na- s/p cath w/rising creatinine. bp improved. difficulty eating. prob. pneumonia.\np- follow resp status, creat. try soft diet. gi following, may need ugi. follow hct in am, fluid boluses as needed if bp drops. send clot w/next bld draw. enc. pt to turn side to side, ?oob when bp staying up.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479175, "text": "CCU NPN 3-11PM\nCV: HR 60 AV paced, BP 96-117/48, given 2 500cc NS fluid boluses this eve based on urine lytes showing dehydration and low UO. UO ~40cc/hr after fluid. Pt denies CP/SOB. transfer to chair, able to take a few steps, transferred from chair to commode and then back to bed. No dizziness, BP stable.\n\nResp: sats 97% on 2L NC, LS with scattered rhonchi, congested cough, strong but not expectorating.\n\nID: sputum with pseudomonas as well as staph auereous coag (+), placed on MRSA contact precautions. BC x 2 drawn prior to giving 1 gm Vanco IV. Prev BS's pnd. T 99.2-98.6.\n\nSkin: intact, bruise on lower R side of back d/t fall at home prior to adm.\n\nGI: ate few bites of pureed food, ice cream, taking fluids and pills without problem. c/o feeling of something stuck in esophagus. ?swallowing eval. Attempted BM on commode without success.\n\nSoc: daughter, grandson in. Updated by RN/MD.\n\nA/P: pt s/p cath with stent x2, worsening renal function post cath, choking episode, with hemoptysis, hypotension, now with MRSA, pseudomonas in sputum. Starting 14 day course Vanco, cont on Ceftaz and Cipro. Fluid bolused over past 24hrs for dehydration, BP improving. Cont to monitor, support pt/family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479167, "text": "NURSING PROGRESS NOTE\nS: \"I HAVE PAIN IN MY CHEST\"\n\nO: 85 Y/O RUSSIAN SPEAKING WOMAN ADMITTED FROM 3 S/P STENT PLACEMENT. AFTER EATING SMALL AMT OF DINNER SHE ? ASPIRAATED A PIECE OF AND STARTED A COUGHING FIT. SHE THEN VOMITED ~ 50 CC BRB. BECAME TRANSIENTLY HYPOTENSIVE SBP 60 (RESOLVED WITHOUT TREATMENT). SHE ALSO C/O MIDSTERNAL CHEST PAIN. TRANFERED TO CCU FOR CLOSE MONITORING. HCT STABLE AT 35.8. NO FURTHER EPISODES OF VOMITING.\n\nNEURO: PLEASANT AND COOPERATIVE, SPEAKS LITTLE ENGLISH, MAINLY RUSSIAN SPEAKING. DAUGHTER IN TO INTERPRET. MOVING ALL EXTREMITIES WELL. S/P CVA ? YEAR. NO DEFICIT NOTED.\n\nCV: AV PACED RATE 60. NO VEA NOTED. MAP DOWN TO 48-52. GIVEN 250 CC FLUID BOLUS. EKG SHOWS NO CHANGES. RIGHT GROIN C&D. + PEDAL PULSES. C/O MIDSTERNAL CHEST DISCOMFORT ? CARDIAC VS GI. GIVEN MSO4 3 MG IVP TOTAL AND 1 SL NTG WITH GRADUAL RELIEF FROM PAIN. COUGHING, C/O CHEST PAIN WITH COUGH.\n\nRESP; COUGHING AND RAISING THICK WHITE SPUTUM. LUNGS WITH RALES IN UPPER AIRWAYS. O2 SAT 96% ON 4L NC. GIVEN ALB/ATR NEB WITH SOME RELIEF FORM SOB. APPEARS MORE COMFORTABLE SINCE TREATMENT.\n\nGI: ABD SOFT, + BOWEL SOUNDS NO BM OVERNIGHT. NO FURTHER VOMITING.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE. GIVEN LASIX 60 MG IVP WITH FAIR RESPONSE.\n\nA: S/P STENT TO LCX, POST PROCEEDURE CHEST DISCOMFORT WITH BLOODY EMESIS.\n\nP: FOLLOW HCT, LASIX IF NEEDED. OFFER EMOTIONAL SUPPORT TO PT. AND FAMILY. KEEP POSTED ON PLAN OF CARE AS DISCUSSED WITH MEDICAL TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479168, "text": "Respireaotry Care:\nPatient treated with 2.5 mg albuterol/0.5 mg ipratropium bromide via aerosol mask. BS: slight expiratory wheez RUL, which cleared with the RX.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479171, "text": "CCU NURSING PROGRESS NOTE 0700-1900\nS. DENIES CHEST PAIN, C/O INTERMITTENT ABDOMINAL CRAMPINESS, STATES FEELS LIKE SHE NEEDS TO MOVE BOWELS\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP 98.9 -99.6 PO, CONTINUES ON LEVO - WBC 13\n\nRESP: SPUTUM FROM YESTERDAY 3+ GM NEG RODS - LUNGS COARSE W/EXP WHEEZES, DENIES SOB, RECEIVING ALBUTEROL NEBS, SATS ON R/A 89% - 92%, SATS ON 2L NC 95-98%; CONTINUES TO HAVE INTERMITTENT CONGESTED COUGH, LOOSE, MOSTLY NON-PRODUCTIVE, RECEIVED DELSYM X1, TYLENOL #3 X1\n\nCV: HR 60 AV PACED, BP REMAINS 70-80'S/SYSTOLIC - HCT 27.7 RECEIVED 1 UNIT PRBC'S - BP TO 90'S THEN DRIFTED BACK TO 70'S, 2ND UNIT HUNG AND INFUSING SLOWLY OVER 4 HOURS\n\nGI: ABDOMEN SOFT, INTERMITTENT CRAMPING DIET NPO TO CLEARS, TOLERATING SIPS H2O THUS FAR, NO STOOL BUT OCCAS STATES SHE FEELS CONSTIPATED\n\nGU: FOLEY IN PLACE DRAINING CLEAR AMBER URINE IN SM AMTS DESPITE 2 U PRBC'S, BUN/CR RISING POST CATH AND WITH LOW BP\n\nNEURO/MS: A+O X3, SLEEPING IN NAPS THIS AFTERNOON, NO ISSUES W/ANXIETY THIS SHIFT\n\nSOCIAL: GRANDDAUGHTER IN MOST OF DAY, NOW DAUGHTER IN W/PT, FAMILY VERY INVOLVED IN CARE, UPDATED FREQUENTLY REGARDING PT CONDITION\n\nA: REMAINS HYPOTENSIVE - ? HYPOVOLEMIA VS SEPSIS VS OTHER\n PROBABLE PNEUMONIA\n\nP: MONITOR BP, HR ASSESS HCT RESPONSE TO PRBC'S X2, INCREASE DIET TO CLEARS AND ASSESS TOLERATION, CONT MEDS FOR COUGH, NEBS AS NEEDED Q 6HR, FOLLOW BUN/CR, EMOTIONAL SUPPORT FOR PT/FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479172, "text": "Respiratory Care:\nThe RN graciuosly said she will do NEBs today becauce of the high level of of RT activity elsewhere. Thanks\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479173, "text": "CCU NPN 7p-7a\nS: \"Okay...Thank you.\"\n\nO: Please see careview for VS and additional data. Pt speaking, understands and speaks minimal English.\n\nCV: Pt HR 60 AV paced, NBP 71-87/32-38, MAPs 46-54, HO aware. 500 cc NS boluses given x 2 with no effect in BP. Pt received 2 units PRBCs during day shift, Hct this am 31.2, K 3.8. Pulses palpable.\n\nResp: Pt LS coarse with exp wheezes noted at bases and at times throughout, neb tx given. Pt denies SOB, RR 12-21 O2 sats 93-99. Pt contines with non productive congested sounding cough. Tylenol with codeine given x 1.\n\nGU: Pt with poor u/o 6-35 cc/hr anber urine, HO aware, no increase in u/o see with fluid boluses. BUN/creat cont to rise from yesterday. BUN 43 (was 33), creat 3.3 (was 2.7).\n\nNeuro: Pt denies pain, family at bedside for translation.\n\nGI: Pt abd soft, +BS x 4 no stool this shift. Pt taking clear liquids with encouragement.\n\nA/P: 85 y/o female continues with hypotension, received 500 NS fluid boluses x 2 with no effect in BP and u/o, increasing BUN/creat with poor u/o. Continue to monitor renal func and u/o, continue to monitor BP. Conitnue to monitor resp status and nebs tx. Continue to increase diet as tol. Continue to provide emotional support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1479176, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 60-62 AV paced BP 87-114/39-50 no fluid boluses over night\n\nResp: coarse BS with junky cough,nonproductive sats 96-99 on 2l NP.\n\nID: afebrile,cont on cipro and ceftaz,vanco x1 given last evening\n\nGU/Volume: uo 25-60/hr -265 since midnight,+4l LOS\n\nNeuro: alert and oriented,did not want to be wakened for am labs,wanted to keep sleeping.\n\nA/P: hemodynamically stable\n draw am labs\n to have PICC placed today for long course of abx\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1479177, "text": "See careview for full assessment data, VS, and transfer note.\npt alert and oriented times three. speaking but understands and speaks some english. Family in to see pt and translated things that she found difficult to explain. Family very supportive. LS rhoncii throughout continues on RA O2Sat 95-100%. Around 1:30 pt was eating lunch and complained of pain in chest accompanied by SOB. Telephoned daughter due to pt's request. Daughter said this is exactly what happend before. Pt told family that She feels that something is stuck and it is causing her pain and trouble breathing. Because of this and he inability to communicate her exact feelings she gets panicy. O2 sat continues to be 100% nebulizer treatment given for pt complaints of SOB. MD in to evaluate and said that she responded well to morphine the other day and that this is how she presented before here episode with hemoptosis. A few minutes after the morphine pt states she feels much better. WIll continue to monitor VS and for pain closely. No EKG changes and BP stable.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479169, "text": "CCU NURSING 0700-1900 S/P CATH/STENT\nS. C/O CHEST PAIN ACROSS CHEST, ^ W/COUGH, DEEP BREATHING\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP TO 101R - BC X2, SPUTUM SENT, WBC'S TO 15 FROM 5, LEVO IV STARTED, TYLENOL GIVEN\n\nCV: PT CONTINUED TO C/O CHEST PAIN AS ABOVE THIS AM, STATS MSO4 DID NOT HELP - AM CPK FLAT, RECEIVED TYLENOL #3 1 TAB THEN REPEATED X1 AFTER PT TOLERATED IT WELL AND SYMPTOMS IMPROVED, PT SLEEPING THROUGHOUT AFTERNOON, WHEN WAKENED, A+O, DENIES FURTHER PAIN; HR REMAINS AV PACED AT 60, BP REMAINS LOW AT 75-107/30'S-60, RECEIVING MULTIPLE BOLUSES NS AND D5NS AT 100/HR, RESPONDING TO BOLUSES BRIEFLT THEN DECREASING TO 70'S AGAIN, PT BASELINE HYPERTENSIVE, W/BP 70/ PT W/O COMPLAINTS AND MENTATING WELL, BP CHECKED BY AUSCULTATION AND NBP BILATERALLY - ALL CORRELATE; NEGATIVE PULSUS PER CARDS FELLOW\n\nHEME: NO FURTHER WRETCHING OR HEMOPTYSIS; SERIAL HCTS 31.2 - 30.1 - 29.0, NO OBVIOUS SOURCE OF BLEEDING, NO ABDOMINAL PAIN OR BACK PAIN\n\nRESP: LUNGS COARSE W/EXP WHEEZES, FREQUENT CONGESTED COUGHING IN AM - RECEIVED TYLNOL #3/TENSILLON PEARL THIS AM - NOW W/O COUGH WHILE ASLEEP, O2 AT 4L NC, SATS 96-100%, RR 12-14, RECEIVING Q 6HR NEBS W/GOOD RESULTS\n\nGI: GI FOLLOWING, CONTINUING PPI/NPO, NO STOOL\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE ~ 20CC/HR, + 1750CC THUS FAR TODAY\n\nSOCIAL: DAUGHTER, GRANDDAUGHTER IN THROUGHOUT DAY, VERY ATTENTIVE TO PT, ASKING NUMEROUS QUESTIONS, RN ALSO SPOKE W/GRANDSON FROM STATE, ALL UPDATED REGARDING CONDITION AND PLAN OF CARE\n\nA: T SPIKE/^ WBC, CONGESTED COUGH, HX FOR POTENTIAL ASP PNEUMONIA\n NO EVIDENCE OF BLEED - HCT DECREASING W/^ FLUID INTAKE\n REMAINS HYPOTENSIVE - ? ETIOLOGY HYPOVOLEMIA VS INFECTION VS OTHER ETIOLOGY\n\nP: MONITOR BP - CONSIDER TRANSFUSION INSTEAD OF FURTHER FLUID BOLUSES W/HCT < 30, CONTINUE TYLENOL #3 FOR PLEURITIC TYPE CHEST PAIN/COUGH,\nCONT SUPPORT PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479170, "text": "NURSING PROEGRESS NOTE 7P-7A\nNEURO: PT. ALERT AND ORIENTED X3. AT TIMES DIFICULT TO COMMUNICATE WITH PT. DUE TO COMMUNICATION BARRRIER. DAUGHTER IN ALL NOC. MOVING ALL EXTREMITIES. ANXIOUS AT TIMES.\n\nCV: BP 64-78, GIVEN FLUID BOLUS 250 CC WITH MODERATE EFFECT. AV PACING RATE 60, NO VEA NOTED. DENIES C/O CP.\n\nRESP: C/O \"UNABLE TO CATCH MY BREATH\". O2 SAT ON 4L NC 97%, EXP WHEEZES NOTED THROUGHOUT. GIVEN ALB/ATR NEBS X3. O2 SOURCE CHANGED TO COOL NEB 70% TO HELP LOOSE SECRETIONS. C/O INCREASED MUCOUS AT BACK OF THROAT. NT SUCTIONING DONE. SUCTIONED FOR SCANT AMT OF THICK WHITE SPUTUM. HAS LOOSE NON-PRODUCTIVE COUGH. GIVEN TESSALON PERLES\nAND TYLENOL#3 FOR C/O HEADACHE AND GENERLIZED BODY PAIN. GIVEN DELSYM COUGH SYRUP WITH SOME RELIEF FROM COUGH.\n\nGU: URINE OUTPUT POOR. 10-15 CC/HR. URINE AMBER COLORED. ? COULD BENEFIT FROM PRBC TO INCREASE RENAL PERFUSION. HCT 29.1\n\nGI: ABD SOFT HYPOACTIVE BOWEL SOUNDS, ATTEMPTED BM BUT NO RESULTS. C/O RIGHT LOWER ABD PAIN. WILL NEED MED FOR CONSTIPATION.\n\nID: AFEBRILE WBC 13.3 CONT ON LEVAQUIN PO.\n\nA: RESP DISTRESS, CONGESTED. S/P STENT PLACEMENT.\n\nP: MED FOR CONSTIPATION. COOL NEB FOR 02 TO HELP LOOSEN SECRETIONS. FOLLOW LYTES. MONITOR I/O. FOLLOW HCT. UPDATE FAMILY ON PLAN OF CARE.\n" } ]
13,447	142,464	1. Respiratory. He has had no issues. 2. Cardiovascular. He has had no issues. 3. Fluid and electrolytes. Initial D stick on admission was 27. Infant started on intravenous fluid of D10W at 80 cc/kg/day. Followup blood sugar was 127. Remainder of blood sugars throughout hospital course have been greater than 60. Infant was initially begun on 24 calorie formula, and weaned off of IVF by early morning on . On , infant was transitioned from Enfamil 24 to Enfamil 20, and continued with adequate intake and stable blood sugars. Infant is currently ad lib feeding Enfamil 20 formula. Birth weight was 3040 grams; weight at discharge is 2975 gm. 4. Gastrointestinal. Bilirubin on day of life 3 was 10.3/0.4; repeat on day of life 4, day of discharge, was 10.2/0.4. 5. Hematology. Initial hematocrit was 66.6. He was followed closely for concerns about symptomatic polycythemia. Hct gradually decreased, to 65 by day of life #3 and 64 on day of life #4, the day of discharge. With normalized blood sugars, stable hematocrit, and no other evidence of symptoms of polycythemia, no other intervention was pursued. 6. Infectious disease. WBC and blood culture were obtained prior to discharge because of maternal GBS colonization and less than 4 hours of antepartum antibiotics. Repeat CBC was obtained on admission to the newborn intensive care unit, and the infant has otherwise been without issues or concerns for infectious disease. WBC was unremarkable on both occasions. 7. Neurologic. The infant had toxicology screen in light of jittery presentation to the newborn intensive care unit. Toxicology screen was negative. Symptoms resolved. 8. Sensory. Audiology - Hearing screen was performed with automated auditory brainstem responses, and the infant passed both ears.	Taking E24.Dsticks AC, wnl this shift.. Abd exam benign. Belly benign, voiding and stooling heme neg.D/S 86 (4th Dstik in a row >60), notified NNP, advised toreduce frequency in monitoring to once per shift. Infant's ivf weaned this shift and are nowheplocked. Dstiks stable off IVF on E20 ad lib feeding. abd benign, +BS, noloops or distention, vdg/stlg qs. NO contact from overnight.Continue to support as they prepare for infant'sd/c. NPN 7p-7aFen: Rec infant on ivf 80cc/kg of d10w and po'ing adlib e24with 3hr minimum. Abdomen benign of 24 cal.Lytes in good range. NPN#1 Infant received on q3h feeds of Enf 24, ad lib vol. Piv initiated as well as infant po fed enfe 24 cal. A: DS stable this shift.P: ? I have placed EIP & VNA options in record. Updated at bedside. Cont to support andupdate. Hct stable, mildly elevated.PLANS:- Now on 20 cals, continue, monitor dstiks.- Repeat bili, Hct in am.- Possible d/c tomorrow if stable.- Discharge planning. To postpartum floor for further care; will be on service (primary care to be at Peds). Temps stable in OAC. ad lib E20, taking 75-95ccovernight. Comfortable appearing.Wt 2870 down 125. Nursing Progress Note1. NeonatologyDoing well. Last dstik 85 (on 24 cals). Voiding/stooling.GI: Bili 10.2/0.4 (unchanged).HEME: Hct 63.4 today.DEV: In crib.RHCM: Received Hep B, passed hearing screen, PKU sent.IMP: Former 37 wk infant with hx hypoglycemia, polycythemia, doing well. Neonatology-NNP Progress NotePE: Remains in room air, bbs cl=, rrr s1s2no murmur, abd sfot, nontender, V&S, afos, activeSee attending note for plan Crit this am: 63.4.Continue to support needs.3. Bili thisam: 10.2/0.4 (down from 10.3).Continue to monitor DS and, feeding tolerance and intake.2. Maternal abx given <4hrs PTD. P- Cont to assess for FEN needs.#2-O/A- Infant cont to be awake and active with clustercares q3hrs. Nursing Progress Note#1-O/A- Infant feeding ad lib volume q3hrs. Current wt 2975gms (+25). See ccc for am lytes. Blood glucose done @ 3hrpostparandial 61. Ad lib feeding, 75-95 cc E20 q feed. Feeding ad lib, switched from E24 to E20 this morning. Examined by MD, to transfer to NBN. EDC -- 38+ wks. Previous jitteriness most likely related to hypoglycemia or matrenal meds.COntinue as at present. Neuro exam non focal and age appropriate.Hct down to 65.7 this am. Appropriate & symmetric tone & activity. Fed and changed infant.P- Cont to enc parental calls and visits.See flowsheet for further details. Off IVF since 4 am yesterday.HEME: Hct 66 this am (stable).GI: Bili 10.8/0.4.IMP: Term infant with hx hypoglycemia and mild polycythemia, doing well. Dadfeed infant. Bottling 30-45ccq3hrs. Dsticks thus far were 78-120. HR 130s, RR 30s. Will follow closely.Parents updated fully on baby's status and treatment.cbc and blood culture from yesterday reassuring - risk of sepsis appears to be low. Alert/active, waking for feedsq4hrs. Cont tosupport developmental milestones.Parenting: Mom and Dad into visit. Dstiks stable on 24 cals, now trying 20 cals. Med-lg spit x2. Will need referral faxed to above # at d'c. Taking ad lib demand. Temp stable inopen crib. Hemodynamically stable, no murmur.FEN: Wt 2950, up 75 grams. P- Cont toassess for G&D needs.#3-O/ Dad in to visit with updates given. IV fluids to be weaned gradually as tolerated.Polycythemia is mild - will recheck Hct tomorrow or if blood sugars fall to determine potential need for parital exchange transfusion.Maternal treatment with Prozac noted - high pitched cry/initially noted irritability may be related. Baby took 45cc and was allowedto go to q4h feeds, at 01:00 feed, glucose 74, infant took50cc E24, and took 50cc at 05:00 feed. AFOF, molding, minimal caput. Called x1 for update. Active bs. Ca Nl.BS have been in good range.Clincally stable. Feeds changed to E20 @ 0900. Hemodynamically stable.FEN: Wt 2975, up 25 grams. Well coordinated with pofeeds. Bili appropriate.PLANS:- D/C today.- F/U with PMD later this week, VNA this week.- Continue ad lib E20 feeding. Not on abx.Not jittery this am. Remains in RA. Repeated in one hour 79 glucometer, 74serum sent to lab. VSS, D/S 55, had small spit of formula (confirmed feed on L&D with transferring nurse admission). Dstik 86 overnight. Tryingto obtain urine specimen.Dev: Temp stable on weaning servo warmer. Voiding with eachdiaper change. No other risk factors for sepsis; afebrile, ROM <2 hrs PTD. Hips stable. NeonatologyDOL #3, CGA 39 wks.CVR: Remains in RA, no spells, no desats. Loving andinvolved. Neonatology TriageAsked to evaluate pt by Dr for sepsis risk.Mom is 31yo G1 P0-1 with unremarkable PNS except GBS positive. Report of sepsis eval for gbs positive Mom. Apgars 8&9; BBO2 only.Baby is 3040g AGA male, well-appearing. P: cont to support and inform. NeonatologyDOL #4, CGA 37 wks.CVR: Remains in RA, no spells, no desats. SVD. Hct still generous but stable to decreasing. Infant's 02 sats 98-100%.Urine bag for toxic screen with no void as of this writing. NPN 1900-07001. Likes pacifier. IV was placed and IV dextrose was initiated at 80 ml/kg/day.Blood sugar from the lab was 45.PE - Alert, slightly high pitched cry but easily consoled.VS - T 98.1 HR 121 RR 42 BP 67/35 47Skin - area of erythema noted on chinHEENT - AF soft and flat, palate intact, Eyes - RR normal bilaterallyResp - lungs clear and equal, breathing very comfortablyCVS - S1 S2 normal intensity, no murmurAbd - soft flat, no distension or organomegalyGU - normal male, foreskin slightly incomplete - urethral opening appears to be normally placed, testes palpable bilaterallyNeuro - jittery on admission - less so on follow-up exam, tone movement symmetricalLabs - FU blood sugar 45, Hct 67.5% plat 198,000Assessment/plan:Term male infant with hypoglycemia and mild polycythemia.Will continue with close monitoring of blood sugar and treat with IV fluids. All in agreement w/plan. Abd soft. Dr. examined infant. At21:00 feed, glucose level 85. GU with testes down bilaterally, somewhat short foreskin. Both parents in for much of day, doing most of care.Discharge teaching done.	16	[ { "category": "Nursing/other", "chartdate": "2176-08-02 00:00:00.000", "description": "Report", "row_id": 1869449, "text": "Neonatology Triage\nAsked to evaluate pt by Dr for sepsis risk.\n\nMom is 31yo G1 P0-1 with unremarkable PNS except GBS positive. EDC -- 38+ wks. No other risk factors for sepsis; afebrile, ROM <2 hrs PTD. Maternal abx given <4hrs PTD. SVD. Apgars 8&9; BBO2 only.\n\nBaby is 3040g AGA male, well-appearing. HR 130s, RR 30s. Pink with minimal acrocyanosis. AFOF, molding, minimal caput. Lungs CTA, no rtx. Heart rrr without murmur. Abd soft without HSM or masses. Hips stable. GU with testes down bilaterally, somewhat short foreskin. Spine straight without defects. Appropriate & symmetric tone & activity. Passed meconium while in .\n\nImp/ asymptomatic term infant at risk for sepsis due to maternal GBS colonization with antibiotics given <4hrs prior to delivery.\n\nPlan/ CBC/diff, Bcx sent. To postpartum floor for further care; will be on service (primary care to be at Peds). No antibiotics unless indicated by CBC or Bcx results.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-03 00:00:00.000", "description": "Report", "row_id": 1869450, "text": "Nrsg Admission Note-0700-1900\nBaby admitted at 1740 for glucose of 27 at 1700. Report of sepsis eval for gbs positive Mom. Infant jittery with glucose (central sent to the lab) at 1750. D stix with no result from glucometer. Piv initiated as well as infant po fed enfe 24 cal. Dr. examined infant. Face with rash areas on chin. Infant's 02 sats 98-100%.Urine bag for toxic screen with no void as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-03 00:00:00.000", "description": "Report", "row_id": 1869451, "text": "Neonatology Attending Admission Note\n\nBaby - ( ) is a 38 week gestation infant admitted to the for evaluation because of hypoglycemia.\n\nPediatrician - Dr. - Pediatrics\n\nMother is 31 old G1 P0-1.\nPregnancy was uncomplicated with the exception of maternal medication with Prozac 30mg/d for depression.\n\nPNS - O pos, HBSAg neg, RPR NR, RI, GBS positive.\n\nRupture of membranes was less than 24 hours prior to admission.\n\nBaby was at 9:40 AM on so is now 34 hours of life.\nThe baby was admitted briefly to the for a sepsis evaluation after birth because of maternal GBS colonization and treatment with antenatal antibiotics only 2 hours PTD.\ncbc - wbc 16,700 diff 48P 2B 30L 15nrbcs Hct 66.6% Plat 228,000\nBlood sugar was 55 at that time.\nBaby was doing well in the Newborn Nursery - bottle feeding -\n1 oz every 2 hours. Baby was noted to be jittery at 5PM and was transferred to the after a heelstick Dstix was 27.\n\nOn admission to the baby was noted to be very jittery and a venous blood sugar was sent to the lab. IV was placed and IV dextrose was initiated at 80 ml/kg/day.\n\nBlood sugar from the lab was 45.\n\nPE - Alert, slightly high pitched cry but easily consoled.\nVS - T 98.1 HR 121 RR 42 BP 67/35 47\nSkin - area of erythema noted on chin\nHEENT - AF soft and flat, palate intact, Eyes - RR normal bilaterally\nResp - lungs clear and equal, breathing very comfortably\nCVS - S1 S2 normal intensity, no murmur\nAbd - soft flat, no distension or organomegaly\nGU - normal male, foreskin slightly incomplete - urethral opening appears to be normally placed, testes palpable bilaterally\nNeuro - jittery on admission - less so on follow-up exam, tone movement symmetrical\n\nLabs - FU blood sugar 45, Hct 67.5% plat 198,000\n\nAssessment/plan:\nTerm male infant with hypoglycemia and mild polycythemia.\nWill continue with close monitoring of blood sugar and treat with IV fluids. IV fluids to be weaned gradually as tolerated.\n\nPolycythemia is mild - will recheck Hct tomorrow or if blood sugars fall to determine potential need for parital exchange transfusion.\n\nMaternal treatment with Prozac noted - high pitched cry/initially noted irritability may be related. Will follow closely.\n\nParents updated fully on baby's status and treatment.\n\ncbc and blood culture from yesterday reassuring - risk of sepsis appears to be low.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869452, "text": "NPN 7p-7a\n\n\nFen: Rec infant on ivf 80cc/kg of d10w and po'ing adlib e24\nwith 3hr minimum. Infant's ivf weaned this shift and are now\nheplocked. Dsticks thus far were 78-120. Bottling 30-45cc\nq3hrs. Abd soft. Active bs. Yellow stool. Voiding with each\ndiaper change. Med-lg spit x2. See ccc for am lytes. Trying\nto obtain urine specimen.\n\nDev: Temp stable on weaning servo warmer. Infant is alert\nremains jittery with activity. Well coordinated with po\nfeeds. Likes pacifier. Sleeps well between cares. Cont to\nsupport developmental milestones.\n\nParenting: Mom and Dad into visit. Updated at bedside. Dad\nfeed infant. Called x1 for update. Cont to support and\nupdate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869453, "text": "1 Fen:\n2 Dev:\n3 Parents:\n\nREVISIONS TO PATHWAY:\n\n 1 Fen:; added\n Start date: \n 2 Dev:; added\n Start date: \n 3 Parents:; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869454, "text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 2870 down 125. Taking ad lib demand. Abdomen benign of 24 cal.\nLytes in good range. Ca Nl.\n\nBS have been in good range.\n\nClincally stable. Not on abx.\n\nNot jittery this am. Neuro exam non focal and age appropriate.\nHct down to 65.7 this am. Given asx nature will not require rx. Previous jitteriness most likely related to hypoglycemia or matrenal meds.\n\nCOntinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869461, "text": "NPN 1900-0700\n\n\n1. Current wt 2975gms (+25). ad lib E20, taking 75-95cc\novernight. Belly benign, voiding and stooling heme neg.\nD/S 86 (4th Dstik in a row >60), notified NNP, advised to\nreduce frequency in monitoring to once per shift. Bili this\nam: 10.2/0.4 (down from 10.3).\nContinue to monitor DS and, feeding tolerance and intake.\n\n2. Temps stable in OAC. Alert/active, waking for feeds\nq4hrs. AFSF. Crit this am: 63.4.\nContinue to support needs.\n\n3. NO contact from overnight.\nContinue to support as they prepare for infant's\nd/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869462, "text": "Neonatology\nDOL #4, CGA 37 wks.\n\nCVR: Remains in RA, no spells, no desats. Hemodynamically stable.\n\nFEN: Wt 2975, up 25 grams. Ad lib feeding, 75-95 cc E20 q feed. Dstik 86 overnight. Voiding/stooling.\n\nGI: Bili 10.2/0.4 (unchanged).\n\nHEME: Hct 63.4 today.\n\nDEV: In crib.\n\nRHCM: Received Hep B, passed hearing screen, PKU sent.\n\nIMP: Former 37 wk infant with hx hypoglycemia, polycythemia, doing well. Dstiks stable off IVF on E20 ad lib feeding. Hct still generous but stable to decreasing. Bili appropriate.\n\nPLANS:\n- D/C today.\n- F/U with PMD later this week, VNA this week.\n- Continue ad lib E20 feeding.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869463, "text": "Case Management Note\nReferral to Care Group VNA (/fax ) and have set up home visit for Wednesday . Will need referral faxed to above # at d'c. All in agreement w/plan.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-02 00:00:00.000", "description": "Report", "row_id": 1869448, "text": " Nursing Admission/Transfer Note:\n Admitted baby boy to warmer from L&D for sepsis evaluation (see MD note). Infant is pink, LS = and clear, no murmur heard. CBC w/diff and blood culture sent and is pending. VSS, D/S 55, had small spit of formula (confirmed feed on L&D with transferring nurse admission). Infant resting comfortably at present. Examined by MD, to transfer to NBN.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869455, "text": "Nursing Progress Note\n\n\n#1-O/A- Infant feeding ad lib volume q3hrs. Taking E24.\nDsticks AC, wnl this shift.. Abd exam benign. Voiding and\nstooling. P- Cont to assess for FEN needs.\n#2-O/A- Infant cont to be awake and active with cluster\ncares q3hrs. Sleeps well between cares. Temp stable in\nopen crib. Little to no jitteriness noted. P- Cont to\nassess for G&D needs.\n#3-O/ Dad in to visit with updates given. Loving and\ninvolved. Appropriate questions. Fed and changed infant.\nP- Cont to enc parental calls and visits.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869456, "text": "Neonatology-NNP Progress Note\n\nPE: Remains in room air, bbs cl=, rrr s1s2no murmur, abd sfot, nontender, V&S, afos, active\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869457, "text": "NPN\n\n\n#1 Infant received on q3h feeds of Enf 24, ad lib vol. At\n21:00 feed, glucose level 85. Baby took 45cc and was allowed\nto go to q4h feeds, at 01:00 feed, glucose 74, infant took\n50cc E24, and took 50cc at 05:00 feed. abd benign, +BS, no\nloops or distention, vdg/stlg qs. A: DS stable this shift.\nP: ? decrease cals today.\n#2 stable in open crib, waking for feeds, calm with cares,\nsleeps well between, sucks some on pacifier. A: AGA P: cont\nto support development\n#3 mom and dad here for 21:00 and 05:00 feeds, dad handles\nbaby quite independently, mom sl less confident. asking many\nquestions about possible discharge, sugar levels etc. A:\nloving, involved family. P: cont to support and inform.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869458, "text": "Case Management Note\nChart has been reviewed and events noted. I have placed EIP & VNA options in record. I will be providing clinial updates to HMO Blue insurance and will cont to follow for any d'c planning needs along with family & team.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869459, "text": "Neonatology\nDOL #3, CGA 39 wks.\n\nCVR: Remains in RA, no spells, no desats. Hemodynamically stable, no murmur.\n\nFEN: Wt 2950, up 75 grams. Feeding ad lib, switched from E24 to E20 this morning. Taking 50-55 cc/feed. Last dstik 85 (on 24 cals). Off IVF since 4 am yesterday.\n\nHEME: Hct 66 this am (stable).\n\nGI: Bili 10.8/0.4.\n\nIMP: Term infant with hx hypoglycemia and mild polycythemia, doing well. Dstiks stable on 24 cals, now trying 20 cals. Hct stable, mildly elevated.\n\nPLANS:\n- Now on 20 cals, continue, monitor dstiks.\n- Repeat bili, Hct in am.\n- Possible d/c tomorrow if stable.\n- Discharge planning.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869460, "text": "Nursing Progress Note\n\n\n1. Feeds changed to E20 @ 0900. Blood glucose done @ 3hr\npostparandial 61. Repeated in one hour 79 glucometer, 74\nserum sent to lab. Eating well q4 hr ad lib amounts taking\n50-105cc.\n\n2. Holding temp well in open crib. Awake and alert for\nfeeds, feeding well.\n\n3. Both parents in for much of day, doing most of care.\nDischarge teaching done. Circumcision being arranged.\nPediatrician appointment to be made by parents.\n\n\n" } ]
72,483	162,745	Patient was admitted to the in the context of evolving dyspnea secondary to terminal cancer. The family immediately decided to make the patient's treatment priority comfort measures. The decision was accepted by the medical staff. The patient was made comfortable with Morphine and outpatient home hospice was arranged. It was the wish of the family to have the patient transferred home as soon as possible. The patient's discharge was accelerated once his comfort on Morphine was assured.	HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Hypotension/Acute Renal failure: Both have resolved. Support to family Renal failure, acute (Acute renal failure, ARF) Assessment: Creat 1.1, Action: Lasix 10 mg IV Response: >2L out but remains hypoxic Plan: Gaols of care comfort and gettinh Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Assessment and Plan HYPOTENSION (NOT SHOCK) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ANXIETY HYPOXEMIA ANEMIA THROMBOCYTOPENIA Patient's dyspnea is likely multifactorial with anemia, hypoxemia, acidemia, restrictive lung disease from pleural mets and probably lymphangitic tumor. 24 hr nursing Cont fentanyl patch.. Assess resp status/distress. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Respiratory failure, acute (not ARDS/) Assessment: Pt tachypneic in 30s, on 100% NRB, desats to 78-79% with turns/effort, anxious Action: Remains on NRB. - Tx plt if <20 - hct/plt - consider heme c/s if still low and concern for TTP 4. - Tx plt if <20 - hct/plt - consider heme c/s if still low and concern for TTP 4. - hepatitis serologies - repeat LFTs - Likely do CT torso ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 10:17 PM 20 Gauge - 10:17 PM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU Brought in with hypoxemia with altered mental status in the recent past and low-grade hemoptysis. Brought in with hypoxemia with altered mental status in the recent past and low-grade hemoptysis. Hold clonazapam & morphine for increased somnolence, MS changes, R <10 Renal failure, acute (Acute renal failure, ARF) Assessment: Creat 1.1, Action: Response: Plan: Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. DNR/DNI 64M NSCLC (/) c/b metastasis and ? Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. Hypotension/Acute Renal failure: Both have resolved. s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , the rightventricular cavity is more dilated with more prominent free hypokinesis.The estimated pulmonary artery systolic pressure is slightly higher.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal aortic diameter at the sinus level. RUQ us unremarkable per prelim read making concern for malignancy less likely. Mild to moderate [+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. HypoxiaHeight: (in) 73Weight (lb): 260BSA (m2): 2.41 m2BP (mm Hg): 117/74HR (bpm): 90Status: InpatientDate/Time: at 10:10Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Hypodensities in the periventricular and subcortical white matter reflect chronic microvascular ischemic change, not significantly changed from . Noresting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. Left-sided pleural disease is again noted with a dominant area of pleural thickening in the left upper hemithorax relatively unchanged from the previous examinations. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. FINAL REPORT CHEST RADIOGRAPH INDICATION: Worsening hypoxia. Hypoxia/Malignancy: Continues. The right atrial pressure is indeterminate.There is mild symmetric left ventricular hypertrophy with normal cavity sizeand global systolic function (LVEF>55%). Areas of fibrosis are again noted within the right lower lung laterally with unchanged area of pleural thickening in the right upper hemithorax. Pt now with Increased work of breathing and on SL morphine as pt has no IV access. Pt now with Increased work of breathing and on SL morphine as pt has no IV access. Pt has had worse hypoxia overnight.	49	[ { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429253, "text": "HX NSCLA P/W SOB, hypotension. Pt reports SOB 7-10 days PTA, worse\n 2days PTA.\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429256, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die.\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n Plan:\n Clonapin 0.5mg started\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. Repeat\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429239, "text": "Chief Complaint: Respiratory distress, hypoxemia, acute renal failure,\n hypotension, acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n In MICU, dyspnea has persisted. Patient has required NRB mask to\n maintain O2 sats in 90's. Afebrile overnight. On antibiotics for\n possible pulmonary infection. Transfused 2 units of PRBC's and given\n fluids with improved blood pressure.\n Received Haldol for anxiety with some improvement.\n Creatinine improving.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 AM\n Levofloxacin - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.1\nC (97\n HR: 92 (87 - 101) bpm\n BP: 117/74(84) {91/33(45) - 181/164(168)} mmHg\n RR: 27 (21 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 3,000 mL\n 1,123 mL\n PO:\n 250 mL\n TF:\n IVF:\n 518 mL\n Blood products:\n 300 mL\n 355 mL\n Total out:\n 100 mL\n 1,600 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Moderate\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ,\n No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds: No(t) Clear\n : , Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished:\n , No(t) Absent : , No(t) Rhonchorous: ), Scattered rales anterior and\n posterior\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: 2+ edema, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 20 K/uL\n 122 mg/dL\n 3.1 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 93 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n 12:44 AM\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:464 mg/dL,\n Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:5.1 mg/dL\n Imaging: CXR: pleural mets. Increased interstitial markings at the\n bases.\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n HYPOXEMIA\n ANEMIA\n THROMBOCYTOPENIA\n Patient's dyspnea is likely multifactorial with anemia, hypoxemia,\n acidemia, restrictive lung disease from pleural mets and probably\n lymphangitic tumor. Renal function is improving - renal failure likely\n due to intravascular volume depletion. Treating possible pneumonia with\n antibiotics. Patient to have LENI's to assess for DVT - possible PE.\n Patient being transfused for his anemia (likely due to chemo; possible\n contribution from low level GI bleed). Will begin opiates for dyspnea\n with morphine; consider fentanyl patch.\n Platelet count down with chemo. No CNS bleed. Monitoring counts.\n LFT's elevated. Will assess with RUQ ultrasound. Hepatitis serology\n pending.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2196-01-13 00:00:00.000", "description": "ICU Event Note", "row_id": 429295, "text": "Clinician: Attending\n Patient remains tachypneic and dyspneic with O2 sat in mid-90's on 100%\n NRB mask. Patient has been transfused 2 units of PRBCs without change\n in hct. No blood per rectum and no melena.\n Long discussion with patient and his wife about his prognosis and his\n desires. Patient has indicated that he does not want to be intubated\n and does not want CPR. Team notified.\n He is also expressing that he does not want further chemo after he gets\n past the acute events of this hospitalization. Mrs. is having\n difficulty accepting his expressed wishes at this time. Staff offering\n support.\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429552, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\nd lasix\n 10mg IV x1 on previous shift and voided ~2L. Arousing to stimulation\n but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Family has been at pt\ns bedside t/o the night.\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429205, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429207, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429208, "text": "Hypotension (not Shock)\n Assessment:\n Sbp stable 96-130/\n Action:\n Transfused with total 2 units prbc\ns and hydrated with ns.\n Response:\n Stable. No decline in bp below 96/\n Plan:\n Monitor bp and vs . check hct post transfusion this am\n Anxiety\n Assessment:\n Anxious, expressing fear .no sleep\n Action:\n Haldol .5 mg iv times three with little effect. Pt requested wife to\n come back. Pt did call wife and she will be in early this am she is\n enroute\n Response:\n Hadol dose ineffective in redusing anxiety\n Plan:\n Discuss anxiety with doctors. Perhaps and increased dose or alternative\n medication for anxiety\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp rate 26-30\ns. Desats to 80\ns with any activity. It takes ~ 5 -10\n minutes for pt to recover from the drop in sats. HE needs a lot of\n encouragement to avoid panic.\n Action:\n NRB\n tried 100 % cool aerosol. Pt desaturated.to 88 %\n Response:\n Sats ~ 93 -95 % on NRB at rest\n Plan:\n Encourage pt to limit his activity.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinin3 4.3 in ed . improved to 3.1 k =4.7\n .\n Action:\n Check K with am hct and treat if elevated with kexelate 15 gm as\n ordered.\n Response:\n Plan:\n Check K.\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429460, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03.\n Pt DNR/DNI\n Events: CPAP trial. Sats 70\ns on 100%NRB & 6L NP. Unable to obtain IV\n access or bedside PICC.\n Family meeting with focus on getting pt home with hospice if possible\n and possibly 24 hr nursing.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 45 minutes first trail, 3.5 hrs second trial. Lasix 10\n mg IV x1\n Response:\n Sats up to mid 90\ns with second CPAP trail but now 70\ns on 100% NRB &\n 6L NP. >2L out with lasix but remains hypoxic\n Plan:\n Goals of care are to keep comfortable. CPAP for comfort\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapem\n Plan:\n * palliative care consult re: Transferring pt to home with palliative\n care consult & ? 24 hr nursing\n Cont fentanyl patch.. Assess resp status/distress. SL morphine sulfate\n as pt does not IV access.\n Support to family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Lasix 10 mg IV\n Response:\n >2L out but remains hypoxic\n Plan:\n Gaols of care comfort and gettinh\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429463, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03.\n Pt DNR/DNI\n Events: CPAP trial. Sats 70\ns on 100%NRB & 6L NP. Unable to obtain IV\n access or bedside PICC.\n Family meeting with focus on getting pt home with hospice if possible\n and possibly 24 hr nursing.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 45 minutes first trail, 3.5 hrs second trial. Lasix 10\n mg IV x1\n Response:\n Sats up to mid 90\ns with second CPAP trail but now 70\ns on 100% NRB &\n 6L NP. >2L out with lasix but remains hypoxic\n Plan:\n Goals of care are to keep comfortable. CPAP for comfort\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapam\n Plan:\n * palliative care consult re: Transferring pt to home with palliative\n care & ? 24 hr nursing\n Cont fentanyl patch. Assess resp status/distress. SL morphine sulfate\n as pt does not IV access.\n Support to family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Lasix 10 mg IV\n Response:\n >2L out but remains hypoxic\n Plan:\n Goals of care are comfort and getting pt home\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429356, "text": "DNR/DNI\n Pt intermittently very anxious but slept fot 1-2hr periods off and on\n after 2300.\n ST w/HR 102 to 110\ns t/o shift, blood pressures stable.\n Continues to void in urinal w/ >400cc per void\n Lost IV access in R hand, PIV in L a/c patent.\n AM labs pending, pt difficult to draw\nwas able to obtain labs from vein\n near L index finger\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt tachypneic in 30\ns, on 100% NRB, desats to 78-79% with turns/effort,\n anxious\n Action:\n Remains on NRB. Morphine 3mg IV x2, klonopin as ordered, encouraged\n slow, deep breathing\n Response:\n Good response to morphine/klonopin admin: Pt had some calm periods of\n rest/sleep as noted above with sats in low 90\ns however, desats to\n 82-85% when voiding. Also continues to experience periods of\n spontaneous tachypnea with desat to 88-89%.\n Plan:\n IV abx as ordered, morphine IV prn. Suggest foley placement if pt will\n allow. Pastoral and or SW consult appropriate\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429353, "text": "DNR/DNI\n Pt intermittently very anxious but slept fot 1-2hrs off and on after\n 2300.\n ST w/HR 102 to 110\ns t/o shift, blood pressures stable.\n Continues to void in urinal w/ >400cc per void\n Lost IV access in R hand, PIV in L a/c patent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt tachypneic in 30\ns, on 100% NRB, desats to 78-79% with turns/effort,\n anxious\n Action:\n Remains on NRB. Morphine 3mg IV x2, klonopin as ordered, encouraged\n slow, deep breathing\n Response:\n Good response to morphine/klonopin admin: Pt had some calm periods of\n rest/sleep as noted above with sats in low 90\ns however, desats to\n 82-85% when voiding. Also continues to experience periods of\n spontaneous tachypnea with desat to 88-89%.\n Plan:\n IV abx as ordered, morphine IV prn\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429289, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K 6.3, crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity and immediately when mask off.. Afeb. On\n vanco, levoflox, ceftriaxone.\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats.. F/U results of studies. Follow temp, WBC. Cont\n antibiotics. Contact precautions for HX MRSA. Ruling out flu\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphine 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water & C/L\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance. Adjust antibiotics to renal function.\n After discussion with pt Dr. , pt & pt\ns wife a decision\n was made to make pt DNR.\n Crit 22.7 after unit PRBC\ns (two total). Plts unchanged at 21K. No\n evidence of active bleeding. Crit from 1800 pnd.\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429178, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n Mr. is a 64 yo M with metastatic lung cancer who presents with\n acute worsening of his dyspnea over the last 2 days. They note that\n while in the last 7 days he has had persistent mental status changes\n thought secondary to an increase in oxycontin. As well over the last\n few days he has had poor PO intake and nausea. He has been more\n hypoxic and has had episodes of shortness of breath. And the home 02\n monitor showed 02 sats in the 70-80s despite being on his home 02 of\n liters.\n .\n In the ED, the patient was initially found to be hypotensive with\n Initial vitals were 82/46, HR 80 02 sat 95% NRB. He was given a total\n of 2L NS and 1 U PRBCs. Additionally, Zosyn and vancomycin were given\n and IV insulin, D 50 and calcium gluconate for a k of 6.1. He was\n guaiac positive.\n .\n Upon arrival to the floor, the patient was found to be tachypnec and\n anxious with periodic hypoxia but without significant pain. He denied\n any recent nausea, vomiting, fever, chills, chest pain (other than rib\n pain). He did have some episodes of dizziness when he had low oxygen\n saturations. He had no syncope or presyncope. A CT scan of the head\n was performed and negative. CTA was deferred given renal failure.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n orthopnea, PND, urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS per last note:\n AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg\n Tablet - 1 Tablet(s) by mouth daily\n CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 0.5 mg\n Tablet - 1 Tablet(s) by mouth twice a day\n DEXAMETHASONE - 4 mg Tablet - 2 tabs Tablet(s) by mouth \n beginning 24 hrs prior to chemo Take for 3 days//6 doses\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider)\n - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth\n once daily\n FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth Twice daily\n LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain\n METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1\n Tablet(s) by mouth twice a day\n OXYCODONE [OXYCONTIN] - 10 mg Tablet Sustained Release 12 hr - 1\n Tablet(s) by mouth twice a day\n OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - \n Tablet(s) by mouth q4-6h prn pain\n OXYCONTIN - - 20 mg po twice a day\n OXYGEN - - Concentrator and LOX portable for ambulation; 2-3L\n via nasal cannula; Dx: COPD; O2 sat 96% on 2L\n PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1\n Tablet(s) by mouth q8 h as needed for nausea Take on the night\n after chemo and then for 2-3 days as needed\n SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg\n Tablet - 1 Tablet(s) by mouth daily\n TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,\n w/Inhalation Device - One capsule inhaled daily Use with\n HandiHaler device\n Medications - OTC\n ASPIRIN [ECOTRIN] - (Prescribed by Other Provider) - 325 mg\n Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily\n DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain\n IBUPROFEN - (OTC) - 800 mg Tablet - 1 Tablet(s) by mouth three\n times a day\n MISC NATURAL PRODUCT NASAL [PONARIS] - (OTC) - Dosage uncertain\n SENNA - (OTC) - Dosage uncertain\n Past medical history:\n Family history:\n Social History:\n COPD\n Metastatic squamous lung cancer: initially dx as stage Ia, s/r RUL\n resection at in who had recurence in and was restaged to\n IIIb. He had wedge resection and is now undergoing chemotherapy with\n intially cisplatin/taxol starting in , now getting gemcytabine\n s/p last dose on \n CEA\n Nc\n Occupation: retired\n Drugs:\n Tobacco: 40 pack year hx\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, no melena\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 05:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 92 (87 - 101) bpm\n BP: 121/71(80) {108/33(45) - 139/74(86)} mmHg\n RR: 26 (21 - 36) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,600 mL\n -400 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 20 K/uL\n 7.9 g/dL\n 122 mg/dL\n 3.1 mg/dL\n 93 mg/dL\n 17 mEq/L\n 108 mEq/L\n 4.7 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n \n 2:33 A12/10/ 12:44 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, Fibrinogen:464 mg/dL, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:5.1 mg/dL\n Imaging: CT chest on : CONCLUSION:\n 1. No pulmonary embolism. Extensive coronary atherosclerosis is\n present.\n 2. Interval disease progression with increased mediastinal\n lymphadenopathy and pleural deposits with involvement of the left chest\n as well as the left fifth rib in the mid axillary line.\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The\n appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy\n reflective of\n patient's underlying metastatic disease.\n ECG: NSR at 81 with new TWI in III, V2. OTW no sig change.\n Assessment and Plan\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429183, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n Mr. is a 64 yo M with metastatic lung cancer who presents with\n acute worsening of his dyspnea over the last 2 days. They note that\n while in the last 7 days he has had persistent mental status changes\n thought secondary to an increase in oxycontin. As well over the last\n few days he has had poor PO intake and nausea. He has been more\n hypoxic and has had episodes of shortness of breath. And the home 02\n monitor showed 02 sats in the 70-80s despite being on his home 02 of\n liters.\n .\n In the ED, the patient was initially found to be hypotensive with\n Initial vitals were 82/46, HR 80 02 sat 95% NRB. He was given a total\n of 2L NS and 1 U PRBCs. Additionally, Zosyn and vancomycin were given\n and IV insulin, D 50 and calcium gluconate for a k of 6.1. He was\n guaiac positive.\n .\n Upon arrival to the floor, the patient was found to be tachypnec and\n anxious with periodic hypoxia but without significant pain. He denied\n any recent nausea, vomiting, fever, chills, chest pain (other than rib\n pain). He did have some episodes of dizziness when he had low oxygen\n saturations. He had no syncope or presyncope. A CT scan of the head\n was performed and negative. CTA was deferred given renal failure.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n orthopnea, PND, urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS per last note:\n AMLODIPINE 10 mg daily\n CLONAZEPAM [KLONOPIN] -0.5 mg twice a day\n ESOMEPRAZOLE MAGNESIUM\n - 20 mg Capsule, daily\n FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth Twice daily\n LISINOPRIL\n METOPROLOL SUCCINATE - 25 mg \n OXYCODONE [OXYCONTIN] -20 mg Tablet Sustained Release 12 hr - 1\n Tablet(s) by mouth twice a day\n Percocet prn\n PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet prn\n SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg\n Tablet - 1 Tablet(s) by mouth daily\n TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,\n w/Inhalation DeviceQD\n ASPIRIN 325 mg\n IBUPROFEN 800 mg TID\n SENNA\n Past medical history:\n Family history:\n Social History:\n COPD\n Metastatic squamous lung cancer: initially dx as stage Ia, s/r RUL\n resection at in who had recurence in and was restaged to\n IIIb. He had wedge resection and is now undergoing chemotherapy with\n intially cisplatin/taxol starting in , now getting gemcytabine\n s/p last dose on \n CEA\n Nc\n Occupation: retired\n Drugs:\n Tobacco: 40 pack year hx\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, no melena\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 05:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 92 (87 - 101) bpm\n BP: 121/71(80) {108/33(45) - 139/74(86)} mmHg\n RR: 26 (21 - 36) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Pulsus: 6-8 mmHg\n Total In:\n 2,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,600 mL\n -400 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 20 K/uL\n 7.9 g/dL\n 122 mg/dL\n 3.1 mg/dL\n 93 mg/dL\n 17 mEq/L\n 108 mEq/L\n 4.7 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n \n 2:33 A12/10/ 12:44 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, Fibrinogen:464 mg/dL, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:5.1 mg/dL\n Imaging: CT chest on : CONCLUSION:\n 1. No pulmonary embolism. Extensive coronary atherosclerosis is\n present.\n 2. Interval disease progression with increased mediastinal\n lymphadenopathy and pleural deposits with involvement of the left chest\n as well as the left fifth rib in the mid axillary line.\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The\n appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy\n reflective of\n patient's underlying metastatic disease.\n ECG: NSR at 81 with new TWI in III, V2. OTW no sig change.\n Assessment and Plan\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429277, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats. NPO except C/L given tenuous resp status. F/U results\n of studies\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphne 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance\n P\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429412, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Continues. Pt on face mask oxygen this AM and satting\n low 90\ns while sleeping. Increased work of breathing despite\n morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 2. Hypotension/Acute Renal failure: Both have resolved. Likely due\n to decreased Po intake and intravascular volume.\n - redose meds now that renal failure improved\n - continue to monitor BP\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving, but still elevated. Possibly due to\n hypotension on presentation. RUQ us unremarkable per prelim read\n making concern for malignancy less likely.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429278, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats. NPO except C/L given tenuous resp status. F/U results\n of studies\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphne 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance\n P\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 429161, "text": "TITLE: MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n admission note by Dr. , including the assessment and plan. I\n would emphasize and add the following points: 64M NSCLC\n (/) c/b metastasis and ? lymphangitic tumor\n treated with recent gemcytobine. Brought in with hypoxemia with altered\n mental status in the recent past and low-grade hemoptysis. Hypotensive\n in the ED, transfused, eventually had NRB placed to allow improved\n oxygenation.\n Exam notable for Tm 98.1 BP 118/74 HR 70 RR 16 with sat 95 on 2L. Labs\n notable for WBC 4K, HCT 23, K+ 6.1, Cr 4.3. CXR c BLL ASD (decreased\n since ) and apical bullae. CT c apical bulla on R, pleural mass on\n L, diffuse micronodual pattern with bronchovascular thickening.\n 64M NSCLC p/w respiratory distress. Agree with plan to treat possible\n pneumonia with vanco / levo / ctx; will check sputum, legionella Ag,\n and influenza swab. Will d/c levo if legionella negative. Will aslo\n check beta-glucan and galactomannan. Doubt PE but can't completely\n exclude this possibility. Will check LENIs in AM and hold on anticoag\n for now and check echo; no clear evidence of recent MI or tamponade.\n ARF is likely mediated by volume and poor forward flow. Will volume\n resuscitate, check lytes and sed, hold NSAIDs. Will give kayexalate as\n needed for hyperkalemia but hold off on renal consult for now. LFT\n abnormalities may also be mediated by flow, but are concerning for\n liver infiltration or viral infection. Will consider USG eval if this\n gets worse. In addition, the combination of ARF, thrombocytopenia,\n anemia, schistocytes and altered mental status makes TTP/HUS spectrum\n disorders possible, though precipitant unclear. check hemolysis\n labs, DIC panel, repeat CBC and smear and consider form evaluation by\n heme. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429397, "text": "Chief Complaint: Respiratory distress, hypoxemia, pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Echo showed increased LVEDP and moderately dilated RV. Patient's work\n of breathing has increased overnight. O2 sats are down from yesterday.\n LENI negative for DVT.\n RUQ ultrasound without significant pathology.\n Hct did increase with transfusion.\n Creat has normalized.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n , , simvastatin, protonix, Klonapin,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 105 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 26 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Moderate\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : Anterior and at bases, No(t)\n Bronchial: , Wheezes : Prolonged expiratory phase, No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: ), Using expiratory accessory\n muscles.\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 26 K/uL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ANEMIA\n ACIDOSIS\n Patient rating dyspnea as despite fentanyl patch. With\n transfusions, patient may have beome volume overloaded. Echo compatible\n with this. Would try diuresing today, now that renal function has\n normalized. Will also try CPAP for comfort and to reduce afterload.\n Continue antibiotics.\n Hct has responded to transfusion. Still unclear what was the source of\n the drop.\n Creat down to 1 with volume resuscitation.\n Blood pressure has normalized with volume resuscitation.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429398, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429409, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Continues. Pt on face mask oxygen this AM and satting\n low 90\ns while sleeping. Increased work of breathing despite\n morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 2. Hypotension/Acute Renal failure: Both have resolved. Likely due\n to decreased Po intake and intravascular volume.\n - redose meds now that renal failure improved\n - continue to monitor BP\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving Given hypotension, potentially ischemic\n secondary to poor perfusion. Will also send off hepatitis serologies\n as could have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429421, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 35 minutes first trail.\n Response:\n Plan:\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapem\n Plan:\n Cont fentanyl patch. Increased clonazapem. Morphine sulfate PRN. Assess\n resp status/distress. Hold clonazapam & morphine for increased\n somnolence, MS changes, R <10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429431, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient using NIV intermittently but continues to be SOB the whole\n shift first time spent 45 minutes on , second time 3.5 hours, still\n tachypneic and tachycardic on NRB + 6L nasal cannula, family members\n still at bedside, patient breathing at a frequency of 30 to 40, remains\n in distress, will continuous to be followed.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429507, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429509, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. At\n Action:\n 10mg SL morphine, repositioned\n Response:\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429511, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. At 21:20 pt desaturated\n to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Of note, pt has not voided this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation.\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429514, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Of note, pt has not voided this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Family has been at pt\ns bedside t/o the night.\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429371, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429383, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429480, "text": "DNR/DNI\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429492, "text": "DNR/DNI\n 64M NSCLC (/) c/b metastasis and ? lymphangitic\n tumor treated with recent gemcytobine. Brought in with hypoxemia with\n altered mental status in the recent past and low-grade hemoptysis.\n Hypotensive in the ED, transfused, eventually had NRB placed to allow\n improved oxygenation.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429589, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. CXR\n yesterday with significant interval changes concerning for acute\n infectious process. Pt now with Increased work of breathing and on SL\n morphine as pt has no IV access. Pt made CMO last night and plans in\n motion for d/c home with hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429590, "text": "Chief Complaint: Respiratory distress, lung ca, pneumonia, anemia,\n acute renal failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient kept comfortable overnight with opiates - sublinqual morphine.\n Oxygenation marginal with NRB mask plus O2 via nasal cannula. Patient\n diuresed with 3L negative fluid balance yesterday.\n Afebrile\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:38 AM\n NON-INVASIVE VENTILATION - START 09:45 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - STOP 10:30 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - START 12:43 PM\n NIV restarted again at 1243 PM PSV 8&8 80%\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - STOP 05:19 PM\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 79%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Mild respiratory\n distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Extremities: Right: 1+ edema, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 26 K/uL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n RESPIRATORY DISTRESS\n ANEMIA\n PNEUMONIA\n Focus of care continues to be comfort for patient. No labs obtained.\n Morphine being administered.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments: Not applicable.\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :D/C Home\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429594, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. CXR\n yesterday with significant interval changes concerning for acute\n infectious process. Pt now with Increased work of breathing and on SL\n morphine as pt has no IV access. Pt made CMO last night and plans in\n motion for d/c home with hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 09:54 ------\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429595, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 79%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n Labs / Radiology\n No labs or radiology studies today.\n Assessment and Plan\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429596, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittently\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data to provide treatment\n guidance.\n Last evening, pt made CMO. Plans initiated for home hospice care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n No labs or radiology studies today.\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 64 yo man with NSCLC admitted with hypotension, SOB; now ICU day 3. Pt\n on face mask and nasal cannula this AM. CXR yesterday with significant\n interval changes concerning for acute infectious process. Pt now with\n Increased work of breathing and on SL morphine as pt has no IV\n access. Pt made CMO last night and plans in motion for d/c home with\n hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n" }, { "category": "Nutrition", "chartdate": "2196-01-15 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429598, "text": "Comments:\n Noted patient is CMO. Will sign off, please reconsult if plan of care\n changes.\n 10:33 AM\n" }, { "category": "General", "chartdate": "2196-01-14 00:00:00.000", "description": "ICU Event Note", "row_id": 429474, "text": "Clinician: Attending\n Patient diuresed today but oxygenation has worsened. Able to maintain\n O2 sat of 90% on Mask Ventilation, but sats drop to 70-85% on 100% NRB\n mask. He remains uncomfortable with dyspnea.\n Family meeting held with patient's wife and 2 daughters. Medical\n condition detailed along with poor prognosis. Decision made to make\n comfort measures the top priority and to attempt to make arrangements\n for home hospice for tomorrow.\n Total time spent: 60 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429582, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, family at bedside, appears somnolent and minimally\n arousable.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Continues. Pt on face mask and nasal cannula\n this AM. CXR yesterday with acute interval changes concerning for\n infectious changes. Pt now Increased work of breathing and on SL m\n despite morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving, but still elevated. Possibly due to\n hypotension on presentation. RUQ us unremarkable per prelim read\n making concern for malignancy less likely.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429563, "text": "Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:38 AM\n NON-INVASIVE VENTILATION - START 09:45 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - STOP 10:30 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - START 12:43 PM\n NIV restarted again at 1243 PM PSV 8&8 80%\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - STOP 05:19 PM\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 85%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Echo", "chartdate": "2196-01-13 00:00:00.000", "description": "Report", "row_id": 64797, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function. Hypoxia\nHeight: (in) 73\nWeight (lb): 260\nBSA (m2): 2.41 m2\nBP (mm Hg): 117/74\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV motion\nabnormality cannot be fully excluded. TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free \nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Due to suboptimal technical quality,\na focal motion abnormality cannot be fully excluded. Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nThe right ventricular cavity is moderately dilated with moderate global free\n hypokinesis. There is abnormal septal motion/position consistent with\nright ventricular pressure/volume overload. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is more dilated with more prominent free hypokinesis.\nThe estimated pulmonary artery systolic pressure is slightly higher.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050219, "text": " 6:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for obvious brain mass, ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cancer, need for anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for obvious brain mass, ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg TUE 8:16 PM\n no hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with cancer, needs anticoagulation. Evaluate\n for brain mass, intracerebral hemorrhage.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus, shift of\n normally midline structure, or evidence of major vascular territorial infarct.\n The -white matter differentiation is preserved. Hypodensities in the\n periventricular and subcortical white matter reflect chronic microvascular\n ischemic change, not significantly changed from . The visualized\n paranasal sinuses and mastoid air cells remain normally aerated. The\n surrounding soft tissues and osseous structures are normal.\n\n IMPRESSION: No acute intracranial abnormality. If there is concern regarding\n metastases, an MRI with gadolinium is more sensitive.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1050389, "text": " 3:26 PM\n UNILAT LOWER EXT VEINS Clip # \n Reason: EVALUATE FOR LEFT LOWER EXT DVT/LT LEG SWELLING\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with LLE edema\n REASON FOR THIS EXAMINATION:\n evaluate for Left Lower ext dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 6:59 PM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND\n\n HISTORY: 64-year-old man with left lower extremity edema. Evaluate for DVT.\n\n COMPARISON: Bilateral lower extremity venous ultrasound from .\n\n FINDINGS: On Doppler son of bilateral common femoral and left-sided\n superficial femoral, and popliteal veins were performed. All vessels\n demonstrated normal flow, augmentation, compressibility and waveforms. No\n intraluminal thrombus was identified.\n\n IMPRESSION: No evidence for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050512, "text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrates.\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hypoxia. Pt has had worse hypoxia overnight. Now in 80's,\n increased work of breathing.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening hypoxia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is a marked increase\n of the pre-existing bilateral reticular and reticulonodular opacities in both\n lungs. The increasing opacities obscure both heart borders and parts of the\n diaphragm. The pre-existing bilateral pleural thickening is unchanged. Also\n unchanged is the moderate mediastinal widening.\n\n The described changes could be caused by either infection or acute\n exacerbation of underlying fibrotic lung disease.\n\n Dr. , the referring physician, notified over telephone.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050197, "text": " 5:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with shortness of breath, hypoxia, hypotension\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, hypoxia, hypertension. History of lung cancer\n post-resection.\n\n COMPARISON: Chest CT , chest CTA .\n\n UPRIGHT AP VIEW OF THE CHEST: Patient is status post left upper lobe wedge\n resection. Left-sided pleural disease is again noted with a dominant area of\n pleural thickening in the left upper hemithorax relatively unchanged from the\n previous examinations. Clips are again demonstrated within the right superior\n mediastinum. Cardiac, mediastinal, and hilar contours are relatively\n unchanged with prominence of the hilar regions compatible with underlying\n pulmonary arterial hypertension. Additionally, widening of the mediastinum\n and fullness of the right paratracheal stripe reflects underlying mediastinal\n lymphadenopathy. There continues to be a patchy ill-defined opacity within the\n left lower lobe, which was seen on the prior study from ,\n which could represent developing infection, lymphatic spread of tumor, or\n atelectasis. Areas of fibrosis are again noted within the right lower lung\n laterally with unchanged area of pleural thickening in the right upper\n hemithorax. No pleural effusions or pneumothorax are identified. The\n patient's known lytic lesion within the left anterior fifth rib is not well\n visualized on the current examination.\n\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy reflective of\n patient's underlying metastatic disease.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1050390, "text": ", M. MED 3:26 PM\n UNILAT LOWER EXT VEINS Clip # \n Reason: EVALUATE FOR LEFT LOWER EXT DVT/LT LEG SWELLING\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with LLE edema\n REASON FOR THIS EXAMINATION:\n evaluate for Left Lower ext dvt\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1050391, "text": " 3:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: LUNG CA, ELEVATED LFT, EVAL FOR CBD DILITATION AND GALLSTONES\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with Lung ca and lft elevations\n REASON FOR THIS EXAMINATION:\n evaluate for cbd dilitation and gallstones\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lung cancer and LFT elevations.\n\n COMPARISON: CT from and \n\n LIVER/GALLBLADDER ULTRASOUND: Grayscale and color Doppler son images\n were obtained and demonstrate the liver to be of normal contour but of\n increased echogenicity with a geographic area of hypodensity seen in the left\n lobe; this is avascular and does not displace vessels. Body habitus limits\n the study, but the gallbladder does not appear distended, and there is no\n apparent cholelithiasis, pericholecystic fluid, or gallbladder \n thickening. The common bile duct measures 7.1 mm, without evidence of\n obstruction. There is no ascites.\n\n IMPRESSION:\n 1. No evidence for gallbladder pathology.\n 2. Likely focal fatty sparing in the left lobe of the liver.\n 3. Diffuse fatty liver in the remaining portion; ultrasound cannot\n distinguish diffuse fatty infiltration from other forms of cirrhosis/fibrosis.\n\n\n\n" }, { "category": "ECG", "chartdate": "2196-01-12 00:00:00.000", "description": "Report", "row_id": 132829, "text": "Baseline artifact. Sinus rhythm. Borderline P-R interval prolongation.\nLow voltage throughout. ST-T wave abnormalities. Since the previous tracing\nof the rate has decreased. ST-T wave abnormalities are more marked.\nClinical correlation is suggested.\n\n" } ]
61,420	145,419	49yo F with h/x of metastatic breast cancer to liver, lungs, brain who was admitted with confusion and altered mental status experienced at an outpatient scheduled CT scan. Currently on cycle #4 Doxil Day #30 and recieving whole brain treatment. First whole brain radiation was (5 treatments thus far, cycle is complete as of ). . # Altered Mental Status- most likely caused by the mutliple new brain massess from her breast cancer metastases. Patient has been very depressed with confusion at times.Head CT scan showed- 1. Innumerable hyperdense lesions distributed throughout the brain with mild mass effect and edema surrounding the largest lesion in the left thalamus. Started whole brain radiation in house, recieved 5 treatments the last being .Did not place patient on anti seizure medications because she had no history of seizures and there is no evidence in patients with brain mets prophylactic anti seizure meds are benficial.Continued Dexamethasone 4 mg Q6H IV to decrease intracranial pressure. Dexamethasone will be tapered per radiation oncology recommendations on discharge.Got Palliative Care consult- which followed the case, have decided to start home w/ nursing services and home resources. Husband was made the proxy via interpreter Dr. had seen the patient and recommended EEG which revealed no seizure activity(indicated moderate encephalopathy). We started Ritalin in attempt to raise her affect and activity level (which was started ). We got a head MRI to better stage her disease which showed :Innumerable enhancing lesions throughout the brain, as on the prior CT, with relatively little edema or mass effect. Largest lesion is a 2-cm left thalamic lesion with mild mass effect on the third ventricle. These are compatible with metastases, not appreciably changed from the head CT. . # Breast Cancer: metastatic, currently on Doxil Cycle # 4 Day # 30 with zometa. -Patient is BRCA1/2 negative. - f/u per primary oncologist Dr. . # Right arm and right leg weakness- most likely caused by her brain metastases, especially given large lesion in the left thalamus. . - the weakness is power in the right upper and lower extremities compared to the left which is power. Her right hand however is limp, unless she is told to move it and the grasp is much weaker than the left hand. These symptoms correlate with her lesion in her thalamus. . # FEN: regular diet # PPx: Pain controlled with morphine, DVT PPx with sc heparin	A large lesion in the left thalamus has surrounding edema and mild mass effect on the third ventricle without hydrocephalus. Findings are non-specific and tracing may be within normal limits.Since the previous tracing of sinus bradycardia is now present. Innumerable bilateral pulmonary nodules, which are also minimally larger in size, without evidence of new lesions. REASON FOR THIS EXAMINATION: Please comment on the location of lesions in the brain No contraindications for IV contrast PFI REPORT Large number of enhancing lesions throughout the brain as on the prior CT, with relatively little edema or mass effect. REASON FOR THIS EXAMINATION: Please comment on the location of lesions in the brain No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 3:46 PM Large number of enhancing lesions throughout the brain as on the prior CT, with relatively little edema or mass effect. Redemonstrated are innumerable bilateral pulmonary nodules, which are only minimally larger compared to prior study. IMPRESSIONS: Innumerable enhancing lesions throughout the brain, as on the (Over) 12:05 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please comment on the location of lesions in the brain Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: FINAL REPORT (Cont) prior CT, with relatively little edema or mass effect. The largest lesion is located in the left thalamus, measuring 1.8 x 2.1 cm, which exerts mild mass effect on the third ventricle. (Over) 2:00 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: restaging, please compare with prior scans from and Ap Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) OSSEOUS STRUCTURES: Redemonstrated are innumerable sclerotic metastatic lesions throughout the thoracolumbar spine, sternum, femurs, and pelvis, which are not significantly changed from prior study. Within the limitations of this study, no large extra-axial hematomas are detected. These are compatible with metastases, not appreciably changed from the head CT. Many of these lesions, however, demonstrate only minimal to no surrounding edema. Largest lesion is a 2-cm left thalamic lesion with mild mass effect on the third ventricle. The major intracranial vascular flow voids are unremarkable. Th largest is a 2 cm left thalamic lesion with mild mass effect on 3rd ventricle. Th largest is a 2 cm left thalamic lesion with mild mass effect on 3rd ventricle. A few scattered retroperitoneal lymph nodes are not enlarged by CT size criteria, with the aortocaval nodes measuring up to 5 mm in short axis. A few scattered lesions are noted in the mid brain. CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are without pericardial effusion. Innumerable hyperdense lesions distributed throughout the brain with mild mass effect and edema surrounding the largest lesion in the left thalamus. The ventricles and sulci are normal in caliber and configuration, except for mild compression of the third ventricle. A few scattered mediastinal lymph nodes are not significantly changed, and not enlarged by size criteria, measuring up to 6 mm in the paratracheal station. Many of the lesions demonstrate low attenuation, compatible with necrosis. For example, a lesion within the right lobe of the liver (2:51) measures 18-mm, previously measured approximately 10 mm. Stable diffuse osseous metastases. TECHNIQUE: Contiguous axial images were acquired through the head without intravenous contrast. Some vasogenic edema is seen surrounding this lesion. OSSEOUS STRUCTURES AND SOFT TISSUE: There is a lucent lesion in the left frontal vertex (2:25), which, given additinal findings is suspicious for metastatic disease. Innumerable hyperdense lesions are seen diffusely distributed throughout the cerebral hemispheres and the cerebellum. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are unremarkable. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis with the administration of IV contrast only. Left frontal lucent lesion are concerning for metastatic disease. Some lesions are situated along the subependymal surface along the lateral ventricles. Abnormal signal within the left frontal calvarium indicates a site of bony metastasis, as indicated on the head CT. The stomach, small bowel, and large bowel are unremarkable. Sinus rhythm with borderline sinus bradycardia. Other lesions are found predominantly throughout the cerebral hemispheres at the -white junction, along the ventricles, in the cerebellum, and a few in the midbrain. Other lesions are found predominantly throughout the cerebral hemispheres at the -white junction, along the ventricles, in the cerebellum, and a few in the midbrain. A few smaller lesions are present within the subcortical white matter.	5	[ { "category": "Radiology", "chartdate": "2197-08-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1142246, "text": " 2:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: restaging, please compare with prior scans from and Ap\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with met breast cancer\n REASON FOR THIS EXAMINATION:\n restaging, please compare with prior scans from and \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer, restaging.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with the administration of IV contrast only. Coronal and\n sagittal reformations were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are without\n pericardial effusion. The great vessels are within normal limits. A few\n scattered mediastinal lymph nodes are not significantly changed, and not\n enlarged by size criteria, measuring up to 6 mm in the paratracheal station.\n\n Redemonstrated are innumerable bilateral pulmonary nodules, which are only\n minimally larger compared to prior study. For example, a nodule within the\n right upper lobe (2:14) measures 9 mm x 9 mm, previously measured 8 mm x 8 mm.\n A nodule within the left upper lobe measures 11 mm x 9 mm, previously measured\n 10 mm x 8 mm. A nodule within the left lower lobe (2:33) measures 16 mm x 14\n mm, previously measured 15 mm x 14 mm. No new lesion is identified. There is\n no pleural effusion.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver is infiltrated by numerous\n metastatic lesions. There is a different enhancement pattern of the lesions\n compared to prior study, making direct comparison difficult. Many of the\n lesions demonstrate low attenuation, compatible with necrosis. Though direct\n comparison is difficult, there is an increase in number of the lesions, as\n well as an increase in size of several of the lesions. For example, a lesion\n within the right lobe of the liver (2:51) measures 18-mm, previously measured\n approximately 10 mm. There is also increasing capsular retraction of the\n liver. The portal venous system is patent without evidence of thrombus. The\n gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable.\n\n The stomach, small bowel, and large bowel are unremarkable.\n\n There is no free air or free fluid. A few scattered retroperitoneal lymph\n nodes are not enlarged by CT size criteria, with the aortocaval nodes\n measuring up to 5 mm in short axis.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are\n unremarkable. There is no pelvic lymphadenopathy or free fluid.\n (Over)\n\n 2:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: restaging, please compare with prior scans from and Ap\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: Redemonstrated are innumerable sclerotic metastatic\n lesions throughout the thoracolumbar spine, sternum, femurs, and pelvis, which\n are not significantly changed from prior study. There is no evidence for\n pathologic fracture.\n\n IMPRESSION:\n 1. Innumerable hepatic metastases, which are increased in number and slightly\n increased in size compared to prior study.\n 2. Innumerable bilateral pulmonary nodules, which are also minimally larger\n in size, without evidence of new lesions.\n 3. Stable diffuse osseous metastases.\n\n" }, { "category": "Radiology", "chartdate": "2197-08-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1142276, "text": " 3:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with confusion/AMS, h/o breast CA\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 4:36 PM\n Multiple hyperdense lesions seen throughout the brain. A large lesion in the\n left thalamus has surrounding edema and mild mass effect on the third\n ventricle without hydrocephalus. Basal cisterns are patent, no evidence of\n herniation or midline shift. Left frontal lucent lesion are concerning for\n metastatic disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with confusion and altered mental status, has a\n history of metastatic breast cancer.\n\n COMPARISON: MRI of the brain and orbit .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast. However, the patient has had contrast enhanced CT of\n the torso an hour ago, limiting evaluation for subarachnoid bleed.\n\n Innumerable hyperdense lesions are seen diffusely distributed throughout the\n cerebral hemispheres and the cerebellum. The largest of these lesions is\n present within the left thalamus (2:15), measuring 2.3 x 1.8 cm, causing mass\n effect on the third ventricle. Some vasogenic edema is seen surrounding this\n lesion. No shift of midline structures or herniation is detected. Within the\n limitations of this study, no large extra-axial hematomas are detected. There\n is no hydrocephalus. The ventricles and sulci are normal in caliber and\n configuration, except for mild compression of the third ventricle.\n\n OSSEOUS STRUCTURES AND SOFT TISSUE: There is a lucent lesion in the left\n frontal vertex (2:25), which, given additinal findings is suspicious for\n metastatic disease. The visualized paranasal sinuses and mastoid air cells\n are clear.\n\n IMPRESSION:\n 1. Innumerable hyperdense lesions distributed throughout the brain with mild\n mass effect and edema surrounding the largest lesion in the left thalamus.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1143197, "text": " 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with metastatic breast cancer to liver, lungs, brain who was\n admitted with confusion and altered mental status experienced at an outpatient\n scheduled CT scan.\n REASON FOR THIS EXAMINATION:\n Please comment on the location of lesions in the brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 3:46 PM\n Large number of enhancing lesions throughout the brain as on the prior CT,\n with relatively little edema or mass effect. Th largest is a 2 cm left\n thalamic lesion with mild mass effect on 3rd ventricle. Other lesions are\n found predominantly throughout the cerebral hemispheres at the -white\n junction, along the ventricles, in the cerebellum, and a few in the midbrain.\n\n PFI VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with confusion and altered mental status,\n history of metastatic breast cancer.\n\n COMPARISON: Head CT . Brain MR, .\n\n TECHNIQUE: Pre- and post-contrast sequences were obtained through the brain.\n MP-RAGE sequences could not be obtained due to patient discomfort.\n Diffusion-weighted sequences were acquired.\n\n BRAIN MRI: Innumerable round, enhancing lesions are present throughout the\n brain. Many demonstrate increased signal on both T1- and T2-weighted\n sequences. Many of these lesions, however, demonstrate only minimal to no\n surrounding edema. The largest lesion is located in the left thalamus,\n measuring 1.8 x 2.1 cm, which exerts mild mass effect on the third ventricle.\n Most of the lesions are located in the bilateral cerebral hemispheres,\n predominantly at the -white matter junction. Some lesions are situated\n along the subependymal surface along the lateral ventricles. A few smaller\n lesions are present within the subcortical white matter. Innumerable\n additional lesions are present within the cerebellar hemispheres. A few\n scattered lesions are noted in the mid brain. Abnormal signal within the left\n frontal calvarium indicates a site of bony metastasis, as indicated on the\n head CT.\n\n There is no intracranial hemorrhage or large mass effect. There is no\n infarction. Ventricles and sulci are normal in size and configuration. The\n major intracranial vascular flow voids are unremarkable. The globes are\n intact, without abnormal enhancement.\n\n IMPRESSIONS: Innumerable enhancing lesions throughout the brain, as on the\n (Over)\n\n 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior CT, with relatively little edema or mass effect. Largest lesion is a\n 2-cm left thalamic lesion with mild mass effect on the third ventricle. These\n are compatible with metastases, not appreciably changed from the \n head CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1143198, "text": ", S. OMED 11R 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with metastatic breast cancer to liver, lungs, brain who was\n admitted with confusion and altered mental status experienced at an outpatient\n scheduled CT scan.\n REASON FOR THIS EXAMINATION:\n Please comment on the location of lesions in the brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large number of enhancing lesions throughout the brain as on the prior CT,\n with relatively little edema or mass effect. Th largest is a 2 cm left\n thalamic lesion with mild mass effect on 3rd ventricle. Other lesions are\n found predominantly throughout the cerebral hemispheres at the -white\n junction, along the ventricles, in the cerebellum, and a few in the midbrain.\n\n\n\n" }, { "category": "ECG", "chartdate": "2197-08-02 00:00:00.000", "description": "Report", "row_id": 223715, "text": "Sinus rhythm with borderline sinus bradycardia. Low precordial lead\nQRS voltage. Findings are non-specific and tracing may be within normal limits.\nSince the previous tracing of sinus bradycardia is now present.\n\n" } ]
82,399	186,926	67year old male h/o HTN, bipolar off meds, tobacco abuse admitted with weeks/months of feeling "unhealthy", chronic NP, mild DOE, chronic LBP. Poor historian but stated he was just feeling bad for so long that decided to come in, though denied any acute changes in cough/dyspnea/fevers/chills. On arrival to ER, he was febrile (pt not aware) and hypoxic 88%RA, CXR with LLL PNA, got 3L IVFs, Levaquin, O2 and transfered to MICU overnight. Did well in ICU, thus transfered to floor . Since on Gen Med floor, continued to do better clinically, was afebrile and cough improved, however had persistant hypoxia, requiring 4L O2. Underwent CT chest which showed extensive linguilar/LLL opacities with b/l GGO. Given clinical improvement in terms of fever and white count down, decided to keep on levaquin X10days with follow up imaging for resolution. He is being discharged on oxygen 3L with rest, 4L with exertion with pulmonary follow up for further w/u (esp given b/l GGOs and months of "fatigue/malaise"). Of note, peviously 2-3PPD X30years (now 6cigs/day) which raises concern for COPD, but CT w/o empysematous changes and exam w/o prolonged expiration. nevertheless given tobacco history, was d/c'd on combivent. Other issues here, has a mid-lower back 5cm circular wound that wound care believes is likely thermal wound (uses heat packs), reccommend silvedine. SW saw pt while here given his unusual social situation. He will return to monastery on discharge. He has f/u arranaged with new PCP and pulm at (see below) . . See progress note below for details: . 67 year old male with h/o HTN, bipolar d/o, heavy tobacco abuse admitted with weeks of malaise, , ?dyspnea, with acute worsening, found to have PNA with hypoxia, sepsis (resolved), now doing much better except for persistant hypoxia . . Community Acquired PNA: admission c fevers, leukocytosis, tachycardia, and tachypnea-->sepsis resolved. NO sputum cx obtained but clinically improved on levaquin. Persistant hypoxia (4L) and CT with extensive LLL/linguilar consolidation and bilateral GGOs. -cont levaquin, day -chest CT as above, will need follow up CXR or CT to ensure resolution or needs further w/u -cont guaifenesin as expectorant -have set up for home O2, 3L at rest, 4L with exertion, hopefully can wean this overtime -continue combivent for possible COPD component, will clarify need base on spirometry after PNA resolved. -vaccines as outpt since ongoing PNA . . Hypoxia: LLL PNA extensive with bilateral GGO seen on CT. Clinically improved though persistant O2 requirement. ?underlying COPD given heavy tobacco history, though admission ABG w/o much hypercapnea and CT w/o emphysema. Not sure if has baseline hypoxia causing his chronic malaise history or whether all due to PNA -as above, set up with home O2 3L rest, 4L exertion -set up with pulm f/u for further w/u hypoxia (spirometry), also needs repeat imaging (f/u nodule and GGOs) . . Wound: mid back. doesnt look infected. pt not at risk for pressure ulcer. Per wound care nurse, more suggestive of thermal injury (pt uses heat packs for chronic LBP) -silvedine cream and dressing changes per wound care -low suspicion for malignancy, but would refer to derm if no improvement over next few weeks . . Social situation: conflicting stories but pt did confide to nurse that his house burned down and he is currenlty homeless living in monastery. This is confirmed and they are happy to pick up patient from hospital -SW/CM have confirmed that pt has insurance/resources to pay for meds/O2 (medicare) . . HTN: Echo with LVH. BNP low so no heart failure causing GGO/crackles/hypoxia. -baseline Echo today prior to d/c, f/u read as outpt . . Bipolar d/o: pleasant, compensated. Poor historian but that he is not used to be hospitalized and is guarded given his social situation -follow, SW c/s as above, no need for psych . . Tobacco abuse: offer nicotine patch while here. . . . Dispo/code: Full Code. Will d/c back to monastery today. has VNA set up, home O2 set up, PCP appt for with Dr. at 2:30pm and pulm appt for Wed with Dr. . Pt has to check in at 3:30pm for breathing test, and then will meet Dr. at 4pm.	Hypoxia.Height: (in) 69Weight (lb): 150BSA (m2): 1.83 m2BP (mm Hg): 103/87HR (bpm): 61Status: InpatientDate/Time: at 11:38Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. 24 Hour Events: Allergies: Lithium Unknown; Ibuprofen Unknown; Erythromycin Base Diarrhea; Last dose of Antibiotics: Levofloxacin - 09:28 AM Infusions: Other ICU medications: Furosemide (Lasix) - 12:20 AM Heparin Sodium (Prophylaxis) - 06:00 AM Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Respiratory: Cough Flowsheet Data as of 10:19 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38C (100.4 Tcurrent: 36.3C (97.4 HR: 67 (67 - 93) bpm BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg RR: 31 (14 - 43) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch Total In: 3,220 mL 522 mL PO: 420 mL TF: IVF: 20 mL 102 mL Blood products: Total out: 400 mL 1,650 mL Urine: 400 mL 1,650 mL NG: Stool: Drains: Balance: 2,820 mL -1,128 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 93% ABG: 7.40/39/63/26/0 Physical Examination General Appearance: No acute distress, Thin, disshelveled Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 12.6 g/dL 245 K/uL 100 mg/dL 0.9 mg/dL 26 mEq/L 4.5 mEq/L 14 mg/dL 104 mEq/L 141 mEq/L 37.6 % 11.0 K/uL BNP 158 10:24 PM 03:55 AM WBC 13 11.0 Hct 37.6 Plt 245 Cr 0.9 TCO2 25 Glucose 100 Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL Imaging: CXR- LLL infiltrate Microbiology: No new data.	18	[ { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 442163, "text": "Chief Complaint: LBP, cough\n 24 Hour Events:\n Pt did well o/n on 5L NC sating low 90's and above\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states he feels the same as last night. Has same\n cough. No CP, SOB. Wants to eat breakfast\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 77 (75 - 93) bpm\n BP: 129/63(79) {114/57(70) - 156/75(94)} mmHg\n RR: 25 (14 - 43) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 264 mL\n PO:\n 180 mL\n TF:\n IVF:\n 20 mL\n 84 mL\n Blood products:\n Total out:\n 400 mL\n 1,450 mL\n Urine:\n 400 mL\n 1,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 245 K/uL\n 12.6 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442171, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442083, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 99.6, pt A/O x 3, tachypneic at times with RR between 24 and 32,\n LS with crackles in L side, rhonchi in R side, on O2 3.5 L NC.\n Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63. Sample for MRSA nares obtained.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442173, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic. Given symmetric crackles on exam, concern for volume\n overload.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - Check BNP/TTE\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442174, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n BNP 158\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - TTE ordered\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442081, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n" }, { "category": "Physician ", "chartdate": "2177-02-21 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 442077, "text": "TITLE:\n Chief Complaint: tachypnea, fevers\n HPI:\n This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n no home medications\n Past medical history:\n Family history:\n Social History:\n \"strained left ventricle\"\n Both parents with ETOH abuse. No DM or CAD.\n Occupation: retired construction worker\n Drugs: denies\n Tobacco: PPD x 50 yrs\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Mild\n Pain location: low back\n Flowsheet Data as of 11:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 81) bpm\n BP: 141/65(83) {141/65(83) - 141/65(83)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,208 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,058 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: 7.40/39/63//0\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar; L>R, Rhonchorous: sparse left rhonci)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: back: 2 cm round lesion, ? ulcer healed; minimally\n tender, no fluctuance\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/13/ 10:24 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 25\n Other labs: Lactic Acid:0.8 mmol/L\n Imaging: CXR: Lingular infiltrate, otherwise, no e/o volume overload or\n effusions.\n ECG: ECG: sinus tachycardia at 100. LVH with strain pattern.\n otherwise no significant ECG changes. Not markedly changed from\n previous ECG in .\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: NPO for now; likely can eat in AM\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending/Resident Admission Note - MICU", "row_id": 442079, "text": "TITLE:\n Chief Complaint: tachypnea, fevers\n HPI:\n This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n no home medications\n Past medical history:\n Family history:\n Social History:\n \"strained left ventricle\"\n Both parents with ETOH abuse. No DM or CAD.\n Occupation: retired construction worker\n Drugs: denies\n Tobacco: PPD x 50 yrs\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Mild\n Pain location: low back\n Flowsheet Data as of 11:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 81) bpm\n BP: 141/65(83) {141/65(83) - 141/65(83)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,208 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,058 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: 7.40/39/63//0\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar; L>R, Rhonchorous: sparse left rhonci)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: back: 2 cm round lesion, ? ulcer healed; minimally\n tender, no fluctuance\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/13/ 10:24 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 25\n Other labs: Lactic Acid:0.8 mmol/L\n Imaging: CXR: Lingular infiltrate, otherwise, no e/o volume overload or\n effusions.\n ECG: ECG: sinus tachycardia at 100. LVH with strain pattern.\n otherwise no significant ECG changes. Not markedly changed from\n previous ECG in .\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: NPO for now; likely can eat in AM\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Attending Note: patient was seen and examined with Dr. . The\n above note reflects our discussion. I would add the following: Mr \n is a 67 yr old\n ppd smoker, with\nstrained left ventricle\n diagnosed\n many years ago, LVH on ECG, on no meds, who presented with dyspnea and\n productive cough x 1 week, question of vomiting, chills but no\n documented fever, back pain. In ED temp 101, HR 91, BP 161/67, RR 44,\n sat 88% on RA, 98% on NRB. Started on levoflox, given 3 L IVF. O2sat\n improved to 94% on 4L. No ischemic changes on EKG. Transferred to MICU\n because of hypoxemic respiratory failure.\n Currently desats to 91% on 4 L, appears unkempt, RRR, bilat crackles\n L>R, abdomen benign, no LE edema.\n Labs significant for WBC 13.1 with left shift, no bands, u/a neg, utox\n negative. ABG shows pO2 63. PA & lat CXR reviewed\n lingular\n infiltrate.\n Impression: hypoxemic respiratory failure due to lingular pneumonia\n with fever, tachypnea, hypoxemia, leukocytosis and lingular infiltrate.\n There may be superimposed CHF. Doubt PE. Given smoking history, should\n consider possibility of malignancy. Agree with levofloxacin. Would\n recommend gentle diuresis. Would get sputum culture if possible, check\n BNP and do TTE. He will need repeat CXR to document improvement,\n possible a chest CT.\n Patient is cooperative and although somewhat eccentric, is a reliable\n historian. Patient is critically ill. 35 minutes spent.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:18 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442082, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442125, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pt is homeless for the past few months, has been living with friends.\n is a full code.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.6 this a.m . Pt A/O x 3, tachypneic at times with RR\n between 24 and 32, LS with crackles in L side, rhonchi in R side, on O2\n 3.5 L NC. Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV lasix\n overnight .Sample for MRSA nares obtained. Medicated with Tylenol 650\n mg po for elevated temp at 0615.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442123, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 99.6, pt A/O x 3, tachypneic at times with RR between 24 and 32,\n LS with crackles in L side, rhonchi in R side, on O2 3.5 L NC.\n Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV\n lasix.Sample for MRSA nares obtained.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442213, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n BNP 158\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - TTE ordered\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 442190, "text": "Chief Complaint: LBP, cough\n 24 Hour Events:\n Pt did well o/n on 5L NC sating low 90's and above\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states he feels the same as last night. Has same\n cough. No CP, SOB. Wants to eat breakfast\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 77 (75 - 93) bpm\n BP: 129/63(79) {114/57(70) - 156/75(94)} mmHg\n RR: 25 (14 - 43) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 264 mL\n PO:\n 180 mL\n TF:\n IVF:\n 20 mL\n 84 mL\n Blood products:\n Total out:\n 400 mL\n 1,450 mL\n Urine:\n 400 mL\n 1,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 245 K/uL\n 12.6 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands.\n Now WBC down to 11 from 13 on admission. Tachycardia resolved. Pt\n tachypnea intermittent now\n - check sputum culture\n - check urine legionella\n - f/u blood cx.\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 4L NC. Likely this is due to LLL Pneumonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely. BNP not elevated on\n admission\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n -TTE ordered for Mon given LVH on EKG\n -Nebs ordered today PRN\n # FEN: Reg diet. Ordered Ca, Vit D, MVI\n # Access: PIVs\n # PPx: hep sc\n # Code: FULL\n # Comm: with patient\n consulting SW today for problems with\n homelessness and dog left in pt\ns car on admission. Pt refused to name\n next of or HCP. Staying at local monastery with whom he seems to be\n on good terms.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 442191, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pt is homeless for the past few months, has been living with friends.\n is a full code.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt A/O x 3, tachypneic at times with RR between 24 and 32, LS with\n crackles in L side, rhonchi in R side, on O2 4 L NC. Frequent moist\n non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV lasix\n overnight .Sample for MRSA nares obtained. Medicated with Tylenol 650\n mg po for elevated temp at 0615. Nebs as ordered.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n Social work is consulted to help Pt. locate dog. Dog was removed from\n Pt.\ns truck by Animal control and is most likely in a shelter. Pt. has\n been staying in a local monastery after his home was burned down. Pt.\n originally from .\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 86.4 kg\n Daily weight:\n Allergies/Reactions:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: \" strained left ventricle\"\n Surgery / Procedure and date: /'. Open reduction and internal\n plate fixation of L zygoma fracture.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:52\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 24h total in:\n 490 mL\n 24h total out:\n 1,650 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:55 AM\n Potassium:\n 4.5 mEq/L\n 03:55 AM\n Chloride:\n 104 mEq/L\n 03:55 AM\n CO2:\n 26 mEq/L\n 03:55 AM\n BUN:\n 14 mg/dL\n 03:55 AM\n Creatinine:\n 0.9 mg/dL\n 03:55 AM\n Glucose:\n 100 mg/dL\n 03:55 AM\n Hematocrit:\n 37.6 %\n 03:55 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with Pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: wooden cross on clear (fishing line).\n Transferred from: ICU 410\n Transferred to: 1176\n Date & time of Transfer: 1145\n" }, { "category": "Echo", "chartdate": "2177-02-25 00:00:00.000", "description": "Report", "row_id": 103511, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypoxia.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 103/87\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 11:38\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w normal LV\ndiastolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild thickening of mitral\nvalve chordae. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS.\nPhysiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith normal LV diastolic function. Right ventricular chamber size and free\nwall motion are normal. The aortic root is mildly dilated at the sinus level.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. The pulmonic valve\nleaflets are thickened. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Normal diastolic function.\nDilated thoracic aorta. Trivial aortic regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2177-02-23 00:00:00.000", "description": "Report", "row_id": 311512, "text": "Sinus rhythm. Poor R wave progression. J point and ST segment elevation\nin leads V3-V6. Clinical correlation is suggested. Non-specific T wave\nchanges in leads III and aVF. Compared to the previous tracing of \nthe inferior T wave changes are new. The ST segment elevation is new and\nleads V2-V3 are now in the correct position.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-02-22 00:00:00.000", "description": "Report", "row_id": 311513, "text": "Sinus rhythm. Possible reversal of leads V2-V3. Prominent QRS voltage\nsuggests left ventricular hypertrophy. Compared to the previous tracing\nof leads V2-V3 are probably reversed and ventricular rate is slower.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-02-21 00:00:00.000", "description": "Report", "row_id": 311514, "text": "Sinus rhythm with borderline sinus tachycardia\nBorderline left axis deviation is nonspecific\nProminent QRS voltage suggests left ventricular hypertrophy\nSince previous tracing of , rate faster and axis appears more leftward\n\n" } ]
16,501	194,712	1. Respiratory: The infant was intubated soon after admission due to increased work of breathing and her ventilator settings at the time of transfer were PIP of 16, a PEEP of 5 and a breath rate of 16 breaths per minute. The infant was in room air. He received one dose of surfactant. His blood gas drawn after that was a pH of 7.33, PCO2 of 42 and a PO2 of 35. His chest x-ray is consistent with mild respiratory distress syndrome. 2. Cardiovascular: The infant received two boluses of normal saline each of 10 cc per kg for mean blood pressures in the low 20s. His blood pressure after the second bolus was 45/30 with a mean of 35. No murmur has been heard. 3. Fluids, electrolytes and nutrition: The initial dextrose stick was 36. The infant required two boluses each of 3 cc per kg of 10% dextrose. His glucose prior to transfer was 78. At the time of transfer he has a double-lumen umbilical venous catheter in running with 10% dextrose at 100 cc per kg per day. 4. Gastrointestinal: There are no issues. 5. Infectious disease: The infant was started on ampicillin and gentamicin at the time of admission for sepsis risk factor. A blood culture was sent prior to administration of antibiotics and his complete blood count showed a white count of 11.1 with a differential of 45 polys and one band. His hematocrit was 42 and the platelet count was 297,000. 6. Hematology: The infant has had no blood product transfusions during the Neonatal Intensive Care Unit stay. 7. Sensory: Audiology screening was not performed but is recommended prior to discharge. 8. State screen was sent.	To begin Amp/ Gent as ordered.DEV: Initial temp - 96.9 rectally- warmed to 97.9 axillary. D10W bolus given and subsequent D/S 78. Baby to be to TCH due to B.I. Pregnancy noteable for bright spot on heart, decline amnio, 1 SAB and 1SVD in . Mother had progressive PTL, infant had decels. Initial BP 36/19(25). Gent and Ampi given. NPN -2100Xray done to confirm placement of lines. Received stim, BMV and bulb sxn'ing. To begin D10w w/ .5u heparin/cc at 80cc/kg/d once line placement is confirmed. tube secured with 3.0 at upper lip. Baby at 2115hrs. + intercostal/subcostal retractions.RR 60's. Neonatology NP Procedure NoteEndotracheal IntubationIndication: surfactant deficiency3.0 ETt placed orally through cords under direct laryngoscopy. DUVC placed. Infat briefly shown to parents and then transported to NICU.RESP: Infant was intubated w/ #3ETT- received first dose of Survanta at 1815. NICU NURSING ADMISSION NOTE Baby is 29wk infant born at . RESPIRATORY CARE NOTEBaby received intubated on vent settings 16/5 rate 20 FiO2 21%. CXR shows tip of tube ~ 2 cm above carina.Infant tolerated procedure well. D/S 48 at . D10W with hep infusing well via DLUVC. Smaller cuff placed on infant- 44/25(30). Neonatology NP Procedure NotePlacement of umbilical venous catheterIndication : need for longterm IV therapy.Umbilical area prepped and draped. double lumen UV line placed. Fetus with some decels today, BPP .Pedi--, ClinicInfant delivered today at 1729 by vaginal delivery following induction due to fetal decels. cxr shows tip of catheter in RA,, line pulled back 1.5 cm.Infant tolerated procedure well. FIO2 has weaned to 21%. tone aga.CXR/KUB: UV line high--pulled back, lung findings c/w RDS.Labs: CBC with WBC=11, 45 P 1 B, crit=42%, plt=297 blood culture sent first blood gas after intubation: 7.33/42/35Imp/Plan: 29 week AGA infant with HMD, hypotension, hypoglycemia, and possible sepsis.--transfer to 7N--wean vent as tolerated, further surfactant doses if infant with elevated MAP and/or high FiO2--NPO, continue IVF D10W at 80 cc/kg/d, monitor dstx closely--monitor BP closely, may require dopamine if hypotension persists.if hypotension persists will need arterial line.--start amp and gentamicin due to possible sepsis, particularly in setting of PTL, hypoglycemia and hypotension. PKU drawn.ID: SEPSIS: CBC w/ Diff + blood cx sent- results are pending. Skin is intact.Plan- for transfer to TCH via TCH transport team Pt ready for transfer. tube secured with 8at upper lip. 3.5 double lumen uvc inserted into umbilical vein and advanced to 9 cm. Map's again drifted to 25-28- re'd first NS bolus (12cc) at 1835 via UVC. Born quickly via NVD. Eyes are open- rec'd erythro ointment and Vit K injection as ordered. line draws back and flusbes easily. Hr 130-150's.F&N: BW-1.190gms. Neonatology at delivery--infant emerged active, cyanotic with increased respiratory distress requiring initial PPV and then CPAP. Attending MD called transport team from TCH and they are en route.VSS. Placed on SIMV- current support of 16/5 x 20. BP and D/S stable. Intial D/s- 36- rec'd D10W bolus at 1840. No complications.Umbilical arterial line attemped X 2 both lines false tracked. Voided since birth. Apgars 6,7. Parents in to visit and transfer consent obtained. Venous gas drawn PO2 35 CO2 42 PH 7.33 rate decreased to 16. Unsuccessful with UA line placement.Infant noted to be hypotensive requiring 2 normal saline boluses (first BP with mean of 25, repeat mean of 30);infant also received 2 glucose boluses for initial dstx of 36, repeat of 48. repeat after 2nd bolus pendingInfant started on IVF at 100cc/kg/dCurrent vent settings of 17/5 x 16 RA with oxygen sat=97%, s/p 1 dose of surfactantPE: wt=1190g (25-50%), L=41 cm (75%), HC=26.5 cm (25-50%) active, intubated infant, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mild ic/sc retx. + Pectis noted.CV: Poor perfusion. NNP aware. Parents given directions and phone number for 7N at TCH. MAp's unchanged- rec'd second bolus at 1850. breath sounds equal, abdomen soft, nontender, nondistended, ext warm, initially decreased perfusion, now improved. Brought to NICU for further care.Upon arrival, infant intubated due to increased work of breathing. GBS unknown, no maternal fever, ROM > 24 hours. length of treatment to be determined based on blood culture results and clinical course.--will need to recheck CXR to recheck UV line placement maternal antibiotics > 4 hours prior to delivery. Equal breath sounds and good chest wall movement present. PTL with PPROM on at 1:30 prompting betamethasone administration due to concern for delivery; infant given 2 doses (2nd dose 6/7 at 8 am), maternal amp and erythro due to PTL but no signs of chorio. Mother was transferred from today due to PROM. full. Infant emerged crying weakly. Infant is only slightly active. Breath sounds are coarse/ crackly. Neonatology Attending Admit and Transfer Note:29 week infant with respiratory distress admitted to NICU for evaluation/care and being transferred to NICU due to lack of beds at NICU.Infant born to a 39 year old G3P1 mother blood type A positive, antibody negative, HepBSAg negative, RPR NR and RI. Unable to place UAC. No meconium passed.	6	[ { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912316, "text": "NICU NURSING ADMISSION NOTE\n Baby is 29wk infant born at . Mother had progressive PTL, infant had decels. Born quickly via NVD. Infant emerged crying weakly. Received stim, BMV and bulb sxn'ing. Apgars 6,7. Infat briefly shown to parents and then transported to NICU.\n\nRESP: Infant was intubated w/ #3ETT- received first dose of Survanta at 1815. Placed on SIMV- current support of 16/5 x 20. FIO2 has weaned to 21%. Breath sounds are coarse/ crackly. + intercostal/subcostal retractions.RR 60's. + Pectis noted.\n\nCV: Poor perfusion. Initial BP 36/19(25). Smaller cuff placed on infant- 44/25(30). Map's again drifted to 25-28- re'd first NS bolus (12cc) at 1835 via UVC. MAp's unchanged- rec'd second bolus at 1850. Hr 130-150's.\n\nF&N: BW-1.190gms. Intial D/s- 36- rec'd D10W bolus at 1840. Voided since birth. No meconium passed. DUVC placed. To begin D10w w/ .5u heparin/cc at 80cc/kg/d once line placement is confirmed. Unable to place UAC. PKU drawn.\n\nID: SEPSIS: CBC w/ Diff + blood cx sent- results are pending. To begin Amp/ Gent as ordered.\n\nDEV: Initial temp - 96.9 rectally- warmed to 97.9 axillary. Infant is only slightly active. Eyes are open- rec'd erythro ointment and Vit K injection as ordered. Skin is intact.\n\nPlan- for transfer to TCH via TCH transport team\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912317, "text": "Neonatology NP Procedure Note\nEndotracheal Intubation\nIndication: surfactant deficiency\n3.0 ETt placed orally through cords under direct laryngoscopy. tube secured with 3.0 at upper lip. Equal breath sounds and good chest wall movement present. tube secured with 8at upper lip. CXR shows tip of tube ~ 2 cm above carina.\nInfant tolerated procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912318, "text": "Neonatology NP Procedure Note\nPlacement of umbilical venous catheter\nIndication : need for longterm IV therapy.\nUmbilical area prepped and draped. 3.5 double lumen uvc inserted into umbilical vein and advanced to 9 cm. line draws back and flusbes easily. cxr shows tip of catheter in RA,, line pulled back 1.5 cm.\nInfant tolerated procedure well. No complications.\n\nUmbilical arterial line attemped X 2 both lines false tracked.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912319, "text": "Neonatology Attending Admit and Transfer Note:\n\n29 week infant with respiratory distress admitted to NICU for evaluation/care and being transferred to NICU due to lack of beds at NICU.\n\nInfant born to a 39 year old G3P1 mother blood type A positive, antibody negative, HepBSAg negative, RPR NR and RI. Mother was transferred from today due to PROM. Pregnancy noteable for bright spot on heart, decline amnio, 1 SAB and 1SVD in . PTL with PPROM on at 1:30 prompting betamethasone administration due to concern for delivery; infant given 2 doses (2nd dose 6/7 at 8 am), maternal amp and erythro due to PTL but no signs of chorio. Fetus with some decels today, BPP .\n\nPedi--, Clinic\n\nInfant delivered today at 1729 by vaginal delivery following induction due to fetal decels. GBS unknown, no maternal fever, ROM > 24 hours. maternal antibiotics > 4 hours prior to delivery. Neonatology at delivery--infant emerged active, cyanotic with increased respiratory distress requiring initial PPV and then CPAP. Brought to NICU for further care.\nUpon arrival, infant intubated due to increased work of breathing. double lumen UV line placed. Unsuccessful with UA line placement.\nInfant noted to be hypotensive requiring 2 normal saline boluses (first BP with mean of 25, repeat mean of 30);\ninfant also received 2 glucose boluses for initial dstx of 36, repeat of 48. repeat after 2nd bolus pending\nInfant started on IVF at 100cc/kg/d\nCurrent vent settings of 17/5 x 16 RA with oxygen sat=97%, s/p 1 dose of surfactant\n\nPE: wt=1190g (25-50%), L=41 cm (75%), HC=26.5 cm (25-50%) active, intubated infant, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mild ic/sc retx. breath sounds equal, abdomen soft, nontender, nondistended, ext warm, initially decreased perfusion, now improved. tone aga.\n\nCXR/KUB: UV line high--pulled back, lung findings c/w RDS.\nLabs: CBC with WBC=11, 45 P 1 B, crit=42%, plt=297\n blood culture sent\n first blood gas after intubation: 7.33/42/35\n\nImp/Plan: 29 week AGA infant with HMD, hypotension, hypoglycemia, and possible sepsis.\n--transfer to 7N\n--wean vent as tolerated, further surfactant doses if infant with elevated MAP and/or high FiO2\n--NPO, continue IVF D10W at 80 cc/kg/d, monitor dstx closely\n--monitor BP closely, may require dopamine if hypotension persists.\nif hypotension persists will need arterial line.\n--start amp and gentamicin due to possible sepsis, particularly in setting of PTL, hypoglycemia and hypotension. length of treatment to be determined based on blood culture results and clinical course.\n\n\n--will need to recheck CXR to recheck UV line placement\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912320, "text": "NPN -2100\nXray done to confirm placement of lines. NNP aware. D/S 48 at . D10W bolus given and subsequent D/S 78. D10W with hep infusing well via DLUVC. Gent and Ampi given. Parents in to visit and transfer consent obtained. Parents given directions and phone number for 7N at TCH. Attending MD called transport team from TCH and they are en route.\nVSS. BP and D/S stable. Pt ready for transfer.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912321, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 16/5 rate 20 FiO2 21%. Venous gas drawn PO2 35 CO2 42 PH 7.33 rate decreased to 16. Baby to be to TCH due to B.I. full. Baby at 2115hrs.\n" } ]
22,508	145,505	The patient underwent PTC by interventional radiology. Please refer the procedure report on line in the medical records for further details. Post procedure, the patient was admitted to the medical service for further observation. The surgical team was consulted for possible surgical intervention. During his overnight stay for observation, the patient experienced hypertension, going from blood pressure of 100/72 post procedurally to pressure of 85 over palpable. Hematocrit drifted down preprocedurally from 43.7 to 26.7. The patient was complaining of right upper quadrant pain, weakness and nausea, which was confirmed on physical examination showing right upper quadrant tenderness to light palpation. The patient received Crystalloid resuscitation of two units of PRBC's and was transferred to the Intensive Care Unit for further management. A CAT scan study after the patient was stabilized showed a large, subhepatic hematoma, measuring three cms in thickness. Intrahepatic biliary ductal dilatation to the level of the common hepatic duct was also seen. During his resuscitation, the patient received a total of four units of PRBC's, three units of FFP and one unit of platelets. The patient remained normotensive with stable hematocrit and was transferred to the Intensive Care Unit on hospital day number eight. The patient was also receiving Levaquin p.o. prophylactically, status post manipulation of the biliary system. Once on the floor and stable, the patient received PTC of the left side to finish decompression of his biliary system, considering his elevation of the total bilirubin level. The patient underwent left sided PTC by interventional radiology without any complications. A repeat CAT scan of the abdomen revealed a stable, subcapsular, hepatic hematoma which had not changed in size. There was no evidence of active extravasation. Transthoracic echocardiogram noted a possible pericardial effusion and this was evaluated with CT of the chest which showed no pericardial effusion but worsening of the right pleural effusion which extends across the posterior mediastinum. There was also a small effusion on the left. The patient underwent a thoracentesis of the right chest, draining 1.5 liters of old clotted blood. The patient underwent the procedure without any complications. Considering his differential diagnosis of primary sclerosing cholangitis versus Klatskin tumor, the patient underwent ultrasound guided needle biopsy of the liver. The procedure was completed without any complications. The pathology and the cytology came back negative for malignant cells. The patient was discharged on hospital day number 13, stable, without any complaints.	SG catheter terminates in right ventricular outflow tract. A pulmonary artery catheter has been placed, and terminates in the region of the right ventricular outflow tract. 11:37 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY Reason: r/o internal bleed. IMPRESSION: (Over) 11:37 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY Reason: r/o internal bleed. He was noted on an MRCP to have a dilated left hepatic duct and multiple abnormal right hepatic ducts and the question of a mass in the common duct just below the bifurcation. 2) Persistant subcapsular hepatic hematoma. Intrahepatic biliary ductal dilatation to the level of the common hepatic duct. The right ducts are noted to have multisegmental disease throughout however a biliary drainage catheter has been placed from the right with inadequate drainage on the right lobe. A right internal jugular vascular catheter has been placed, terminating in the lower SVC near the junction of the right atrium. The injection of contrast material revealed a stricture of the common duct and a small collapsed common duct extending toward the ampulla. Liver hematoma post PTC now with new pulmonary and pericardial effusion. Injection of contrast material outlined multiple small abnormal ducts in the central area of the right lobe and on the lateral view this was seen to be anteriorly almost certainly representing the medial segment of the left lobe or the anterior segment of the RUL(segment 5). TECHNIQUE: Helically-acquired contiguous axial images of the abdomen and pelvis were obtained without and after intravenous administration of contrast. Discoid atelectasis left mid and lower lung zone. Injection of contrast material revealed filling of a single irregular duct going posteriorly in the liver. Within the upper abdomen, note is made of contrast within the gallbladder and a drainage catheter in the right upper quadrant. LEFT ductal system FINAL REPORT INDICATION: Status post hepatic subcapsular hematoma after PTC placement. The obstructing mass lesion of the common hepatic duct identified on MR is not as clearly seen on this exam. Mild (1+) mitral regurgitation is seen. Otherwise hemodynamics stable overnight.RESP: LSCTA. Mild (1+)mitral regurgitation is seen.TRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. Moderate [2+]tricuspid regurgitation is seen. tolerates lying flat wo co. cv=initially borderline hypotensive w maps <60, pads , w 9, cvp 5-6 & co/ci/svr 6.8/3.76/595-initially rxed w total 1l ns w sl improvement. CCU NPN: please see flowsheet for objective dataCardiac: hemodynamically stable no issuesResp: lungs clear,sats mid 90's RAGI: decreased drainage from biliary bag. IMPRESSION: 1) Stable appearance of subcapsular hepatic hematoma. The leftventricular cavity size is normal.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - akinetic; mid inferior - akinetic; septal apex -hypokinetic; inferior apex - akinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal. There is abnormal diastolic septal motion/position consistent withright ventricular volume overload.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild pulmonary artery systolichypertension. heme=hct stable-34.8. PAP's remain low.Resp: Lungs CTA. There is interval decrease in the amount of pneumobilia but persistent mild intrahepatic biliary dilatation. Inferior myocardial infarction of indeterminate age.Clinical correlation is suggested. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is a large pericardial effusion. There is abnormaldiastolic septal motion/position consistent with right ventricular volumeoverload. 4) Continued presence of biliary stents, pneumobilia, and mild intrahepatic biliary dilatation. Resting regional wall motionabnormalities include inferior akinesis with inferoseptal hypokinesis. If hemodynamically stable overnight swan will be dc'd in am. incisional pain unchanged . Left ventricular wall thicknesses arenormal. cultured-bl & urine (low svr).a:hypotensive w <hct-responded to rbc & calcium.p:follow lung assessment-watch for failure. pulm=breath sounds=clear. Abd softly distended with BS times four quadrants. r biliary drain intact-drained 105 dk bilious drainage. The left ventricular cavity size is normal. GI WISE POS BS ABD SOFT, R FLANK DSG DRY AND INTACT DRAIN PUT OUT 240CC BILE THIS SHIFT HO AWARE, PT STARTED ON PROTONIX SKIN INTACT BUT JAUNDICE PEDAL PULSES DIFF TO DOPPLER, NO ANASARCA NOTED. T-tube to gravity and draining bilious in moderate amounts.Tolerating POS well.ID: Afebrile. passing flatus-wo bm. inr > from 1.1 to 1.4-rxed w 1uffp & 5mg vit k--am labs donot reflect rx. The aortic valve leaflets (3) appear structurally normal with goodleaflet excursion and no aortic regurgitation. There is diverticulosis but no diverticulitis. The effusion appearsloculated. The effusion appearsloculated. RESP WISE PT'S LUNGS CLEAR ON LEFT DIMINISHED ON R WITH FEW CRACKLES INITIALLY PT ON ARRIVAL HAD EXP WHEEZES , PT CONT ON RA SAT'S 97%. contin to co sl abd discomfort-rlq. Inferior myocardial infarction - age undetermined.Lateral T wave changes offer additional evidence of ischemia. The mitral valve leaflets arestructurally normal. ?dc pa-line--chg to mlc. CT PELVIS AFTER IV CONTRAST: A small amount of high density free fluid is seen in the pelvis, decreased from the prior exam.	24	[ { "category": "Radiology", "chartdate": "2185-07-08 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 795990, "text": " 11:37 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY\n Reason: r/o internal bleed. please do both CT and CT angio\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p PCA and plasty of CBD stricture (likely cholangioca)\n REASON FOR THIS EXAMINATION:\n r/o internal bleed. please do both CT and CT angio\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post PCA and CBD plasty. Decreased hematocrit.\n\n TECHNIQUE: Helically-acquired contiguous axial images of the abdomen and\n pelvis were obtained without and after intravenous administration of contrast.\n\n CONTRAST: 70 cc Optiray.\n\n COMPARISON: MR .\n\n CT ABDOMEN W/O AND W/ CONTRAST: There is a large subcapsular hepatic hematoma\n measuring 3 cm in thickeness. The hematoma is high attenuation, reflecting\n the subacute stage. Dependent within the hematoma is a layer of high-density\n material, which may be either acute layering blood or contrast given during\n the recent procedure. There is no active extravasation of contrast\n material. The liver is displaced towards the midline by pressure effect. The\n liver enhances homogeneously.\n There is diffuse intrahepatic biliary ductal dilatation involving both lobes.\n The percutaneous biliary drainage catheter enters the right lobe of the liver\n travelling into the CBD, and terminates in the duodenum. Pneumobilia from\n recent intervention is seen in the left lobe of the liver. The obstructing\n mass lesion of the common hepatic duct identified on MR is not as clearly\n seen on this exam. There is mild thickening of the common hepatic duct wall.\n Vicarious excretion of contrast material is within the gallbladder. A focus\n of gas is seen within the gallbladder.\n\n The pancreas, spleen, adrenal glands and kidneys are unremarkable. Ascites is\n distributed around the spleen, abdomen and pelvis. Small and large bowel are\n normal in caliber without bowel wall thickening or dilatation.\n\n CT OF THE PELVIS: There is a balloon Foley catheter is within the bladder. A\n gas- fluid level is seen within the bladder. The prostate is enlarged at 4.7\n x 3.4 cm.\n\n There are small bilateral pleural effusions with adjacent atelectasis, right\n greater than left.\n\n BONE WINDOWS: No blastic or lytic lesions identified.\n\n IMPRESSION:\n (Over)\n\n 11:37 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY\n Reason: r/o internal bleed. please do both CT and CT angio\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Large subacute subcapsular hepatic hematoma. No evidence for active\n bleed.\n\n 2. Intrahepatic biliary ductal dilatation to the level of the common hepatic\n duct. No extrahepatic biliary tree mass is identified.\n\n Findings discussed with the surgical team prior to dictation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-07 00:00:00.000", "description": "INTRO PERC TRNASHEPATIC STENT", "row_id": 795836, "text": " 7:43 AM\n PTBD Clip # \n Reason: CHOLANGIO CA\n Contrast: OPTIRAY Amt: 80CC\n ******************************* CPT Codes *****************************\n INTRO PERC TRNASHEPATIC STENT BILIARY STRICTURE DILATION NO \n -51 MULTI-PROCEDURE SAME DAY PERC TRANSHEPATIC CHOLANGIOGRA \n -51 MULTI-PROCEDURE SAME DAY CATH/STENT FOR INT/EXT BILIARY \n BILIARY STRICTURE DILATION NO -59 DISTINCT PROCEDURAL SERVICE \n PERC TRANSHEPATIC CHOLANGIOGRA CATH, TRANSLUM ANGIO NONLASER \n CATHETER, DRAINAGE C1769 GUID WIRES INCL INF \n C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF \n *************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n This is a 64 y/o man who presents with jaundice and a bilirubin of 12. He was\n noted on an MRCP to have a dilated left hepatic duct and multiple abnormal\n right hepatic ducts and the question of a mass in the common duct just below\n the bifurcation.\n\n Informed consent was obtained and the patient was prepped and draped. A\n puncture was then made into the right duct system and contrast material\n outlined a dilated duct near the hilum of the liver that could either\n represent the left or right duct. Injection of contrast material revealed\n filling of a single irregular duct going posteriorly in the liver. It was\n decided to enter this duct peripherally and after the duct was punctured far\n posteriorly a glide wire was passed through the dilated structure in the\n central region. The injection of contrast material revealed a stricture of\n the common duct and a small collapsed common duct extending toward the\n ampulla.\n\n Because this duct was not deemed adequate three other punctures were made; two\n very high in the right lobe without success although one duct was entered. It\n did not connect with the hilum because of obstruction peripheral to the hilum\n but central to the puncture. Injection of contrast material outlined multiple\n small abnormal ducts in the central area of the right lobe and on the lateral\n view this was seen to be anteriorly almost certainly representing the medial\n segment of the left lobe or the anterior segment of the RUL(segment 5). There\n was no filling of the dilated left hepatic duct and actually no contra\n st material in ducts in segments 6 or 7 and 8.\n\n It was then decided to use the only accessible duct and eventually the\n stricture centrally in what would appear to be the right duct system was\n entered and passed into the common duct. The stricture just below the\n bifurcation was dilated partially with an 8 mm balloon and an 8.5 biliary\n catheter was placed in satisfactory position for drainage. Over approximately\n 5 days the tube continues to drain and Mr. has been scheduled for a\n drainage of the left duct system and further evaluation of the right.\n\n Drainage of the Left duct system was accomplished on .\n\n\n\n (Over)\n\n 7:43 AM\n PTBD Clip # \n Reason: CHOLANGIO CA\n Contrast: OPTIRAY Amt: 80CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 1556687, "text": "\"IM COLD\"\nAT 10AM PT TRANSFERRED FROM CC7. PT HYPOTENSIVE, OVERNIGHT AND MORE SO THIS AM RECEIVED 1.5 LITERS OOVER NIGHT AND AN ADDITIONAL 500CC BOLUS PRIOR TO COMING TO CCU ONLY 175CC URINE OUT. PT C/O NAUSEA AND PAIN AT DRAIN SITE.\nWHEN PT ARRIVED TO CCU HE WAS JAUNDICE SCLERA INVOLVED ALSO, HAD 1ST UNIT OF BLOOD AND A LITER OF NS WIDE OPEN. 15 MINUTES LATER 2ND UNIT OF BLOOD UP WIDE OPEN. PT SHIVERING C/O HE WAS COLD TEMP 97.5 PO.\nSICU TEAM ACCOMPANIED PT ON ARRIVAL R RADIAL ALINE PLACED W/O DIFFICULTY AND THEN R IJ PLACED PA LINE FLOATED IN W/O DIFFICULTY PT TOLERATED WELL.\nPORT CXR DONE PA LINE ADVANCED D/T PLACEMENT SHOWN ON XRAY. PT TAKEN TO CT SCAN TO ASSESS PROBABLE SUBCAPSULAR LIVER HEMATOMA AFTER PTC PROCEDURE. LABS DRAWN AT 11AM STAT HCT WAS 34.3% PT 1 BAG OF PLATELETS PRE BAG PLTS 276 GIVEN BECAUSE PT WAS ON ASA AND PLAVIX. FSBS WAS 100 AT 1P AND THEN AT 430P WAS 96. LABS DRAWN AT 3P HO AWARE OF RESULTS HCT 30.2% PT, PTT, INR WNL AND PLTS 245. HO SAW PT AT 430P INCREASED HCT TO BE DRAWN Q4 VS Q6 STARTING AT 5P. HO ASKED ABOUT GIVING PAIN MED TO PT - NOT AT THIS TIME NOT WANT TO MASK ANYTHING. PT SLEPT MOST OF AFTERNOON. WIFE IN ROOM WITH PT MOST AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-10 00:00:00.000", "description": "Report", "row_id": 1556692, "text": "Nursing Progress Note\n\nCV: Tele sinus rhythm with occ PVC's. Swan dc'd changed to Triple lumen CXR shows good placement. Denies chest pain.\n\nResp: Lungs CTA. O2 sats 95-98% 2l.\n\nGU/GI: Diet advanced. Tolerating sm amts of clear liquids. Not much of an appetite. Abd is soft with bowel sounds. Passing flatus. Biliary drain to gravity. RLQ pain with palpation. OOB to chair tolerated well. Hct 34 for 24hrs.\n\nA&P: Hct remains stable. To remain in unit for observation overnight then transfer to floor in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-11 00:00:00.000", "description": "Report", "row_id": 1556693, "text": "ccu nsg progress note-nsicu border.\no:cv=hemody stable throughout night.\n gi=bm x1-semiformed guiac neg. prior to & after co increased abdominal discomfort (not simular to rlq discomfort) more located around umbilicus. nsicu resident notified. hct/plat stable 35.7/205. ast/alt/alk phos sl elevated.\n id=afebrile. wbc 7.3.\n labs=k 3.6. cal 8.1. phos 1.9.\n\na:new onset abd discomfort.\n\np:abd to be evaluated. am labs need to be addressed. contin present management.\n" }, { "category": "Radiology", "chartdate": "2185-07-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796904, "text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check for pneumo, size of the effusion\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with bile obstruction, s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n please check for pneumo, size of the effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis.\n\n CHEST, AP PORTABLE: There is interval withdrawal of right IJ central line.\n There is a slight reduction of the left pleural effusion. There is no\n evidence of pneumothorax. There is a small right pleural effusion. The left\n hemidiaphragm is not well-visualized, consistent with a left lower lobe\n collapse/consolidation.\n\n IMPRESSION: There is slight reduction in the size of the left pleural\n effusion, without evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 796809, "text": " 8:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate pericardial effusion\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with liver bleed post PTC, now w/ new pulm and pericardial\n effusions\n REASON FOR THIS EXAMINATION:\n evaluate pericardial effusion\n CONTRAINDICATIONS for IV CONTRAST:\n renal function\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pericardial effusion with loculation seen on cardiac echo today.\n Please evaluate further. Liver hematoma post PTC now with new pulmonary and\n pericardial effusion. Please evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast CT of the chest.\n\n FINDINGS: There is minimal thickening of the pericardium anteriorly, however,\n there is no pericardial effusion. The pleural space on the right, which is\n filled with intermediate density fluid, extends across the posterior\n mediastium and perhaps explains in part the finding on echocardiography. There\n is also some loculated fluid extending along the medial border of the pleural\n space on the right. There are portions of this large effusion which do appear\n loculated. There a smaller effusion on the left. There is adjacent compressive\n atelectasis but no true consolidative change seen within the lungs. There may\n be a left sided Bochdalek hernia containing fat. The airways are patent\n centrally. There is no mediastinal adenopathy and the heart is not enlarged.\n The bones reveal minor degenerative changes in the spine.\n\n The imaged organs of the upper abdomen are described in detail on the CT of\n the abdomen performed earlier today.\n\n IMPRESSION: No CT evidence for pericardial effusion. Finding on\n echocardiogram may be explained by extension of the right pleural space across\n the spine in the posterior mediastinum containing loculated fluid.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-15 00:00:00.000", "description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER", "row_id": 796686, "text": " 9:24 AM\n CATH CHEK/REMV Clip # \n Reason: R tube not flashing, please evaluate\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: CONRAY Amt: 30\n ***************************** CPT Codes *****************************\n CHALNAGIOGRAPHY VIA EXISTING C -76 BY SAME PHYSICIAN \n TUBE CHOLANGIOGRAM \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ? klatzkin tumor\n REASON FOR THIS EXAMINATION:\n R tube not flashing, please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n This is a 63 year old man with a Klatzkin tumor who required a biliary\n catheter check because the tube did not appear to be flushing adequately.\n Patient was brought to the interventional suite and prepped and draped.\n Contrast material was injected into the biliary tree that showed good position\n and complete drainage of the biliary system.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796179, "text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check new line position\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with PA line changed over wire to cvl\n REASON FOR THIS EXAMINATION:\n Check new line position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INDICATION: Line placement.\n\n Comparison is made to previous radiograph of 2 days earlier.\n\n A right internal jugular vascular catheter has been placed, terminating in the\n lower SVC near the junction of the right atrium. No pneumothorax is\n identified. Cardiac and mediastinal contours are stable. There are bilateral\n small pleural effusions, increased on the left and new on the right. There are\n also increasing opacities in the retrocardiac region bilaterally.\n\n IMPRESSION:\n 1) Vascular catheter in satisfactory position, with no pneumothorax.\n 2) Bilateral pleural effusions, increased on the left and new on the right.\n Adjacent basilar lung opacities likely reflect atelectasis, but other process\n such as an infection cannot be excluded in the appropriate setting.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-14 00:00:00.000", "description": "INTRO PERC TRNASHEPATIC STENT", "row_id": 796567, "text": " 8:14 AM\n PTC Clip # \n Reason: LEFT BILIARY DRAINAGE\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: OPTIRAY Amt: 50\n ***************************** CPT Codes *****************************\n INTRO PERC TRNASHEPATIC STENT -58 SERVIC BY SAME MD DURING POST OP \n BILIARY BIOSPY VIA T-TUBE 78 RELATED PROCEDURE DURING POSTOPER \n -51 MULTI-PROCEDURE SAME DAY BILIARY STRICTURE DILATION NO \n 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY \n CHALNAGIOGRAPHY VIA EXISTING C -76 BY SAME PHYSICIAN \n -51 MULTI-PROCEDURE SAME DAY CATH/STENT FOR INT/EXT BILIARY \n BILIARY STRICTURE DILATION NO -59 DISTINCT PROCEDURAL SERVICE \n TUBE CHOLANGIOGRAM \n ***************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n 63 year old male who enters with an ERCP and MRCP.\n\n A tube cholangiogram was performed via the indwelling right biliary drainage\n catheter. The right ducts are noted to have multisegmental disease\n throughout however a biliary drainage catheter has been placed from the right\n with inadequate drainage on the right lobe. The left biliary tree was noted\n to continue to be markedly dilated and under ultrasound guidance a needle was\n passed into the left biliary tree. After the ducts were filled a second\n puncture was made more peripherally into the left ducts outlining marked\n dilatation and obstruction of the ducts at the bifurcation of the superior and\n inferior segments of the lateral segment of the left lobe. The small\n guidewire was then passed into the left biliary tree to the obstruction into\n the common bile duct after which the small sheath was exchanged for a 7 French\n bright-tipped sheath and the obstruction dilated with an 8 mm balloon. The\n balloon was removed as well as the sheath and an 8 French biliary drain was\n placed with the pigtail coiled in the duodenum. The sideports of the biliary\n drainage catheter were left in satisfactory position to drain internally the\n left duct system.\n\n CONCLUSION: S/P balloon dilatation of a stricture which appears malignant.\n Biopsies were also taken prior to biliary tube placement. The material sent\n to the Pathology lab for histology. The appearance on the biliary tree is\n that of sclerosing cholangitis and primary carcinoma of the bile ducts in the\n position that would be called a Klatzkin tumor.\n\n\n\n\n\n\n\n\n (Over)\n\n 8:14 AM\n PTC Clip # \n Reason: LEFT BILIARY DRAINAGE\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2185-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 795985, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, check PA placement\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new RIJ PA line\n REASON FOR THIS EXAMINATION:\n r/o PTX, check PA placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Pulmonary artery catheter placement.\n\n A pulmonary artery catheter has been placed, and terminates in the region of\n the right ventricular outflow tract. No pneumothorax is evident. The heart\n size and mediastinal contours are within normal limits for technique. Linear\n opacities are seen in the left mid and lower lung zones. There is also slight\n blunting of the left costophrenic sulcus. Biapical thickening is noted and\n may relate to apical pleural thickening or fluid tracking to the apices on\n this supine projection.\n\n Within the upper abdomen, note is made of contrast within the gallbladder and\n a drainage catheter in the right upper quadrant.\n\n IMPRESSION:\n\n 1. SG catheter terminates in right ventricular outflow tract.\n 2. Discoid atelectasis left mid and lower lung zone.\n 3. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-12 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 796353, "text": " 10:11 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: evaluate liver and biliary system, esp. LEFT ductal system\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p hepatic subcapsular hematoma after PTC placement\n REASON FOR THIS EXAMINATION:\n evaluate liver and biliary system, esp. LEFT ductal system\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hepatic subcapsular hematoma after PTC placement.\n Evaluate biliary ductal system.\n\n COMPARISON: There are no prior examinations for comparison.\n\n FINDINGS: The liver is grossly normal in echogenicity. There is a large\n subcapsular hematoma measuring 2.3 cm in thickness. There is no intrahepatic\n or extrahepatic biliary ductal dilatation. The common bile duct is normal at\n 3 mm. The gallbladder wall is thickened, however the gallbladder is\n contracted. No gallstones are identified. A drainage catheter is seen\n traversing through the right lobe of the liver. No focal hepatic lesions\n identified.\n\n IMPRESSION:\n 1) No evidence for biliary ductal dilatation.\n 2) Persistant subcapsular hepatic hematoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-16 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 796796, "text": " 12:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Evaluate for effusions/pericardial effusion. Evaluate liver\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Klatskin tumor, s/p liver bleed post PTC\n REASON FOR THIS EXAMINATION:\n Evaluate for effusions/pericardial effusion. Evaluate liver hematoma. (C+)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH IV CONTRAST\n\n CLINICAL INDICATION: Klatskin tumor, post PTC.\n\n TECHNIQUE: Helically aquired images are obtained through the abdomen and\n pelvis after 150 cc Optiray.\n\n CONTRAST: Nonionic contrat was chosen because of the patient's generalized\n debility.\n\n Comparison is made to study of .\n\n CT ABDOMEN AFTER IV CONTRAST: There is a moderate/large sized right pleural\n effusion and a small left effusion, both larger since the prior exam. There\n is associated bibasilar atelectasis. The superior aspect of the pericardium\n is not imaged but there is no visualized pericardial effusion. The patient\n has left and right sided internal/external biliary drains which terminate in\n the duodenum. There is interval decrease in the amount of pneumobilia but\n persistent mild intrahepatic biliary dilatation. A subcapsular hepatic\n hematoma is not changed in size. There is no evidence of active extravasttion\n (would be indicated by extravasation of contrast). There is some residual high\n density material within the gallbladder and a small amount of air is also seen\n within the gallbladder. The spleen, adrenal glands, and kidneys appear\n normal. There is a parapelvic cyst in the left kidney. The pancreas enhances\n homogeneously. There is no interval pancreatic duct dilatation. The portal\n vein, splenic vein, SMV, and SMA are patent. There is no adenopathy within the\n abdomen.\n\n CT PELVIS AFTER IV CONTRAST: A small amount of high density free fluid is\n seen in the pelvis, decreased from the prior exam. The ureters are\n nondilated. The bladder is not thickened. There is diverticulosis but no\n diverticulitis. There are no pelvic masses or enlarged inguinal lymph nodes.\n There are no suspicious lytic or blastic osseous lesions.\n\n IMPRESSION:\n 1) Stable appearance of subcapsular hepatic hematoma.\n\n 2) Interval worsening of bilateral pleural effusions and associated\n atelectasis.\n (Over)\n\n 12:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Evaluate for effusions/pericardial effusion. Evaluate liver\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3) Decreae in amount of high density (likely bloody) ascites.\n\n 4) Continued presence of biliary stents, pneumobilia, and mild intrahepatic\n biliary dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-18 00:00:00.000", "description": "BX-NEEDLE LIVER BY RADIOLOGIST", "row_id": 796925, "text": " 1:20 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)\n Reason: US GUIDED BX OF L HEPATIC LOBE. PT WITH CIRRHOSIS AND KLATSKIN TUMOR\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Klatskins tumor, ? PSC.\n REASON FOR THIS EXAMINATION:\n (US-guided biopsy of L hepatic lobe) cirrhosis, tumor.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND GUIDED LIVER BIOPSY :\n\n HISTORY: Abnormal LFTs.\n\n TECHNIQUE & FINDINGS: Alternatives, benefits and risks, including infection\n and bleeding, were explained to the patient. Informed consent was obtained.\n Skin was prepped and draped in the usual sterile manner. Local anesthesia was\n infiltrated. Left lobe of the liver was localized using ultrasound guidance,\n an 16 gauge core biopsy of the liver was performed. Patient tolerated the\n procedure well without immediate complications.\n\n IMPRESSION: Successful ultrasound guided biopsy of the left lobe of the liver.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 1556688, "text": "PT A/O, CARDIAC WISE SR OCC PVCS 60-70, ALINE PRESSURES 80-100'S SYS\nDIPS WHEN HE IS SLEEPING HO AWARE. PA PRESSURES 20'S/TEENS PWCP 14 CVP 4. RESP WISE PT'S LUNGS CLEAR ON LEFT DIMINISHED ON R WITH FEW CRACKLES INITIALLY PT ON ARRIVAL HAD EXP WHEEZES , PT CONT ON RA SAT'S 97%. GI WISE POS BS ABD SOFT, R FLANK DSG DRY AND INTACT DRAIN PUT OUT 240CC BILE THIS SHIFT HO AWARE, PT STARTED ON PROTONIX SKIN INTACT BUT JAUNDICE PEDAL PULSES DIFF TO DOPPLER, NO ANASARCA NOTED. URINE IN FOLEY DK YELLOW 70-100/HR AVERAGE.\nPLAN CONTINUE TO MONITOR HCT, RESP STATUS (HURTS TO TAKE DEEP BREATH)\nLEVEL OF PAIN, NEED FOR MAINTENCE MEDS (THYROID MED?)\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-09 00:00:00.000", "description": "Report", "row_id": 1556689, "text": "ccu nsg progress note-nsicu border.\no:neuro=alert/awake oriented. cooperative. very pleasant.\n pulm=initially on ra w sats low 90's-abg @ 2300 7.39/38/86/24/-1 w sat 95-nc added @ 2l--abg @ 0500 7.39/38/69/24/-1 w sat 95-nc increased to 4l. breath sounds=clear. wo co sob/dyspnea. tolerates lying flat wo co.\n cv=initially borderline hypotensive w maps <60, pads , w 9, cvp 5-6 & co/ci/svr 6.8/3.76/595-initially rxed w total 1l ns w sl improvement. hct found to be 27.5/26.5 down from 30.8-tx w total 2 u rbc & calcium/mg/k replaced w improvemnt in #'s-maps >60-70, pad 12-16, w 10, cvp 8 & co/ci/svr 7.3/4.03/723. rhythm sr w short pr occas/freq pvc's-episodes of sb w rate to mid 50's. synthroid restarted-tsh sent.\n gi=npo. r biliary drain intact-drained 105 dk bilious drainage.\n heme=hct <to 26.5-tx w 2urbc-reck pending. inr > from 1.1 to 1.4-rxed w 1uffp & 5mg vit k--am labs donot reflect rx.\n gu=foley. adeq uo. approx 4.8l positive overall.\n id=afebrile. cultured-bl & urine (low svr).\n\na:hypotensive w <hct-responded to rbc & calcium.\n\np:follow lung assessment-watch for failure. maint maps >60. #'s. maint hct >30 & follow inr. ck am labs-rx as indicated. contin present management. support as indicated.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-11 00:00:00.000", "description": "Report", "row_id": 1556694, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: hemodynamically stable HR 56-82 SB-SR,BP 126-146/61/88\n\nResp: lungs clear,sats on RA 92-94. pt experiencing pain with deep breaths\n\nGU: UO 35-90/hr biliary drain put out 500cc this shift\n\nComfort: having abd pain felt a little better after breakfast,team is aware. also having incisional pain,no pain meds ordered.\n\nA/P: called out,no beds\n pt may need pain meds as deep breathing is diff .\n" }, { "category": "Nursing/other", "chartdate": "2185-07-12 00:00:00.000", "description": "Report", "row_id": 1556695, "text": "CCU Nursing Progress Note: 1900-0700\nS-\"I just feel lousey.\"\n\nSEE CAREVUE FOR ALL VS AND OBJECTIVE DATA\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:A/O/X/3. Very pleasant and cooperative. C/o pain at inscion site and surgical team still denying pt of pain medication. Given Bendadryl to help sleep and sleeping comfortably overnight with tolerable pain.\nCV-HR 60s to 80s. NSR with very few PVCs. SBPs 100s to 130s. Otherwise hemodynamics stable overnight.\nRESP: LSCTA. Placed on 2L for RA Sat of 92-93%. Currently sating > 95%. Denies SOB but has inscional pain on deep inspiration.\nGU/GI: Foley DC'd and since has voided 300cc in urinal. Urine brown and clear in appearance. Abd softly distended with BS times four quadrants. T-tube to gravity and draining bilious in moderate amounts.\nTolerating POS well.\nID: Afebrile. No issues. Continues Abx empirically.\nACC: Aline and TLL dc'd and left with 2PIVs\nA/P: Transfer to floor when bed available.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-12 00:00:00.000", "description": "Report", "row_id": 1556696, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: hemodynamically stable no issues\n\nResp: lungs clear,sats mid 90's RA\n\nGI: decreased drainage from biliary bag. fair to poor appetite. incisional pain unchanged . c/o nausea this afternoon and received 2mg zofran.\n\nGU: voiding using urinal\n\nActivity: OOB x2 to chair. this am sat up in chair for 2hrs this am,less time at lunch\n\nID: afebrile\n\nA/P: stable awaiting floor bed\n" }, { "category": "Nursing/other", "chartdate": "2185-07-09 00:00:00.000", "description": "Report", "row_id": 1556690, "text": "Nursing Progress Note\n\n\nO: CV: Tele sinus to sinus brady with occ PVC's. See flow sheet for vital signs. PAP's remain low.\n\nResp: Lungs CTA. O2 sat 96-98% on 4l NP.\n\nGU/GI: Pt remains NPO. Abd is soft with bowel sounds present. C/o R LQ pain intermittently. G tube to gravity drained 400cc of bile. Denies nausea or vomiting. HCt 34/35. LFT's declining. TB 8.6. IV fluid decreased to 20/hr. Urine output > 80/hr.\n\nNeuro: Alert and oriented. MAE.\n\nA&P: Hct stable after 2 UPRBC's. Continue to monitor HCT Q4 overnight. If hemodynamically stable overnight swan will be dc'd in am.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-10 00:00:00.000", "description": "Report", "row_id": 1556691, "text": "ccu nsg progress note-nsicu border.\no:neuro=slept. responsive/appropriate.\n pulm=breath sounds=clear.\n cv=hemody stable throughout night. see care view for #'s.\n gi=remains npo. contin to co sl abd discomfort-rlq. passing flatus-wo bm.\n gu-adeq uo.\n id=afebrile.\n heme=hct stable-34.8.\n labs=am sent. k 3.7 & phos 2.1.\n\na:stable throughout night.\n\np:contin present management. ?dc pa-line--chg to mlc. ?dc a-line. support as indicated.\n" }, { "category": "Echo", "chartdate": "2185-07-15 00:00:00.000", "description": "Report", "row_id": 72346, "text": "PATIENT/TEST INFORMATION:\nIndication: evaluate LV and PASP prior to possible liver transplant.\nHeight: (in) 68\nWeight (lb): 142\nBSA (m2): 1.77 m2\nStatus: Inpatient\nDate/Time: at 15:12\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - akinetic; mid inferior - akinetic; septal apex -\nhypokinetic; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal. There is abnormal diastolic septal motion/position consistent with\nright ventricular volume overload.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a large pericardial effusion. The effusion appears\nloculated. There are no echocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly decreased (LVEF 40%). Resting regional wall motion\nabnormalities include inferior akinesis with inferoseptal hypokinesis. Right\nventricular chamber size and free wall motion are normal. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+]\ntricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is a large pericardial effusion. The effusion appears\nloculated. There are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 178299, "text": "Sinus bradycardia. Inferior myocardial infarction - age undetermined.\nLateral T wave changes offer additional evidence of ischemia. Since the\nprevious tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2185-07-07 00:00:00.000", "description": "Report", "row_id": 178300, "text": "Sinus bradycardia. Inferior myocardial infarction of indeterminate age.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n" } ]
30,699	108,670	65yo F w/ widely metastatic breast cancer, on dexamethasone taper for brain metastases, and w/ bilat nephrostomy p/w SOB and fever w/ likely PNA +/- UTI. Given symptoms of fever, nonproductive cough, hypoxia, and CTA findings of new nodular and linear ground glass opacities, initially treated for pneumonia. Given her recent history of long hospitalizations and recent NH stay, will treat for health-care acquired pneumonia with cefepime, levaquin, and vancomycin. She was also presumably started on IV bactrim in the ER for ? of PCP (given that she was on dexamethasone) and new ground-glass opacities on CT, LDH elevated from baseline. Upon transfer to the ICU, the patient refused positive pressure ventilation, stating that she just wanted to be comfortable. After discussing the matter with her and the health care team, the patient was made comfort measures only. Antibiotics were discontinued and she was put on a morphine gtt to treat her sense of dyspnea. She expired at 4:50am on with her family at the bedside.	Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Infusions: Other ICU medications: heparin sc. URINE CULTURE (Pending): from L and R nephrosotomies Urine legionella PND BCx PND Assessment and Plan Hypoxia/respiratory distress with desats to mid 80s on NRB this AM. Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Meropenem, cipro, bactrim, vanco, prednisone. Chief Complaint: Hypoxia, hypotension HPI: For full details, please see admission H&P. Left mastectomy and multiple chemo regimens, including adria and cytoxan. Left mastectomy and multiple chemo regimens, including adria and cytoxan. Comfort care (CMO, Comfort Measures) Assessment: Action: Response: Plan: Pt was comfortable on morphine gtt .pt expired @ 0445 am . Upon arrival to ICU, pt was placed on droplet precautions. Upon arrival to ICU, pt was placed on droplet precautions. Will change ciprofloxacin to levofloxacin for atypical coverage. URINE CULTURE (Pending): from L and R nephrosotomies Urine legionella PND BCx PND Assessment and Plan Hypoxia/respiratory distress - presented with hypoxia most likely to infectious source. - will change ciprofloxacin to levofloxacin for atypical coverage. CXR was initially read as pneumonia of the RML and she was given cefepime 2gm IV x1 and levofloxacin 750mg IV x1. Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Bactrim (SMX/TMP) - 09:30 PM Ciprofloxacin - 10:17 PM Vancomycin - 11:17 PM Meropenem - 12:00 AM Infusions: Other ICU medications: Other medications: Medications on transfer: Zonisamide 100 mg PO BID Keppra 750 mg PO TID SQHeparin Protonix 40 mg PO Q12H Celexa 10 mg PO daily Nystatin Oral Suspension MVI Compazine PRN Vancomycin 1000 mg IV Q12H ISS Morphine IR 7.5 mg PO Q6H PRN Tylenol PRN Prednisone 40 mg PO BID Meropenem 500 mg IV Q6H Ciprofloxacin 400 mg IV Q12H Bactrim 400 mg IV Q12H Past medical history: Family history: Social History: 1. Assessment and Plan RESPIRATORY DISTRESS HYPOXEMIA HYPOTENSION PNEUMONIA METASTATIC BREAST CA ANEMIA THROMBOCYTOPENIA URINARY INFECTION CXR picture with diffuse, primarily upper zone infiltrates most suggestive of atypical pneumonia. ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 10:17 PM Indwelling Port (PortaCath) - 10:19 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Comfort measures only Disposition :ICU Total time spent: Patient is critically ill Anemia Chronic, will monitor. Anemia Chronic, will monitor. She was transferred to the for possible non-invasive ventilation (BiPAP) and closer hemodynamic monitoring. She was transferred to the for possible non-invasive ventilation (BiPAP) and closer hemodynamic monitoring. - f/u induced sputum to r/o PCP. Plan to d/c antibiotics, steroids, and add morphine prn dyspnea/pain. Plan to d/c antibiotics, steroids, and add morphine prn dyspnea/pain. - pt requesting to be comfortable andpass in peace, will change to CMO - will d/c all antibiotics and steroids for HCAP and PCP coverage Continue droplet precautions until influenza is ruled out - Continue oxygen support with NC and face mask, consider mask ventilation if tolerated. Metastatic Breast CA s/p several therapies Further management per primary oncologist. Metastatic Breast CA s/p several therapies Further management per primary oncologist. Since the previous tracingof sinus tachycardia is now present. Given recent hospitalizations, will cover broadly for HAP. - prn morphine Pneumonia As above Hypotension Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will send nasopharyngeal aspirate to r/o influenza. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Also given XRT to pelvic mets which led to hydronephrosis and bilateral neprhostomy tubes. Also given XRT to pelvic mets which led to hydronephrosis and bilateral neprhostomy tubes. Assessment and Plan RESPIRATORY DISTRESS HYPOXEMIA PNEUMONIA METASTATIC BREAST CA ANEMIA ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines / Intubation: 22 Gauge - 10:17 PM Indwelling Port (PortaCath) - 10:19 PM Comments: Prophylaxis: DVT: SQ UF Heparin Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: ICU Total time spent: 60 minutes Patient is critically ill	14	[ { "category": "ECG", "chartdate": "2121-01-04 00:00:00.000", "description": "Report", "row_id": 274006, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Since the previous tracing\nof sinus tachycardia is now present.\n\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317025, "text": "This is a 65 y/o female with metastatic breast cancer who lives in the\n NH where she was found to be hypoxic to 80% on RA, associated with\n nonproductive cough, SOB, nausea, abdominal pain and weakness. In the\n ED, Temp was 102.2, BP 142/86, HR 113, and sats 80% on RA, improving to\n 95% on 5LNC. CXR revealed ? pneumonia of the RML and she was given IV\n antibiotics vs PCP. was admitted on to the floor under\n oncology service with cough, SOB, and hypoxia.\n On the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. On the floor, in the PM , the patient triggered\n for hypoxia with an oxygen saturation of 90% on a NRB. She was also\n SOB. She is currently being treated for pneumonia, possible PCP\n pneumonia vs. HAP. She is on broad-spectrum ABx including Bactrim +\n steroids for PCP. was also found to be hypotensive earlier in the\n evening with SBPs in the 80s which also resulted in a trigger. She was\n given a 500 mL IVF bolus and her SBP improved to the 100s. Her code\n status was confirmed with the patient and her family, DNR/DNI. She was\n transferred to the for possible non-invasive ventilation (BiPAP)\n and closer hemodynamic monitoring. Upon arrival to ICU, pt was placed\n on droplet precautions. Oxygen administered via NRB 100% as well as NC\n 5 LPM which has maintained the sat above 90%, hence, the BiPAP has\n never been needed.\n Dyspnea (Shortness of breath)\n Assessment:\n Dyspneac, non-productive cough, sat 89-98%, afebrile, LS crackles\n throughout, anxious, and restless, c/o headache, BP dropped to low 80s.\n Action:\n Oxygen administered via NRB 100% and NC 5 LPM, respiratory status\n monitored very closely as pt pulls out the oxygen occasionally which\n results in desaturation to low 80s, given Tylenol for headache and\n Morphine Po as ordered PRN for restlessnesswith moderate effect, given\n a bolus of 250 cc NS, multiple antibiotics (Vancomycin, Bactrim,\n Ciprofloxacin, Levofloxacin, and Meropenam IV) administered.\n Response:\n Continues to be very restless, saturation maintained above 90% with O2\n on, tolerated fluids well, headache relieved, BP improved to systolic\n above 90.\n Plan:\n Monitor respiratory status very closely, wean Oxygen as tolerated to\n maintain sat above 90%, monitor BP and bolus as needed to maintain SBP\n above 82 as per HO, continue antibiotics, keep pt on droplet\n precautions to R/O the flue, may need deep tracheal suctioning to\n induce sputum to be sent for cx., consider administering anti-anxiety\n meds, reassure pt and keep her and family updated on her condition and\n POC. Pt is /DNR, no pressors as confirmed by pt, she also doesn\n like BiPAP as she reported but might consider, but definitely no\n intubation.\n" }, { "category": "Physician ", "chartdate": "2121-01-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 317017, "text": "Chief Complaint: 65 year old woman with metastatic breast ca,\n transferred to MICU with respiratory distress and hypoxemia, and\n hypotension.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Admitted yesterday with cough and shortness of breath to OMED\n yesterday. Tonight developed worsening hypoxemia and hypotension.\n Patient had several weeks of weakness at her nursing home. No hx of\n orthopnea or PND\n Initially came to ED with O2 sats in the 80's. Sent for CTA, which\n showed evidence of possible atypical pneumonia. Given Bactrim for\n possible PCP, with Cefipime, vanco, cipro, and steroids.\n Tonight O2 sats dropped. Placed on 100% NRB. Code status changed to\n DNR/DNI tonight. Transferred to MICU for possible non-invasive\n ventilation. Had BP in the 80's; responded to fluid resuscitation.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meropenem, cipro, bactrim, vanco, prednisone.\n Past medical history:\n Family history:\n Social History:\n Metastatic breast ca - dx . Left mastectomy and multiple chemo\n regimens, including adria and cytoxan. Developed bone mets in .\n Brain mets in --given whole brain radiation. Also given XRT to\n pelvic mets which led to hydronephrosis and bilateral neprhostomy\n tubes. Brain mets recurred in treated with cyberknife. On seizure\n prophylaxis.\n Nephrostomy tube for hydronephrosis\n Hypertension\n Cataracts\n L-hip replacement\n s/p carpal tunnel release.\n Occupation:\n Drugs:\n Tobacco: Former smoker\n Alcohol: Occasional\n Other: Divorced\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Signs or concerns for abuse : No\n Pain location: Hip\n Flowsheet Data as of 11:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 80 () bpm\n BP: 103/57\n RR: 22 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 60 mL\n PO:\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -290 mL\n Respiratory\n O2 Delivery Device: High flow nasal cannula, High flow neb\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90\n 28.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:// INR 1, Differential-Neuts:69, Band:20,\n Lactic Acid:1.9, LDH:795, Ca++:8, Mg++:1.7, PO4:3.0\n Fluid analysis / Other labs: UA - moderate bacteria, WBC's, leukocyte\n esterase from nephrostomy tube\n Imaging: CXR - interstitial to alveolar infiltrates bilaterally.\n CT - bilateral, primarily in upper zone- ground glass opacities. Region\n of atelectasis right mid zone. Probable new liver met.\n Assessment and Plan\n RESPIRATORY DISTRESS\n HYPOXEMIA\n PNEUMONIA\n METASTATIC BREAST CA\n ANEMIA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 317018, "text": "Chief Complaint: 65 year old woman with metastatic breast ca,\n transferred to MICU with respiratory distress and hypoxemia, and\n hypotension.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Admitted yesterday with cough and shortness of breath to OMED\n yesterday. Tonight developed worsening hypoxemia and hypotension.\n Patient had several weeks of weakness at her nursing home. No hx of\n orthopnea or PND\n Initially came to ED with O2 sats in the 80's. Sent for CTA, which\n showed evidence of possible atypical pneumonia. Given Bactrim for\n possible PCP, with Cefipime, vanco, cipro, and steroids.\n Tonight O2 sats dropped. Placed on 100% NRB. Code status changed to\n DNR/DNI tonight. Transferred to MICU for possible non-invasive\n ventilation. Had BP in the 80's; responded to fluid resuscitation.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications: heparin sc.\n Other medications:\n Meropenem, cipro, bactrim, vanco, prednisone.\n Past medical history:\n Family history:\n Social History:\n Metastatic breast ca - dx . Left mastectomy and multiple chemo\n regimens, including adria and cytoxan. Developed bone mets in .\n Brain mets in --given whole brain radiation. Also given XRT to\n pelvic mets which led to hydronephrosis and bilateral neprhostomy\n tubes. Brain mets recurred in treated with cyberknife. On seizure\n prophylaxis.\n Nephrostomy tube for hydronephrosis\n Hypertension\n Cataracts\n L-hip replacement\n s/p carpal tunnel release.\n Occupation:\n Drugs:\n Tobacco: Former smoker\n Alcohol: Occasional\n Other: Divorced\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Signs or concerns for abuse : No\n Pain location: Hip\n Flowsheet Data as of 11:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 80 () bpm\n BP: 103/57\n RR: 22 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 60 mL\n PO:\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -290 mL\n Respiratory\n O2 Delivery Device: High flow nasal cannula, High flow neb\n SpO2: 98%\n ABG: ////\n Physical Examination\n Patient comfortable lying at 30 degrees with NRB mask and nasal prongs.\n . Chest with rales anteriorally bilaterally. No wheeze. PMI\n diffuse. No gallop or murmur. S1 and S2 normal. Active bowel sounds.\n Abdomen soft and non-tender. Extremities warm and well perfused, no\n edema. Patient alert and oriented.\n Labs / Radiology\n 90\n 28.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:// INR 1, Differential-Neuts:69, Band:20,\n Lactic Acid:1.9, LDH:795, Ca++:8, Mg++:1.7, PO4:3.0\n Fluid analysis / Other labs: UA - moderate bacteria, WBC's, leukocyte\n esterase from nephrostomy tube\n Imaging: CXR - interstitial to alveolar infiltrates bilaterally.\n CT - bilateral, primarily in upper zone- ground glass opacities. Region\n of atelectasis right mid zone. Probable new liver met.\n Assessment and Plan\n RESPIRATORY DISTRESS\n HYPOXEMIA\n HYPOTENSION\n PNEUMONIA\n METASTATIC BREAST CA\n ANEMIA\n THROMBOCYTOPENIA\n URINARY INFECTION\n CXR picture with diffuse, primarily upper zone infiltrates most\n suggestive of atypical pneumonia. The 20% bands on WBC differential,\n however, is more suggestive of bacterial infection. This bandemia may\n relate to the probable urine infection rather than the pulmonary\n infection. I concur with the presumptive treatment for PCP given her hx\n and the elevated LDH on her blood studies. Bronchoscopy now could not\n be accomplished without intubating the patient and she does not want to\n go that route. Will switch cipro to levofloxacin to get better\n coverage of atypical organisms. Legionella antigen pending. Will send\n DFA for influenza. At this point ,O2 sats are acceptable on NRB mask.\n Will hold on mask ventilation for now.\n Patient with widely metastatic breast ca\n new liver met noted on CT\n scan. Patient is DNR/DNI.\n Anemia is chronic and likely related to chemo and tumor. No evidence\n of bleeding now. No need for transfusion now. Platelet count dropping;\n concern about marrow involvement with tumor. Will check for HIT.\n Patient with hypotension on OMED unit. Is responding to fluids.\n Probable drop in SVR in association with infection. Getting stress dose\n steroids as part of treatment for PCP. BP drops further, will need\n to address possible vasopressors. Team will address with patient now.\n ICU Care\n Nutrition: oral diet\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments: Family notified.\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 317022, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n For full details, please see admission H&P. In brief, this is a 65 y/o\n female with metastatic breast cancer who was admitted yesterday to the\n oncology service with cough, SOB, and hypoxia. Hypoxic to 80% on RA at\n NH -> in ambulance improved to 100% on NRB. She had been c/o weakness\n for the past several weeks along with worsening back pain. She has had\n a nonproductive cough 3 days PTA. She has had intermittent nausea and\n some abdominal pain, but no vomiting. She denies any burning when she\n urinates but does note that her R nephrostomy tube has been painful and\n the urine in it has been bloodier. She denies any swelling in her legs,\n PND, or orthopnea. She denies any recent bruising, bleeding, or skin\n changes.\n In the ED, VS on arrival were T 102.2, BP 142/86, HR 113, and sats were\n 80% on RA, improving to 95% on 5LNC. CXR was initially read as\n pneumonia of the RML and she was given cefepime 2gm IV x1 and\n levofloxacin 750mg IV x1. However, radiology said her CXR did not show\n evidence of pneumonia so she was sent for CTA which was concerning for\n atypical pneumonia. Given her ongoing dexamethasone taper, she was\n given bactrim 350 mg IV x 1 for PCP.\n the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. ID was consulted and agreed with the above management.\n On the floor, in the PM , the patient triggered for hypoxia with\n an oxygen saturation of 90% on a NRB. She was also SOB. She is\n currently being treated for pneumonia, possible PCP pneumonia vs. HAP.\n She is on broad-spectrum ABx including Bactrim + steroids for PCP. \n was also found to be hypotensive earlier in the evening with SBPs in\n the 80s which also resulted in a trigger. She was given a 500 mL IVF\n bolus and her SBP improved to the 100s. Her code status was confirmed\n with the patient and her family, DNR/DNI. She was transferred to the\n for possible non-invasive ventilation and closer hemodynamic\n monitoring.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:30 PM\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Medications on transfer:\n Zonisamide 100 mg PO BID\n Keppra 750 mg PO TID\n SQHeparin\n Protonix 40 mg PO Q12H\n Celexa 10 mg PO daily\n Nystatin Oral Suspension\n MVI\n Compazine PRN\n Vancomycin 1000 mg IV Q12H\n ISS\n Morphine IR 7.5 mg PO Q6H PRN\n Tylenol PRN\n Prednisone 40 mg PO BID\n Meropenem 500 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Bactrim 400 mg IV Q12H\n Past medical history:\n Family history:\n Social History:\n 1. Breast cancer - dx by chest MRI, s/p left mastectomy - ER+,\n her2/neu +, LN +, treated initially w/ adriamycin, cytoxan,\n developed bone mets in , treated w/ xeloda, then herceptin +\n gemcitabine, then herceptin + paclitaxel, brain mets dx -> s/p\n WBXRT, 2000cGy, completed in , also underwent XRT to thoracic and\n lumbar mets, XRT to pelvic mets in , pelvic involvement ->\n hydronehprosis -> bilateral nephrostomy tubes, had also been receiving\n herceptin, vinblastine, and , mets recurred in -> s/p\n 5 treatments w/ Cyberknife in for recurrence; also on seizure\n medication currently, chemotherapy changed to Tykerb and Xeloda \n 2. HTN\n 3. GERD\n 4. Cataracts s/p surgery\n 5. Breast reduction surgery \n 6. Left hip replacement \n 7. Tendon releases and carpal tunnel release\n N/C.\n Occupation: Retired\n Drugs: None\n Tobacco: Quit several years ago\n Alcohol: Occasional\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Pain: Mild\n Pain location: Lower back\n Flowsheet Data as of 12:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 84 (80 - 84) bpm\n BP: 110/62(74){76/50(57) - 110/62(74)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 1,072 mL\n 233 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 133 mL\n Blood products:\n Total out:\n 350 mL\n 260 mL\n Urine:\n 350 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n -27 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n Physical Examination\n General Appearance: Thin, Mild respiratory distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Anteriorly B/L., No(t) Wheezes : , Diminished: Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 90\n 9.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 28.4\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:12.1/28.0/1.0, Differential-Neuts:69,\n Band:20, Lymph:3, Mono:2, Eos:0, Ca++:8, Mg++:1.7, PO4:3.0\n Imaging: CXR - Interstitial and alveolar infiltrates B/L.\n CTA - B/L upper zone ground glass opacities, right mid zone\n atelectasis. Probably new liver met.\n Microbiology: U/A grossly positive\n UCx pending\n BCx pending\n Urine Legionella pending\n Urine histoplasma pending\n Assessment and Plan\n Hypoxia/respiratory distress\n Pt presented with hypoxia most likely to infectious source. CTA\n negative for PE. CXR with diffuse, primarily upper zone infiltrates c/w\n atypical PNA. She does have significiant bandemia on her CBC which\n would indicate a bacterial etiology. Bandemia may also be to UTI.\n Given recent hospitalizations, will cover broadly for HAP. Will\n continue meropenem and vancomycin. Will change ciprofloxacin to\n levofloxacin for atypical coverage. ID also following, appreciate recs.\n F/u cultures and various studies. Will send nasopharyngeal aspirate to\n r/o influenza. Continue droplet precautions. Given her recent high dose\n steroids will continue empiric treatment for PCP with Bactrim and\n steroids. Obtain induced sputum to r/o PCP. bronch given necessity\n for intubation which pt clearly does not want. Continue oxygen support\n with NC and face mask. Consider mask ventilation if needed.\n Pneumonia\n As above\n Hypotension\n Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will\n support with PRN IVF bolus. Pt clearly does not want pressors or\n central line placement if that was required to support her blood\n pressure. Will monitor.\n UTI\n U/A grossly positive from both right and left nephrostomy tubes. UCx\n pending. Continue levofloxacin and meropenem.\n Anemia\n Chronic, will monitor. No evidence of bleeding.\n Thrombocytopenia\n Concern for marrow involvement of tumor vs. HIT. Will send HIT\n antibody.\n Metastatic Breast CA s/p several therapies\n Further management per primary oncologist. Likely new liver met on CT.\n Continue antiseizure meds for brain mets.\n ICU Care\n Nutrition: Regular diet.\n Glycemic Control: ISS while on steroids.\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 317073, "text": "Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL \n Transferred to last night for hypoxemia and potential initiation\n of NIPPV\n Borderline hypotensive in the 80s upon arrival, given gentle IVF\n Remained on NRB overnight\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone 20 mg x5 days, insulin sliding scale, mvt, celexa,\n protonix, heparin, keppra\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Genitourinary: hematuria/pain from nephrostomy tubes\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 89 (80 - 90) bpm\n BP: 98/60(69){76/46(57) - 110/63(74)} mmHg\n RR: 19 (18 - 26) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,853 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,753 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 88%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, Anxious, appears uncomfortable\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, also anteriorly)\n Abdominal: Soft, Non-tender, bilateral nephrostomy tubes\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 90 K/uL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: CXR today: worsened bilateral alveolar opacities, especially\n in the upper lobes\n Microbiology: Cx from bilateral nephrostomy tubes growing GNR\n DFA for influenza pending\n Cryptococcal Ag pending\n Assessment and Plan\n 65 y/o F with metastatic breast Ca who presents with hypoxemic\n respiratory failure of unclear etiology. Differential includes\n bacterial infection, viral infection, hypersensitivity pneumonitis,\n COP, versus lymphangitic spread of her malignancy. Patient currently\n is 93% on NRB plus nasal cannula, and expressed to us that she does not\n wish to be aggressively treated any longer. She does not want to try\n NIPPV and only wants to be made comfortable. Plan to d/c antibiotics,\n steroids, and add morphine prn dyspnea/pain. Family and Oncology are\n aware.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Comfort measures only\n Disposition :ICU\n Total time spent: 25\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317079, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n This am patient expresses her wishes to the team to pass away\n comfortably, refused supplemental O2, pressors or any lines that may\n need to be placed to support vitals. Patient is DNR/DNI. Patient status\n discussed w/family yesterday.\n Action:\n CMO, IVF/IV ABX D/C, morphine drip started ASDIR and titrated to\n accommodate patient comfort level , palliative care nurse consulted to\n help the patient and family to cope w/patient\ns decision and status,\n priest called per family request\n Response:\n Patient appears to be comfortable, family at bedside\n Plan:\n Continue w/morphine drip, titrate as needed, provide support to family\n for end of life care\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317047, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n Hypoxia/respiratory distress - presented with hypoxia most likely \n to infectious source.\n -CTA negative for PE.\n - CXR with diffuse, primarily upper zone infiltrates c/w atypical PNA.\n with significiant bandemia on her CBC. However. bandemia may also be\n to UTI.\n - continue broad HAP coverage with meropenem and vancomycin.\n - will change ciprofloxacin to levofloxacin for atypical coverage.\n - f/u ID recs.\n - continue empiric treatment for PCP with Bactrim and steroids.\n - F/u nasopharyngeal aspirate to r/o influenza. Continue droplet\n precautions.\n - f/u induced sputum to r/o PCP.\n /u fungal studies (bd glucan, galactomannan)\n - not a bronch candidate\n - Continue oxygen support with NC and face mask. Consider mask\n ventilation as needed.\n - prn morphine\n Pneumonia\n As above\n Hypotension\n Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will\n support with PRN IVF bolus. Pt clearly does not want pressors or\n central line placement if that was required to support her blood\n pressure. Will monitor.\n UTI\n U/A grossly positive from both right and left nephrostomy tubes. UCx\n pending. Continue levofloxacin and meropenem.\n Anemia\n Chronic, will monitor. No evidence of bleeding.\n Thrombocytopenia\n Concern for marrow involvement of tumor vs. HIT. Will send HIT\n antibody.\n Metastatic Breast CA s/p several therapies\n Further management per primary oncologist. Likely new liver met on CT.\n Continue antiseizure meds for brain mets.\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI, consider CMO\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 317050, "text": "Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL \n Transferred to last night for hypoxemia and potential initiation\n of NIPPV\n Borderline hypotensive in the 80s upon arrival, given gentle IVF\n Remained on NRB overnight\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone 20 mg x5 days, insulin sliding scale, mvt, celexa,\n protonix, heparin, keppra\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Genitourinary: hematuria/pain from nephrostomy tubes\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 89 (80 - 90) bpm\n BP: 98/60(69){76/46(57) - 110/63(74)} mmHg\n RR: 19 (18 - 26) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,853 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,753 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 88%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, Anxious, appears uncomfortable\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, also anteriorly)\n Abdominal: Soft, Non-tender, bilateral nephrostomy tubes\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 90 K/uL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: CXR today: worsened bilateral alveolar opacities, especially\n in the upper lobes\n Microbiology: Cx from bilateral nephrostomy tubes growing GNR\n DFA for influenza pending\n Cryptococcal Ag pending\n Assessment and Plan\n 65 y/o F with metastatic breast Ca who presents with hypoxemic\n respiratory failure of unclear etiology. Differential includes\n bacterial infection, viral infection, hypersensitivity pneumonitis,\n COP, versus lymphangitic spread of her malignancy. Patient currently\n is 93% on NRB plus nasal cannula, and expressed to us that she does not\n wish to be aggressively treated any longer. She does not want to try\n NIPPV and only wants to be made comfortable. Plan to d/c antibiotics,\n steroids, and add morphine prn dyspnea/pain. Family and Oncology are\n aware.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Comfort measures only\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317059, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n Hypoxia/respiratory distress\n with desats to mid 80\ns on NRB this AM.\n - pt requesting to be comfortable and\npass in peace\n, will change to\n CMO\n - will d/c all antibiotics and steroids for HCAP and PCP coverage\n Continue droplet precautions until influenza is ruled out\n - Continue oxygen support with NC and face mask, consider mask\n ventilation if tolerated.\n - IV morphine gtt titrated to comfort\n - Pt clearly does not want pressors or central line placement\n - no further labs draws\n Metastatic Breast CA s/p several therapies\n - will contact oncologist re: change in level of care\n - Continue antiseizure meds\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: d/c regular insulin sliding scale, d/c FSG checks\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: d/c SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI changing to CMO today\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317070, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n This am patient expresses her wishes to the team to pass away\n comfortably, refused supplemental O2, pressors or any lines that may\n need to be placed to support vitals. Patient is DNR/DNI. Patient status\n discussed w/family yesterday.\n Action:\n CMO, IVF/IV ABX D/C morphine drip started ASDIR and titrated to\n accommodate patient comfort level , palliative care nurse consulted to\n help the patient and family to cope w/patient decision and status,\n priest called per family request\n Response:\n Patient appears to be comfortable, family at bedside\n Plan:\n Continue w/morphine drip, titrate as needed, provide support to family\n for end of life care\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317044, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2121-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317118, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n Pt was comfortable on morphine gtt .pt expired @ 0445 am . Both sons\n were at the bedside at time of death\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317034, "text": "This is a 65 y/o female with metastatic breast cancer who lives in the\n NH where she was found to be hypoxic to 80% on RA, associated with\n nonproductive cough, SOB, nausea, abdominal pain and weakness. In the\n ED, Temp was 102.2, BP 142/86, HR 113, and sats 80% on RA, improving to\n 95% on 5LNC. CXR revealed ? pneumonia of the RML and she was given IV\n antibiotics vs PCP. was admitted on to the floor under\n oncology service with cough, SOB, and hypoxia.\n On the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. On the floor, in the PM , the patient triggered\n for hypoxia with an oxygen saturation of 90% on a NRB. She was also\n SOB. She is currently being treated for pneumonia, possible PCP\n pneumonia vs. HAP. She is on broad-spectrum ABx including Bactrim +\n steroids for PCP. was also found to be hypotensive earlier in the\n evening with SBPs in the 80s which also resulted in a trigger. She was\n given a 500 mL IVF bolus and her SBP improved to the 100s. Her code\n status was confirmed with the patient and her family, DNR/DNI. She was\n transferred to the for possible non-invasive ventilation (BiPAP)\n and closer hemodynamic monitoring. Upon arrival to ICU, pt was placed\n on droplet precautions. Oxygen administered via NRB 100% as well as NC\n 5 LPM which has maintained the sat above 90%, hence, the BiPAP has\n never been needed.\n Dyspnea (Shortness of breath)\n Assessment:\n Dyspneac, non-productive cough, sat 89-98%, afebrile, LS crackles\n throughout, anxious, and restless, c/o headache, BP dropped to low 80s.\n Action:\n Oxygen administered via NRB 100% and NC 5 LPM, respiratory status\n monitored very closely as pt pulls out the oxygen occasionally which\n results in desaturation to low 80s, given Tylenol for headache and\n Morphine Po as ordered PRN for restlessnesswith moderate effect, given\n a bolus of 250 cc NS, multiple antibiotics (Vancomycin, Bactrim,\n Ciprofloxacin, Levofloxacin, and Meropenam IV) administered.\n Response:\n Continues to be very restless, saturation maintained above 90% with O2\n on, tolerated fluids well, headache relieved, BP improved to systolic\n above 90.\n Plan:\n Monitor respiratory status very closely, wean Oxygen as tolerated to\n maintain sat above 90%, monitor BP and bolus as needed to maintain SBP\n above 82 as per HO, continue antibiotics, keep pt on droplet\n precautions to R/O the flue, may need deep tracheal suctioning to\n induce sputum to be sent for cx., consider administering anti-anxiety\n meds, reassure pt and keep her and family updated on her condition and\n POC. Pt is /DNR, no pressors as confirmed by pt, she also doesn\n like BiPAP as she reported but might consider, but definitely no\n intubation.\n" } ]
24,257	117,663	A/P: 24M w/ T1DM, admitted to OSH w/ acute n/v following binge drinking episode, noted to have pneumomediastinum on CT chest, transferred for further management. . 1. DKA: He was admitted with a metabolic acidosis with anion gap of 17 and glucose in the 300s. He was taken into the MICU, where an insulin drip was D5 1/2NS was started with potassium repletion. His gap normalized and his sugars quickly became controlled. There were no clear infection though low grade temperature and initial wbc count on admission to osh. He was pan cultured here with no indications of infection by microbiology or chest xray. After stabilization and discontinuation of the insulin drip, he was started on 38U of glargine with good control of his sugars. His morning sugars were 85 and 57 and his glargine was decreased to 35U prior to discharge with close follow up at . His prandial sugars were controlled on a carbohydrate counting regiment. 2. Pneumomediastinum: He experienced severed nausea and vomitting secondary to alcohol abuse prior to admission. On chest xray he was noted to have a possible pneumomediastinum. Thoracic surgery was called, and on follow up CT showed pneumomediastinum with no clear esophageal perforation, this was consistent with the negative barium swallow conducted at the outside hospital, no antibiotics were started. His throat pain improved and his diet was advanced. He tolerated POs without difficulty. Thoracics was consulted prior to discharge and did not have recommendations for further outpatient studies to evaluate the pneumomediastinum but rather just follow clinically. He was advised to terminate his alcohol consumption as this was clearly associated with his pneumomediastinum. He was clearly instructed that continued alcohol use could result in esophageal rupture, recurrent DKA, and or death. He acknowledged his understanding of this information and agreed to stop drinking alcohol. 3. Etoh/Smoking: He agreed that he would stop smoking and drinking, he was prescribed zyban and a nicotine patch to assist in his positive goal 4. Lung Nodule: Small <5mm lung non calcified lung nodules were noted on his chest CT, he was advised to follow up with his PCP and reevaluate these lesions after one year. 5. ARF: His elevated creatinine resolved with hydration. . 6. FEN: diet.NPO, IVF + Kcl for repletion. lytes, diabetic diet . 7. PPX: SQ heparin, PPI IV . 8. Full Code, presumed . 9. Dispo: Follow up with his Diabetes Physician, PCP	NO INTERVENTION NECESSARY R/T PNEUMOMEDIASTINUM AT THIS TIME. The mediastinal and hilar contours are normal. LS= CLEAR/DIM. BBS= ESSENTIALLY CLEAR. NSR @ 71-92, NO ECTOPY NOTED. Heart, great vessels, and pericardium are normal. ABD SOFT, PRESENT BS. DENIES ANY CHEST PAIN. DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS.GI: ABLE TO TOLERATE PO'S WELL. INDICATION: Pneumomediastinum. The esophagus appears normal without a disproportionate volume of mediastinal air. SBP OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPTOENSIVE CRISIS NOTED. IMPRESSION: Pneumomediastinum. FINDINGS: The heart size is normal. IV ZOSYN D/C'D AND PO CIPRO Q12HRS AND PO FLAGYL TID ORDERED FOR PROPHYLAXIS. MAE X 4 WITHOUT DIFFICULTY. TX TO FOR FURTHER MANAGEMENT OF DKA AND PNEUMOMEDIASTINUM.NEURO: VERY PLEASANT, ALERT AND ORIENTED X 3. B ilateral, layering pleural effusions are tiny. SOME THROAT PAIN- NO C/O N,V,D. NO C/O SOB OR DIFFICULTY BREATHING. NO C/O SOB OR DIFFICULTY BREATHING. ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. REPEAT CHEST CT DONE THIS AM TO EVAL PNEUOMEDIASTINUM. SPEECH CLEAR. CONTINUE ICU SUPPORTIVE CARE. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. TECHNIQUE: Multidetector noncontrast images of the chest were performed. AFEBRILE.RR: BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. UA SENT AS ORDERED. PM LYTES K=3.4, NA=141, GLU=139. BARIUM SWALLOW NEGATIVE FOR EXTRAVASATION- CHEST CT SHOWED AGAIN PNEUMOMEDIASTINUM WITHOUT CLEAR ESOPHAGEAL RUPTURE. ALERT AND ORIENTED X 3- ABLE TO PERFORM ADL'S WITHOUT DIFFICULTY AND ASSIST WITH CARE. Bones and imaged upper abdomen are normal. DENIES PAIN. FOLLOWS COMMANDS, SPEECH CLEAR. DENIES SOB OR DIFFICULTY BREATHING. IMPRESSION: 1. NBP= 119-150/61-90. PASSING FLATUS, NO BM THIS SHIFT.GU: ABLE TO VOID IN URINAL WITHOUT DIFFICULTY, CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.SKIN: GROSSLY INTACT.ENDO: GAP IS CLOSING. Few air locules are noted in the superior pneumomediastinum and a thin sliver of air is seen tracking along the descending aorta. SP02 > OR = TO 95.CV: S1 AND S2 AS PER AUSCULTATION. FOLLOW UP W/ THORACIC FOR ANY INTERVENTION OR TREATMENT. The tracheobronchial tree is intact. BS X 4 QUADRANTS. BS X 4 QUADRANTS. PIV X3, LEFT ANTECUB #18G X2 AND RIGHT HAND #20G X1. CHEST X-RAY, AP PORTABLE VIEW. TOLERATES.SOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.PLAN: REPEAT CT CHEST TO R/O RUPTURED ESOPHAGEOUS. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.INTEG: GROSSLY INTACT.ENDO: AS PT 20UNITS OF LANTUS. THORACIC TEAM CONSULTED FOR RECOMM OF TREATMENT. There are no pleural effusions. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. BILATERAL CHEST EXPANSION NOTED. BILATERAL CHEST EXPANSION NOTED. NO ISSUES.PLAN: CONTINUE ATTEMPTS AT CONVERTION TO LONG LASTING INSULIN COVERAGE. MAE X 4. CT OF THE CHEST WITHOUT CONTRAST: A small volume of pneumomediastinum tracks into the soft tissues of the lower neck. AFEBRILE. AFEBRILE. PT ALERT AND ORIENTED X3. No pneumothorax. THANK YOU! THANK YOU! PLEASANT, COOPERATIVE W/ CARE. Two, tiny noncalcified lung nodules are identified, one in the left upper lobe (3 mm, 3:12) and another in the left lower lobe (4 mm, 3:36). PT ARRIVED VIA EMS IN NO ACUTE DISTRESS- TX TO MICU 777 WITH NO UNTOWARD INCIDENT.THIS IS A 24 Y/O M PT WITH PMH SIGNIFICANT ONLY FOR DM- FOLLOWED AT THE CLINIC. 02 SAT 96-100% ON RA. PERRLA, 3/BRISK. AM WBC= 10.2. Two noncalcified, less than 5-mm nodules. PT HAS SOME TENDERNESS TO RT SIDE OF NECK- VERY SMALL AMOUNT OF CREPITUS NOTED BUT VERY MINIMAL. WEAN OFF OF INSULIN GTT. No lymphadenopathy. PERRLA, 3/. FULL CODE. PER THORACIC VIA VERBAL REPORT FROM DR. / MICU PT ALLOWED TO EAT. PASSING FLATUS.GU: ABLE TO VOID IN URINAL. PT H20 AND CRACKERS W/O DIFFICULTY, REPORTED NO BURNING EFFECT AFTER SWALLOWING. CURRENTLY ON INSULIN GTT- TITRATING AS PROTOCOL. SP02 > OR = TO 95%.CV: S1 AND S2 AS PER AUSCULTATION. NO SEIZURE ACTIVITY NOTED. BEDREST MAINTAINED. The lung fields are clear. No mediastinal fluid or inflammatory stranding is seen. There is no pneumothorax. PT'S ENVIRONMENT SECURED FOR SAFETY.NEURO: VERY PLEASANT. SYMPTOM REPORTED TO DR. / MICU TEAM. DENIES CP. No CT evidence to suspect airway or esophageal tear. WILL CONTINUE TO MONITOR. D51/2 NS W/ 40MEQ KCL INFUSING AT 150CC/HR AS ORDERED. RECEIVED TOTAL OF 2 GMS MAG, CURRENTLY RECEIVING MAINTANENCE FLUID WITH POTASSIUM.GI: NPO AT THIS TIME. WILL ATTEMPT TO WEAN OFF AS PT. THIS AM- BS ARE IN THE 300'S- CAUTIOUS COVERAGE WITH REGULAR INSULIN AS TO NOT BOTTOM OUT BLOOD GLUCOSE WITH LONG ACTING INSULIN. 2. NO BM, NO N/V. NO STOOL THIS SHIFT. SEE PROGRESS NOTES. One-year followup CT chest is recommended. PT HAS 18G PIV TO LT AC AND 20G PIV TO RT HAND. PERLA- 3MM/, . COMPARISON: None. 1900-0700 NPN:PLEASE SEE CAREVUE FLOWHSEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. ROOM AIR. STRONG PEDAL PULSES. BLD CX X2 AND URINE CX SENT FOR R/O INFECTION ATTRIBUTING TO DKA. RR 15-20. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. 9:07 AM CT CHEST W/O CONTRAST Clip # Reason: for evaluation of pneumomediatstinum Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM MEDICAL CONDITION: 24 year old man with dka, n/v, pneumomediastinum reported at osh REASON FOR THIS EXAMINATION: for evaluation of pneumomediatstinum No contraindications for IV contrast FINAL REPORT PROCEDURE: CT chest without contrast.	5	[ { "category": "Nursing/other", "chartdate": "2166-08-30 00:00:00.000", "description": "Report", "row_id": 1578297, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: VERY PLEASANT. ALERT AND ORIENTED X 3- ABLE TO PERFORM ADL'S WITHOUT DIFFICULTY AND ASSIST WITH CARE. PERRLA, 3/. SPEECH CLEAR. MAE X 4. AFEBRILE.\n\nRR: BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. ROOM AIR. BILATERAL CHEST EXPANSION NOTED. RR 15-20. NO C/O SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. DENIES ANY CHEST PAIN. SBP OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS.\n\nGI: ABLE TO TOLERATE PO'S WELL. DID NOT EAT TOO MUCH FOR DINNER- HOPEFULLY- WILL BE ABLE TO CONSUME MORE THIS MORNING. SOME THROAT PAIN- NO C/O N,V,D. BS X 4 QUADRANTS. NO STOOL THIS SHIFT. PASSING FLATUS.\n\nGU: ABLE TO VOID IN URINAL. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: GROSSLY INTACT.\n\nENDO: AS PT 20UNITS OF LANTUS. WE ARE BASING NPH COVERAGE BASED ON PT'S RECOMMENDATION AS HE CALCULATES THIS BASED ON WHAT HE HAS CONSUMED. INSULIN GTT HAS BEEN OFF SINCE 9PM. THIS AM- BS ARE IN THE 300'S- CAUTIOUS COVERAGE WITH REGULAR INSULIN AS TO NOT BOTTOM OUT BLOOD GLUCOSE WITH LONG ACTING INSULIN. PT TO RECEIVE ANOTHER DOSE OF NPH AFTER BREAKFAST THIS MORNING- AWAITING ORDER FROM MD.\n\nSOCIAL: MOM IN TO VISIT. NO ISSUES.\n\nPLAN: CONTINUE ATTEMPTS AT CONVERTION TO LONG LASTING INSULIN COVERAGE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2166-08-29 00:00:00.000", "description": "Report", "row_id": 1578295, "text": "NURSING ADMISSION AND PROGRESS NOTE 2200-0700\nREPORT RECEIVED FROM HOSPITAL. PT ARRIVED VIA EMS IN NO ACUTE DISTRESS- TX TO MICU 777 WITH NO UNTOWARD INCIDENT.\n\nTHIS IS A 24 Y/O M PT WITH PMH SIGNIFICANT ONLY FOR DM- FOLLOWED AT THE CLINIC. PT WAS IN USUAL STATE OF HEALTH UNTIL THIS PAST PT ADMITS TO HAVING DRANK CAPTAIN RUM HEAVILY THIS WEEKEND AND ON MONDAY STARTED TO HAVE SEVERE NAUSEA AND VOMITING- UNABLE TO KEEP ANYTHING DOWN FOR SEVERAL DAYS. FINGERSTICKS INCREASED TO > 600- ON , PT PRESENTED HOSPITAL ER WITH HE WAS NOTED TO BE IN DKA WITH BS > 300 AND CXR SIGNIFICANT FOR PNEUMOMEDIASTINUM (D/T WRETCHING AND VIOLENT VOMITING). BARIUM SWALLOW NEGATIVE FOR EXTRAVASATION- CHEST CT SHOWED AGAIN PNEUMOMEDIASTINUM WITHOUT CLEAR ESOPHAGEAL RUPTURE. TX TO FOR FURTHER MANAGEMENT OF DKA AND PNEUMOMEDIASTINUM.\n\nNEURO: VERY PLEASANT, ALERT AND ORIENTED X 3. FOLLOWS COMMANDS, SPEECH CLEAR. MAE X 4 WITHOUT DIFFICULTY. PERRLA, 3/BRISK. AFEBRILE. NO SEIZURE ACTIVITY NOTED. PT RECEIVED ONE TIME DOSE OF 15MG TORADOL FOR BACK PT FEELS THIS IS DUE TO BED- \"I'M NOT USED TO SLEEPING ON HOSPITAL BEDS- THEY'RE STIFF\".\n\nRR: RA. NO C/O SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED. PT HAS SOME TENDERNESS TO RT SIDE OF NECK- VERY SMALL AMOUNT OF CREPITUS NOTED BUT VERY MINIMAL. SP02 > OR = TO 95.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPTOENSIVE CRISIS NOTED. DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAS 18G PIV TO LT AC AND 20G PIV TO RT HAND. RECEIVED TOTAL OF 2 GMS MAG, CURRENTLY RECEIVING MAINTANENCE FLUID WITH POTASSIUM.\n\nGI: NPO AT THIS TIME. ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. PASSING FLATUS, NO BM THIS SHIFT.\n\nGU: ABLE TO VOID IN URINAL WITHOUT DIFFICULTY, CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: GROSSLY INTACT.\n\nENDO: GAP IS CLOSING. CURRENTLY ON INSULIN GTT- TITRATING AS PROTOCOL. WILL ATTEMPT TO WEAN OFF AS PT. TOLERATES.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nPLAN: REPEAT CT CHEST TO R/O RUPTURED ESOPHAGEOUS. WEAN OFF OF INSULIN GTT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n" }, { "category": "Nursing/other", "chartdate": "2166-08-29 00:00:00.000", "description": "Report", "row_id": 1578296, "text": "1900-0700 NPN:\n\nPLEASE SEE CAREVUE FLOWHSEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT, COOPERATIVE W/ CARE. PERLA- 3MM/, . DENIES PAIN. LS= CLEAR/DIM. 02 SAT 96-100% ON RA. DENIES SOB OR DIFFICULTY BREATHING. REPEAT CHEST CT DONE THIS AM TO EVAL PNEUOMEDIASTINUM. THORACIC TEAM CONSULTED FOR RECOMM OF TREATMENT. SEE PROGRESS NOTES. NSR @ 71-92, NO ECTOPY NOTED. NBP= 119-150/61-90. DENIES CP. STRONG PEDAL PULSES. AFEBRILE. PIV X3, LEFT ANTECUB #18G X2 AND RIGHT HAND #20G X1. INSULIN GTT INFUSING AT 2U/HR FOR MOST OF SHIFT W/ FS= 110-138, GTT INCREASED TO 3U/HR AT 1800 FOR FS= 150. SEEN BY CLINIC MD- RECOMM LANTUS INSULIN IF PT EATING W/ HUMALOG S/S COVERAGE PER CARBOHYDRATE RATIO. PER THORACIC VIA VERBAL REPORT FROM DR. / MICU PT ALLOWED TO EAT. NO INTERVENTION NECESSARY R/T PNEUMOMEDIASTINUM AT THIS TIME. WILL CONTINUE TO MONITOR. DIABETIC 2200CAL DIET ORDERED- AWAIT DINNER TRAY. PT C/O BURNING SENSATION FROM RIGHT SIDE OF THROAT DOWN TO RIGHT ARMPIT AREA W/ SIP OG GINGERALE. SYMPTOM REPORTED TO DR. / MICU TEAM. PT H20 AND CRACKERS W/O DIFFICULTY, REPORTED NO BURNING EFFECT AFTER SWALLOWING. IV ZOSYN D/C'D AND PO CIPRO Q12HRS AND PO FLAGYL TID ORDERED FOR PROPHYLAXIS. AM WBC= 10.2. BLD CX X2 AND URINE CX SENT FOR R/O INFECTION ATTRIBUTING TO DKA. D51/2 NS W/ 40MEQ KCL INFUSING AT 150CC/HR AS ORDERED. PM LYTES K=3.4, NA=141, GLU=139. ABD SOFT, PRESENT BS. NO BM, NO N/V. PT VOIDING ADEQUATE TO LARGE AMTS OF CLEAR YELLOW URINE IN URINAL AT BEDSIDE. UA SENT AS ORDERED. BEDREST MAINTAINED. FULL CODE. PT'S PARENTS AT BEDSIDE VISITING FOR MOST OF SHIFT- UPDATED ON POC.\nPLAN- TITRATE INSULIN GTT PER KOSLIN PROTOCOL. ADMIN LANTUS AND HUMALOG AS ORDERED R/T % AND CARBS AT DINNER. TEAM REQUEST INSULIN BE GIVEN AFTER DINNER INCASE N/V RESUMES. FOLLOW UP W/ THORACIC FOR ANY INTERVENTION OR TREATMENT. CONTINUE ICU SUPPORTIVE CARE.\n" }, { "category": "Radiology", "chartdate": "2166-08-29 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 882426, "text": " 9:07 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: for evaluation of pneumomediatstinum\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with dka, n/v, pneumomediastinum reported at osh\n\n REASON FOR THIS EXAMINATION:\n for evaluation of pneumomediatstinum\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n INDICATION: Pneumomediastinum. DKA with nausea and vomiting.\n\n TECHNIQUE: Multidetector noncontrast images of the chest were performed.\n\n CT OF THE CHEST WITHOUT CONTRAST: A small volume of pneumomediastinum tracks\n into the soft tissues of the lower neck. The tracheobronchial tree is intact.\n The esophagus appears normal without a disproportionate volume of\n mediastinal air. No mediastinal fluid or inflammatory stranding is seen. B\n ilateral, layering pleural effusions are tiny. Two, tiny noncalcified lung\n nodules are identified, one in the left upper lobe (3 mm, 3:12) and another in\n the left lower lobe (4 mm, 3:36).\n\n Heart, great vessels, and pericardium are normal. No lymphadenopathy. Bones\n and imaged upper abdomen are normal.\n\n IMPRESSION:\n 1. Small amount of pneumomediastinum and lower neck soft tissue emphysema,\n likely a result of wretching against a closed glottis in a patient with this\n history. No CT evidence to suspect airway or esophageal tear.\n 2. Two noncalcified, less than 5-mm nodules. One-year followup CT chest is\n recommended.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882382, "text": " 11:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: for pneumomediastinum\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with ?pneumomediastinum\n REASON FOR THIS EXAMINATION:\n for pneumomediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old man with pneumomediastinum.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: None.\n\n FINDINGS: The heart size is normal. The mediastinal and hilar contours are\n normal. Few air locules are noted in the superior pneumomediastinum and a\n thin sliver of air is seen tracking along the descending aorta.\n\n The lung fields are clear. There are no pleural effusions. There is no\n pneumothorax.\n\n IMPRESSION: Pneumomediastinum. No pneumothorax.\n\n\n" } ]
29,008	145,153	In summary, Mr. is a 22 year old male admitted following motor vehicle accident for multiple fractures and diaphragmatic rupture. Hospital course was complicated by delerium, peristent tachycardia, and transaminitis. . S/p MVA. Patient was admitted to the Trauma Service and taken directly to the operating room for exploratory lap and repair of his diaphragmatic injury. Orthopedics was consulted given his multiple bone fractures; he was taken to the operating room for washout and debridement of left open tibia fracture to bone; closed reduction left supracondylar femur fracture with manipulation; closed reduction left proximal tibia fracture with manipulation; application multiplanar external fixator; IM nail left femur and closed reduction right wrist fracture with manipulation. There were no intraoperative complications. . Pain. Patient had difficulty with pain control initially. PCA Dilaudid was initiated and the dose was quickly increased to 0.37 mg. Dilaudid 1-2 mg IV prn for rescue pain was also added and he did seem to benefit from this. It was discussed with patient and his mother that at some point long acting narcotics would likely be initiated for long term pain control. He was placed on an aggressive bowel regimen. However, patient developed delerium in setting of opioid use, so opioids were discontinued and patient was started on ultram. Tylenol is being avoided due to elevated LFTs. NSAIDs are being avoided due to impaired bone healing. Opioids are being avoided due to recent delerium. Pain was adequately controlled at time of discharge on standing ultram. . Delerium. Patient developed delerium during hospitalization. It was felt to be due to opioid pain medications which were stopped. Patient was evaluated by neurology and psychiatry. Vit B12, folate, TSH, RPR within normal limits. LP performed showed no evidence of infection. EEG and Brain MRI were normal. He was placed on standing seroquel at night. Opioids were avoided. Delerium resolved and patient was alert and oriented on day of discharged. . Elevated transaminases. Likely multifactorial etiology, including systemic inflammatory response, medications including Zosyn. LFTs continue to trend down. ALT peaked at 385 on , AST peaked at 220 on , LDH peaked at 457 on . Alk Phos continued to trend up on discharge, likely secondary to active bone remodeling. Acetaminophen was discontinued on . Please check LFTs weekly until fully resolved. . Thrombocytosis. Patient had elevated platelet count to 1.5 million, likely reactive thrombocytosis due to systemic inflammatory state due to trauma and multiple operations. Platelets were trending down and were 1 million at time of discharge. . Tachycardia. Patient had sinus tachycardia post-operatively to the 150s, that was thought to be pain and stress related. A PE CT was done and was negative for PE. Metoprolol was started to prevent tachycardia-induced cardiomyopathy. An echo was done and was normal. Metoprolol is being titrated down beginning on . Goal is to stop metoprolol as HR improves. Overall tachycardia is improving. . Insomnia. Patient reported difficulty sleeping due to discomfort, multiple braces/casts in place, etc. He was getting standing seroquel at night with minimal improvement. Benzodiazepines and ambien were avoided due to delerium. He was given prn benadryl and standing seroquel. Seroquel should ultimately be stopped but patient is currently using it for insomina. . Prophylaxis. Patient was maintained on Lovenox daily. S/p prophylactic IVC filter placement. . Communication. Patient and mother .	Incompletely evaluated displaced femoral diaphysis fracture. Possible nondisplaced fracture of the navicular. There is a small area of ill-defined lucency at the lateral aspect of the navicular suspicious for nondisplaced fracture. Intra-articular distal tibial fracture. AP PELVIS: There is incompletely evaluated fracture of the femoral diaphysis with significant displacement and overriding fracture fragments. IMPRESSION: Biliary sludge; otherwise unremarkable abdominal ultrasound. Very small left apical pneumothorax is, in retrospect, unchanged compared to the recent chest radiograph, with visceral apical line just below the left second posterior rib level. Along with this, the left hemidiaphragm is largely absent, retracted medially to its spinal attachment. TECHNIQUE: Non-contrast CT of right ankle was performed. Small amount of intraperitoneal air, an unusual finding in a setting of blunt trauma, and free fluid, likely related to chest tube placement, traversing the peritoneal space. IMPRESSION: Extensively comminuted, intra-articular left olecranon fracture. FINDINGS: There is an undisplaced fracture through the distal tibia involving the articular surface of the tibial plafond and extending into the medial malleolus. CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is small amount of intraperitoneal air and small amount of free fluid adjacent to the anterior abdominal wall. Findings concerning for significant left diaphragmatic injury. INDICATION: Pneumothorax. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, prostate, and the seminal vesicles are unremarkable. FINAL REPORT CT RIGHT ANKLE INDICATION: MVC. Equivocal tiny pneumothorax at right lung apex is also noted, not clearly seen on the prior studies. Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR FINAL REPORT INDICATION: IVC filter placement. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT Reason: EX FIX LEFT TIBIA AND FEMURAL NAILING Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR FINAL REPORT HISTORY: Multiple fractures assed in o.r. They demonstrate open reduction internal fixation of comminuted ulnar fracture and comminuted radial fracture. PE No contraindications for IV contrast FINAL REPORT STUDY: CTA chest with and without contrast and reconstructions. There is a fibular neck fracture and proximal fibular shaft fractures. There is a comminuted fracture of the lateral process of the talus. RIGHT WRIST - Overlying material obscures fine detail status post ORIF of distal radial comminuted fracture, with no obvious hardware-related complications. IMPRESSION: Enlarging, still small left basilar effusion. There is a fracture line involving the anterior aspect of the talus involving the articular surface of the talar head. There is a comminuted nondisplaced fracture of the proximal fibular shaft. There is a small radiolucent line on the medial aspect of the left lower hemithorax. Nondisplaced fractures through the medial malleolous extending the mortise. Sinus tachycardiaOtherwise normal ECGNo previous tracing available for comparison IMPRESSION: Thin radiolucency along the medial aspect of the left lower hemithorax may represent a small pneumothorax. Minimal blunting of the left medial pleural sulcus probably due to residual effusion. CT OF THE CHEST WITHOUT IV CONTRAST: There is a small-to-moderate left pleural effusion with associated compressive atelectasis of the dependent left lower lobe. FINDINGS: The left-sided chest tube has been removed with a small residual pneumothorax. IMPRESSION: Normal unenhanced head CT. There is a non-displaced fracture at the lateral aspect of the patella. spiral comminuted tibial metediaphyseal fx with mild posterior displacement of distal frag. mildly displaced oblique fibular head and mid shaft fx. SUPINE ABDOMINAL RADIOGRAPH: There is a nonobstructive bowel gas pattern. The estimated pulmonary artery systolic pressure isnormal. Sinus tachycardiaBorderline short P-R interval - is nonspecific and probably normal variantSince previous tracing of , probably no significant change Left pleural effusion is again noted. Small-to-moderate left pleural effusion and associated compressive (Over) 10:23 AM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT CHEST W/O CONTRAST Reason: with p.o. Normal biventricular cavity sizes with preservedglobal and regional biventricular systolic function. There is nomitral valve prolapse. Small left pleural effusion. marked lipohemarthrosis and soft tissue edema. small lateral patellar avulsion type fx. The P-R interval is shortwithout evidence of pre-excitation. The medial femoral condyle appears preserved. Right ventricular function.Height: (in) 71Weight (lb): 165BSA (m2): 1.95 m2BP (mm Hg): 120/60HR (bpm): 117Status: InpatientDate/Time: at 12:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The right PICC line tip terminates in superior SVC. Right PICC line terminates within the mid superior vena cava. CT OF THE PELVIS WITHOUT IV CONTRAST: The patient is status post interval ORIF of proximal left femoral fracture. Normal PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Interval diaphragmatic repair with spleen and stomach and other abdominal organs now below the diaphragm without evidence of herniation. Left pleural effusion and adjacent basilar atelectasis is unchanged. COMPARISON: Radiographs, left knee, . The stomach and spleen are now below the diaphragm without evidence of herniation.	40	[ { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991009, "text": " 3:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o evolution of PTX\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with chest tube to w/s s/p mvc with multiple fractures and\n placement of chest tube\n REASON FOR THIS EXAMINATION:\n r/o evolution of PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Pneumothorax.\n\n Very small left apical pneumothorax is, in retrospect, unchanged compared to\n the recent chest radiograph, with visceral apical line just below the left\n second posterior rib level. Equivocal tiny pneumothorax at right lung apex is\n also noted, not clearly seen on the prior studies. Left hemidiaphragm appears\n less distinct compared to the previous study, likely due to a small amount of\n pleural fluid. Examination is otherwise unchanged with left-sided chest tube\n remaining in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "R CT LOW EXT W/O C RIGHT", "row_id": 991021, "text": " 5:01 PM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: evaluate R ankle fractures -- DO CT with 3D recons of Right\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mvc with multiple lower extremity fractures -- DO CT of\n Rigth ankle with 3D recons\n REASON FOR THIS EXAMINATION:\n evaluate R ankle fractures -- DO CT with 3D recons of Right ankle\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb FRI 7:10 PM\n Complex comminuted talar fracture extending from the lateral to medial side\n with fracture lines extending to the talar dome. Please see series 401b\n images 52 -55 for minimal (1mm) vertical offset of the talar dome. Mildly to\n non-displaced comminuted fractures of the medial and lateral malleoli also\n also present, with medial nondisplaced fractures extending to the mortise.\n ______________________________________________________________________________\n FINAL REPORT\n CT RIGHT ANKLE\n\n INDICATION: MVC. Evaluate for fracture.\n\n COMPARISON:\n\n Radiograph right ankle, .\n\n TECHNIQUE:\n\n Non-contrast CT of right ankle was performed. Axial, coronal, and sagittal\n reconstructions were reviewed.\n\n FINDINGS:\n\n There is an undisplaced fracture through the distal tibia involving the\n articular surface of the tibial plafond and extending into the medial\n malleolus. There is a fracture involving the tip of the lateral malleolus\n with some adjacent soft tissue swelling. The peroneal tendons abut this\n fracture line but are not entrapped.\n\n There is an intra-articular fracture through the talar dome. There is a\n fracture line extending from the anterior aspect of the talar dome\n anteroinferiorly to the talar neck. There is a fracture line involving the\n anterior aspect of the talus involving the articular surface of the talar\n head. There is a comminuted fracture of the lateral process of the talus. The\n talus fracture involves the posterior subtalar joint. There is minimal (less\n than 1 mm) impaction of the talar dome fracture.\n\n There is a small area of ill-defined lucency at the lateral aspect of the\n navicular suspicious for nondisplaced fracture.\n\n The calcaneus is not completely included on the scan range but the visualized\n (Over)\n\n 5:01 PM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: evaluate R ankle fractures -- DO CT with 3D recons of Right\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n calcaneus is normal. The cuboid and cuneiforms are normal. The metatarsal\n bases are normal.\n\n There is no evidence of a significant soft tissue injury. The ATFL and PTFL\n are intact.\n\n IMPRESSION:\n 1. Intra-articular distal tibial fracture.\n 2. Talar fracture involving the articular surface of the talar dome, talar\n head, and posterior subtalar joint with comminuted fracture of lateral process\n of the talus.\n 3. Possible nondisplaced fracture of the navicular.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "LO WRIST(3 + VIEWS) LEFT IN O.R.", "row_id": 990682, "text": " 11:30 AM\n WRIST(3 + VIEWS) LEFT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n -76 BY SAME PHYSICIAN\n : FX SET IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n LEFT WRIST THREE VIEWS.\n\n HISTORY: Patient with distal radius fracture.\n\n FINDINGS: Three fluoroscopic images from the operating room demonstrates\n fracture involving the right distal radius with intra-articular extension.\n There is ulnar positive variance, likely due to the impaction. There is\n slight dorsal tilt of the radial articular surface. Please refer to the\n operative note for additional details.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L ELBOW, AP & LAT VIEWS LEFT", "row_id": 990601, "text": " 5:27 AM\n ELBOW, AP & LAT VIEWS LEFT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n THREE VIEWS OF THE LEFT ELBOW\n\n INDICATION: 23-year-old man status post MVC. Evaluate for fracture.\n\n COMPARISON: Not available.\n\n FINDINGS: There is an extensively comminuted fracture of the left olecranon,\n extending to the articular surface with significant destruction of fracture\n fragments. Intra-articular small bony fragments are present.\n\n IMPRESSION: Extensively comminuted, intra-articular left olecranon fracture.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 992707, "text": " 9:58 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please evaluate for DVT\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fever of unknown etiology\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with fever of unknown etiology. Please evaluate\n for DVT.\n\n COMPARISON: None available.\n\n LOWER EXTREMITY BILATERAL VENOUS ULTRASOUND: Ultrasound evaluation of the left\n and right lower extremity deep venous system using -scale, color, and\n pulse wave Doppler demonstrates the common femoral vein, superficial femoral\n vein, popliteal vein, and posterior tibial veins to be fully compressible and\n demonstrate normal phasic respiratory variation of flow.\n\n IMPRESSION: No ultrasonographic evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 992176, "text": " 6:02 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: 22 yo with persistent tachycardia, febrile after polytrauma?\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with persistent tachycardia, febrile after polytrauma--? PE\n REASON FOR THIS EXAMINATION:\n 22 yo with persistent tachycardia, febrile after polytrauma? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA chest with and without contrast and reconstructions.\n\n INDICATION: 22-year-old male with persistent tachycardia and febrile after\n polytrauma.\n\n TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet\n to the upper abdomen with IV contrast administration. Multiplanar reformatted\n images were obtained.\n\n COMPARISON: CT chest without contrast from the same date.\n\n CTA CHEST: No dissection flap is identified in the thoracic aorta to suggest\n dissection. No filling defects are identified within the central pulmonary\n arteries and proximal segmental branches to suggest pulmonary embolism. The\n bolus was not optimized to detect subsegment filling defects within the\n pulmonary arteries. There is no pericardial effusion. The heart and great\n vessels appear unremarkable. There is unchanged appearance to a small-to-\n moderate left pleural effusion with associated relaxation atelectasis. There\n is no right pleural effusion. The major airways are patent down to the\n subsegmental level. No pulmonary parenchymal abnormalities are identified.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. No evidence of aortic dissection or central/segmental pulmonary artery\n emboli.\n\n 2. Mild-to-moderate left pleural effusion and associated relaxation\n atelectasis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-21 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 991087, "text": " 8:52 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o evo of ptx\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with chest tubes\n REASON FOR THIS EXAMINATION:\n r/o evo of ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-VIEW CHEST ON .\n\n Comparison made to prior study of . Again seen is a left-sided chest\n tube, with tip directed towards the apex. No discrete pneumothorax is seen.\n There is a slight increase in the amount of left pleural fluid. Otherwise\n lungs are clear. Heart and mediastinal contours unchanged.\n\n IMPRESSION: Enlarging, still small left basilar effusion. No discrete\n pneumothorax seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-25 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 991655, "text": " 11:37 AM\n WRIST(3 + VIEWS) RIGHT; ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: assess alignment s/p ORIF\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n assess alignment s/p ORIF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ORIF.\n\n Three views of the right wrist and two views of left elbow are compared to\n and .\n\n RIGHT WRIST - Overlying material obscures fine detail status post ORIF of\n distal radial comminuted fracture, with no obvious hardware-related\n complications. The cross-table lateral projection is not optimal. The\n triquetral-pisiform interval appears mildly increased, however it might be a\n projectional.\n\n LEFT ELBOW - Overlying material obscures fine details. Two K pins and wire\n fixation of olecranon fracture in near autonomic alignment and no obvious\n hardware-related complications. No new fractures or dislocations. Surgical\n clips are present.\n\n IMPRESSION: ORIF right wrist and left elbow with no obvious hardware-related\n complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-26 00:00:00.000", "description": "OL TIB/FIB (AP & LAT) IN O.R. LEFT", "row_id": 991818, "text": " 10:58 AM\n TIB/FIB (AP & LAT) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. IN O.R. LEFTClip # \n Reason: ORIF LEFT TIBIA IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Left tibia/fibula two views of the .\n\n HISTORY: ORIF left tibia and fibula in the OR\n\n FINDINGS: Thirteen fluoroscopic images from the operating room demonstrates\n interval placement of a large fracture plate along the medial proximal tibia\n fixating a complex comminuted fracture of the tibial plateau. There are also\n interfragmentary screws seen within the tibial plateau. There are fracture\n plates seen within the distal femur fixating a distal metaphyseal fracture.\n Portion of an intramedullary rod within the distal femur is also seen.\n Interfragmentary screw through the lateral femoral condyle is also visualized.\n There is a fracture involving the proximal shaft of the fibula. Please refer\n to the operative note for additional details.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 990598, "text": " 4:55 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for diaphragm rupture\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for diaphragm rupture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH INTRAVENOUS CONTRAST\n\n INDICATION: 22-year-old man status post MVC. Evaluate for diaphragm rupture.\n\n COMPARISON: Not available.\n\n TECHNIQUE: MDCT axial images of chest, abdomen, and pelvis were obtained\n following administration of 110 cc of Optiray intravenously. Coronal and\n sagittal reformatted images were obtained.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The stomach and spleen are located within\n the thoracic cavity, immediately overlying the posterior ribs (\"dependent\n viscera\" sign). Along with this, the left hemidiaphragm is largely\n absent, retracted medially to its spinal attachment. There are small air\n locules posterior to the stomach, which may represent small residual\n pneumothorax. Patchy opacities, predominantly at the right base likely\n represent contusion, aspiration is another consideration. Central airways are\n patent to the segmental levels, bilaterally. The patient is intubated, with\n endotracheal tube terminating at the level of the clavicular heads. The aorta\n and great vessels are unremarkable. There is no pericardial or pleural\n effusion.\n\n Left-sided chest tube enters at the thoracoabdominal junction and traverses\n peritoneal space adjacent to the spleen and a stomach, reaching apical pleural\n space.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is small amount of\n intraperitoneal air and small amount of free fluid adjacent to the anterior\n abdominal wall. Abdominal loops of large and small bowel are unremarkable\n given lack of oral contrast. The liver, spleen, adrenal glands, pancreas,\n gallbladder are unremarkable. Kidneys enhance equally and excrete contrast\n normally. There are no pathologically enlarged mesenteric or retroperitoneal\n lymph nodes.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, prostate, and\n the seminal vesicles are unremarkable. There is a Foley catheter within the\n urinary bladder.\n\n BONE WINDOWS: Demonstrate no evidence of fracture.\n\n (Over)\n\n 4:55 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for diaphragm rupture\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Stomach and spleen located within the thoracic cavity, very concerning for\n extensive left diaphragmatic rupture, with retraction.\n\n 2. Left lower lobe collapse/consolidation.\n\n 3. Patchy opacities predominantly at the right lung base, in the setting of\n trauma likely represent parenchymal contusions; aspiration is another\n diagnostic consideration.\n\n 3. Small amount of intraperitoneal air, an unusual finding in a setting of\n blunt trauma, and free fluid, likely related to chest tube placement,\n traversing the peritoneal space. While no bowel injury is seen, this cannot be\n completely excluded. Comparison with any CT done prior to the chest tube\n placement would be most helpful if available.\n\n Findings were discussed with Dr. (Trauma Surgery) upon completion\n of the study.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 990599, "text": " 5:03 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with mvc, intubated\n REASON FOR THIS EXAMINATION:\n fx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN WED 5:59 AM\n normal cervical spine ct , md\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE WITHOUT CONTRAST\n\n INDICATION: 22-year-old man status post MVC, intubated. Question fracture.\n\n COMPARISON: Not available.\n\n TECHNIQUE: CT of the cervical spine without intravenous contrast.\n\n FINDINGS: There is no acute fracture or abnormal alignment. The odontoid\n process is midline. Atlanto-axial and atlanto-occipital relationships are\n maintained. There is no prevertebral soft tissue swelling.\n\n Patient is intubated, ET tube terminating at the level of clavicular heads.\n\n Imaged lung apices are clear.\n\n IMPRESSION: No acute fracture or abnormal alignment in the cervical spine.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L FEMUR (AP & LAT) LEFT", "row_id": 990600, "text": " 5:27 AM\n FEMUR (AP & LAT) LEFT; KNEE (2 VIEWS) LEFT Clip # \n TIB/FIB (AP & LAT) LEFT\n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR AND LEFT TIBIA AND FIBULA, FIVE IMAGES.\n\n LEFT FEMUR: There is a proximal segmental oblique spiral fracture of the femur\n with marked displacement and overriding of the fragments, at least 6.5 cm.\n\n There is an extensively comminuted intra-articular distal femoral fracture,\n centered at diametaphysis with multiple fracture lines reaching articular\n surface, particularly laterally, with multiple intra-articular bony fragments.\n There is dorsal angulation of distal fracture fragments.\n\n LEFT TIBIA/FIBULA: There is extensively comminuted intra-articular tibial\n fracture, specifically lateral components, with multiple displaced intra-\n articular fragments. There is extensive comminution of the spiral component at\n proximal tibial metadiaphysis and 2.8 cm overriding, and dorsal and fibular\n angulation of the distal fracture fragments.\n\n There is a fibular neck fracture and proximal fibular shaft fractures.\n\n Single view of ankle is intact.\n\n IMPRESSION: Extensively comminuted fractures of the distal femur and proximal\n tibia, with displaced and angulated fractures of the proximal femur and\n fibula.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990696, "text": " 1:20 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval ct placement/diaphram\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man sp L diaphragmatic hernia repair/chest tube\n REASON FOR THIS EXAMINATION:\n eval ct placement/diaphram\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left diaphragmatic hernia repair with chest tube.\n\n FINDINGS: No previous images, except for the CT scan showing diaphragmatic\n traumatic hernia.\n\n The heart and lungs are essentially within normal limits at this time. The\n left chest tube is in place and there is no pneumothorax. Endotracheal tube\n tip lies about 4 cm above the carina and nasogastric tube extends well into\n the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 990596, "text": " 4:49 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST AND AP PELVIS:\n\n INDICATION: Trauma.\n\n FRONTAL CHEST, ONE VIEW: The study is read in conjunction with subsequently\n obtained CT torso. Cardiomediastinal silhouette is normal. Stomach,\n containing the NG tube, lies within the left hemithorax, with left lower lobe\n collapse, findings concerning for diaphragmatic injury. The left chest tube\n enters at the left thoracoabdominal junction, traverses adjacent to the\n stomach and terminates within the stomach, projecting over the left\n hemithorax.\n\n AP PELVIS: There is incompletely evaluated fracture of the femoral diaphysis\n with significant displacement and overriding fracture fragments.\n\n IMPRESSION:\n 1. Findings concerning for significant left diaphragmatic injury.\n 2. Incompletely evaluated displaced femoral diaphysis fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 990597, "text": " 4:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST\n\n INDICATION: 22-year-old man status post high speed MVC. Evaluate for\n hemorrhage.\n\n COMPARISON: Not available.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, shift of normally\n midline structures or hydrocephalus. The density values of brain parenchyma\n are within normal limits. The -white matter differentiation is preserved.\n Surrounding soft tissues and osseous structures are unremarkable. Imaged\n paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION: No acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "OL FEMUR (AP & LAT) IN O.R. LEFT", "row_id": 990635, "text": " 8:49 AM\n FEMUR (AP & LAT) IN O.R. LEFT; -77 BY DIFFERENT PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: FEMUR FX IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Femoral fracture.\n\n Two lateral radiographs of the left femur obtained in O.R. show a transverse\n fracture of the mid shaft of the femur with 100% posterior displacement of the\n distal fragment relative to the proximal fragment and some overlap with loss\n of length. Bone detail is not optimally assessed.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT", "row_id": 990679, "text": " 11:26 AM\n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n TIB/FIB (AP & LAT) IN O.R. LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: EX FIX LEFT TIBIA AND FEMURAL NAILING\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple fractures assed in o.r.\n\n These three exams consist of twelve radiographs of the left hip, left femur,\n and left knee obtained in O.R. There is a comminuted transverse fracture of\n the midshaft of the femur fixated by a long intramedullary rod introduced\n proximally with single interlocking trochanteric proximal nail. Below the tip\n of this rod external traction screws have been placed in the distal femoral\n shaft. There is a markedly comminuted fracture of the distal femur as well as\n proximal portions of the left fibula and tibia. Marked widening of the lateral\n knee compartment. No radiographs obtained of the presumed traction screws in\n the distal tibia. Bone detail suboptimally assessed in these intraoperative\n radiographs.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-26 00:00:00.000", "description": "O ABD (SINGLE VIEW ONLY) IN O.R.", "row_id": 991836, "text": " 12:42 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: IVC FILTER IN O.R.\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: IVC filter placement.\n\n 1 fluoroscopic image submitted after IVC filter placement. A radiologist was\n not present in the OR. An IVC filter is seen with the tip overlying the\n L1 vertebra.\n\n Impression: IVC filter in appropriate position\n\n" }, { "category": "Radiology", "chartdate": "2115-12-24 00:00:00.000", "description": "LOP ELBOW, AP & LAT VIEWS LEFT IN O.R. PORT", "row_id": 991565, "text": " 9:20 PM\n ELBOW, AP & LAT VIEWS LEFT IN O.R. PORT; WRIST(3 + VIEWS) RIGHT IN O.R. PORTClip # \n Reason: ORIF L ELBOW & R WRIST IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL INFORMATION: ORIF left elbow and right wrist in the operating room.\n\n FINDINGS:\n\n Two views of the left elbow and eight views of the right wrist are submitted.\n These are intraoperative fluoroscopic spot views. They demonstrate open\n reduction internal fixation of comminuted ulnar fracture and comminuted radial\n fracture. Both fractures are intra-articular. Please refer to operative note\n for full detail. These images are not of diagnostic quality.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 992381, "text": " 2:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval hepatobiliary anatomy, please perform RUQ U/S\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC, diaphragmatic hernia repair, multiple orthopaedic\n procedures now with elevated LFTs\n REASON FOR THIS EXAMINATION:\n please eval hepatobiliary anatomy, please perform RUQ U/S\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with motor vehicle collision, diaphragmatic hernia\n repair. Now with elevated LFTs.\n\n COMPARISON: CT abdomen and pelvis, and .\n\n ABDOMINAL ULTRASOUND: The liver is homogeneous in echotexture, with no focal\n liver lesions identified. The hepatic parenchymal echogenicity is normal. The\n gallbladder demonstrates a moderate amount of sludge. There is no evidence of\n gallstones. There is no intrahepatic biliary ductal dilatation, and the\n common bile duct measures 2 mm. The pancreas is not well visualized secondary\n to bowel gas.\n\n The aorta is unremarkable. No ascites is identified.\n\n IMPRESSION: Biliary sludge; otherwise unremarkable abdominal ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 992131, "text": " 10:23 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT CHEST W/O CONTRAST\n Reason: with p.o. and IV contrast please, please eval for diaphragma\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Field of view: 43\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p diaphragmatic rupture now w/abdominal pain\n REASON FOR THIS EXAMINATION:\n with p.o. and IV contrast please, please eval for diaphragmatic/intraabdominal\n injury, if unable to inject full load of IV contrast through PICC please\n perform with decreased amount of IV contrast or with p.o. contrast only\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male after motor vehicle accident with traumatic\n diaphragmatic rupture, status post laparotomy and repair, now with abdominal\n pain.\n\n COMPARISON: CT torso , abdominal radiograph .\n\n TECHNIQUE: MDCT axial images of the full torso after oral contrast, but no IV\n contrast due to lack of peripheral IV access. The patient has a PICC\n catheter, but this is not suitable for CT power injection.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: There is a small-to-moderate left\n pleural effusion with associated compressive atelectasis of the dependent left\n lower lobe. Small subcentimeter foci of density along the pleural surface of\n the right middle lobe are probably the sequela of resolving contusion.\n Otherwise, the lungs are clear. The unopacified view of the heart and great\n vessels is unremarkable.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The patient is status post laparotomy\n and diaphragmatic repair. The stomach and spleen are now below the diaphragm\n without evidence of herniation. The non-contrast view of the liver, spleen,\n gallbladder, adrenal glands, pancreas, kidneys, and bowel are unremarkable.\n Oral contrast passes freely through to the descending colon and stool mixed\n with gas extends to the rectum. No free gas within the peritoneum is\n identified. An IVC filter is in standard configuration.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The patient is status post interval\n ORIF of proximal left femoral fracture. There is a small amount of low-\n density fluid in the deep pelvis. Foley catheter is within the decompressed\n bladder. The pelvic loops of bowel are unremarkable.\n\n BONE WINDOWS: The patient is status post ORIF of left proximal femur\n fracture.\n\n IMPRESSION:\n 1. Interval diaphragmatic repair with spleen and stomach and other abdominal\n organs now below the diaphragm without evidence of herniation.\n 2. Small-to-moderate left pleural effusion and associated compressive\n (Over)\n\n 10:23 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT CHEST W/O CONTRAST\n Reason: with p.o. and IV contrast please, please eval for diaphragma\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Field of view: 43\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n atelectasis of the dependent left lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 992702, "text": " 9:33 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for structural abnormalities\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with multiple fractures, diaphragm rupture, now with\n delirium\n REASON FOR THIS EXAMINATION:\n Please evaluate for structural abnormalities\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 22-year-old man status post MVA with multiple fractures\n and delirium.\n\n TECHNIQUE: Sagittal short TR, short TE spin echo images were obtained through\n the brain. Axial imaging was performed with long TR, long TE, fast spin echo,\n FLAIR, gradient echo and diffusion technique. Axial, coronal, short TR, short\n TE spin echo imaging was repeated after intravenous gadolinium contrast.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n There is no abnormal enhancement.\n\n IMPRESSION: Normal study.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-19 00:00:00.000", "description": "RP TIB/FIB (AP & LAT) RIGHT PORT", "row_id": 990901, "text": " 11:22 PM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: please obtain tibia and fibula in addition to ankle, please\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with right ankle tenderness and ecchymosis\n REASON FOR THIS EXAMINATION:\n please obtain tibia and fibula in addition to ankle, please eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right ankle tenderness and ecchymosis status post MVC.\n\n Two views of the right tibia were obtained portably. No dedicated views of\n the right ankle were obtained. There is some overlying material.\n\n There are several fractures about the ankle -- a subtle fracture rising from\n the lateral aspect of the distal fibula, with some overlying soft tissue\n swelling; a probable small fracture fragment along the lateral calcaneus; and\n a nondisplaced fracture of the medial malleolus. Irregularity along the medial\n talar dome is noted - ? OCD or more likely overlap from the medial malleolus.\n\n At the periphery of these films, an unusual lucent cleft is seen in the\n posterior knee joint and there is a small knee joint effusion.\n\n No fracture is detected involving the diaphysis of the tibia or fibula.\n\n IMPRESSION - RIGHT LOWER LEG:\n\n 1. Suspect multiple fractures about the right ankle for which dedicated ankle\n views would be recommended.\n\n 2. Right tibial plateau fracture cannot be excluded and should be correlated\n clinically.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990936, "text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p chest tube to water seal\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with diaphragmatic rupture s/p repair POD 2 now s/p\n chest tube to water seal.\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p chest tube to water seal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male status post MVC with diaphragmatic rupture status\n post repair, now status post chest tube to waterseal. Evaluate for\n pneumothorax.\n\n COMPARISON: .\n\n SEMI-UPRIGHT PORTABLE CHEST, ONE VIEW: Left chest tube unchanged in position.\n There is a small radiolucent line on the medial aspect of the left lower\n hemithorax. This may represent a very small pneumothorax, however right\n lateral decubitus films are recommended for better evaluation. There is no\n apical or lateral pneumothorax. Lungs are otherwise grossly clear. Pleural\n surfaces are normal. Cardiomediastinal silhouette is stable.\n\n IMPRESSION: Thin radiolucency along the medial aspect of the left lower\n hemithorax may represent a small pneumothorax. Right lateral decubitus is\n recommended for better evaluation.\n\n Findings were communicated to by telephone at the time of\n interpretation.\n\n jr\n\n" }, { "category": "Radiology", "chartdate": "2115-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991381, "text": " 8:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with traumatic diaphragmatic rupture s/p repair, now with chest\n pain, tachycardia.\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:51 P.M. ON \n\n HISTORY: Diaphragmatic rupture and repair.\n\n IMPRESSION: AP chest compared to through 15:\n\n Lungs clear. Heart size normal. Minimal blunting of the left medial pleural\n sulcus probably due to residual effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991967, "text": " 9:47 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 38cm DL PICC inserted to R cepjalic. Pls determine tip place\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with mult inj related to MVA\n REASON FOR THIS EXAMINATION:\n 38cm DL PICC inserted to R cepjalic. Pls determine tip placement. Pg #.\n Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10 A.M.\n\n COMPARISON: at 1:30 a.m.\n\n INDICATION: PICC line placement.\n\n Right PICC line terminates within the mid superior vena cava. There is\n otherwise no substantial change from a recent study performed several hours\n earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992312, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess picc line\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with right PICC who attempted to pull it out\n REASON FOR THIS EXAMINATION:\n assess picc line\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line position.\n\n Portable AP chest radiograph compared to .\n\n The right PICC line tip terminates in superior SVC. The heart size is normal.\n Mediastinal contours are unremarkable. Lungs are clear. Left pleural\n effusion is again noted.\n\n IMPRESSION: Appropriate position of the right PICC line.\n\n Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 992159, "text": " 1:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA w/ changing mental status\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 22-year-old male status post motor vehicle accident with change\n in mental status. Evaluate for acute intracranial hemorrhage.\n\n COMPARISON: .\n\n FINDINGS: No acute intracranial hemorrhage, mass lesion, shift of normally\n midline structures or hydrocephalus is identified. The -white matter\n differentiation is normal. The surrounding soft tissues and osseous\n structures are unremarkable. The paranasal sinuses and mastoid air cells are\n clear.\n\n IMPRESSION: No acute intracranial abnormality detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992117, "text": " 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for cardiopulm process\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mult orthopaedic operations, now w/temperature\n REASON FOR THIS EXAMINATION:\n please eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Right PICC line continues to terminate in the superior vena cava but appears\n to have increased redundancy in the region of the right axilla compared to\n previous exam. Left pleural effusion and adjacent basilar atelectasis is\n unchanged. No new areas of consolidation are identified to suggest acute\n infectious pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991917, "text": " 1:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mult c fevers 102 s/p prev diaphragm repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fevers.\n\n Layering left pleural effusion appears larger compared to the previous\n examination. New poorly defined left perihilar and retrocardiac opacity may\n potentially represent an area of aspiration or developing infection and\n attention to these areas on followup radiographs is suggested.\n Mild-to-moderate gastric distention is present in the upper abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 993589, "text": " 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate resolution of pulmonary contusion\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with pulmonary contusion and diaphragmatic rupture.\n REASON FOR THIS EXAMINATION:\n evaluate resolution of pulmonary contusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP VIEW\n\n Compared to a chest radiograph.\n\n REASON FOR EXAM: Evaluate resolution of pulmonary contusions. This is a 22-\n year-old man, status post MVA with pulmonary contusion and diaphragmatic\n rupture.\n\n FINDINGS:\n\n There is no airspace disease or interstitial disease in either lung. No\n pulmonary contusions. There is no pneumothorax or pleural effusion. Again\n noted is a right PICC line catheter with distal tip projecting over the\n brachiocephalic/atrial junction. Cardiomediastinal structures are\n unremarkable. No osseous fractures are seen.\n\n IMPRESSION:\n 1. No evidence of pulmonary contusion.\n 2. No pneumothorax or pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 992562, "text": " 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for structural abnormality\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with delirium\n REASON FOR THIS EXAMINATION:\n Please evaluate for structural abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 22-year-old man with delirium. Assess for structural abnormality.\n\n TECHNIQUE: Contiguous 5 mm axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: Comparison is made to and .\n\n There are no intracranial hemorrhages or masses. The /white matter\n differentiation is maintained. The ventricles and extra-axial CSF spaces are\n normal.\n\n The visualized orbits are normal. The visualized paranasal sinuses, mastoid\n air cells, and middle ear cavities are clear. No suspicious bony\n abnormalities are seen.\n\n IMPRESSION: Normal unenhanced head CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-19 00:00:00.000", "description": "L CT LOW EXT W/O C LEFT", "row_id": 990879, "text": " 4:51 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: CT of LEFT KNEE - evaluate left tibial plateau fracturePLEAS\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with left tibial plateau fracture, has ex-fix\n REASON FOR THIS EXAMINATION:\n CT of LEFT KNEE - evaluate left tibial plateau fracturePLEASE DO REFORMATS\n CONTRAINDICATIONS for IV CONTRAST:\n NO IV CONTRAST NECESSARY\n ______________________________________________________________________________\n WET READ: 5:59 PM\n comminuted distal femoral fx with impaction , intrarticular extension, and\n marked dorsal angulation of distal frag. The medial femoral condyle appears\n preserved. spiral comminuted tibial metediaphyseal fx with mild posterior\n displacement of distal frag. Comminuted tibial plateua fx with intraarticular\n extension and 1.5 cm lateral deviation of the lateral tibil plateau with\n widening of the lateral compartment suggestive of ligamentous injury.\n numerous large intra-articular bony fragments. mildly displaced oblique\n fibular head and mid shaft fx. small lateral patellar avulsion type fx.\n marked lipohemarthrosis and soft tissue edema.\n ______________________________________________________________________________\n FINAL REPORT\n CT LEFT KNEE\n\n INDICATION: Evaluate for tibial plateau fracture.\n\n TECHNIQUE: Non-contrast CT was performed through the left knee.\n\n COMPARISON: Radiographs, left knee, .\n\n FINDINGS:\n\n There are comminuted fractures of the distal femur, proximal tibia and fibula\n and of the patella.\n\n There is an intramedullary rod in the left femoral shaft. The distal end of\n the rod is visualized in the current CT scan field of view. There is a\n markedly comminuted fracture of the distal femur transversely across the\n supracondylar portion of the femur and extending down to the intercondylar\n notch at the articular surface. The component of the fracture line extends to\n the articular surface of the lateral femoral condyle. There is at least 2 cm\n of impaction and shortening of the femur fracture. There is a prominent\n displaced angulated fragment arising from the distal lateral diametaphyseal\n cortex angulated 90 degrees, laterally, projecting into the overlying soft\n tissues. There is anterior angulation of the distal component of the femoral\n fracture.\n\n There is a comminuted fracture of the proximal tibia extending from the\n intercondylar eminence through to the proximal tibial shaft. The fracture\n involves the articular surfaces of the medial and lateral tibial plateaus\n adjacent to the intercondylar eminence. There is between 4 and 6 mm inferior\n (Over)\n\n 4:51 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: CT of LEFT KNEE - evaluate left tibial plateau fracturePLEAS\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n displacement of the lateral tibial plateau with respect to the medial tibial\n plateau (6 mm posteriorly 4 mm anteriorly). As a result of the comminuted\n fracture, the medial and lateral tibial plateaus both from separate bony\n fragments from each other and from the remainder of the tibial shaft. There\n is approximately 8 mm of lateral displacement of the distal tibial component\n suspect to the medial tibial shaft.\n\n There is a fracture through the proximal fibula involving the head and neck of\n the fibula. There is probable avulsion or tear of the conjoined tendon. There\n is a comminuted nondisplaced fracture of the proximal fibular shaft.\n\n There is wide diastasis of the lateral compartment of the knee joint,\n measuring approximately 2 cm.\n\n There is a non-displaced fracture at the lateral aspect of the patella.\n\n There is an external fixator in situ, fixated at the distal femoral shaft and\n proximal-to-mid tibial shafts.\n\n There are multiple intra-articular fragments.\n\n IMPRESSION:\n 1. Comminuted intra-articular fractures of the distal femur and proximal\n tibia.\n 2. Fractures of the lateral aspect of the patella and fibula.\n 3. Probable injury to the conjoined tendon insertion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 990944, "text": " 9:27 AM\n ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: Need dedicated ankle films - AP, Lateral and MORTISE views (\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p polytrauma, right ankle injury\n REASON FOR THIS EXAMINATION:\n Need dedicated ankle films - AP, Lateral and MORTISE views (previous imaging\n did not include mortise)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post polytrauma with right ankle injury.\n\n FINDINGS: Five radiographs of the right ankle are reviewed without\n comparison. This is a comminuted fracture through the distal lateral\n malleolous as well as a mildly displaced fracture of the lateral talus. There\n are also nondisplaced fracture lines extending through the medial malleolous,\n some of which extend to the ankle mortise. Mortise alignment is intact. There\n is a subtle lucency through the medial talus that may also represent a\n nondisplaced fracture. There is marked soft tissue swelling.\n\n IMPRESSION:\n 1. Distal lateral malleolous and lateral talar avulsion fractures.\n 2. Nondisplaced fractures through the medial malleolous extending the mortise.\n\n Given multiplicity of fractures, a CT scan is recommended for further\n evaluation. Findings discussed with Dr. today on the phone.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 990627, "text": " 8:33 AM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: ABDOMIN TRAMA\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old with abdominal trauma.\n\n COMPARISON: None.\n\n SUPINE ABDOMINAL RADIOGRAPH: There is a nonobstructive bowel gas pattern. Tip\n of NG tube is seen within the stomach. Left sided chest tubd is incompletely\n imaged. Streaky linear lucencies are identified in the left lateral abdomen,\n which likely represents post-operative intrabdominal air. Staples overlie the\n midline abdomen and right pelvis/flank. No radiopaque foreign body is\n otherwise detected.\n\n IMPRESSION: No evidence of obstruction or retained foreign body.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-21 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 991116, "text": " 1:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o ptx s/p left chest tube pull\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with diaphragmatic rupture, L comminuted femur fx, now\n s/p chest tube pull on left.\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p left chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: Diaphragmatic rupture status post chest tube pull.\n\n FINDINGS: The left-sided chest tube has been removed with a small residual\n pneumothorax. There is a small pleural effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 85592, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Tachycardia s/p trauma. ?pericardial effusion. Right ventricular function.\nHeight: (in) 71\nWeight (lb): 165\nBSA (m2): 1.95 m2\nBP (mm Hg): 120/60\nHR (bpm): 117\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RAP (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%) Transmitral and tissue Doppler\nimaging suggests normal diastolic function, and a normal left ventricular\nfilling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\nIMPRESSION: Normal study. Normal biventricular cavity sizes with preserved\nglobal and regional biventricular systolic function. No pericardial effusion.\nResting tachycardia.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 218340, "text": "Artifact is present. Sinus tachycardia. The P-R interval is short\nwithout evidence of pre-excitation. Compared to the prior tracing\nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2115-12-23 00:00:00.000", "description": "Report", "row_id": 218341, "text": "Sinus tachycardia\nBorderline short P-R interval - is nonspecific and probably normal variant\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2115-12-18 00:00:00.000", "description": "Report", "row_id": 218342, "text": "Sinus tachycardia\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" } ]
22,278	166,339	1. Cardiac: 3rd degree heart block s/p pacemaker placement; HTN Patient initially very bradycardic with mild HTN upon admission. Her EKG showed a RBBB with a ventricular rate of 36. Her atenolol was decreased from 75 mg to 25 mg qd. Her cardiac enzymes were negative. The patient was placed on telemetry and transferred to the floor. Shortly after transfer, it was noted on telemetry that the patient had progressed into 3rd degree heart block. She was mentating normally and was hemodynamically stable, but her heart rate continued in the 30s. Cardiology was consulted and it was decided at this time that the patient should be transferred from the medicine service to the CCU. In the CCU, the patient had a temporary pacer initially placed. Then on a pacemaker was placed. Patient did experience a lead misplacement complication and a mild pericardial effusion. She did recover from this and was completely asymptomatic at the time of discharge to the rehab facility. An echo was repeated on which showed that the overall left ventrical systolic function was preserved, right ventrical size and motion was normal, small pericardial effusion which was slightly larger than the prior study, no tamponade. Her EF was 45-50% c mild aortic and moderate mitral regurgitation. A chest x-ray following her pacer placement showed that her cardiac leads were in the correct position and there was no active lung disease. The patient also became hypotensive following pacer placement and therefore all hypertensive medications were held. Her blood pressure then increased to 148/73 and atenolol 25 mg qd was re-started with good control. The patient became mildly hypertensive and therefore her out-patient regimen was restarted except that Norvasc 5 mg qd was held. Therefore the patient was d/c'ed c atenolol 50' qd, Zestril 40' qd and ASA 325' qd. The patient will follow-up with her PCP for further evaluation and monitoring in one week and will follow-up with the device clinic on c Dr. . 2. Hematology The patient's hematocrit was noted to have decreased following her pacer placement from the high 30s to the low 30s. She was asymptomatic, no BRBPR, guiac negative, no hematuria. A CT of the abdomen showed that there was no retroperitoneal hemorrhage. She was closely monitored and her hematocrit stabilized and she remained asymptomatic. It was felt that this likely had been due to her procedure and the pericardial effusion. Her rehab facility will re-check her hematocrit in days to ensure stabilization. The patient was also started on Vitamin B12, Folate 1' qd and Iron 325' qd. 3. GERD/Esophageal stricture s/p EGD The patient remained asymptomatic throughout her hospital stay and was maintained on her out-patient protonix 40 mg qd. She will follow-up with PCP for further care. 4. Hypothyroidism The patient remained stable and her outpatient Levoxyl was continued as previously prescribed. 5. r/o DVT The patient experienced new onset left foot swelling following her pacer placement. Patient had also been taking estrogen upon admission. There were no palpable cords, no calf tenderness, no SOB/CP. No tenderness in foot or lower extremity. An US of the extremity was performed to verify there were no DVTs. She had pneumoboots for the majority of her hospital stay as well.	Pt denies pain.VAnco IV s/p pacemaker.PULM: RRR, on RA. Distal pulses palpable.Resp: LS CTA. EKG confirmed CHB. Cont to wean Dopamine as tolerated. CXR this AM reveal wire had migrated approx 2 cm back, EP aware and in to advance wire, settings unchanged. Following Ativan doses pt speech slowed. Pt remains off of Dopamine gtt. Pt slept w/ minimal interruption remainder of noc.CV: Hemodynamically improving. CHEST, AP: There is stable cardiomegaly. DP/ PT pulses +2/+1MS:MS: AAOx3. Call out to floor if VS/effusion remain stable. The hilar and mediastinal contours are within normal limits. Pt denies SOB/ difficulty breathing. NBP 85-107/36-49. Pt denied any pain overnoc. Pt remained asymptomatic and NBP stable. Became hypotensive after removal of temporary pacemaker. DDD pacemaker placed . Pt remains off of antihypertensives. Interval removal of pacer wire and placement of permanent pacer with right atrial and ventricular leads appropriately positioned. Effusion stable. DDD permanent pacemaker placed. Remains +200cc LOSID: Pt afebrile. NIBP 98-112/42-49. CT PELVIS W/O IV CONTRAST: The rectum, sigmoid colon, distal ureters are all within normal limits. Pt cont to be covered empirically w/ Vancomycin following permanent pacemaker placement. Cont to ambulate as tolerated. There has been interval removal of temporary pacer wire. Remains on Dopamine gtt peripherally for BP support. AM Hct 36.2. Distal pulses palpable w/ ease. Pt tolerating po liquids w/o difficulty. vagal episode per report. Permanent pacemaker placed w/o difficulty but pt vagaled following removal of temp wire via RIJ. Speech slowed following Ativan doses. Pt ambulated to commode w/ the assist of two w/o incidence. Permanent pacemaker placed. Pt denies any pain. RR 14-20.GI/GU: Abd soft. Pt remained vpaced remainder of shift w/o incidence. Initial BP obtained 86/39. Pt exhibited good response to bolus w/ BP in 100's/50's-Dopa slowly weaned to off at 1400-remains off w/ range high 80's-90's w/ MAP's in 60's. +BS. + BS. CHEST AP: There is stable LV enlargement. Right femoral venous sheath site stable. Otherwise unchanged radiographic appearance of the chest compared to previous study. CHEST AP: Permanent pacemaker leads remain in appropriate positioning. CCU Nursing Progress Note 7p-7aS: "That number is pretty low for me (in reference to BP)O: Please see careview for complete VS/ additional objective dataMS: AAOx3. Pt remained hypotensive requiring fluid boluses and Dopamine for support. No vomitus but + dry heaves. IVF WO. Pulses Paroduxes negative. Echo this am for further evaluation of hypotension following permanent pacemaker placement. HCT cont to trend down. w/ SPC-supervision onlyResp-Lungs CTA bilat, SpO2 on RA 95-98%, 0 SOB noted Pt HR stable Vpaced-AV paced at times 70's 0 ectopy noted. Nausea x2 tx w/ 2 mg Zofran.ID: Afebrile overnoc.Skin: IntactAccess: 2 PIVA/P: CHB. 3) Small pericardial effusion Nursing Shift NoteS:"I don't feel my heart beating anymore"O: Pt A+Ox3, pleasant and cooperative w/ care, ambulatory w/ P.T. Administered 2mg Zofran w/ gd effect. Venous sheath site stable. HO aware of marginal BP and no additional pressor support or fluids ordered. There are noechocardiographic signs of tamponade.Conclusions:Overall left ventricular systolic function is grossly preserved. Overall leftventricular systolic function is mildly depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Mild to moderate (+) mitral regurgitation isseen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. Mild (1+) aorticregurgitation is seen.3. Atrial sensed ventricular paced rhythmSince previous tracing of , no significant change Regular ventricular pacingPacemaker rhythm - no further analysisSince previous tracing, ventricular paced rhythm noted The left ventricular cavity size is normal. Shortness of breath.Height: (in) 64Weight (lb): 147BSA (m2): 1.72 m2BP (mm Hg): 115/57HR (bpm): 64Status: InpatientDate/Time: at 11:07Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. Mild to moderate (+)mitral regurgitation is seen. There are no echocardiographic signs of tamponade.Compared with the findings of the prior study (tape reviewed) of , thepreviously trivial pericardial effusion is now larger. 2) No other significant cardiopulmonary abnormality. Mild (1+) aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. FINDINGS: The heart is normal in size. The right IJ temporary pacing electrode tip is at the apex of the right ventricle, in good position on the single view provided. Since the previous tracingof no significant change. Rightventricular chamber size and free wall motion are normal. There is mildmitral annular calcification. IMPRESSION: No active lung disease. Allowing for technical differences the position is not significantly changed since the earlier study of the same day. FINDINGS: A single AP supine image. R/o pericardial effusion.Height: (in) 64Weight (lb): 146BSA (m2): 1.71 m2BP (mm Hg): 103/42HR (bpm): 84Status: InpatientDate/Time: at 08:24Test: Portable TTE (Complete)Doppler: Limited doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.PERICARDIUM: There is a small pericardial effusion. Left ventricular function. There is a smallpericardial effusion. Overall left ventricularsystolic function is difficult to assess but is probably mildly depressed.Septal hypokinesis is present.2. The cardiac leads are in position. A-V dissociationConduction defect of RBBB typePossible old inferior myocardial infarctionSince previous tracing, A-V dissociation noted IMPRESSION: 1) Satisfactory placement of temporary pacing wire. Sinus bradycardia - consider sinus rhythm with 2:1 S-A block.Conduction defect of RBBB typeInferior infarct - age undeterminedNo previous tracing for comparison There is no evidence of cardiac failure. Regular ventricular pacingPacemaker rhythm - no further analysisSince previous tracing, faster heart rate PATIENT/TEST INFORMATION:Indication: Hypotension. ischemiaOld inferior myocardial infarctSince previous tracing, ST segment depression noted TECHNIQUE: PA and lateral chest radiograph. The lungs are clear. There is no apparent abnormalities in bony structures. The aortic valve leaflets are mildly thickened. There is no pneumothorax.	25	[ { "category": "Nursing/other", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 1553954, "text": "CCU Nursing Progress Note 7p-7a\nS: \" I didn't think that this would be such a long ordeal. I figured I would be home by now\".\n\nO: Please see careview for complete VS/ additional objective data.\n\nIn brief pt found to be in CHB while on F2. Transferred to CCU overnoc for temporary pacing wire placement. Permanent pacemaker placed yesterday evening w/o incidence. Upon removal of RIJ cordis/ temp wire while still in EP lab ? vagal episode per report. Pt became hypotensive w/ SBP to the 50s. Pt received 1 mg Atropine and started on Dopamine gtt. IVF WO. Dopamine gtt titrated to 5 mcg/kg/min. Per report pt nauseated while in lab ? r/t hypotension or effects of Fentanyl/ Versed received in lab.\nCV: Pt transferred to CCU and arrived on 2.5 mcg of Dopamine. Initial BP obtained 86/39. Dopamine gtt titrated up to 10 mcg/kg/min but decreased to 7.5 mcg for most of shift. Pt received 500cc NS IVFB x2. DDD permanent pacemaker placed. A sensed, V paced. Settings 60-120. HR 74-120. No ectopy. NBP 85-107/36-49. Goal to maintain MAPs>60. HO aware of marginal BP and no additional pressor support or fluids ordered. Venous sheath site stable. Sm hematoma noted per EP nurse. noted. PM HCT stable at 40. AM Hct 36.2. DP/ PT pulses +2/+1MS:\n\nMS: AAOx3. Pleasant and cooperative. Pt denies any pain or discomfort. Upon return from EP lab pt nauseated. No vomitus but + dry heaves. Administered 2mg Zofran w/ gd effect. No other issue until 0630 when dry heaves reappeared but resolved w/ additional 2 mg. No other change in VS noted. Echo obtained while in EP lab. if there is an effusion it is very sm in size. EF noted to be 45-50%.\n\nResp: LS cta. Pt on 2L NC. No ^ need for O2 requirements. No SOB or difficulty breathing. Pt tolerating lying flat. O2 sats 96-99%.\n\nGI/GU: +BS. Abd soft. Nausea x2 tx w/ 2 mg Zofran.\n\nID: Afebrile overnoc.\n\nSkin: Intact\n\nAccess: 2 PIV\n\nA/P: CHB. Permanent pacemaker placed. Remains on Dopamine gtt peripherally for BP support. Central access. Cont to wean Dopamine as tolerated. Echo this am for further evaluation of hypotension following permanent pacemaker placement. Cont teaching. Cont to support pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 1553955, "text": "Nursing Shift Note\nS:\"I don't feel my heart beating anymore\"\n\nO: Pt A+Ox3, pleasant and cooperative w/ care, ambulatory w/ P.T. w/ SPC-supervision only\n\nResp-Lungs CTA bilat, SpO2 on RA 95-98%, 0 SOB noted\n\n Pt HR stable Vpaced-AV paced at times 70's 0 ectopy noted. This AM BP 90's/50's, MAP's 60's, team order 500cc NS over 60 minutes w/ intention to wean off Dopamine. Pt exhibited good response to bolus w/ BP in 100's/50's-Dopa slowly weaned to off at 1400-remains off w/ range high 80's-90's w/ MAP's in 60's. Pacer interrogated successfully this AM and CXR confirm lead placement, pacer site CDI -hem/ooze w/ positive distal pulses, repeat Echo this AM reveal 0 change in effusion from previous study- repeat Hct 34 from 36 this AM.\n\nGI- BS+x4, Abd soft, NT, ND-good appetite and able to take PO's easily\n\nGU-I+O's approx 2L negative since admit however, >30cc/hr UOP-foley D/C at 1500 today-DTV by 2100-2300\n\nSkin-WDI, R groin CDI -hem/ooze, R IJ temp wire site CDI, raised however, 0 evidence of hematoma\n\nMusk-OOB today, ambulate w/ P.T.-superviion w/cane. Pt requesting rehab stay however, await rec's for D/C\n\nID-3rd dose Vanco today empirically s/p pacer placement, WBC elevated to 14(7), pt remains afebrile w/ 0 other s/s infection. UA sent and negative for leukocytes, Blood cultures x 2 sent and pending\n\nA/P: Pt is an 87 y/o female s/p DDD pacer placement complicated by vagal post temp wire removal requiring Dopa-now remains slightly hypotensive but hemodynamically stable and tolerating new pace rhythm good. Plan to continue close monitoring of BP-team made aware of any changes below baseline, follow cultures and fever curve, DTV as above, D/C planning\n" }, { "category": "Nursing/other", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 1553952, "text": "CCU Nursing Progress Note 7p-7a\nS: \" How long will this be in my neck\"\n\nO: Please see careview for complete VS/ additional objective data.\n\nMS: Upon arrival pt 3. Pleasant and cooperative w/ care. Pt anxious upon arrival requiring reassurance at times. Pt received 0.5mg IV Ativan x2 doses for ^ anxiety during temp wire placement. Pt yelling out stating she wanted the drape off her face. Following Ativan doses pt speech slowed. Pt was able to respond accordingly as to where she was, and the date but stated that the year was and she was unclear as to whom the president was.\n\nCV: CHB. HR 32-37( rate occasionally noted to be ^ 50s yet upon further review abherrant P waves were noted as being conducted.) Pt remained asymptomatic and NBP stable. Pt denied any pain overnoc. After attempting Atropine .6 and 1 mg doses and Albuterol neb w/o improvement team elected to place temp wire. Temporary pacemaker in place at 0430 after lengthy attempt at introducer placement. Wire placement confirmed by CXR. Pt vpaced at 60 bpm. Threshold 0.60 and sensitivity 0.060. Pacing wires attached to pacing box and wires also secured to pt. Site CDI. Pt remained vpaced remainder of shift w/o incidence. H/H and electrolytes stable. Norvasc dose dc'd and Atenolol dose decreased from 75mg- 25mg. Atenolol had been ^d to 75mg (50mg) in the past week. Distal pulses palpable.\n\nResp: LS CTA. No SOB/ difficulty breathing. Pt tolerated lying flat during procedure. RR 10-19. O2 sats 94-97% on RA. During temp pacemaker placement while draped pt sats decreased to 94%. Placed on 2L NC w/ improved sats to 98-100%.\n\nGI/GU: Abd soft. + BS. Gd appetite per report. No BM. No f/c per request of pt. Pt voiding sm amts of urine 25-100cc/hr. BUN/CR 14/0.9.\n\nID: Afebrile. No abx. WBC 7.1.\n\nSkin: Intact.\n\nAccess: 2 PIVs, Transvenous introducer via RIJ.\n\nSocial: Daughter in law called for update this am. Will be into visit after rounds around 11 am\n\nA/P: 87 yo female presented to EW w/ abd/ epigastric pain . While on F2 HR 37 bpm. EKG confirmed CHB. Pt transferred to CCU for temp transvenous pacing wire. Pt arrived to CCU w/ HR in 30s but otherwise VSS. Attempted to ^ HR w/ Atropine and Albuterol doses w/o effect. Although VSS, transvenous pacing wire placed at 0430 this am. Speech slowed following Ativan doses. No other issues overnoc.\n? F/C placemnt if pt cont to void sm amts of urine.\nPermanent pacemaker placement scheduled for this afternoon. Cont to support pt and family as indicated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 1553953, "text": "Nursing Note\nS:\"Have I gone for the pacemaker yet\"\n\nO: Neuro-A+Ox3, however, requires occasional reminders for day of week\n\nResp-Lungs CTA bilat, 0 SOB noted, SpO2 on 2LNC 98%\n\nCar-Pt currently 100% Vpaced-pacer set to VVI, rate of 66, 8 mA w/ threshold 0.6 sec. BP stable 100's-120's/60's, does report feelings of \"heart beating\" from temporary wire. CXR this AM reveal wire had migrated approx 2 cm back, EP aware and in to advance wire, settings unchanged. Pt exhibited episode x 1 this AM of pacer noncapture, voltage increased from 5 to 8 mA w/ relief of symptoms. Awaiting pacer placement this afternoon\n\nGI-NPO since AM, BS+ x 4, Abdomen soft nontender. Pt has h/o esophageal strictures\n\nGU- foley patent and draining CYU, >35 cc/hr UOP, o burning or pain w/ urination\n\nSkin- WDI, 0 open lesions\n\nMusk-gait not assessed, moves all extremities, previously functioned I'ly in senior housing\n\nSocial- Lives alone has adult son who quadriplegic, daughter-in-law has been appointed contact person however, is resistant to signing HCP, has daughter who lives in VA, no contact yet. Sister-in-law phone # in chart.\n\nIV-PIV x 2, #20's both patent and flush easily.\n\nA/ Pt is an 87 y.o. female who presents to F2 with CHB, pain in chest and recent c/o dizziness and GI upset, transfer to CCU for temporary wire placement in anticipation of permanent pacer placement today.\n\n\nSkin- WDI,\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 1553956, "text": "CCU Nursing Progress Note 7p-7a\nS: \"That number is pretty low for me (in reference to BP)\n\nO: Please see careview for complete VS/ additional objective data\n\nMS: AAOx3. Extremely pleasant and cooperative. Pt MAE. Follows commands w/o difficulty. Pt denies any pain. Pt ambulated to commode w/ the assist of two w/o incidence. Pt requested to walk but around the same time BP remained lower. Pt declined use of sleep aid. Pt slept w/ minimal interruption remainder of noc.\n\nCV: Hemodynamically improving. AV/ V paced. DDD pacemaker placed . A sensing/ Vpaced. HI/Lo settings 80-120. Pacemaker appropriately sensing/capturing. LIJ pacemaker dsg site CDI. RIJ site stable. No hematoma/ ooze yet slightly reddened. Right femoral venous sheath site stable. HR 74-83. No ectopy noted. NIBP 98-112/42-49. MAPs improving and remained consistently > 60. Pt remains off of Dopamine gtt. No IVFB given. HCT at 2100 30.9(34.1 prior draw and 10 pt drop in past 24hrs). HO notified and pt was ordered for Abd CT to r/o peritoneal bld. Scan results negative. Distal pulses palpable w/ ease. Pulses Paroduxes negative. AM labs still pending. Per Echo EF 50% and sm anterior effusion unchanged.\n\nResp: LS cta. Faint bibasilar crackles upon auscultation. Pt was off all supplemental O2 but NC 2L reapplied overnoc to improve sats from 93% to 99%. Pt denies SOB/ difficulty breathing. RR 14-20.\n\nGI/GU: Abd soft. +BS. No stool since admission. Improved appetite per report. Pt tolerating po liquids w/o difficulty. F/c dc'd on prior shift. Pt dtv but ambulated to commode and able to urinate. Pt voiding 200cc cyu q 2hrs. Remains +200cc LOS\n\nID: Pt afebrile. Tmax 98.3 po. Pt cont to be covered empirically w/ Vancomycin following permanent pacemaker placement. WBC improved 9.6(14).\n\nSkin: Intact. No breakdown noted. Sm amt of peripheral edema noted.\n\nAccess: 1 PIV\n\nSocial: Daughter called and spoke w/ pt.\n\nA/P: Pleasant 87 yo female found to be in CHB on floor. Pt sent to CCU for temp pacing wire. Permanent pacemaker placed w/o difficulty but pt vagaled following removal of temp wire via RIJ. Pt remained hypotensive requiring fluid boluses and Dopamine for support. BP steadily showing improvement and remains stable off of Dopamine gtt overnoc. Effusion stable. HCT cont to trend down. No active S/S of bld. Sent for Abd ct which was negative for retroperitoneal bld. Pt remains off of antihypertensives. ? need for swan to evaluate fluid status. Cont to ambulate as tolerated. ? Call out to floor if VS/effusion remain stable.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 1553957, "text": "NPN 8a-330pm:\n\nNeuro/ID: A&Ox3, pleasant, cooperative. AFebrile. Pt denies pain.\nVAnco IV s/p pacemaker.\n\nPULM: RRR, on RA. O2 sats>94%\n\nCV: 100% Vpaced rate 70-80. SBP >110. off dopamine. HCT 32.1 up from 29 yesterday. ASA given MD recommendation.\n\nGi/GU: Good appetite, bS present. NO BM. MOM and given.\n\nSocial: Daughter inlaw called for update, talked to pt on phone.\n\nPLAn: Transfer to floor when bed available, transfer note complete\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834029, "text": " 8:32 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o PTX , assess leads\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placementdual chamber\n REASON FOR THIS EXAMINATION:\n r/o PTX , assess leads\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status post pacemaker placement. Evaluate for\n pneumothorax and assess leads.\n\n CHEST AP: Permanent pacemaker leads remain in appropriate positioning. The\n lungs are clear without evidence of pneumothorax. Otherwise unchanged\n radiographic appearance of the chest when compared to previous study dated\n at 12:09AM.\n\n IMPRESSION: No pneumothorax. Appropriately positioned pacemaker leads.\n Otherwise unchanged radiographic appearance of the chest compared to previous\n study.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-03 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 834288, "text": " 2:43 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LT LEG SWELLING\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placement c new onset left foot swelling, no\n pain or other associated symptoms\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 87-year-old woman with new onset left foot swelling. Please\n evaluate for deep vein thrombosis.\n\n COMPARISON: None.\n\n -scale and Doppler son of the left common femoral, superficial\n femoral and popliteal veins were performed. Normal flow, augmentation and\n compressibility and wave forms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833999, "text": " 11:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o mediastinal bleed\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placement- pt became hyptonesive after temp\n pacemaker removed\n REASON FOR THIS EXAMINATION:\n r/o mediastinal bleed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status post pacemaker placement. Became\n hypotensive after removal of temporary pacemaker. Evaluate for mediastinal\n bleed.\n\n COMPARISON: .\n\n CHEST AP: There is stable LV enlargement. The aorta is tortuous. The hilar\n and mediastinal contours are within normal limits. The lungs are clear.\n Pulmonary vasculature is normal. There are no pleural effusions. There has\n been interval removal of temporary pacer wire. There is a new dual-lead\n permanent pacer with leads appropriately positioned. Osseous and soft-tissue\n structures are unremarkable.\n\n IMPRESSION: No evidence of mediastinal hematoma. Interval removal of pacer\n wire and placement of permanent pacer with right atrial and ventricular leads\n appropriately positioned.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "P CHEST FLUORO WITHOUT RADIOLOGIST PORT", "row_id": 833889, "text": " 4:05 AM\n CHEST FLUORO WITHOUT RADIOLOGIST PORT Clip # \n Reason: please help is assessment of temporary pacer wire placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with complete heart block\n REASON FOR THIS EXAMINATION:\n please help is assessment of temporary pacer wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST FLUORO:\n\n A chest fluoro was performed without a radiologist present. 25 seconds of\n fluoro time was used. No films submitted.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833890, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PACERWIRE PLACEMENT\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status-post pacer wire placement.\n\n COMPARISON .\n\n CHEST, AP: There is stable cardiomegaly. The aorta is unfolded and tortuous.\n Hilar and mediastinal contours are otherwise unremarkable. The pulmonary\n vasculature is normal. The lungs are clear. There are no pleural effusions.\n Pacer wire tip is in the right ventricle. Osseous and soft tissue structures\n are unremarkable.\n\n IMPRESSION: Pacer wire tip in right ventricle. No other acute\n cardiopulmonary process observed on chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 833872, "text": " 5:20 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman c h/o angina presents with epigastric and chest pain x \n days.\n REASON FOR THIS EXAMINATION:\n R/O MI\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n INDICATION: Chest pain.\n\n The heart is upper limits of normal in size and demonstrates left ventricular\n configuration. The aorta is tortuous and the pulmonary vascularity is normal.\n The lungs appear clear, and there are no pleural effusions. Degenerative\n changes are seen in the spine.\n\n IMPRESSION: Left ventricular configuration of the heart and tortuous thoracic\n aorta. Is there a history of systemic hypertension?\n\n No evidence of acute pulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 834109, "text": " 11:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for retroperitoneal bleed\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with s/p R heart cath yesterday, now w/ 10 pt hct drop and\n hypotension.\n REASON FOR THIS EXAMINATION:\n please evaluate for retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right heart catheterization with ten point hematocrit\n drop and hypotension. Evaluate for retroperitoneal bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Helically aquired contiguous axial images were obtained from the\n lung bases to pubic symphysis without IV contrast.\n\n CT ABDOMEN W/O IV CONTRAST: Tiny pleural effusions are present bilaterally.\n There is mild dependent atelectasis as well. Cardiac pacemaker wires are also\n identified. A small pericardial effusion is seen. The noncontrast enhanced\n liver, pancreas, spleen, adrenal glands, kidneys, ureters, stomach, and loops\n of large and small bowel are all within normal limits. There is no free air\n or free fluid. There is no mesenteric or retroperitoneal lymphadenopathy. The\n gallbladder is not well visualized. There is no evidence of retroperitoneal\n hemorrhage.\n\n CT PELVIS W/O IV CONTRAST: The rectum, sigmoid colon, distal ureters are all\n within normal limits. There is no free fluid in the pelvis. There is air\n seen within the bladder without bladder wall thickening. These findings may\n be related to recent instrumentation. No significant pelvic or inguinal\n lymphadenopathy is identified. No pelvic hematoma is seen.\n\n BONE WINDOWS: Degenerative changes are noted within the lower lumbosacral\n spine. No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1) No evidence of retroperitoneal hemorrhage.\n\n 2) Tiny bilateral pleural effusions with mild atelectatic changes at the lung\n bases.\n\n 3) Small pericardial effusion\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833910, "text": " 9:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval temp pacemaker wire placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with temp pacemaker wire- please eval placement\n REASON FOR THIS EXAMINATION:\n please eval temp pacemaker wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Evaluate placement of temporary pacemaker electrode.\n\n FINDINGS: A single AP supine image. Comparison study taken five hours\n earlier.\n\n The right IJ temporary pacing electrode tip is at the apex of the right\n ventricle, in good position on the single view provided. Allowing for\n technical differences the position is not significantly changed since the\n earlier study of the same day. The heart and pulmonary vessels are\n unremarkable. There is no evidence of cardiac failure. No pulmonary\n infiltrates or pleural effusions can be identified.\n\n IMPRESSION:\n 1) Satisfactory placement of temporary pacing wire.\n\n 2) No other significant cardiopulmonary abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 834074, "text": " 2:55 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for lead placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman c h/o angina presents with epigastric and chest pain x \n days.\n REASON FOR THIS EXAMINATION:\n please assess for lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 year old woman with angina.\n\n TECHNIQUE: PA and lateral chest radiograph. The comparison is made with the\n previous chest radiograph dated and 4th.\n\n FINDINGS: The heart is normal in size. The cardiac leads are in position.\n The lungs are clear. There is no pneumothorax. There is no apparent\n abnormalities in bony structures.\n\n IMPRESSION: No active lung disease.\n\n" }, { "category": "Echo", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 103171, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial/ventricular ectopy. Left ventricular function. Shortness of breath.\nHeight: (in) 64\nWeight (lb): 147\nBSA (m2): 1.72 m2\nBP (mm Hg): 115/57\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:07\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild to moderate (+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is difficult to assess but is probably mildly depressed.\nSeptal hypokinesis is present.\n2. The aortic valve leaflets are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen.\n\n\n" }, { "category": "Echo", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 103146, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. S/P pacemaker placement. R/o pericardial effusion.\nHeight: (in) 64\nWeight (lb): 146\nBSA (m2): 1.71 m2\nBP (mm Hg): 103/42\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 08:24\nTest: Portable TTE (Complete)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is grossly preserved. Right\nventricular chamber size and free wall motion are normal. There is a small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (tape reviewed) of , the\npreviously trivial pericardial effusion is now larger.\n\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312969, "text": "A-V dissociation\nConduction defect of RBBB type\nPossible old inferior myocardial infarction\nSince previous tracing, A-V dissociation noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312970, "text": "Sinus bradycardia - consider sinus rhythm with 2:1 S-A block.\nConduction defect of RBBB type\nInferior infarct - age undetermined\nNo previous tracing for comparison\n\n" }, { "category": "ECG", "chartdate": "2195-07-03 00:00:00.000", "description": "Report", "row_id": 312963, "text": "Atrial sensed and demand ventricular pacing. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 312964, "text": "Atrial sensed ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 312965, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, faster heart rate\n\n" }, { "category": "ECG", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 312966, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, ventricular paced rhythm noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 312967, "text": "A-V paced rhythm\nSince previous tracing, paced rhythm noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312968, "text": "A-V dissociation\nRight bundle branch block\nLateral ST depression - ? ischemia\nOld inferior myocardial infarct\nSince previous tracing, ST segment depression noted\n\n\n" } ]
20,965	133,030	1. GASTROINTESTINAL: The patient with presumed cholangiocarcinoma and history of cholangitis being treated with antibiotics for coagulase-negative Staphylococcus and in her bile. The patient reports no fevers since discharge. The patient had followed up with Hematology/Oncology and per the discussion of Hematology/Oncology and the family there was a decision made to not prefer any surgical options. The patient had represented for elective internalization of the percutaneous drains. The patient had finished a full course of the fluconazole, Flagyl, vancomycin; however, Levofloxacin had been extended for an additional week. The patient underwent successful internalization of her drains; however, the percutaneous drains were left in place to ensure no further issues. The plan was to have the drains removed at a later time. It was clear that these stents were fully functional. 2. RESPIRATORY: The patient had reported no respiratory distress on admission; however, on the day of intended discharge on , the patient developed sudden onset of acute shortness of breath while showering prior to discharge. The patient's oxygen saturations dropped and the patient was diagnosed with a massive pulmonary embolus. The patient was transferred to the Cardiac Catheterization Laboratory for thrombectomy and required intubation for severe respiratory distress. At that time, it was found that the right pulmonary artery was occluded in the superior portion as well as the inferior portion. The inferior portion was successfully Angiojetted with local lytics to restore flow to that area. Also, at that time, an IVC filter was placed. 3. CARDIAC: On the morning of , the patient had a massive pulmonary embolus with resulting cardiogenic shock. The patient was intubated and placed on pressors subsequently. The patient was maintained on Levophed and Vasopressin throughout the night. However, on the morning of , it became evident that the patient not only had shock liver but acute renal failure in the setting of decreased blood pressures on the prior day. The patient had also been given Amiodarone for rapid atrial fibrillation post procedure and had tolerated this well. The patient's family including her three daughters were aware of the situation and the significant decline in the patient's health. They were aware of the heart failure and subsequent shock liver and acute renal failure. Given the fact that the patient had expressed prior wishes to be DNR/DNI and it was only reversed in the setting of the acute event, the continued care of the patient was discussed with her three daughters. It was decided on the morning of to withdrawal pressor support. After withdrawal of pressor support, the patient's blood pressure rapidly declined and she was pronounced at 12:21 p.m. on . The patient's family was present and declined postmortem examination. The approximate cause of death was cardiac arrest due to pulmonary embolism in the setting of cholangiocarcinoma. , M.D. Dictated By: MEDQUIST36 D: 02:12 T: 14:21 JOB#:	There issevere global right ventricular free wall hypokinesis.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Unstable SVT episodes resolved with AMio drip. There is apical sparing of the right ventricular dysfunctionwhich is consistent with (but not diagnostic for pulmonary embolus).The aorticvalve leaflets are mildly thickened. CCU Nursing Progress noteS: Orally IntubatedO: ID - hypothermic, with WBC 27.1. Requiring intubation and max Levophed support. Lactic Acid 17.7A: Cholangiocarcinoma; admitted for IR procedure. ABG acidotic requirirng bicarb resuscitation. Pulses dopplerable, extremities cool and mottled.RESP: Intubated. BP is maintained on pressors Levo 04-0.6mcgs and Vasopressin 0.5u. Cont on triple Abx, Flagyl, Vanco and Levofloxacin.CV - HR SR/ST with frequent APC's, and rare PVC's. 7:37 AM BILIARY STENT Clip # Reason: STENT Admitting Diagnosis: CHOLANGIOCARCINOMA\BILIARY DRAIN Contrast: OPTIRAY Amt: 10 ******************************* CPT Codes ****************************** * BILIARY STRICTURE DILATION WIT 78 RELATED PROCEDURE DURING POSTOPER * * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER * * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER * * -59 DISTINCT PROCEDURAL SERVICE CHALNAGIOGRAPHY VIA EXISTING C * * 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY * * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER * * -59 DISTINCT PROCEDURAL SERVICE BILIARY STRICTURE DILATION NO * * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON * * -59 DISTINCT PROCEDURAL SERVICE TUBE CHOLANGIOGRAM * * TUBE CHOLANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** FINAL REPORT INDICATIONS: 83 y/o woman with biliary obstruction who had bilateral biliary drains placed previously. PATIENT/TEST INFORMATION:Indication: Tamponade.Status: InpatientDate/Time: at 11:10Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: The left ventricular cavity is unusually small. There is severe global right ventricular free wallhypokinesis. Last ABG (1700) 7.12/28/268/10; 2 amps of bicarb given.GI: Hypoactive BS. Trivial mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Vasopressin started 0.05u/hr. Venous sheath in right groin; venous and arterial sheath in left groin.S/O: Intubated. ICa 0.89, 2g IV Ca Gluc infusing. Heparin dc'd x2hrs per house staff, then resumed @300u/hr.Resp - Orally intubated with coarse BS. The right ventricularcavity is markedly dilated. ANESTHESIA: MAC and local 1% lidocaine. IMPRESSION: Bilateral tube cholangiograms confirming previously observed high common bile duct stricture extending into right and left hepatic ducts. DSG on upper abd and r flank for clamped bile duct drains. (Over) 7:37 AM BILIARY STENT Clip # Reason: STENT Admitting Diagnosis: CHOLANGIOCARCINOMA\BILIARY DRAIN Contrast: OPTIRAY Amt: 10 FINAL REPORT (Cont) Post stenting cholangiogram demonstrating brisk flow through the stents into the common bile duct and duodenum. Repeat labs after repletion. Clamped drains on abdomen.GU: Dark colored urine via foley catheter.NEURO: On arrival, MAE, following commands. Cont with drips. The tricuspid valve leaflets are mildly thickened.Moderate to severe [3+] tricuspid regurgitation is seen. Sx for minimal bloody secretsions. The right catheter was cut and wire was advanced into the duodenum. Now returns for stenting of the obstructed area. Restart Heparin per scale. Respiratory Care:Ptrecieved from the cath lab holding area on a vent. Final abdominal image demonstrated appropriate positioning of the bilateral biliary drains. with ABG 268-22-7.0. With the sheath tips positioned at the respective right and left hepatic ducts, cholangiograms were performed which confirmed the previously high common duct stricture extending into both the right and left hepatic ducts. CCU NPN: Admit Note82y.o. Intubated. Multiple episodes of SVT with no BP, tx by sinus massage. s/p PE today with RPA pulmonary angiography and thrombectomy. Arrived to CCU on Heparin at 800u/hr, Levophed at 0.4mcg/kg/min, and vented. 1% lidocaine was infused at both of the catheter exit sites. They were simultaneously deployed with their distal tips just distal to the area of obstruction and the proximal ends within the respective right and left hepatic ducts. Hemodynamics obtained. Labs- Alt, 1257, Ast 3353, Amylase 1017, T. bili 5.9, LDH 3616.GU - Foley draining scant amts brown urine. There is nopericardial effusion. Left ventricular systolic function is hyperdynamic (EF>75%).RIGHT VENTRICLE: The right ventricular cavity is markedly dilated. BUN 23/Creat 1.8Neuro/ Sedation - Fentanyl 50mgcs and Versed 1mg IVP given for comfort q2-3hrs. On pressors, Antiarryhtmics.P: DNR. Rx with 3 amps NaHCo3 with subsequent ph 7.21. Levophed at max of 0.8mcg/kg/min. Emergently brought to cath lab for pulmonary angiography with thrombectomy; clot found in RPA.	8	[ { "category": "Nursing/other", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 1537278, "text": "Respiratory Care:\nPtrecieved from the cath lab holding area on a vent. She had an\nangio-jet for removal of a clot from her PA. w/greatly improved blood\nflow post procedure. Vent. settings as per CareVue. She has been very Acidotic w/hyperventilation from Met. Acidosis\n" }, { "category": "Nursing/other", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 1537279, "text": "CCU NPN: Admit Note\n82y.o. female admitted this hospitalization for internalization of Percutaneous Transhepatic drains by IR as palliative care for cholangiocarcinoma. Procedure successfully done . This am walking to BR became SOB, with low SBP, found to be in SVT/A-fib. Emergently brought to cath lab for pulmonary angiography with thrombectomy; clot found in RPA. IVC also placed during procedure. Hemodynamics obtained. VS very tenuous during procedure. Requiring intubation and max Levophed support. ABG acidotic requirirng bicarb resuscitation. To CCU for monitoring. Pt DNR/DNI prior to event this AM, but made a full-code for emergent procedure. Arrived to CCU on Heparin at 800u/hr, Levophed at 0.4mcg/kg/min, and vented. Venous sheath in right groin; venous and arterial sheath in left groin.\n\nS/O: Intubated. PLease see FHP for more details.\n\nCV: HR 85-220 ?NSR/ST/ A-fib. Multiple episodes of SVT with no BP, tx by sinus massage. BP 59-107/40's. Levophed at max of 0.8mcg/kg/min. AMio drip bolus given and drip started at 1mg/min. Vasopressin started 0.05u/hr. Heparin drip at 800u/hr, PTT 150 drip held per protocol. Other coags severely elevated. Unstable SVT episodes resolved with AMio drip. ICa 0.89, 2g IV Ca Gluc infusing. Pulses dopplerable, extremities cool and mottled.\n\nRESP: Intubated. O2 sats difficult to obtain. Vent A/C 650 26 60% 5. LS coarse throughout. Last ABG (1700) 7.12/28/268/10; 2 amps of bicarb given.\n\nGI: Hypoactive BS. Clamped drains on abdomen.\n\nGU: Dark colored urine via foley catheter.\n\nNEURO: On arrival, MAE, following commands. Fentanyl and Ativan IVP given for comfort sedation.\n\nSOC: 3 daughters involved in decision making. Family meeting with MDs resulted in DNR code status, support with meds at current time. Family in to see pt.\n\nID: On antbx previously. WBC 21.9. Lactic Acid 17.7\n\nA: Cholangiocarcinoma; admitted for IR procedure. s/p PE today with RPA pulmonary angiography and thrombectomy. Intubated. Acidotic. On pressors, Antiarryhtmics.\n\nP: DNR. Cont with drips. Wean pressors as tolerated. Repeat labs after repletion. Follow ABGs. Restart Heparin per scale.\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537280, "text": "CCU Nursing Progress note\nS: Orally Intubated\n\nO: ID - hypothermic, with WBC 27.1. Cont on triple Abx, Flagyl, Vanco and Levofloxacin.\n\nCV - HR SR/ST with frequent APC's, and rare PVC's. Amio load 6hr @1mg/min completed then decreased to 0.5mg/min. BP is maintained on pressors Levo 04-0.6mcgs and Vasopressin 0.5u. Pt is flat and up to 15' for bilateral sheaths. Venous in r is oozing bloody drainage and pressure dsg applied. L groin venous and art sheaths have minimal bloody drainage and have transparent dsg intact. Pulses +3/D bilaterally. Extremitities are cool and dusky. Soft limb restraints both legs, d/t pt bending at knee. Heparin restarted 8pm at 550u/hr with subsequent PTT >150/PT 42.8 and INR 12.1. Heparin dc'd x2hrs per house staff, then resumed @300u/hr.\n\nResp - Orally intubated with coarse BS. Sx for minimal bloody secretsions. Vent settings 60%/650/26br. with ABG 268-22-7.0. Rx with 3 amps NaHCo3 with subsequent ph 7.21. Able to decrease FI02 to 40%. Finger sats not registering on monitor.\n\nGI - Abd is soft with hypoactive BS and +flatus. Pt is oozing foul smelling mucoid bloody, yellow stool. DSG on upper abd and r flank for clamped bile duct drains. Labs- Alt, 1257, Ast 3353, Amylase 1017, T. bili 5.9, LDH 3616.\n\nGU - Foley draining scant amts brown urine. BUN 23/Creat 1.8\n\nNeuro/ Sedation - Fentanyl 50mgcs and Versed 1mg IVP given for comfort q2-3hrs. Pt seemingly able to sleep for periods of time. Intermittently nods head to simple questions (pt primary language Portugese) posed by daughters. 3 daughters taking turns at bedside throughout night.\n\nA: Cont to require 2 pressors and antiarrhythmics, Acidotic\n\nP: Cont monitor labs closely, Bicarb as ordered, titrate Heparin per PTT, Turn and position for comfort with Fentanyl and Versed prn, cont help support family through hospitalization.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537281, "text": "pt.remains on ac ventilation, abg acidotic, bs appear claer bilat., will remain a is for today\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537282, "text": "AFTER DISCUSSION C FAMILY PT MADE COMFORT MEASURES ONLY . PT MED C MSO4,WAS UNRESPONSIVE .PRESSERS DC,PT EXTUBATED AND PT DIED SOON AFTER .\n" }, { "category": "Radiology", "chartdate": "2134-03-30 00:00:00.000", "description": "CHANGE PERC BILIARY DRAINAGE CATHETER", "row_id": 821966, "text": " 7:37 AM\n BILIARY STENT Clip # \n Reason: STENT\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\BILIARY DRAIN\n Contrast: OPTIRAY Amt: 10\n ******************************* CPT Codes *****************************\n BILIARY STRICTURE DILATION WIT 78 RELATED PROCEDURE DURING POSTOPER \n CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER \n CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER \n -59 DISTINCT PROCEDURAL SERVICE CHALNAGIOGRAPHY VIA EXISTING C \n 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY \n CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER \n -59 DISTINCT PROCEDURAL SERVICE BILIARY STRICTURE DILATION NO \n CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON \n -59 DISTINCT PROCEDURAL SERVICE TUBE CHOLANGIOGRAM \n TUBE CHOLANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE \n ***************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 83 y/o woman with biliary obstruction who had bilateral biliary\n drains placed previously. Now returns for stenting of the obstructed area.\n\n ANESTHESIA: MAC and local 1% lidocaine.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and who was\n present and supervising throughout. The patient's abdomen was prepped and\n draped in standard sterile fashion. 1% lidocaine was infused at both of the\n catheter exit sites. The right catheter was cut and wire was advanced\n into the duodenum. The catheter was subsequently exchanged for a 7 French\n bright tipped sheath. The left catheter was then cut and exchanged over a\n wire for a 6 French bright tipped sheath. With the sheath tips positioned at\n the respective right and left hepatic ducts, cholangiograms were performed\n which confirmed the previously high common duct stricture extending into both\n the right and left hepatic ducts. The area of obstruction was measured and it\n was determined that bilateral 4 cm stents would be appropriate. After\n exchanging both wires for exchanged length wires, two 8 mm x 4 cm smart\n stents were advanced. They were simultaneously deployed with their distal\n tips just distal to the area of obstruction and the proximal ends within the\n respective right and left hepatic ducts. The stents were then dilated with 6\n mm x 4 cm balloons. Post stenting cholangiogram was performed through each\n sheath demonstrating appropriate positioning of the stents with good flow into\n the common bile duct and into the duodenum. The right and left sheaths were\n then exchanged for new 8 French biliary drains. The pigtails were locked and\n the catheters were secured with 0 silk sutures. Final abdominal image\n demonstrated appropriate positioning of the bilateral biliary drains. The\n drains were capped to internal drainage. The patient tolerated the procedure\n well and there were no immediate post procedure complications.\n\n IMPRESSION: Bilateral tube cholangiograms confirming previously observed high\n common bile duct stricture extending into right and left hepatic ducts.\n\n Successful deployment of Kissing 8 mm x 4 cm smart stents across biliary\n obstruction. The stents were balloon dilated with a 6 mm x 4 cm balloon.\n (Over)\n\n 7:37 AM\n BILIARY STENT Clip # \n Reason: STENT\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\BILIARY DRAIN\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Post stenting cholangiogram demonstrating brisk flow through the stents into\n the common bile duct and duodenum.\n\n Placement of bilateral 8 French internal external biliary drains which are\n capped to internal drainage. The patient is to return in one week for tube\n cholangiogram and biliary drain removal.\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 76110, "text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nStatus: Inpatient\nDate/Time: at 11:10\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity is unusually small. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Left ventricular systolic function is hyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: The right ventricular cavity is markedly dilated. There is\nsevere global right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\nto severe [3+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nechocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Left\nventricular systolic function is hyperdynamic (EF>75%). The right ventricular\ncavity is markedly dilated. There is severe global right ventricular free wall\nhypokinesis. There is apical sparing of the right ventricular dysfunction\nwhich is consistent with (but not diagnostic for pulmonary embolus).The aortic\nvalve leaflets are mildly thickened. No aortic regurgitation is seen (limited\nviews). The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate to severe [3+] tricuspid regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 186315, "text": "Atrial fibrillation with rapid ventricular response\nInferior ST-T changes are nonspecific\nRepolarization changes may be partly due to rate/rhythm\nLow QRS voltages in precordial leads\nSince previous tracing of , rate increased and atrial fibrillation is new\n\n" } ]
2,733	184,830	1. CAD/Ischemia-NSTEMI (subendocardial, inferior distribution). Cardiac catheterization showed 100% occlusion of distal RCA which could not be stented (could not be crossed by wire). Post procedure TTE showed that her RV was had good systolic motion. She was continued on ASA, statin BB, ACEI, and she will return as an outpatient for replacement of her Aortic valve; at this time, decision will be made whether graft to RCA would be beneficial. She had no further chest pain while in-house. 2. Pump: TTE post-procedure showed EF=55% with no significant wall motion abnormalities. She was kept euvolemic with respect to I/O's while in-house. 3. Severe AS: As per catheterization, AV area was 0.7 cm2. Peak gradient by TTE was 84 mm HG. CT surgery was consulted, and the decision was made for AV replacement as an outpatient, and she will return for this procedure. 4. Rhythmn: NSR on telemetry while in-house. 5. Back Pain-percocet PRN, morphine PRN were used while in-house. 6. Disposition: She was discharged in good condition, to return in weeks for surgery for AV replacement.	Transferred for cath which revealed critical AS (gradient 0.70 cm2). Absence of septal Q waves in leads I and aVL. Distal pulses palpable bilaterally.Resp: LS cta. Clinical correlation isrequired. +BS. CO/CI 6.5/3.02. Low amplitudeT waves in lead II. NIBP 84-112/50s. Pt denies SOB.GI/GU: Abd soft. Normal regional LV systolic function. S/p STEMI. NoAR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal ECG. Normal ECG. Cont on ASA, BB. Tmax 98.4 po. The ICA to CCA ratio is 1.2. Popssible inferior pathology. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.Conclusions:1. The ascending aorta is mildly dilated.3. Sinus rhythmConsider possible inferior infarct - age undeterminedNo change from previous BUN/Cr 15/0.6.ID: Afebrile. Small Q wavesin leads II, III and aVF. DC swan in am. Pt is currently receiving 1st liter. Repleted w/ 40 meq IV KCL. Sinus rhythm. K+ 3.4. Will return this am. Echo in am. Started on Colace. T wave inversions in leads III and aVF. The cardiac, mediastinal, and hilar contours are unremarkable. HR 54-62. Sinus bradycardia. Sinus bradycardia. Received Percocet x1 w/o further complaint.CV: VSS. Cont IVF/ avoid diuresis for presumed RV involvment and preload dependece. Repeat 3.9. Minimal plaque was identified. Name of meds unclear. Pt remains on 2L supplemental O2. Pt c/o back pain d/t limited movement. Compared to the previous tracing of nodiagnostic interim change.TRACING #2 Hold Plavix until decision is made re AVR. No abx. PEARL. HCT stable at 31.8. Tolerating po meds. REASON: Aortic stenosis. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 65Weight (lb): 209BSA (m2): 2.02 m2BP (mm Hg): 109/63HR (bpm): 66Status: InpatientDate/Time: at 10:12Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Right femoral arterial line dc'd at 2300. Unsuccessful PCI of RCA. There is mild impaction of the right third wisdom. IMPRESSION: Roots appear normal. Ordered for a total of 2.5L. Will reattempt PTCA of lesion during this admission. Mildly dilated ascending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. On the left, peak systolic velocities are 86, 54, 80. Compared to the previous tracing of no significant change. Nomid-cavitary gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. MAE. No further c/o chest pain. No BM. Cont supportive care. Regional left ventricular wall motion is normal.2. Severe AS. There is severeaortic valve stenosis.4. Cont mgmt of pain. REASON FOR THIS EXAMINATION: stenosis/occlusion FINAL REPORT STUDY: Carotid series complete. Faint bibasilar crackles. PAP 30s/15-20. In the left front incisor and the adjacent incisor, a defect is present suggesting carries. Mixed venous 70%. No ectopy noted. This is consistent with no stenosis. This is consistent with no stenosis. IMPRESSION: No acute cardiopulmonary process identified. Pt is currently -2L since admission. Advance activity as tolerated. No resting LVOT gradient. COMPARISON: None. Received mylanta x1 for indigestion.Received 230cc of contrast during intervention post cath IVF of 1/2NS cont at 75cc/hr. UO via f/c 330-400cc q 1-2hrs. FINDINGS: Duplex evaluation was performed of both carotid arteries. MAPs>65. Cks this am 574(peaked 602). No previous tracing available for comparison.TRACING #1 Non VIP swan. Soft tissues and surrounding osseous structures are unremarkable. On the right, peak systolic velocities are 76, 66, 90 in the ICA, CCA, and ECA respectively. The mitral valve leaflets are mildly thickened. Cont to follow. Dentition in reasonable condition. There is antegrade flow in both vertebral arteries. Spoke to pt and spouse regarding HCP. RR 9-16. Pt tolerating lying flat without difficulty. CCU Nursing Progress Note 1900-0700S: "That was worst than the procedure (re art sheath pull)O: Please see careview for complete VS/additional objective data.MS: AAOx3. The aortic valve leaflets are severely thickened/deformed. Hemostasis achieved after 25 minutes. Pt received IV Fentanyl 25 mcg upon arrival. After initial dose of 12.5 mg po Metoprolol SBP transiently noted to be 84. IMPRESSION: No evidence of stenosis in either carotid artery. No PCWP attempted. The lungs are clear. O2 sats 96-100%. Left ventricular wall thickness, cavity size, and systolic function arenormal (LVEF>55%). Cath also revealed occluded distal RCA lesion as well as ^RV/PCWP consitent w RV involvement. PANOREX VIEW: Multiple fillings are present but no lucencies or abnormalities in the region of any of the roots seen. When he returns today he and pt will complete. At 0400 pt requesting additional pain med. given to husband. Awaiting consult from surgery for AVR. Husband will bring in today. Pleasant and cooperative. No additional calls or visitors .A/P: 57 yo female w/ no significant hx. Pt was extremely uncomfortable while pressure was held at sight. SINGLE AP PORTABLE UPRIGHT VIEW CHEST: A left sided Swan-Ganz catheter is seen with its tip in the pulmonary artery trunk. Pt was also asleep at that time. REASON FOR THIS EXAMINATION: evaluate dentition, assess risk given plan for AV replacement FINAL REPORT CLINICAL HISTORY: Evaluate dentition prior to aortic valve replacement. No additional diuresis since mg administered in cath lab. WBC 8.8.Skin: Intact.Social: Husband very supportive. During arterial sheath pull pt received additional 50 mcg IV Fentanyl as well as Percocet x2 with resolution of pain. 7:14 AM CHEST (PORTABLE AP) Clip # Reason: pulmonary edema, infiltrate Admitting Diagnosis: CHEST PAIN\CATH MEDICAL CONDITION: 57 year old woman with NSTEMI and dyspnea on exertion.	9	[ { "category": "Echo", "chartdate": "2144-03-20 00:00:00.000", "description": "Report", "row_id": 78964, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 209\nBSA (m2): 2.02 m2\nBP (mm Hg): 109/63\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:12\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. No\nmid-cavitary gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS. No\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The ascending aorta is mildly dilated.\n3. The aortic valve leaflets are severely thickened/deformed. There is severe\naortic valve stenosis.\n4. The mitral valve leaflets are mildly thickened.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862000, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema, infiltrate\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with NSTEMI and dyspnea on exertion.\n REASON FOR THIS EXAMINATION:\n pulmonary edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman with chest pain and dyspnea on exertion.\n\n COMPARISON: None.\n\n SINGLE AP PORTABLE UPRIGHT VIEW CHEST: A left sided Swan-Ganz catheter is\n seen with its tip in the pulmonary artery trunk. The lungs are clear. The\n cardiac, mediastinal, and hilar contours are unremarkable. Soft tissues and\n surrounding osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-20 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 862083, "text": " 2:10 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: stenosis/occlusion\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with aortic stenosis to undergo aortic valve replacement.\n REASON FOR THIS EXAMINATION:\n stenosis/occlusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Aortic stenosis.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque was identified.\n\n On the right, peak systolic velocities are 76, 66, 90 in the ICA, CCA, and ECA\n respectively. The ICA to CCA ratio is 1.2. This is consistent with no\n stenosis.\n\n On the left, peak systolic velocities are 86, 54, 80. This is consistent with\n no stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: No evidence of stenosis in either carotid artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-21 00:00:00.000", "description": "TEETH (PANOREX FOR DENTAL)", "row_id": 862167, "text": " 4:05 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: evaluate dentition, assess risk given plan for AV replacemen\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with aortic stenosis to undergo aortic valve replacement.\n\n REASON FOR THIS EXAMINATION:\n evaluate dentition, assess risk given plan for AV replacement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Evaluate dentition prior to aortic valve replacement.\n\n PANOREX VIEW: Multiple fillings are present but no lucencies or abnormalities\n in the region of any of the roots seen. There is mild impaction of the right\n third wisdom. In the left front incisor and the adjacent incisor, a defect is\n present suggesting carries.\n\n IMPRESSION: Roots appear normal. Dentition in reasonable condition.\n\n\n" }, { "category": "ECG", "chartdate": "2144-03-21 00:00:00.000", "description": "Report", "row_id": 191404, "text": "Sinus rhythm\nConsider possible inferior infarct - age undetermined\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 191405, "text": "Sinus bradycardia. Normal ECG. Compared to the previous tracing of no\ndiagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 191406, "text": "Sinus bradycardia. Normal ECG. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-03-23 00:00:00.000", "description": "Report", "row_id": 191403, "text": "Sinus rhythm. Absence of septal Q waves in leads I and aVL. Small Q waves\nin leads II, III and aVF. T wave inversions in leads III and aVF. Low amplitude\nT waves in lead II. Popssible inferior pathology. Clinical correlation is\nrequired. Compared to the previous tracing of no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2144-03-20 00:00:00.000", "description": "Report", "row_id": 1297719, "text": "CCU Nursing Progress Note 1900-0700\nS: \"That was worst than the procedure (re art sheath pull)\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. Pt c/o back pain d/t limited movement. Pt has underlying back pain that is managed w/ pain meds/ relaxants at home. Name of meds unclear. Husband will bring in today. Pt received IV Fentanyl 25 mcg upon arrival. During arterial sheath pull pt received additional 50 mcg IV Fentanyl as well as Percocet x2 with resolution of pain. At 0400 pt requesting additional pain med. Received Percocet x1 w/o further complaint.\n\nCV: VSS. HR 54-62. No ectopy noted. K+ 3.4. Repleted w/ 40 meq IV KCL. Repeat 3.9. Cont to follow. NIBP 84-112/50s. MAPs>65. PAP 30s/15-20. Non VIP swan. No PCWP attempted. After initial dose of 12.5 mg po Metoprolol SBP transiently noted to be 84. Pt was also asleep at that time. Right femoral arterial line dc'd at 2300. Hemostasis achieved after 25 minutes. Pt was extremely uncomfortable while pressure was held at sight. No further c/o chest pain. Cont on ASA, BB. CO/CI 6.5/3.02. Mixed venous 70%. HCT stable at 31.8. Cks this am 574(peaked 602). Distal pulses palpable bilaterally.\n\nResp: LS cta. Faint bibasilar crackles. RR 9-16. O2 sats 96-100%. Pt tolerating lying flat without difficulty. Pt remains on 2L supplemental O2. Pt denies SOB.\n\nGI/GU: Abd soft. +BS. Started on Colace. No BM. Tolerating po meds. Received mylanta x1 for indigestion.\nReceived 230cc of contrast during intervention post cath IVF of 1/2NS cont at 75cc/hr. Pt is currently receiving 1st liter. Ordered for a total of 2.5L. No additional diuresis since mg administered in cath lab. UO via f/c 330-400cc q 1-2hrs. Pt is currently -2L since admission. BUN/Cr 15/0.6.\n\nID: Afebrile. Tmax 98.4 po. No abx. WBC 8.8.\n\nSkin: Intact.\n\nSocial: Husband very supportive. Will return this am. Spoke to pt and spouse regarding HCP. given to husband. When he returns today he and pt will complete. No additional calls or visitors .\n\nA/P: 57 yo female w/ no significant hx. S/p STEMI. Transferred for cath which revealed critical AS (gradient 0.70 cm2). Cath also revealed occluded distal RCA lesion as well as ^RV/PCWP consitent w RV involvement. Unsuccessful PCI of RCA. Will reattempt PTCA of lesion during this admission. Awaiting consult from surgery for AVR. Hold Plavix until decision is made re AVR. Cont IVF/ avoid diuresis for presumed RV involvment and preload dependece. Echo in am. DC swan in am. Advance activity as tolerated. Cont mgmt of pain. Cont supportive care.\n\n\n\n" } ]
7,614	146,426	Resp failure most likely secondary to sepsis in setting of PNA on CXR- unlikely to be related to fluids since patient is presenting with picture of sepsis. He was hypotensive, low UOP, elevated WBC, febrile in the ED and found to have a RLL PNA on CXR. Also has underlying COPD. extubated , doing well. Note that the patient started at a baseline of multiple comorbidities so it is possible that only a small insult was necessary to exacerbate his FTT. SV02 was 78 - sputum culture grew: pseudomonas( to ceftaz) and strep pneum( to pcn) - legionella negative - on levaquin 750 po q daily (started ) requiring 14 day course ending on (switched to q 48 hours for CrCl of 34) - pt was OOB to chair with chest PT doing well - blood culture negative - U/A negative, urine culture negative . Cardiac: -Hypertension: -- metoprolol 25 -CAD: No evidence active ischemia on EKG. -- troponin 0.46, 0.38, 0.27, 0.26 -- on ASA and atorvastatin . Eye surgery: opthomalogy consulted and evaluated patient and recommended erythromycin ointment to eye - spoke with optho on phone, stitch stays in place for > 6 weeks - continue to monitor for signs of infection . COPD- continue nebs/ inhalers on vent. steroids stopped . DM- Tight control while in ICU. on ISS. would continue this in rehab. . Renal failure: creatinine had gone up in setting of lasix and diuresis. (1.6 appears to be baseline.) - discharge home with 40 po lasix q daily . FEN- on TF. able to tolerate thick nectar, soft po intake for meds with assistance. NGT left in place. . Psych meds: - continued on celexa as well as home dose ritalin and zyprexa for agitation and anxiety . Prophylaxis: PPI, pneumoboots, heparin SQ . Code- DNR/DNI	Suctioned via ETT scant whitish secretion noted.Late in the afternon put back to PS 15/+5/40%, tolerated ,ABG done 7.33/34/121, cont PS.CV- HR 65-80 NSR with occasional PVC's,BP 123/66-165/86. K = 3.7; will discuss repletion w/ MD.GI/GU: Abd obese, nontender, + bs. L SC TLC is patent and slightly ecchymotic at site.Resp: Pt. Pt tolerating TF at goal of 65cc/hr with minimal residuals. Minimnal edema noted to upper ext. General anasarca, peripheral pulses weak but palpable.Resp: Pt continues to be supported by vent. PT WITH LOW GRADE TEMP TO 100.4. No goal mentioned.Endo: Sliding scale and fixed doses in place.Skin: Pt. Respiratory Care Pt continues on CPAP/PSV in NARD. ABG this am on 60% HFN: 7.41/52/99/34.CV: HR 60's-80's, SR w/ rare-freq PACs/PVCs. Pt tolerating TFs via NGT @ goal of 65 cc/hr w/ free H2O boluses q 6 hr. TFs running @ goal of 65 cc/hr; pt tolerating well. Weak periph pulses, feet cool bilat, ?edema. Minimal movement of lower ext noted.RESP- Vent settings rec on A/C 650x18/40%/+5, sat 98-100,LS clear, diminished at the bases. MICU Nursing Progress Note 0700-1900Code: FullAllergies: NKDAUneventful shift, pt started on started on Lasix drip, vent weaned, pt tolerating well.Neuro: Pt remains lightly sedated on Fentanyl 75mcg/hr and Versed 2mg/hr. Calcium repleted.GI- Abd soft, BS+, TF 40ml/hr via OGT, then stopped TF for possible extubation.No BM this shift. Pt has generalized weeping of upper extrem.Lines: Left Subclavian TLC; WNL.ID: Afebrile o/n. When lightened up, pt nods approp to questions and MAEx4 on command.CV: HR=50-60s, SB to NSR w/ occ PVCs. Urine for Legionella sent.ENDO- Insulin gtt @ 8.5u/hr, blood sugar q 1hr.ID- Temp 96.8-97ax, cont on Abt Vancomycin, Ceftriaxone and Azithromycin.Awaiting culture.Skin- Intact, edema both arms noted.PLAN- To wean off vent, monitor resp status, neuro status, maintain on minimal sedation. FULL CODE Universal Precautions NKDANeuro: Sedated on fent at 25mcg/kg/min, versed at 3mg/hr w/ good effect. Repeat cardiac are tending down. BS=bilat, diminihsed aeration. PT NORMOTHERMIC, TMAX 98.6. PT SELF D/C;D. NOTED AT TIME OF RESP DISTRESS EPISODE THIS AM, ? NT suctionned by Resp tx X 1.CV: HR 70-105SR with freq PAC's/PVC's. R/T SEDATION, PROPAFOL D/C'D, PLEASE SEE BELOW. Peripheral pulses weakly palpable.ID: Afebrile. RIGHT EYE REMAINS COVERED WITH SOFT DSD, RECIEVING OINTMENT QID.GI--REPLETE WITH FIBER TF INFUSING AT GOAL RATE 65CC/HR WITH MIN RESIDUALS. AM lytes still pending.GI/GU: Abd soft/distended, + bs. Pt given Albuterol/Atrovent nebs x 2. LS coarse.CV: HR 70's-90's, SR w/ rare-freq PVCs. SUMP REPLACED, AND PLACEMENT CONFIRMED BY CXR. (2) Left Subclavian TLC; WNL.ID: Afebrile o/n. Lung sounds remain clear in apices and diminished in bases.Cardiac: Remains dependent on levophed gtt at 0.02mcg/kg/min to maintain b/p. Intubated w/ a #7.5 ETT 21 @lip. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Replete with fiber infusing at 30ml/hr and tolerating well with scant residuals.GU: Oliguric with u/o 15cc/hr. SR with occasional ectopy on monitor.GI: Abd soft/nontender. BS clear after suctioning. Hypothermic with temp 95.3 at start of shift. ABG this am: 7.49/39/71/31.CV: HR 70's-80's, SR w/ rare-freq PVCs. RIGHT RAD ALINE DAMPENED. admin mdi's q4h. Edema to upper ext and scrotum noted. Phos 2.2->pt rec'd neutraphos.GI: TF of replete with fiber @ goal 65ml/hr until 0600 when Dobhoff noted to be out of position. Placed back on A/C and again later placed on PSV w/CPAP. Requires freq K repletion. Cont to monitor lytes, with K+ to remain ~ 4.0. Mildly thickened aortic and mitralvalves. Temp currently 98.7 hugger off. Given 2L ns which led to resp compromise leading to intubation/pre-cept tlc placement. Left ventricular function.Height: (in) 69Weight (lb): 220BSA (m2): 2.15 m2BP (mm Hg): 134/65HR (bpm): 86Status: InpatientDate/Time: at 17:06Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.LEFT VENTRICLE: Normal LV cavity size. Respiratory Care NotePt received on HiFlo aerosol as noted. Bilateral LS clear and diminished at the base, thick yellow secreation on suction.O2 sats 99-100.Cv:NSR with occassional pvc's, SBP 120-190, monitored via rt radial a line. Pt's continues to be tachycardic even though sedation is at original (pre-wean) doses. Pt has gen anasarca +2 pitting to ext's with good pulses to palp. Wean sedation as tol by pt. SBP 90-130's monitoring via rt radial a line.GU/GI; continued on TF replete with fiber/65ml/hr as goal and with minimal residuaal. Am labs Na 138/K4.2 and HCT 40.4.GU/GI: NPO for possible extubation, abd soft distended, BS present. PT HYPOTHERMIC WITH TMIN 95 THIS AM, TEMP CURRENTLY 97'S WITH BAIR HUGGER OFF. STEROIDS D/C'D.CV--PT REMAINS IN SR/ST 58-100'S. Resp Care Note, Pt weaned off sedation to get RSBI done on 0 peep/5 ips 39 with increased WOB. Continued on ssame vent setting with A/C mode , 650/14/5 and 50% O2.Bilateral LS diminished on rt side and clear on lt side. LS this am clear with cx's to LLL (dependent).GI) Abd sl dist and soft to palp with + BS. Pt remains on insulin gtt as noted with FSBS checks q 1hr.GU) Pt has had low U/O via foley throughout this shift. Lasix today IF creatine improved this am. RIGHT EYE WITH LOOSE DSD APPLIED.GI--TF REPLETE WITH FIBER AT GOAL RATE 65CC/HR STARTED. resp careremains intubated/vented, reducing sedation and converted to spontaneous mode. Bilateral lung sounds clear to course and diminished at the base. Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details.Suctioned for sml amts thick yellow. Intubated w/a #7.5 ETT 21 @ lip. Suctioned for moderate amounts of thk tan secretions. When awake hypertensive and good response to few bolous of sedation.CVP 11-16 and SVo2 76-80. Pt is +1.5L since MN and +10L for LOS.Endo: Attempted to switch pt to sliding scale coverage with poor effect. Tolerating TF 65ml/hr with minimal residuals. Abd soft distended and BS present and no BM this shift. O2 sats 96-99%.Cv: NSR with occassional to frequent pvc"S and runs of v tac, self resolving and asymptomatic.	44	[ { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364310, "text": "Respiratory Care Note:\n Patient admitted to MICU with sepsis, intubated, sedated and on full vent support. BS=bilat, slightly diminished t/o. 7.5 ET tube is secure at 21cm by lip. Started on bronchodilators and plan is to attempt to compensate for met., deficit with increased ventilation. See Carevue flowsheet for settings and abgs.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364311, "text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: Sedated on fent at 25mcg/kg/min, versed at 3mg/hr w/ good effect. When lightened up, pt nods approp to questions and MAEx4 on command.\n\nCV: HR=50-60s, SB to NSR w/ occ PVCs. On levophed for BP - when no IV boluses are infusing, BP maintained at 100/50s w/ .02mcg/kg/min of Levo. Levo can generally be turned off when IV bolus is infusing. Weak periph pulses, feet cool bilat, ?edema. Repeat cardiac are tending down. CVP=, up to 13-14 when bolusing w/ fluids.\n\nResp: 40% 650x18, P=5 - ABG ok - no vent changes made. Lungs clear un upper fields, diminished in bases. This am, was coarse in R base. Sx for minimal bloody/brown secretions - spec sent. Maintaining RR 18. SV02=75-76% since the machine was recalibrated this am.\n\nGI/GU: abd large, round, +BS, passing flatus, but no BM. OGT clamped at this time - nutrition consult in, but will start some TF today and then nutrition can see him tomorrow. Foley cath w/ clear yellow urine, marginal u/o at 15-30cc hour. IVB don't increase u/o much.\n\nSkin: Bruise/hematoma w/ old bleeding on L wrist. Otherwise, intact. Heels/coccyx intact. E-mycin to R eye - taped closed per optho. Eye is not infected per optho.\n\nPain: Fent and versed gtts - pt comfortable, nods head \"no\" when asked about pain when light; when sedated, VSS indicating no discomfort.\n\nID: afebrile. On vanco, ceftriaxone, azithromycin. Sputum spec sent.\n\nLabs: Lytes repleted this am - repeat labs to be drawn this afternoon. FS 395 - insulin gtt started and following protocol.\n\nAccess: RIJ presept cath, R-rad aline, PIVx2.\n\nSocial: several family members at bedside today. Updated by team.\n\nPlan: Repeat labs - replete prn. Titrate insulin gtt protocol. Antibx as ordered. Monitor u/o and fluid status. Maintain fent and versed gtts for comfort. Tx R eye as ordered. Monitor cardiac/neuro/resp status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364312, "text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364334, "text": "NPN 1900-0700 written at 0445 est\nreview care vue for all objective data\n\nCode: Full\nUnevent ful night.\n\nNeuro: lightly sedated with versed 2mg/hr and fentanyl 75mcg/hr gtt, Patient opening eyes, and MAE but not following commands. Bilateral wrist restraints are in place for safety.\n\nResp: sedated as above mentioned, no vent changes over night, continued on PSV 10 and peep 5 with fio2 50%. Bilateral lung sounds clear to coarse and diminished at the base. Thick whitish to yellow secreation with suction. RR 14-20 and O2 sats 95-100%. RSBI this am was 46 and will do SBT later.\n\nCv:NSR with occassional pvc's,lytes within normal limits, SBP 120-150.\n\nGI/GU: Tolerating TF replete w/fiber 65 ml/hr, abd soft distended, BS present but no bowel movements ?since admission no effect with reg colace and prn senna. Started on lasix iv gtt and titerated goal is to keep even while maintaing cvp >5.\n\nEndo: Insulin gtt as per ss and lantus 60u given as HS, aiming to switch ss and fixed dose.\n\nSkin :intact, except edema and redness on scortum.\nSocial: No calls\n\nPlan: SBT and blood gas later and wean sedation and vent as tolerated.\n Closely monitor blood sugar and d/c insulin drip\n Titarate lasix gtt aim even to neg balance.\n ? enema for bowel movements.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364335, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV in NARD. Pt passed SBT but was not extubated due to level of concinesus. B/S sl coarse sx'ing scant. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364336, "text": "MICU NSG 7A-7P\nRESP--PT RECEIVED ON PS 10 PEEP 5 50%. PS DECREASED TO 5, AND THEN PT PLACED ON SBT PS 5 PEEP 0 50%. ABG WITHOUT CHANGE. PLANS TO EXTUB THIS EVENING. PT WEANED OFF SEDATION AND REMAINS HEAVILY SEDATED, WILL POSTPONE EXTUBATION TILL MORE AWAKE.\n\nNEURO--FENTANYL AND VERSED GTT WEANED TO OFF. PT OBTUNDED THIS AFTERNOON. PT RECEIVED THIS AM ( HOME DOSE) AND WAS LESS RESPONSIVE AFTER RECEIVING. TEAM AWARE AND ARE FOLLOWING.\n\nCV--TLCL RESITED, NOW IF LEFT SC. RIGHT IJ SITE REMOVED AND TIP SENT FOR CX. PT WITH LOW GRADE TEMP TO 100.4. PT CONTS WITH ANASARKA, ARMS/SCROTUM WEEPING. LASIX GTT REMAINS AT 2MG/HR AND PT DIURESING WELL, GOAL CVP IS >5.\n\nGI--TF ON HOLD AT 1300 FOR POSSIBLE EXTUBATION. NO BM THIS SHIFT, RECEIVED SENNA, LACTULOSE THIS AM. PASSING FLATUS. PT WEANED OFF INSULIN GTT AFTER TF SHUT OFF. FS 1700 68 AND PT 1 AMP D50.\n\nGU--U/O 100-200CC/HR VIA FOLEY.\n\nSOCIAL--FAMILY IN VISITING MOST OF DAY. UPDATED ON PT'S CONDITION AND PLAN OF CARE.\n\nPLAN--EXTUB WHEN MORE AWAKE.\n--LASIX GTT FOR DIURESES.\n--\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364332, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV as documented in NARD. B/S dim t/o sx'd for sm thick yellow. MDI's as documented. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364333, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nUneventful shift, pt started on started on Lasix drip, vent weaned, pt tolerating well.\n\nNeuro: Pt remains lightly sedated on Fentanyl 75mcg/hr and Versed 2mg/hr. Pt arousable to voice, able to MAE, but does not follow commands. Appears comfortable. Remains in bilateral wrist restraints for safety.\n\nCV: HR NSR 69-80 with occasional to frequent PVCs, ABP 118-132/57-68, CVP 6-11 with goal being 5. BP noted to increase to 160's during turns. Short 5 beat run of VT x 1, self-resolving and asymptomatic. General anasarca, peripheral pulses weak but palpable.\n\nResp: Pt continues to be supported by vent. Current settings CPAP+PS 50%/+ with ABG 7.34/43/146. RR 9-15, sats >97%, STV ~500, MV .\nLung sounds variable. Suctioned x 3 for small amounts of thick, yellow secretions.\n\nGI: BS x 4, no stool this shift, given PRN senna this AM with no effect. Pt tolerating TF at goal of 65cc/hr with minimal residuals. NGT patent, placement checked.\n\nGU: Foley patent and draining clear, yellow urine. UO 30-240. Started on Lasix drip, currently infusing at 3mg/hr. Fluid goal is to keep pt even while maintaining CVP ~ 5. Pt is +1L since MN, +12L for LOS. Being repleted with 40mEq K (AM K 4.1). Labs due to be drawn at 8pm.\n\nID: Tmax 98.9 PO, receiving ABX therapy of Ceftazidime, Levofloxacin and one time dose of Vancomycin for pseudomonas/streptococcus pneumonia.\n\nEndo: Remains on insulin drip. BS 129-161, drip being titrated according to protocol. Glargine dose increased, see for details.\n\nSkin: Intact, mild swelling to scrotum.\n\nSocial: Family at bedside most of day, updated on pt's condition and plan of care.\n\nPlan:\ncontinue to wean vent support\nsedation as needed for comfort\ntitrate lasix drip to CVP of 5 or even fluid balance\nmore aggressive stool regimen?\ncontinue to monitor BS\nroutine ICU care and monitoring\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 1364348, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Pt continues to have periods of ^ anxiety/aggitation, yelling/moaning out @ times, c/o of pain @ times, responds well w/ Morphine. 40 mg Lasix given x 1; pt diuresed ~ 800 cc after Lasix.\n\nROS:\n\nNeuro: Pt slept on and off throughout the night; anxiety/aggitation much improved when compared to previous nights (pt was started back on his Ritalin, Zyprexa yesterday). Oriented to person only, continues to yell out for help @ times (though much less than last night), also calls out for his wife frequently (this is his baseline per family). Follows simple commands, though somewhat inconsistently, MAE. Morphine prn for pain.\n\nResp: LS coarse, diminished @ bases. NTS x 1 for thick, tan secretions. Pt has a congested, somewhat weak cough and is not able to bring up secretions very effectively. Requires much encouragement to cough/deep breathe. RR 20's-30's, he was maintaining his sats >95% on 60% FiO2 via face tent until he fell asleep. Sats briefly dropped to 89%. FiO2 ^ to 80% @ that time. Sats have been 94-100% since.\n\nCV: HR 60's-80's, SR w/ rare-freq PVCs/PACs. NIBP 100's-120's / 50's-70's. CVP 6-8. HCT stable. + anasarca.\n\nGI/GU: Abd obese, nontender, + bs, no bm overnight. Pt tolerating TFs via NGT @ goal of 65 cc/hr w/ free H2O boluses q 6 hr. Foley intact, draining ~ 60-370 cc/hr of yellow urine w/ sediment. Lasix (40 mg) given x 1 tonight; pt diuresed ~ 800 cc after Lasix. He is negative ~ 600cc since midnight.\n\nSkin: Pt w/ large, red, raised, ring-shaped area on buttocks tonight. Barrier cream applied. Site is tender to touch, surrounding skin WNL. Pt has generalized weeping of upper extrem.\n\nLines: Left Subclavian TLC; WNL.\n\nID: Afebrile o/n. WBC slightly up this am (15 from 14.2). Continues on Levaquin for sputum growth.\n\nSocial: RN spoke w/ pt's wife and son o/n; both updated on pt's condition. Pt is a DNR/I.\n\nPlan: Continue to monitor resp status, pulm toilet prn; ? get oob to chair today; ? swallow study when ms/gag improves; frequent reorientation to environment; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 1364349, "text": "Nursing Progress Note:\n\nNeuro: Pt. has been alert at times, intermittently sleeping answers questions with yes/no or simple phrases such as \"you go right ahead\", singing along to . He makes eye contact, and is very pleasant but is confused. He moves upper ext. purposefully and lower ext. move on bed. Pt. OOB to chair for 2 hours and tolerated it well.\n\nCV: HR 60s-70s NSR with occasional PACs, NBP 100s-120s/30s-60s. Minimnal edema noted to upper ext. L SC TLC is patent and slightly ecchymotic at site.\n\nResp: Pt. remains on 80% face tent with RR in 20s and 02 sats >96%. he does desat into low 90s if Fi02 is lowered and sats go into 80s if face tent is removed. Pt. encouraged to deep breathe and cough, chest PT done with turns. Pt. now has productive cough and is able to bring secretions into back of throat and mouth.\n\nGI: Tube feeds at goal of 65cc/hour with minimal residuals, 250cc free H20 boluses being given q 4 hours. BSX4, no BM on shift. Pt. had speech/swallow and was approved for nectar thick liquids/soft solids.\n\nGU: UO brisk. 40mg Lasix given X1. Pt's fluid balance is currently even. No goal mentioned.\n\nEndo: Sliding scale and fixed doses in place.\n\nSkin: Pt. has a reddened, circular, slightly raised area to buttocks which has improved during the day.\n\nPlan: Dispo to rehab tomorrow. Pt. is already screened.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-10 00:00:00.000", "description": "Report", "row_id": 1364350, "text": "NSG 7AM-7PM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\nPT ALERT, , ORIENTED TO SELF ONLY/ CRIED OUT AT TIME: \"HELP ME\". NO APPARENT DISTRESS. MAE/ PEERLA. RESTING IN LONG NAPS. RESTLESS AT TIME/ MORPHINE 4MG X2 GIVEN WITH POS EFFECT.\n\nHEART RYTHM WITH RARE PVCS/ HR 60S-70S/ REMAINS ON METOPROL/ BP 110S-120S/MAP 60S-70S/ HEMODYNAMICALLY STABLE./ 5 RUNS OF VTACH ALARMED/ RESOLVED WITH NO INTERVENTION/K 40MEQ GIVEN TO KEEP K LEVEL:4.4. K LEVEL THIS AM:3.7/ WILL REPLETE PER TEAM DISCRETION.\n\nAFEBRILE/ TMAX:97.7 AXILLARY.\n\nRECEIVED LASIX 40MG/TO MAINTAIN FLUID GOAL NEG 500CC/ FLUID STATUS AT THIS HR NEG 400/ POSITIVE AT MN.\n\nRESP EFFORT UNLABORED AND EVEN/ RR:20S/ LUNG SOUNDS DIMINISHED/ MAITAINS SATO2 90S-100% ON 50% FACE TENT/ NO ATTEMPT TO WEAN. CONGESTED COUGH/ NASAL TRACH SUCTION ATTEMPTED/ SUCTIONED SMALL AMOUNT OF TENACIOUS TAN SPUTUM. STRONG COUGHS AT TIMES/ UNABLE TO EXPECTORATE.\n\nABD LARGE, OBESE/FIRM, POS BS. NO BM. NGT IN PLACE/ CONFIRMED WITH AIR BOLUS. REPLETE WITH FIBER AT GOAL 65CC/HR/ NO RESIDUAL.\n\nFOLEY PATENT DRAINING CLEAR YELLOW URINE.\n\nSKIN W/D/ STAGE II TO BIL GLUTEAL/ REPOS AND BARRIER CREAM APPLIED.\n\nWIFE CALLED THIS AM/ UPDATE GIVEN/ PT REMAINS \n\nCONT CURRENT POC\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 1364346, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Morphine (2 mg) given x 1 for ^ tachypnea/anxiety w/ good effect.\n\nROS:\n\nNeuro: Pt awake most of night, calling out for wife and frequently yelling for \"help\"; when asked what he needs he says, \"I don't know\". Per pt's wife, he calls for \"help\" @ baseline. Pt is oriented to person only, does follow simple commands, MAE.\n\nResp: Pt maintaining O2 sats b/w 95-100% on 60% HFN via face mask. RR 20's-30's. LS coarse throughout. + productive cough; however, he needs to be orally sxn to remove secretions and needs freq encouragement to cough/deep breathe. Chest PT done. ABG this am on 60% HFN: 7.41/52/99/34.\n\nCV: HR 60's-80's, SR w/ rare-freq PACs/PVCs. ABP 130's-140's / 60's-70's. CVP 2-6. + anasarca w/ generalized weeping. HCT stable this am. K = 3.7; will discuss repletion w/ MD.\n\nGI/GU: Abd obese, nontender, + bs. TFs running @ goal of 65 cc/hr; pt tolerating well. Foley draining ~ 30-100 cc/hr of yellow urine w/ sediment. Receiving doses of Lasix prn (none given o/n).\n\nLines: (1) Right Radial A-line; site red. (2) Left Subclavian TLC; WNL. All dressings changed.\n\nID: Afebrile o/n. WBC = 14.2 today (up from 11.9). Continues on Levaquin for sputum growth.\n\nSocial: RN spoke w/ wife and son o/n; both update on pt's condition. Pt is DNR/I---no plans for mask ventilation.\n\nPlan: Continue pulm toilet; get oob to chair today; morphine prn; Frequent reorientation to environment; support/info to pt/family; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364343, "text": "Respiratory Therapy\nPt presents on .8 hi flow via FT. Sats in hight 90's. BS slightly coarse bilat. 0630 Pt desatting to high 80's. BS coarse rhonchi rt W diminished base, on lt greatly diminished W coarse exp wheezes fine insp wheezes. NTS for moderate amount thick light tan secretions. Followed by alb/atrovent neb via FM tolerated well. Increased aeration bilaterally. Remains on .95% High flow via closed FM. Plan: continue to monitor and support.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 1364347, "text": "See and carevue for detailed documentation\n\nPatient agitated in early am, calling out, c/o pain in LE, c/o need to use bed pan. Patient with frequent PVC, tachycardia to 106, with BP 160/80's. Rec'd morphine with slight improvement. NP suctioned for moderate amounts thick creamy secretions. Neb given without change. Patient remained anxious, agitated. Rec'd 5mg IV lopressor with decreased HR, BP. Settled well. Patient again with c/o LE pain, anxious. Rec'd morphine with good result. Patient now restarted on olanzapine, methylphenidate. Plan to use morphine for c/o pain, restart baseline meds to control anxiety.\n\nNeuro: Patient oriented x1, occassionally interacting appropriately. Often calling out \"help\", wife's name-> baseline as per family. Reassured, comforted by visitors. Reoriented shift without result. OOB deferred as per family request for patient comfort.\n\nResp: Patient tachypneic with congested, non-productive cough. NP suctioned x2 for moderate amounts creamy secretions. Oral suction without result. Strong cough, poor gag. Nebs given shift without change. BS coarse out, diminished in bases.\n\nCV: In NSR HR now 70-80. Frequent PVCs. BP stable 120-130/50's. Afebrile. Aline removed as per team. L subclavian intact. CVP 10-12.\nContinues on levoquin,\n\nGU: Foley to gravity with good urine output. + ~800ml for shift. Lasix givne x1.\n\nGI: Tolerating tube feeds well with residual of 30-50ml. Small BM x2.\n\nSocail: Family at bedside shift. Anxious particularly with patient c/o pain. Sypportive of patient, stressing patient comfort priority. Discussed paln of care with attending this evening. Now hopeful for patient to transfer to rehab, although aware patient fragile and in need of ICU care at present.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364315, "text": "Nursing progress notes 0700-1900\nPt is 83y/o with PMH of IDDM, CHF, COPD TIA, s/p recent eye surgery presented to ED for lethargic/weak. In ED Temp 102.3, low B/P 80's,unable to walk. Given NS bolus 2l, intubated for resp compromise.Started to MICU for further treatment.Started on Levophed, sedated on fentanyl/Versed, Insulin gtt initiated for blood sugar over 200,cultures sent, Abt started.\nNeuro- Received sedated on Fentanyl 25mcg/hr, Versed 3mg/hr, stopped for 30 min for neurochecks, Pt became more awake, responding to verbal stimuli, opens eyes to verbal commands.Pupils reactive.Able to hold the hand. Minimal movement of lower ext noted.\n\nRESP- Vent settings rec on A/C 650x18/40%/+5, sat 98-100,LS clear, diminished at the bases. At 1100hr.Fentanyl decreased to 20 mcg/hr,Versed decreased to 2mg/hr. MV/RR reduced.At 1200 vent settings changed to PS 15/+5, pt did not tolerate well, BP high in 170's. back to A/C 650x14/40%/+5.Propofol started 10 mcg/hr. Fentanyl and Versed weaned off,sat maintains 99%. Suctioned via ETT scant whitish secretion noted.Late in the afternon put back to PS 15/+5/40%, tolerated ,ABG done 7.33/34/121, cont PS.\n\nCV- HR 65-80 NSR with occasional PVC's,BP 123/66-165/86. Levophed off since 0500hrs today. For high BP hydralazine 10 mg IVP given. Calcium repleted.\n\nGI- Abd soft, BS+, TF 40ml/hr via OGT, then stopped TF for possible extubation.No BM this shift. NGT inserted(Dobhoff), chest x ray done for the placement.\n\nGU- Foley patent, urine 25-40ml/hr. Urine for Legionella sent.\n\nENDO- Insulin gtt @ 8.5u/hr, blood sugar q 1hr.\n\nID- Temp 96.8-97ax, cont on Abt Vancomycin, Ceftriaxone and Azithromycin.Awaiting culture.\n\nSkin- Intact, edema both arms noted.\n\nPLAN- To wean off vent, monitor resp status, neuro status, maintain on minimal sedation. Antihypertensives as needed.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364316, "text": "Respiratory Care\nPt remains intubated and on vent support. Intubated w/ a #7.5 ETT 21 @lip. Vent changes were from A/C to PSV w/CPAP. While on PSV pt had a period that required sedation (^BP, ^RR). Placed back on A/C and again later placed on PSV w/CPAP. Pt remains on PSV. Lung sounds were clear and diminished in the bases (more in RLL). Pt continues to have a prolonged exp phase. Received MDI's with good effect. Suctioned for scant thick white. Last ABG showed metabolic acidosis. Care plan is to continue to wean PS and obtain a RSBI and SBT in AM ? of extubation tomorrow. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364317, "text": "Resp Care Note, Pt weaned down to 5/5.VT'S in the 300's. Sedated with propofol. Biting on the ETT @ times.RSBI done on 0 peep/5 ips 80. Suctioned for scant amts thick white secretions. MDI'S given. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364344, "text": "MICU NSG 7A-7PM\nRESP--PT WITH EPISODE OF RESP DISTRESS THIS AM. NTSX'D X2 FOR MOD TO COPIOUS AMOUNTS THICK YELLOW TO TAN SECRETIONS. PT WITH RR 40'S AND 02 SAT DROPPING TO 85%. PLACED ON 95% HIGH FLOW NEB WITH FACE MASK, HAD BEEN ON FACE TENT PREVIOUSLY. RECEIVED ALB/ATRO NEB AS WELL AS LASIX, AND LOPRESSOR. PT SLOWLY IMPROVED. PT WITH POOR COUGH, RECEIVING PULMON TOILET (CPT, COUGHING, DEEP BREATHING) WITH MIN MOVEMENT OF SECRETIONS. PT WITH POOR ACTIVITY TOLERANCE, BECOMES SOB WITH MIN ACTIVITY. ABG SENT, WITH MIN CHANGE FROM PREVIOUS ABG.\n\nNEURO--PT LETHARGIC AT TIMES, APPEARS FATIGUED,OTHERS YELLING OUT FOR \"HELP\". KNOWS NAME, BUT OTHERWISE DISORIENTED. FAMILY IN AT BEDSIDE, PROVIDING SUPPORT. PT ABLE TO MAE ON BED, BUT WEAK. SWALLOW EVAL ON HOLD DUE TO FATIGUE, AND POOR GAG/COUGH.\n\nCV--REMAINS IN SR WITH FREQ PAC'S, OCCAS PVC'S. RIGHT RAD ALINE DAMPENED. PT WITH , ARMS, SCROTUM WEEPING. AFEBRILE THIS SHIFT.\n\nGI--NGT FOUND OUT, ? PT SELF D/C;D. NOTED AT TIME OF RESP DISTRESS EPISODE THIS AM, ? PT . SUMP REPLACED, AND PLACEMENT CONFIRMED BY CXR. TF REPLETE WITH FIBER RESTARTED, CURRENTLY INFUSING AT 30CC/HR GOAL 65CC/HR. SM BM X3.\n\nRENAL--LASIX 20MG IV THIS AM WITH GOOD RESPONSE. U/O 30-200CC/HR.\n\nSOCIAL--FAMILY IN AT BEDSIDE, UPDATED ON PT'S CONDITION.\n\nPLAN--PULMON TOILET\n--PT DNR/DNI--NO PLANS FOR MASK VENTILATION\n--MORPHINE PRN FOR AIR HUNGER IF NO RELIEF FROM OTHER COMFORT ATTEMPTS\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364345, "text": "MICU NSG 7A-7PM\naddendum--pt med with morphine 1mg iv for anxiety, air hunger, dyspnea. pt currently resting comfortably.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364339, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: Pt doing well on 60% face tent; mental status seems to be improving. Sliding Scale added to fixed dose of insulin tonight, as blood sugars are now increasing w/ TFs. No significant events to report.\n\nROS:\n\nNeuro: Pt opening eyes spontaneously, follows simple commands @ times, MAE on bed. Making incomprehensbile sounds tonight, began calling out for help (per pt's wife, he often calls out for help @ baseline). No sedatives given o/n.\n\nResp: Pt s/p extubation yesterday afternoon; doing well on 60% face tent. RR 20's-30's, sats 98-100%. LS coarse, pt able to cough up secretions into the back of his throat (requires assist w/ yankeur sxn). LS coarse. ABG this am: 7.49/39/71/31.\n\nCV: HR 70's-80's, SR w/ rare-freq PVCs. ABP 130's-160's / 60's-70's. Requires freq K repletion. K this am = 3.6 (will discuss repletion w/ MD). + anasarca (w/ generalized weeping).\n\nGI/GU: Abd soft, distended, + BS, no stool o/n. TFs currently running @ 50 cc/hr (goal is 65). Tolerating well. Foley draining ~ 40-100 cc/hr of clear/yellow urine. Pt is negative ~ 200cc since midnight.\n\nLines: (1) Right Radial A-Line; WNL. (2) Left Subclavian TLC; WNL.\n\nID: Afebrile o/n. WBC trending down. Continues on ABX for PNA.\n\nSocial: Pt is DNR/DNI. Family in to visit late last night, also multiple phone calls o/n; all updated on poc, pt's condition.\n\nPlan: Monitor resp status and wean O2 as tolerated; replete lytes prn; support/info to pt/family; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364340, "text": "NURSING NOTE 0700HRS - 1600HRS\n\n\n\nEVENTS...MENTAL STATUS CONTINUES TO SLOWLY IMPROVE, OF ALL SEDATION..REQUIRES CHEST PT AND ENCOURAGEMENT WITH CLEARING OF SECRETIONS AND NEB TREATMENTS..? FOR LASIX THIS EVE..FOR SWALLOW EVAL TOMORROW..BBLOCKER FOR RATE/B/P CONTROL..SLIDING SCALE TIGHTENED\n\n\n\n\nNEURO..SLOWLY IMPROVING MENTAL STATUS LETHARGIC BUT ORIENATATED X1/2 OPENS EYES SPONTANEOUSLY, INCONSISTENTLY FOLLOWS COMMANDS ATTEMPTS MOVE LIMBS BUT IS SLOW TO DO SO... RECOGNISES FAMILY MEMBERS..DENIES PAIN..OF ALL SEDATION MEDS AT PRESENT, TO FOLLOW NEURO STATUS , IF PATIENT BECOMES AGITATED TO RE-REVIEW MEDS...\nOPTHOMOLGY FOLLOWING RERT EYE AND EYE DROPS CONTINUE TO BE APPLIED\n\n\n\nCVS...B/P STABLE @ 120-150 SYSTOLIC AND HR 75-85BPM WITH FREQUENT PCV'S/PAC'S [ TEAM AWARE] K @ 4.0 THIS PM AND IS PRESENTLY RECEIVING 20MCQ IV , TO TRY MAINTAIN K CLOSER TO 4.5...BBLOCKER COMMENCED FOR RATE CONTROL AND IS TOLLERTATING\nAFEBRILE, AB'S CONTINUE FOR LEFT LL PNEUMONIA...\nON LONG ACTING INSULIN @ 2000HRS THEN COVERED WITH S/S WHICH WAS TIGHTENED TODAY...\nPATIENT IS DNR AS PER FAMILY MEETING WITH DR YESTERDAY\n\n\nRESP..LUNGS SOUND COURSE UPPER DIMINSHED LOWER, BUT WITH CHEST PT HAS MANAGED TO COUGH SECRETIONS TO BACK OF THROAT THE YANKER USED TO EXTRACT..RECEIVING NEBS PRN..ABG STABLE THEREFORE O2 REDUCED TO 60% HIGH FLOW..NEEDS ENCOURAGEMENT TO COUGH/DEEP BREATH..RR AT 25-35 SATS MAINTAINED > 95%..PATIENT IS DNI ASOF FAMILY MEETING YESTERDAY\n\n\nGI...TOLLERATING FEED AT GOAL VIA PEDI-TUBE, LARGE BOWEL MOTION TODAY..SEEN BY SWALLOW BUT READY FOR EVAL TODAY AND WILL RE-REVIEW TOMORROW...PATIENT COUHGHED ON ICE CHIPS TODAY..\n\n\nGU..BORDERLINE U/O TODAY [ TEAM AWARE] TO HAVE DOSE OF LASIX THIS EVE..CREAT AT BASELINE @ 1.6\n\n\nSKIN..RE-POSTIONED INTACT\n\n\nLINES..ART /CENTRAL LINE PATENT..\n\n\nSOCIAL..MANY FAMILY MEMBERS TODAY...UPDATED BY TEAM TODAY\n\n\n\nPLAN.. CHEST PT/WEAN O2 AS TOLLERTED..FOLLOW NEURO STATUS ? TO RE-COMMENCE HOME PSYCH MEDS...LASIX THIS EVE FOR NEG BALANCE..MAINTAIN K > 4.0..SWALLOW EVAL TOMORROW..DNR/DNI STATUS\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364341, "text": "Respiratory Care Note\nPt received on HiFlo aerosol as noted. Pt given Albuterol/Atrovent nebs x 2. BS coarse throughout - decreased on R side with 12N neb - with improved aeration after rx x 2. Attempted NT suction at 5pm - unalbe to pass catheter through either nare. Pt has a congested cough with a small amt thick, yellow secretions. BS clear after suctioning.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364342, "text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt remains lethargic, generally follows commands. Unable to cough well on demand. Verbally denies pain, cont to frequently stat \"Help me\" as family reports he did PTA. Moving all extremeties on bed.\n\nResp: Pt has remained on high flow FT @ 80%FiO2, with O2 sat 91-99%. RR 24-34 and regular. Lung snds coarse throughout. Intermit strong, productive cough but pt swallows sputum. NT suctionned by Resp tx X 1.\n\nCV: HR 70-105SR with freq PAC's/PVC's. BP 126/92-150/65. CVP 5-8. K+ 3.5 repleted, and is 4.6 this am. Phos 2.2->pt rec'd neutraphos.\n\nGI: TF of replete with fiber @ goal 65ml/hr until 0600 when Dobhoff noted to be out of position. AM FSG 144, Humalog 4units (per sliding scale) held. Abd soft/obese with + bowel snds. Pt incont of soft, brown stool X 2.\n\nGU: Urine yellow/clear. Pt rec'd Lasix 20mg X 1 with good results. Fluid balance MN->0600 -640ml, but +6.5liters LOS.\n\nSkin: Multiple skin tears on arms, leg. Scrotum with skin tear.\n\nID: Temp 98.8ax.\n\nSocial: Son, wife called for status overnight.\n\nPlan: Cont to freq encourage C&DB. Chest PT. Cont to monitor lytes, with K+ to remain ~ 4.0. Support family. Pt presently DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364313, "text": "Pt is 83y/o male with PMH of IDDM, CHF, COPD, TIA, s/p recent eye surgery who presented to ED for feeling weak/lethargic. In ED Temp 102.3, b/p 80's, unable to walk. Given 2L ns which led to resp compromise leading to intubation/pre-cept tlc placement. Tx to MICU for further treatment. Started on Levophed when dropped sbp to 60's and additional 2L NS ineffective to maintain b/p. Sedated on Fent/Versed, insulin gtt initiated for blood sugars over 200. Bld, urine, sputum cultures sent.\n\nNeuro: Remains sedated on 25mcg/hr fentanyl and 3mg/hr versed. Able to nod head to yes/no questions and follow commands when sedation has been off for approx 45min. denies pain. Pupils reactive. Minimal movement of lower ext noted.\n\nResp: Vent setting unchanged this shift. A/C 650x18/40%/5 with Am abg showing adequate oxygenation and compensated metabolic acidosis. Lung sounds remain clear in apices and diminished in bases.\n\nCardiac: Remains dependent on levophed gtt at 0.02mcg/kg/min to maintain b/p. Current b/p 120's/60's. However systolic b/p dropps to 80's with gtt off. Can briefly turn gtt off if recently bolused with NS however. SR with occasional ectopy on monitor.\n\nGI: Abd soft/nontender. Positive bowel sounds. No BM this shift however. Replete with fiber infusing at 30ml/hr and tolerating well with scant residuals.\n\nGU: Oliguric with u/o 15cc/hr. AM BUN 36 Cr 1.4\n\nDerm: Grossly intact. Edema to upper ext and scrotum noted. Aline and TLC sites benign withpaten lumens. PIV x2 patent. Peripheral pulses weakly palpable.\n\nID: Afebrile. Hypothermic with temp 95.3 at start of shift. Bear hUgger initiated. Temp currently 98.7 hugger off. Continues on Vancomycin, ceftriaxone, and azrithromycin. Awaiting culture data.\n\nSocial: Family in to visit last noc. Updated by RN\n\nPlan: Wean off levophed as tolerated, frequent blood sugar checks, IV abx, follow culture data, neuro checks with sedation off. Full Code.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364314, "text": "Respiratory Care Note:\n Patient remains intubated and sedated. No vent changes made overnight. ABGs with compensated metabolic acidosis. BS=bilat, diminihsed aeration. RSBI attempted, too sedate, tidal volumes only 200cc. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1364337, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Pt was not extubated overnight, as he remains unresponsive off of all sedatives.\n\nROS:\n\nNeuro: Pt unresponsive; he does w/d to pain @ times. Not opening eyes/not following commands. No sedation given o/n.\n\nResp: Remains intubated on PSV: 5/5/50%. RSBI this am = 88. ABG on above settings = 7.37/50/173/30. Will recheck another gas on SBT. RR mid-high 20's, sats 98-100%. LS coarse.\n\nCV: HR 70's-90's, SR w/ rare-freq PVCs. ABP 120's-150's / 60's-70's. HCT stable. CVP 6-8. + anasarca (w/ generalized weeping). AM lytes still pending.\n\nGI/GU: Abd soft/distended, + bs. TFs on hold for pending extubation. No bm o/n. Foley draining ~ 70-280 cc/hr of clear/yellow urine (on 2 mg/hr of Lasix). Pt is negative ~ 900cc since midnight.\n\nLines: (1) Right Radial A-Line; WNL. (2) Left Subclavian TLC; bleeding, but otherwise wnl.\n\nID: Low grade temps o/n. WBC stable. Continues on Abx for PNA.\n\nSocial: RN spoke w/ pt's son and wife o/n; both updated on poc, pt's condition. Pt is a full code.\n\nPlan: ? extubate this am (or head CT if ms does not improve); continue to diurese; replete lytes prn; continue abx and f/u on all cx data (reculture if pt spikes > 101); routine ICU care and monitoring.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1364338, "text": "NURSING NOTE 0700HRS - 1600HRS\n\nEVENTS..EXTUBATED AT 11.30HRS, FAMILY MEETING, PATIENT NOW DNR/DNI..\n\n\n\nNEURO...PATIENT CONTINUES NON ROUSBALE,VERY OCCASSIONALLY FOLLOWS COMMAND TO SQUEEZE HAND AND WRIGGLE TOES COUGHING AND BITING ONSUCTION CATHTER ..MOVEMENT NOTED ON RT ARM/LEG..LEFT PUPIL 3/REACTIVE RY EYE CLOSED POPST SURGERY AND EYE DROPS/EYE CARE CONTINUE..ALL SEDATION D/C AT THIS TIME , TO CONTINUE TO ENCOURAGE MOVEMENT FOLLOW NEURO STATUS CLOSELY...\n\n\n\nRESP...EXTUBATED AT 11.30HRS WITH SATISFCTORY POST ABG..CONTINUES WITH SATS > 95% RR 25-35 FAIRLY STRONG COUGH BUT REQUIRES SUCTIONING FROM BACK OF THROAT FOR THICK YELLOW SECRETIONS..LUNGS SOUND COURSE, CHEST PT CONTINUES..NOT FOR RE-INTBATION AFTER DISCUSSION WITH FAMILY...APPERAS COMFORTABLE AT THIS TIME...\n\n\nCVS...B/P 130-150 SYSTOLIC ..HR 70-80 WITH FREQUENT PAC'S /PVC,S K/MG STABLE FOR RE- DNR AS PER FAMILY\nAFEBRILE , AB'S CONTINUE..\nB/S STABLE SO FAR , NOW ON LONG ACTING INSULIN @ BEDTIME...\n\n\nGI...ORAL G TUBE REMOVED DURING EXTUBATION AND PEDI-TUBE PLACED XR CONFIRMING PLACEMENT..FEED RE-COMMENCED PM AT LOWER DOSE TO TITRATE UP TO GOAL..NO BOWEL MOTION AND B/ SPRESENT..\n\n\nGU..LAIX DRIP STOPPED THIS AM, AIM IS FOR EVEN BALANCE TODAY, PRESENTLY NEG, CONTINUE TO OBSERVE..\n\n\nSKIN..INTACT AND RE-POSTIONED..\n\n\nLINES..ART LINE SATISFACTORY , CENTRAL LINE RE-DRESSED..\n\n\nSOCIAL..MANY FAMILY VISITED TODAY, FAMILY MEETING DECISION AS ABOVE FRO DNR/DNI...\n\n\n\nPLAN..FOLLOW RESP/NEURO STATUS..MONITOR K/MG..SUPPORT FOR FAMILY\n\n\n" }, { "category": "Echo", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 99280, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function.\nHeight: (in) 69\nWeight (lb): 220\nBSA (m2): 2.15 m2\nBP (mm Hg): 134/65\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 17:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nLEFT VENTRICLE: Normal LV cavity size. Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal. LV\nsystolic function appears depressed with basal lateral hypokinesis. Estimated\nejection fraction (?45%). Right ventricular chamber size is normal. Right\nventricular systolic function is normal. Mildly thickened aortic and mitral\nvalves. There is no significant mitral regurgitation detected in suboptimal\nviews. There is no aortic valve stenosis. There is a trivial/physiologic\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the basal\nlateral wall motion abnormality was probably present previously although was\nnot reported.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364323, "text": "MICU NSG 7A-7PM\nRESP--PT REMAINS ORALLY INTUB VENT SETTINGS AC 14 650 PEEP 5 50%. BREATHING OVER VENT. SX'D FOR THICK YELLOW SECRETIONS VIA ETT. PLEASE SEE CAREVIEW FOR ABG'S. PSEUDOMONAS AND STREPTOCOCCUS CX'D FROM SPUTUM, AND ABX SWITHCED TO CEFTAZIDIME 2GM IV Q12, AZITHRO AND CEFTRIAXONE D/C'D.\n\nCV--RIGHT RAD ALINE DAMPENED AND POSITIONAL, BUT HAS GOOD BLOOD RETURN. BP TRENDING DOWN THIS AM, ? R/T SEDATION, PROPAFOL D/C'D, PLEASE SEE BELOW. PT WITH (+) EDEMA, WITH WEEPING FROM LEFT ARM PIV SITE. IV D/C'D. BLISTER NOTED ON SCRTOUM. PT NORMOTHERMIC, TMAX 98.6. PICC LINE ORDERED, IR PLANS TO PLACE IN AM. SVO2 70-80. RIGHT EYE REMAINS COVERED WITH SOFT DSD, RECIEVING OINTMENT QID.\n\nGI--REPLETE WITH FIBER TF INFUSING AT GOAL RATE 65CC/HR WITH MIN RESIDUALS. SM BROWN OB NEG BM THIS AM. INSULIN GTT CONTS, PLEASE SEE CAREVIEW FOR GTT TITRATION AND FS.\n\nNEURO--PROPAFOL GTT D/ AND PT TRANSITIONED TO FENT GTT CURRENTLY INFUSING AT 75MC/HR AND VERSED GTT CURRENTLY INFUSING AT 2MG/HR. PT TO VOICE, BUT NOT FOLLOWING COMMANDS. WHEN AWAKE, PT BECOMES RESTLESS AND THRASHES.\n\nRENAL--CREAT INC TO 1.7 THIS AM, LASIX ON HOLD FOR TODAY. PT U/O 12-100CC/HR.\n\nSOCIAL--FAMILY IN AT BEDSIDE, UPDATED ON PT'S CONDITION.\n\nPLAN--PICC TO BE PLACED BY IR IN AM\n--PT TO REST ON AC\n--NEW ABX\n--LASIX ON HOLD AT PRESENT DUE TO INC IN CREAT\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364324, "text": "resp care\nremaisn intubated/vented in ac mode. settings unchanged today. abg with metabolic acidosis. suctioning thick yellow. admin mdi's q4h. no weaning today per rounds, reassess daily.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364325, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick pl yellow secretions. MDI'S given. Sedated with fentanyl and midazolam. No spont resp @ this time will attempt an RSBI @ a later time.Cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364326, "text": "Resp Care Note, Pt weaned off sedation to get RSBI done on 0 peep/5 ips 39 with increased WOB. Placed back on A/C.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364320, "text": "Respiratory Care\nPt remains intubated and on vent support. Intubated w/a #7.5 ETT 21 @ lip. Vent changes were PSV w/CPAP to A/C due to ABG trending. pH 7.18 and PaCo2 trending up. Lung sounds were course to clear t/o and diminished in the bases. Suctioned for moderate amounts of thk tan secretions. Pt received MDI's with good effect. Pt continues to have a prolonged exp phase. Last ABG showed a metabolic acidosis that has improved, with good oxygenation. Care plan is to remain on A/C noc and obtain a RBSI in AM with a NIF. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364321, "text": "NPN 1900-0700, written at 0445 est\nReview care vue for all objective data\n\nNeuro: sedated, trying to open his eyes when awake, continue sedation when he is on ventilator to keep him comfortable.\n\nResp: sedated with propofol 25mic/kg/min and tried to titerate to 22when his SBP was around 90's and back to 25mic/kg/min when wake. Continued on ssame vent setting with A/C mode , 650/14/5 and 50% O2.\nBilateral LS diminished on rt side and clear on lt side. Moderate thick yellow secreation on suction.RSBI this am 85 and planing to do bloodgas and NIF later. O2 sats 96-99%.\n\nCv: NSR with occassional to frequent pvc\"S and runs of v tac, self resolving and asymptomatic. pottassium 40 meq repleted and am labs pending. SBP 90-130's monitoring via rt radial a line.\n\nGU/GI; continued on TF replete with fiber/65ml/hr as goal and with minimal residuaal. Abd soft distended and BS present and no BM this shift. Urine out 60-300ml/hr and no lasix given this shift.\n\nEndo: insulin gtt titarated as per blood glucose.\nSkin intact\nID: temp 98.2 and continued on antibiotics.\nSocial: wife telephoned last night.\n\nPLan: to wean sedation and vent as tolerated by patient/blood gas\n continue all other supportive tretment\n F/U echo result for cardiac function\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364322, "text": "Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details.Suctioned for sml amts thick yellow. MDI'S given. Sedated with propofol. Getting insulin. HR-PVC'S. RSBI 85. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364327, "text": "9pm to 7am:\n\nNeuro) Pt remains intubated (oETT) with fentanyl and versed gtt for sedation with good effect. Sedation off this am for about 15 min, and pt started to move all ext's with no purpose. Pt also started to become very restless and SBP increased to 170-190's. While sedated pt will occ open eyes to verbal stimuli. but does not follow any commands. Bil wrist restraints on for safty.\n\nCV) Pt remians in NSR with occ PVC's and rare short runs of VT (100-110). Afibrile with stable VS. MAP > 70 and CVP 6->10 this am. Pt has gen anasarca +2 pitting to ext's with good pulses to palp. A-line very positional with sharp to dampened wave form. Good blood return to A-line. Am labs pending.\n\nResp) No changes made to vent settings. Currently at 50%/650X14/5. Will repeat am ABG2/2 it was done while RSBI done by RT. Pt has been deep sx'd for sml amounts og thick yellow-> white secetions. Minimal oral secretions. No plans to extubate today MD. LS this am clear with cx's to LLL (dependent).\n\nGI) Abd sl dist and soft to palp with + BS. TF at goal at 65 cc/hr with no residuals. No BM at this shift. Pt remains on insulin gtt as noted with FSBS checks q 1hr.\n\nGU) Pt has had low U/O via foley throughout this shift. Pt given total of 500 cc in IV boluses with some effect on U/O.\n\nSkin) see care vue.\n\nPLAN: IR for PICC placement today.\n Wean sedation as tol by pt.\n ? Lasix today IF creatine improved this am.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364328, "text": "resp care\nremains intubated/vented, reducing sedation and converted to spontaneous mode. tolerating but more tachycardic and tachypnea due to lightening of sedation. small amts yellowish sputum. mdi's given q4h. c/w daily weaning assessment, due to cardiovascular status proceeding with slow weaning.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364329, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nEvents: Attempted to transition to bolus sedation with poor effect, pt tolerating CPAP+PS, attempted to transition pt to sliding scale with poor effect, restarted on continuous IV sedation and insulin drip.\n\nNeuro: Pt sedated on Fentanyl 75mcg and Versed 3mg, unsuccessful attempt to transition pt to bolus sedation. Pt able to MAE, does not follow commands, arousable to voice. Pt appears more comfortable and less restless with increased sedation. Bilateral wrist restraints remain on for pt safety.\n\nCV: HR SR/ST 66-108 with occasional PVC, ABP 113-158/58-83, CVP 10-14, SVO2 77-89. Pt's HR and BP noted to increase with turns and mouth care. Attempted to wean sedation however pts HR increased to 110's with SBP to 170's. Pt's continues to be tachycardic even though sedation is at original (pre-wean) doses. Rare short run of VT, self resolving, asymptomatic. Anasacra noted, peripheral pulses difficult to palpate.\n\nResp: Pt currently on CPAP+PS, tolerating well, current vent settings 50%/+ with ABG of 7.30/45/134. Lung sounds clear to coarse in apices, diminished in bases. Suctioned x 3 for scant amounts of thick, white secretions. RR 12-22 with sats >94%, STV ~700, MV .\n\nGI/GU: BS x 4, no stool this shift. Given PRN senna with no effect. Tolerating TF at 65cc/hr with minimal residuals. Foley patent and draining clear, yellow urine. UO 25-75cc/hr. Pt is +1.5L since MN and +10L for LOS.\n\nEndo: Attempted to switch pt to sliding scale coverage with poor effect. Pt's BS to 200s, drip restarted and currently at 6 units/hour.\n\nID: Tmax 98.6, continues on ABX therapy (Ceftazidime) for streptococcus/psuedomonas pneumonia. No new culture data.\n\nSocial: Family at bedside most of the day, updated by MD on pt's condition and plan of care.\n\nPlan:\nsedate as needed for comfort\ncontinue to wean vent support\nmonitor BS and adjust drip according to protocol\nconsider diuresis once stable\nroutine ICU care and monitoring\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364330, "text": "NPN 1900-0700, written at EST\nreview carevue for all objective data\n\nFull code\nuneventful night\n\nNeuro: sedation titerated to keep him comforable over the vent and now versed 2mg/hr gtt and fentanyl 75mic/hr gtt.Eyes opens to pain. IN the begining of shift patient was agitated and improved with increasing sedation. Bilateral wrist restrints are in place to secure the lines and tubes.\n\nCV: NSR with occassional to frequent pvc's, stated the shift with tachycardia and nsr after increasing the fentanyl.sbp 110-140's monitoring via rt radial a-line.\n\nResp: sedated, no vent changes over night. RSBI this am was 43 and ontinued on SBT. AM blood gas 7.33/43/114 and may repeat blood gas later. Bilateral lung sounds clear to course and diminished at the base. Thick yellow secreation with suction.\n\nGU/GI:urine out put 30-40 ml/hr via foleys catheter. Tolerating TF 65ml/hr with minimal residuals. Abd soft distended, hypo active BS and no BM this shift, po senna given.\n\nEndo: Insulin on ss,titerated according to blood sugar.\nSKIN: intact except redness on his scortum, +2 edema present.\nSocial: wife telephoned\n\nPLan: Continue wean sedation/vent as tolerated\n close monitoring blood sugar and ? start ss and fixed dose\n No BM for many days\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364331, "text": "Resp Care\nPt remains on vent. Intubated with 7.5 ett @ 21, patent and secure. Suctioned for mod amt of thick yellow secretions. Mdis given. Rsbi 43. Currently on sbt, awaiting abg. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364318, "text": "NPN 1900-0700, written at 0440 est\nreview carevue for all objective data\n\nFull code\n\nNeuro: Remains lightly sedated with propofol and when awake trying to open eyes to painful stimuli. Lower extrimities minimal movements and edematous. Wrist restaints are in place for safety.\n\nResp: Sedated with propofol 20mic/kg/min gtt and needs few bolous as when patient awake and biting tube and hypertensive. Vent weaned down to 5/5 and 40% and tidal volume 300's. RSBI done on peep 0/5, ips 80.Blood gas prior to RSBI 7.34/34/141 and will repeat on psv 5/5. Bilateral LS clear and diminished at the base, thick yellow secreation on suction.O2 sats 99-100.\n\nCv:NSR with occassional pvc's, SBP 120-190, monitored via rt radial a line. When awake hypertensive and good response to few bolous of sedation.CVP 11-16 and SVo2 76-80. Am labs Na 138/K4.2 and HCT 40.4.\n\nGU/GI: NPO for possible extubation, abd soft distended, BS present. No BM this shft. Urine out put 40-80ml/hr.\n\nEndo: Insulin gtt titerated as per blood glucose.\nSkin: intact, edema noted on extrimities.\nID: afebrile, 95.8 later in the shift, extra warming blanket given, continued on antibiotics.\n\nSocial: Telephoned by wife last night and updated his condition by RN\n\nPLAN: wean sedation and possible extubation if tolerated,\n monitor temp and bear hugger if still hypothermic\n frequent blood sugar checks/insulin gtt\n ?antihypertensive if hypertensive with weaning sedation.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364319, "text": "MICU 6 NSG 7A-7PM\nRESP--PT RECEIVED ON PS 5 PEEP 5 40%. RR SLOWLY INC FROM 20-30 OVER COURSE OF AM, WITHSLOW DECREASE IN O2 SAT. ABG SENT 7.18/49/92. PT PLACED ON AC 14 650 PEEP 5 50%, BREATHING OVER VENT. PLEASE SEE CAREVIEW FOR REPEAT ABG'S. PT WITH THICK TAN PURULENT LOOKING SECRETIONS SX'D FROM ETT. STEROIDS D/C'D.\n\nCV--PT REMAINS IN SR/ST 58-100'S. WITH OCCAS PAC'S. BP LABILE 90-200/. RECEIVED HYDRALIZINE 25MG PO THIS AM FOR HTN WITH GOOD EFFECT. PLAN HAS BEEN TO DIURESE PT, WITH DECREASE IN CVP AND BP. BEDSIDE ECHO DONE WITH RESULTS PENDING. PT WITH (+)2 EDEMA IN EXTREMITIES. PT HYPOTHERMIC WITH TMIN 95 THIS AM, TEMP CURRENTLY 97'S WITH BAIR HUGGER OFF. RIGHT IJ TLCL SUTURE BROKEN AND REPLACED BY TEAM. WHITE PORT TPA'D WITH SUCCESS.\n\nNEURO--PT CONTS ON PROPAFOL GTT AT 20-30MC/KG/MIN. WHEN SEDATION OFF PT BECOMES RESTLESS, AND HYPERTENSIVE, FOLLOWS COMMANDS. RIGHT EYE WITH LOOSE DSD APPLIED.\n\nGI--TF REPLETE WITH FIBER AT GOAL RATE 65CC/HR STARTED. PEDI NGT COILED IN ESOPHAGUS AND REMOVED. NO BM THIS SHIFT. CONTS ON INSULIN GTT, PLEASE SEE CAREVIEW FOR GTT RATES AND FS.\n\nGU--CREAT 1.3 THIS AM. U/O POOR THIS AM 15-30CC/HR. WITH FAIR RESPONSE TO 12PM LASIX DOSE. WILL RECEIVE ANOTHER THIS PM.\n\nSOCIAL--WIFE, CHILDREN AND GRANDCHILDREN IN TO VISIT. UPDATED ON PT'S CONDITION.\n\nPLAN--DIURESE AS TOL\n--REPEAT LYTES THIS EVENING\n--ALLOW PT TO REST ON AC OVERNIGHT THEN CHECK RSBI AND NIF IN AM\n--INSULIN GTT PER SS\n" }, { "category": "ECG", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 288901, "text": "Sinus rhythm\nVentricular premature complexes\nAtrial premature complex\nRight bundle branch block\nQ-Tc interval appears prolonged but is difficult to measure - clinical\ncorrelation is suggested\nSince previous tracing of the same date, ventricular ectopy present\n\n" }, { "category": "ECG", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 285290, "text": "Sinus rhythm with atrial premature beats. Right bundle-branch block.\nNon-specific ST-T wave changes. Compared to the previous tracing of the\naxis is less leftward.\n\n" } ]
7,371	114,153	1. Aortic dissection - The patient was admitted to the CCU for continuous monitoring and blood pressure control. The patient was started on Nipride and Labetalol drip with a goal systolic blood pressure of 100 to 120s. The patient did fairly well with the Nipride drips, Carvedilol drips. Amlodipine, Metoprolol and Captopril were titrated up and Labetalol and Nipride drips were weaned off. Vascular Surgery was consulted in the Emergency Department and they followed the patient throughout the hospital stay. Their recommendation was that he did not need any surgical intervention at this time as the patient did not show any evidence of myasthenia and repeat transthoracic echocardiogram and magnetic resonance imaging scans of the area of dissection were stable with only interval increased hematoma. Vascular Surgery signed off prior to discharge. Dr. and Batime recommended that we consult Cardiothoracic Surgery. CCU Team in conjunction with Cardiothoracic Surgery ordered further tests because of the computerized tomography scan and magnetic resonance imaging scan to further characterize the dissection regarding points of origin and extension and anatomy of the actual aorta. The patient was to follow up with Dr. and Dr. as an outpatient for possible future intervention such as graft placement. Serial vascular examinations were stable. Pulse was stable throughout entire stay. The patient's blood pressure was tightly controlled on oral medications and he was subsequently discharged on Amlodipine 5, two tablets p.o. q. day, Atenolol 100 mg tablets one tablet p.o. q.d. and Lisinopril 20 mg tablet, one tablet p.o. q. day with adequate systolic blood pressure control to less than 120. 2. Hypertension - Aggressive blood pressure control was done initially with Nipride and Labetalol drips. The patient was subsequently transferred over to an outpatient medication regimen with adequate control of blood pressure with systolics less than 120. He was discharged with Amlodipine, Metoprolol and Lisinopril. 3. Hypercholesterolemia - The patient was continued on his outpatient dose of Lipitor. 4. Urinary tract infection - The patient had some complaints of mild abdominal pain throughout the entire stay with subsequent suprapubic tenderness. No costovertebral angle tenderness on examination. Urinalysis was sent off and resulted in positive study for urinary tract infection. Urine culture was also sent off and subsequently grew out as an Escherichia coli. The patient was placed on Levaquin for a total of ten day treatment. 5. Derm - The patient on second day of admission developed a maculopapular rash on the back and abdomen as well as left deltoid. Etiology of the rash was likely due to one of the drugs that was administered, however, it was unclear as to which might have caused it. The rash was self-resolving and prior to discharge was completely gone. No evidence of eosinophilia on differential. 6. Gastrointestinal - The patient complained of intermittent epigastric pain. Abdominal examination was initially unremarkable and then had some mild suprapubic tenderness. Urinalysis was sent off and resulted in Escherichia coli growth in his urine. He was started on Levaquin for a ten day treatment. Despite that the patient still had some minor epigastric tenderness. Computerized tomography scan and magnetic resonance imaging scan were done which showed interval increase in his hematoma, unclear as to what his epigastric pain might have been coming from. I started him on an empiric trial of proton pump inhibitor, Pantoprazole and sent off his Helicobacter pylori serologies to be followed up as an outpatient. Etiology of the patient's intermittent mild epigastric pain was likely either gastritis or gastric component of reflux. The patient did much better on the proton pump inhibitor trial with resolution of his epigastric pain. 7. Fluids, electrolytes and nutrition - His electrolytes were checked q. day and repleted as needed. The patient was placed on a cardiac diet. 8. Prophylaxis - The patient was placed on a proton pump inhibitor and advised to ambulate on the unit. The patient was also placed on a diet.	CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is calcification surrounding the abdominal aorta. The intramural hematoma extends to the level of the diaphragmatic hiatus. Eccentric left lateral outpouching of lumen of the thoracic aorta at T7, T8 level, which may represent entrance site. CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There has been interval expansion of the intramural hematoma. Distally, the intramural hematoma extends to just above the celiac axis. IMPRESSION: Stable intramural hematoma of aorta, extending from the takeoff of the left subclavian artery to just above the celiac axis. The hematoma spans the thoracic aorta including the possible origin of the artery of Adamckewicz, which is not visualized. Initially on labetolol @ 0.5 and nipride @ 1mcg, both weaned off and restarted on PO meds. At the descending thoracic aorta, there is an eccentric area of outpouching at the left lateral aspect of the aorta at T7-T8 level. Evaluation of abdominal aorta again demonstrates intramural hematoma extending superiorly to the level above the celiac axis. DENIES C/O BACK/CHEST PAIN.RESP: ON ROOM AIR. DENIES C/O CHEST/BACK PAIN. (Over) 5:34 AM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: assess for change in dissection Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT ABNORMAL! KEYWORD: AORTA DENIES C/O ITCH. A mild focal bulging of the aorta is noted 4 cm above the iliac bifurcation. There is a crescentic signal hyperintensity at the left lateral aspect of the descending thoracic aorta on the dark blood HASTE sequence, compatible with intramural hematoma (greater than 10 days age). The hematoma is best seen at the mid and lower thorax, and extends superiorly just to the origin of the left subclavian artery, which was confirmed on the coronal reconstructed contrast enhanced images. REASON FOR THIS EXAMINATION: assess for change in dissection No contraindications for IV contrast WET READ: PSLa FRI 5:56 AM enlarging intramural hematoma compared with , celiac SMA patent FINAL REPORT ABNORMAL! DENIES C/O SOB.GI: ABD SOFT, + BOWEL SOUNDS, NO BM OVERNIGHT. Cont on captopril 75mg, norvasc 10mg, lopressor 100mg. MOVING ALL EXTREMITIES WELL, TO BEDSIDE COMMODE. DENIES ITCHINESS.ID: TEMP MAX 100.4 GIVEN TYLENOL 650 MG POSTABLE NOC. FINDINGS: Comparison is made to CT chest on . There is atheromatous plaque within the abdominal aorta. BP 100s-120s, well controlled on PO meds. MOVING ALL EXTREMITIES, TO VOID AT BEDSIDE. CT showed type B dissection from subclavian to celiac artery (no change in length) w/ expansion in width of hematoma. CCU NPN 7A-7PNeuro: A&Ox3, MAE. Sinus rhythm. LOPRESSOR AND CAPTOPRIL WELL. GAIT STEADY.CV: HR 58-64 SB-SR. NO VEA. (Cont) There is a tiny pulmonary nodule within the left lower lobe. There is a sub cm cyst seen in the upper pole of the left kidney, and a 1 cm cyst in the lateral interpolar region of the right kidney. At the arch, the aorta measures 2.7cm. CONTRAST: 150 cc of Optiray was administered. TECHNIQUE: Contiguous axial images were obtained from the lung apices to the aortic bifurcation before and after the administration of intravenous contrast. Foley d/c, voiding cl yellow urine. The SMA and celiac axis are patent. Sats 98% on RA.GI/GU: +BS, abd soft, non-tender. BP STABLE 88-101/45. CONGESTED, NONPRODUCTIVE COUGH NOTED. Otherwise, the remainder of the abdominal aorta demonstrates no evidence of dissection. 1:00 PM MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA Admitting Diagnosis: TYPE B DISSECTION Contrast: MAGNEVIST Amt: 40CC FINAL ADDENDUM ADDENDUM TO MRA OF CHEST AND ABDOMEN DATED : There is some atherosclerotic plaque in the infrarenal abdominal aorta. Started on PO protonix. IMPRESSION: There has been interval expansion of the intramural hematoma extending from immediately distal to the takeoff of the left subclavian artery to the level of the diaphragmatic hiatus. BP STABLE 92-104/54. The renal arteries are patent and there is normal perfusion of the kidneys bilaterally. DR. Voiding adequate amt CYU via urinal.Skin: Red raised rash on trunk and extremeties, denies itching. The aortic lumen which contains contrast is decreased in caliber. GIVEN AMBIEN FOR SLEEP WITH GOOD EFFECT.CV: HR 56-60 SB-SR, NO VEA NOTED. MRA on hold until Monday when radiologist is able to be here.Pulm: LS CTA, sats 97% on RA.GI/GU: +BS, abd soft, non-tender. -Abd bruit. Reports , need ativan. Nonetheless, this area could represent an entrance site of intramural hematoma due to ulcer. 1:00 PM MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA Admitting Diagnosis: TYPE B DISSECTION Contrast: MAGNEVIST Amt: 40CC FINAL REPORT INDICATION: Evaluate chest for aortic dissection versus hematoma. "O: PT. The heart and pericardium are unremarkable. REMAINS OFF NIPRIDE, LABETOLOL. Both renal arteries are patent.	7	[ { "category": "Radiology", "chartdate": "2168-01-15 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 809417, "text": " 5:34 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: assess for change in dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with type B aortic dissection now with worsening abdominal\n pain.\n REASON FOR THIS EXAMINATION:\n assess for change in dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa FRI 5:56 AM\n enlarging intramural hematoma compared with , celiac SMA patent\n ______________________________________________________________________________\n FINAL REPORT ABNORMAL!\n INDICATION: Type B aortic dissection with worsening abdominal pain.\n\n COMPARISON: and .\n\n TECHNIQUE: Contiguous axial images were obtained from the lung apices to the\n aortic bifurcation before and after the administration of intravenous\n contrast.\n\n CONTRAST: 150 cc of Optiray was administered.\n\n CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There has been interval\n expansion of the intramural hematoma. The hematoma begins just distal to the\n left subclavian artery. The aortic lumen which contains contrast is decreased\n in caliber. The intramural hematoma extends to the level of the diaphragmatic\n hiatus. No intimal flap is identified. There is no evidence of aneurysmal\n dilatation of the aorta. The heart and pericardium are unremarkable. There\n is a subcentimeter nodule within the left lower lobe. The lungs are otherwise\n clear. There are no pleural effusions.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is\n calcification surrounding the abdominal aorta. There is atheromatous plaque\n within the abdominal aorta. The celiac axis and SMA are widely patent. Both\n renal arteries are patent. The liver, gallbladder, spleen, pancreas, adrenal\n glands and intra-abdominal bowel loops are unremarkable. The kidneys enhance\n symmetrically.\n\n There is no free fluid or free air within the abdomen.\n\n The osseous structures are unremarkable.\n\n IMPRESSION: There has been interval expansion of the intramural hematoma\n extending from immediately distal to the takeoff of the left subclavian artery\n to the level of the diaphragmatic hiatus. The SMA and celiac axis are patent.\n The renal arteries are patent and there is normal perfusion of the kidneys\n bilaterally.\n\n (Over)\n\n 5:34 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: assess for change in dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT ABNORMAL!\n (Cont)\n There is a tiny pulmonary nodule within the left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2168-01-18 00:00:00.000", "description": "MR CHEST/MEDIASTINUM W&W/O CONTRAST", "row_id": 809697, "text": " 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM TO MRA OF CHEST AND ABDOMEN DATED :\n\n There is some atherosclerotic plaque in the infrarenal abdominal aorta. A\n mild focal bulging of the aorta is noted 4 cm above the iliac bifurcation. At\n this area, the aorta measures 2.5 cm, with the aorta diameter above and below\n measuring 1.8 cm.\n\n\n 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate chest for aortic dissection versus hematoma.\n\n TECHNIQUE: MRI examination of the abdomen was performed utilizing T1 weighted,\n T2 weighted, 3D gradient echo, true FISP and cine sequences before and after\n intravenous gadolinium injection. Abdominal aorta was also evaluated.\n\n Multiplanar reformatted images were generated on a 3D workstation, which was\n essential for delineation of anatomy.\n\n FINDINGS: Comparison is made to CT chest on .\n\n There is a crescentic signal hyperintensity at the left lateral aspect of the\n descending thoracic aorta on the dark blood HASTE sequence, compatible with\n intramural hematoma (greater than 10 days age). The hematoma is best seen at\n the mid and lower thorax, and extends superiorly just to the origin of the\n left subclavian artery, which was confirmed on the coronal reconstructed\n contrast enhanced images. Distally, the intramural hematoma extends to just\n above the celiac axis. No intimal flap is seen. At the descending thoracic\n aorta, there is an eccentric area of outpouching at the left lateral aspect of\n the aorta at T7-T8 level. This area measures 23-24 mm in length, and 32 mm in\n diameter, without significant change vs. most recent CT. This appearance of\n out- pouching is commonly seen in penetrating ulcer, however we do not see any\n atherosclerotic disease in elswhere in the thoracic aorta. Nonetheless, this\n area could represent an entrance site of intramural hematoma due to ulcer. The\n hematoma spans the thoracic aorta including the possible origin of the artery\n of Adamckewicz, which is not visualized. If relevant, a dedicated thin section\n spinal MRI can be performed to attempt to localize that vessel.\n\n The root of ascending aorta measures 3.0 cm in diameter. At the level of main\n pulmonary artery, the ascending aorta measures 3.2 cm, and the descending\n aorta measures 3.2 cm. The main pulmonary artery measures 2.4 cm. At the arch,\n the aorta measures 2.7cm. All measurement were done on axial plane.\n\n Evaluation of abdominal aorta again demonstrates intramural hematoma extending\n superiorly to the level above the celiac axis. Otherwise, the remainder of the\n abdominal aorta demonstrates no evidence of dissection. The liver, adrenal\n glands, the pancreas and the spleen are unremarkable. There is a sub cm cyst\n seen in the upper pole of the left kidney, and a 1 cm cyst in the lateral\n interpolar region of the right kidney.\n\n IMPRESSION: Stable intramural hematoma of aorta, extending from the takeoff of\n the left subclavian artery to just above the celiac axis. No intimal flap is\n seen. Eccentric left lateral outpouching of lumen of the thoracic aorta at T7,\n T8 level, which may represent entrance site. This area is also without\n significant change.\n\n (Over)\n\n 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n If clinically relevant, a dedicated thin section spinal MRI can be performed\n to evaluate artery of Adamkewicz, which is beyond the current study's\n resolution.\n\n Findings were discussed with (MD) upon finishing the study.\n\n KEYWORD: AORTA\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-01-17 00:00:00.000", "description": "Report", "row_id": 1360952, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"THIS RASH DOESN'T REALLY ITCH\"\n\nO: PT. A&O X3. MOVING ALL EXTREMITIES WELL, TO BEDSIDE COMMODE. GAIT STEADY.\n\nCV: HR 58-64 SB-SR. NO VEA. BP STABLE 88-101/45. TOL. LOPRESSOR AND CAPTOPRIL WELL. DENIES C/O BACK/CHEST PAIN.\n\nRESP: ON ROOM AIR. O2 SATS 95%. LUNGS CLEAR. CONGESTED, NONPRODUCTIVE COUGH NOTED. OFFERED COUGH SYRUP, REFUSED AT THIS TIME. DENIES C/O SOB.\n\nGU: VOIDING WELL, URINE CLEAR YELLOW.\n\nGI: APPETITE FAIR, NO BM YET AFTER RECEIVING COLACE AND SENNA. PASSING GAS. ABD SOFT.\n\nSKIN: STILL HAS RED, RASH OVER UPPER BODY AND LOWER EXTREMITIES. DENIES ITCHINESS.\n\nID: TEMP MAX 100.4 GIVEN TYLENOL 650 MG PO\n\nSTABLE NOC. SLEPT IN LONG NAPS AFTER RECEIVING AMBIEN.\n\nP: WAITING FOR MRA MON/TUES.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-15 00:00:00.000", "description": "Report", "row_id": 1360949, "text": "CCU Nsg admit\nCV: Tele SB-SR 50s-70s. Initially on labetolol @ 0.5 and nipride @ 1mcg, both weaned off and restarted on PO meds. Captopril 50mg, lopressor 100mg, norvasc 10mg. CT showed type B dissection from subclavian to celiac artery (no change in length) w/ expansion in width of hematoma. To go to MRA tonight/tomorrow to evaluate further for possible stenting on Monday.\n\nNeuro: A&O x 3, MAE.\n\nPulm: LS CTA. Sats 98% on RA.\n\nGI/GU: +BS, abd soft, non-tender. -Abd bruit. Taking POs w/o difficulty. Foley d/c, voiding cl yellow urine. BUN/Creat 23/0.8.\n\nSocial: Pt lives w/ his wife who is a nurse 2. Reports that he has stopped smoking since last admit and is using the patch. Also reports decrease in drinking-1-2 drinks/day x 3-4 days a week.\n\nA/P: Titrate BP meds as tol for goal SBP<120. MRA to evaluate further, possible aortic stenting on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-16 00:00:00.000", "description": "Report", "row_id": 1360950, "text": "nursing progress note 7p-7a\nS: \"WHAT COULD HAPPEN WITH THIS RASH?\"\n\nO: PT. A&O X3. ASKING APPROPRIATE QUESTIONS REGARDING HOSPITALIZATION AND MEDICATIONS. MOVING ALL EXTREMITIES, TO VOID AT BEDSIDE. GIVEN AMBIEN FOR SLEEP WITH GOOD EFFECT.\n\nCV: HR 56-60 SB-SR, NO VEA NOTED. TOL. INCREASED DOSE OF CAPTOPRIL. BP STABLE 92-104/54. DENIES C/O CHEST/BACK PAIN. REMAINS OFF NIPRIDE, LABETOLOL. AWAITS MRA ? TODAY.\n\nRESP: LUNGS CLEAR, O2 SATS 95% ON ROOM AIR. DENIES C/O SOB.\n\nGI: ABD SOFT, + BOWEL SOUNDS, NO BM OVERNIGHT. TAKING SIPS OF GINGER-ALE.\n\nGU: VOIDING USING URINAL IN GOOD AMTS.\n\nSKIN: RED, RAISED RASH NOTED ON TRUNK, ARMS, BACK, FACE (RIGHT SIDE), LEGS. DENIES C/O ITCH. DR. NOTIFIED AND IN TO SEE PT. WILL FOLLOW FOR NOW.\n\nACCESS: #20 G PIV RIGHT WRIST, FLUSHES EASILY, NO REDNESS NOTED.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-16 00:00:00.000", "description": "Report", "row_id": 1360951, "text": "CCU NPN 7A-7P\nNeuro: A&Ox3, MAE. independently, amb in room.\n\nCV: Tele SR 60s-70s, no ectopy. BP 100s-120s, well controlled on PO meds. Cont on captopril 75mg, norvasc 10mg, lopressor 100mg. MRA on hold until Monday when radiologist is able to be here.\n\nPulm: LS CTA, sats 97% on RA.\n\nGI/GU: +BS, abd soft, non-tender. C/O epigastric pain this morning, reports having it a few times at home during the past week. Concerned about being able to distinguish this pain from dissection pain. Started on PO protonix. Voiding adequate amt CYU via urinal.\n\nSkin: Red raised rash on trunk and extremeties, denies itching. Cont to monitor.\n\nSocial: wife in to visit, updated by RN and HO.\n\nA/P: C/O to floor. MRA on hold until Monday, checklist done. Reports , need ativan. Emotional support for pt and family.\n" }, { "category": "ECG", "chartdate": "2168-01-15 00:00:00.000", "description": "Report", "row_id": 195112, "text": "Sinus rhythm. Compared to the previous tracing of no diagnostic\nchanges.\n\n" } ]
14,585	107,708	A/P: 40M with HIV/AIDS (CD4 17) with chronic diarrhea cryptosporidium, c. diff, and CMV colitis, pancytopenia, electrolyte abnormalities, transfer from floor for hypotension, hypothermia, and new O2 requirement. . #) Septic shock: Likely due to Pseudomonas in blood +/- ? left lower lobe infiltrate He was started on Broad spectrum abx cefepime/levo to double cover for Pseudomonas. He was started on Levophed and dopamine was weaned off on to maintain MAPs>60. He completed a 7 day course of stress dose steroids. Intravenous fluids and antibiotics were continued until when patient was made comfort measures. . #) Pancytopenia : Multifactorial: Likely HIV + medication . a. Thrombocytopenia - ITP vs. medication (bactrim/ganciclovir/flagyl) vs. myelosuppression from HIV/AIDs. Also possible include infection with PCP, . s/p BMBx by heme on . . b. Anemia - Hct on admission 22.7. Likely from GIB and HIV. Peripheral smear did not show evidence of hemolysis and iron studies in consistent with anemia of chronic disease. Pt also has been having guaiac positive stools. On he was transfused 1U PRBCs and 2U PRBCs on . c. Neutropenia and lymphopenia - marrow suppression likely HIV, infection. GCSF was continued until blood counts increased and no longer neutropenic. . #) GIB/Coagulopathy: Likely from INR of 2.0 as well as low platelets. Patient has been putting out bloody watery BMs from mushroom cath. He was transfused with plts, PRBCs, received 10Sc of Vit K on and FFP. GI was consulted regarding GI Bleed - no intervention because of low platelet count. . #) Access: Patient had double lumen PICC placed. . #) Diarrhea - Etiology multifactorial including crytosporidia and C.Difficile, but completed a 14 day course of flagyl treatment. He was started on opium tincture and loperamide. Patient had over 4L stool production. He had frequent labs checked to replete electrolytes and aggressive fluid resuscitation. This was stopped when he was made comfort measures only. . #) AIDS - CD4 of 17 in . He was restarted on HAART medications but these were stopped when made comfort measures. . #) AIDS cholangiopathy - seen on RUQ u/s and pt with elevated AP. It is a biliary obstruction from infection associated strictures of biliary tract, most common being cryptosporidiumm as well as CMV, microsporidia, cyclospora. Followed LFTs. . #) Norwegian scabies-received ivermectin PO x 1 on and permethrin cream. He remained on contact precautions. . #) Esophageal candidiasis-originally dxd by EGD in and he is s/p 14 day trt with fluconazole. Pt again dxd with thrush at . Was on fluconazole IV (started ) but switched to Voriconazole until antibiotics were stopped. . #) Code Status - Patient was a DNR/DNI but initially was willing to have pressors. As treatments did not seem to be effective, GI losses remained great, and patient remained with low CD4 count despite HAART therapy a family meeting was held on with patient's infectious disease doctor, Dr. and the ICU team. The patient expressed his wishes to be comfort measures only. On all iv fluids and antibiotics were stopped. He was transitioned to a morphine drip and passed away peacefully with his family at his bedside on at 7:25p.m.	w/ Permetherine @ 00:00 and has patches of severe dry skin, tx w/ Eucerin @ .Endo: FSBS 130-150, follow SSSocial: Dr. met w/ pt. Gtt.C/V: pt on Dopa and Levo Gtts, able to wean and d/c Dopa, but Levo continues @ 0.232 mcq/min/kq down from .280mcq. Able to wean of Dopa Gtt but continues on Levo. PATIENT/TEST INFORMATION:Indication: Tachycardia; Evaluate for endocarditisHeight: (in) 68Weight (lb): 78BSA (m2): 1.37 m2BP (mm Hg): 100/50HR (bpm): 100Status: InpatientDate/Time: at 16:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. recieved of Norepinephrine 0.235 mcg/kg/hr weaned to 0.093 mcg/kg/hr.Tolerated well. PM lytes to be checked @ MN.RESP: LS coarse upper, diminished @ bases. appears to be less lethargic since RBC/PLt/FFP transfusion.Resp: Pt. candidiasis, C. diff colits. BP-86-96/60's, HR has come down from 140's ST to 98-105's with Dopa being off. Ivermectin due .Permethrin due . Potassium 2.7.Neuro:A&Ox3, articulates well, follows commands, PERRL, labored MAE, cachectic, weak cough.Resp: LS cta dim @ bases,SpO2:97-100%,RR 30's,weak, nonproductive cough, Sputum sent for 3rd TB.CV:Pt. is on 2L NC, O2 sats 98-100%, LS clear in upper lobes and diminished in lower lobes, occasional dry cough, CXR shows right mid-lobe PNA, ENT consult : multiple samples sent, no nodules visualized indicating doubtful of TB, although pt. has received 1 L D5W w/ 60mEq K+Cl for K+=2.6 and an additional 1 L D5W w/ 60mEq K+Cl is currently infusing. received on Dopamine @ 20mcg/kg/min and Levophed @ 0.15mcg/kg/min w/ sbp=88-94, Map=58-70 and HR 110-140s. 4gm Ca+Glu repleted today for ICa+=0.9. 4:38 PM CHEST (PA & LAT) Clip # Reason: R/o infectious or infiltrative processPt needs mask. Levofloxacin D/C'd. Pt refusing PO meds.CV: NSR 60s-90s. CMV colitis, Cryptosporidium, esoph. CMV colitis, Cryptosporidium, esoph. repleted 60mEq K+Cl for K+=3.5 and 15mmol Phosp repleted for Phos=1.7, and 500cc FB for sbp 90 and HR 120-140s, HR decreased to 9\85-93 w/ FB.Neuro: Pt. micu west 1900-0700 npn**Code Status: DNR/DNIAllergy: IodinePrecuations: Droplet for question TB and Contact for scabiesSignificant Events: Pt. is currently receiving Levophed 0.235 mc/kg/hr, sbp 90-115, MAP>60, HR 90-140 NS/ST no ectopy, HR decreasing from 140 to 100 since IVF and blood products infusing, suggesting need for hydration/volume, Dopamine OFF now for 24 hrs. agreed to D'C anti-retroviral mediction as effectiveness and absorption is in question. Access has not been obtained as of now due to decreased PLT.Id: Temp 95.7-99.5 for shift, Bair Hugger adjusted accordingly, Vanco Dc'd, ABX: Cefepime/Flagyl/Levofloxacon/VeroconizoleEndo: FSBS covered per SSSkin: Applied Eucerin on dry areas/neck, coccyx abrasion/breakdown protected w/ duoderm, Scabies present on skin.Social: Friends visited today/Health Care Proxy came and will visit tomorrow morning, Dr. met w/ pt. Repeat Lytes sent are PND.HEME: HCT-stable @ 30.4, PLT-29, PT/PTT 14/30.0 INR- 1.2. Monitor I&O's, as replete fluids as needed. PICC port was clotted off, 1 cc of TPA was given with good effect. Was ordered for U/S but has not been done as yet.RESPIR: Remains on RA with O2 sats 98-100%, RR 24-28, L/S clear.GU: U/O 60-80cc/hr, BUN/CRE 37/0.8. need to replete remaining PO KCL via IV.Resp: Patient continues to maintian >95% O2 sats on RA. HAD BEEN ALERT AND ORIENTED X 3- LUCID AND NEUROLOGICALLY INTACT ENOUGH TO TAKE CARE OF LAST WILL AND TESTAMENT WHICH WAS WITNESSED AND NOTARIZED AT THE BEDSIDE. CLEAR BIL BREATHSOUNDS NOTED ON AUSCULTATION. PT PASSES AWAY AT ON , DR PRONOUCED. skin appears to be improving, rec'ing creme's as ordered. Respiratory Precautions D/C'd. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES. MIcu Nursing note Neuro pt is awake and alert following commands, this morning pt sent for head ct which was neg for a bleed, they felt his mental staus was slighly off, pt knows place sometimes is unable to state month.Cv pt hemeodymanically stable, pulses weak but palp, bilaterally, pthad 2 episodes where hr down in the 40's when asleep, bp stable at that time. PT WOULD LIKE TO KEEP BAG ON.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. MONITOR FOR HYPOTENSION AND FLUID BOLUS IF NECESSARY. Nsg Progress Note 0700-1900CV - Pt hemodynamically stable. CO2-14CV:HR:89-111 ST/NSR, SBP:100-111,Mean:73-95,Fluid goal 1 to 1 1/2 L positive, pedal pulses positive.Calcium Gluconate repletion. AM K+-3.3, rec'd 60mEq IV, Ca 7.5, MagS+ 1.7, was repleted. LYTES RESULTS PENDING POST REPLETION.RESPI. Continue IV antibx's. SOCIAL SERVICES IS ACTIVELY ATTEMPTING TO ARRANGE PLCMT INTO HOSPICE NH.PT HAS BEEN COMFORTABLE FOR MOST OF SHIFT. POSITIVE SKIN BREAKDOWN IN COCCYX.ID. Nursing Note:0700-1900Code Status:DNR/DNIPrecautions:Contact and Allergies:IodineNeuro:Calm, Cooperative Male,A&Ox3,PERRL,Pt OOB to Chair with2 assists; tolerated well. Micu Nursing note Neuro to very lathargic this am when bp 80/50 pt fluid boluses with 1l n/s and 1 liter Bp improved over an hr pt became more responsive when sbp > 100/. Pt has padding and diaper on; chg'd q1hr. Pt receiveing MSO4 as requested to keep him comfortable. REMAINS LUCID- ORIENTED X 3- LETHARGIC AT TIMES. START CALORIE COUNT. PT CONTINUES TO BE ON RETROVIALS AND ANTIBIOTICS.PLAN. OCCASSIONAL COUGHING NOTED, ENCOURAGED PATIENT TO TURN MORE OFTEN, AMENABLE.GI/GU. 60mEq PO of KCL, and 40mEq IV of KCL were ordered for correction of a Potassium level of 2.9. MAE's, but stregnth is weak.CV: HR has been ST with no ectopy this shift. Did not want to get out of bed today.C/V: BP stable to 98-110/60, HR 70's-80's SR with no ectopy noted. Rec'ing IVF- NS 125cc/hr, Na+-141, T CO2-19.ID: Temp 96-95.6, WBC-11.3. Dr discussed issues with the family.A/P: Continue to replete Lytes as needed, and continue IVF's as ordered. micu Nursing note Neuro pt awake and alert this am, at 1400 woke pt to turn was confused didn;t understand why i was turning him even after explaining it to pt took 10 min to reorient pt to what we were doing, pt follows commands but seem to have periods on confusion.Cv pt through most of the day hr 70-90 sr at 1400 pt turned hr ^ 130 st called resident Bp stable at the time pt boluses with 500 cc n/s , hr dropped back to the 80's while getting bolus then after bolus finished hr back up into 120's Ivf changed to 1/2 ns at 150 hr, labs sent at that time ( and pending ) nowGi abd soft nontender, pt still has flexflow rectal tube system passing green lig stool 800 cc this shift pt continues on octotide and opium for loose stool, pt taking poor intake incouraged to eat and drink but still has poor po intake, pt passing clear yellow urine via foley 100-200 cc hr.Id pt hypothermic again was in bear hugger x5 hr pt remain on iv antibiotics and antivirals hct 27, wbc 14 plt 38 this amSkin pt still picking at skin pulling off scabs on neck and head told that he must stop because skin below and is bleeding , scalp washed andcream applied to head and body, scale covered with cap in order to remind pt not to pick at skin, pt remains on multi skin creams for dry skin and scabes,Social spoke with family today about pt and that he does have periods of confusion they would like to speak with hiv specialist tomorrow to have a time line about therapy of new drug, also we need social service andcase worked to see pt about what type of care will be needed and if pt should be dischaged back to a long term care facility or a medical floor, at present pt talking a large amount of nursing time for care and would be to much care for nursing on floor, with need for lyte replacement and nutrition support and dirrehea control along with the fact pt will need a privite room, Right now is the time we need to balance the needs of the psycosocial along with medical, have the most amount of freedom and least restrictive enviornment, with the need for medical care will address this again with house staff tomorrow and also need to speak with id about long term needs, for isolation,A/p follow up with social services, care worked, Hiv and id, follow up with labs tonight may need replacement lytes and now looks to need more iv fluids, follow mental status and would talk with hiv speicalist about mental status and what meds may be part of making pt more confused	36	[ { "category": "Echo", "chartdate": "2150-07-31 00:00:00.000", "description": "Report", "row_id": 80574, "text": "PATIENT/TEST INFORMATION:\nIndication: Tachycardia; Evaluate for endocarditis\nHeight: (in) 68\nWeight (lb): 78\nBSA (m2): 1.37 m2\nBP (mm Hg): 100/50\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 16:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , there is no\ndefinite change.\n\n\n" }, { "category": "ECG", "chartdate": "2150-08-01 00:00:00.000", "description": "Report", "row_id": 204011, "text": "Baseline artifact\nSinus tachycardia\nDiffuse nonspecific ST-T wave changes\nSince previous tracing of , further T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2150-07-29 00:00:00.000", "description": "Report", "row_id": 204012, "text": "Technically difficult study\nSinus tachycardia\nST-T wave abnormalities\nSince previous tracing, precordial QRS voltages less\n\n" }, { "category": "Radiology", "chartdate": "2150-08-07 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 920905, "text": " 9:26 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: HIV,ELAVATED BILIRUBINE\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and CD4 less than 50. CMV colitis, Cryptosporidium,\n esoph. candidiasis, C. diff colits, rising tbili, ap\n REASON FOR THIS EXAMINATION:\n RUQ ultrasound,\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Liver and gallbladder ultrasound.\n\n CLINICAL HISTORY: 40-year-old man with HIV, CMV colitis, Cryptosporidium,\n esophageal candidiasis, C. diff colitis, rising bilirubin.\n\n FINDINGS: Right upper quadrant ultrasound was performed on .\n Comparison made to prior study dated .\n\n The hepatic parenchymal echotexture is within normal limits. No focal hepatic\n lesions are identified. There is no intrahepatic biliary ductal dilatation.\n The common bile duct is dilated, measuring up to 10 mm, and tapering in the\n pancreatic head. No pancreatic masses are identified. There is marked\n gallbladder wall thickening, measuring up to 11 mm in thickness. No\n gallstones are identified. Degree of gallbladder wall thickening is increased\n compared to prior study, although this could be secondary to decreased\n gallbladder distension.\n\n IMPRESSION: Extrahepatic biliary ductal dilatation and markedly thickened\n gallbladder wall. The combination of findings is concerning for HIV\n cholangiopathy, given the patient's clinical history:\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 920269, "text": " 12:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for cardiopulmon process\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO M with advanced AIDS, crypto, pancytopenic, scabies neutropenic, with\n hypotension, concern for SIRS, with new productive cough\n REASON FOR THIS EXAMINATION:\n please evaluate for cardiopulmon process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Advanced age, crypto-----pancytopenic, _____, neutropenic, concern\n for SIRS with new productive cough. Question cardiopulmonary process.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The heart is not enlarged. There is triangular opacity at the right base,\n though cardiac and diaphragmatic silhouettes are preserved. Appearance is\n compatible with atelectasis -- question subsegmental or segmental. There is\n new accentuation of interstitial markings at the left infrahilar,\n retrocardiac, and left base regions, compared to . No CHF, frank\n consolidation, or effusion is identified. A right subclavian PICC line is\n present, tip in region of SVC/RA junction, unchanged. No pneumothorax is\n detected.\n\n IMPRESSION: Atelectasis at right base. Increased interstitial markings at\n left base, more pronounced than on . Question early infectious\n infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 921039, "text": " 11:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute bleed,\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with progressive HIV, pancytopenia, scabies, on ARVs, with\n change in mental status\n REASON FOR THIS EXAMINATION:\n acute bleed,\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of progressive HIV, pancytopenia, scabies, change in\n mental status. Evaluate for acute bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage.\n The -white matter differentiation appears grossly preserved. There is\n slight prominence of the ventricles and sulci that may be related to volume\n loss. The basal cisterns appear patent. Imaged paranasal sinuses appear\n clear.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921246, "text": " 10:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/ PNA, pulmonary edema\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO M with advanced AIDS, crypto, pancytopenic, scabies neutropenic, with\n hypotension, concern for SIRS, with new productive cough\n REASON FOR THIS EXAMINATION:\n r/ PNA, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n INDICATION: Hypertension. Productive cough.\n\n COMPARISON RADIOGRAPH: and .\n\n The heart size is normal. There is a persistent area of opacity in the right\n lower lobe with associated displacement of the fissure suggestive of\n atelectasis. There is a new area of opacity in the left retrocardiac region\n with air bronchograms, concerning for infectious pneumonia or aspiration.\n There is a persistent small right pleural effusion and there is a new small\n left pleural effusion.\n\n IMPRESSION:\n\n Persistent right lower lobe opacity, most likely atelectasis. New left\n retrocardiac opacity, concerning for infectious pneumonia or aspiration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 919912, "text": " 4:38 PM\n CHEST (PA & LAT) Clip # \n Reason: R/o infectious or infiltrative processPt needs mask. Is on T\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 yo M c HIV p/w progressive pancytopenia\n\n REASON FOR THIS EXAMINATION:\n R/o infectious or infiltrative processPt needs mask. Is on TB precautions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV and progressive pancytopenia, evaluate for infectious or\n infiltrative process.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: The right-sided PICC is in place with tip terminating in mid SVC,\n in unchanged position. Heart size and mediastinal contours are within normal\n limits. The lungs are clear. There is no pleural effusion or pneumothorax.\n Osseous structures appear within normal limits.\n\n IMPRESSION: No evidence of acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-31 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 919981, "text": " 8:38 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Pt has very high Alk Phos. Pls evaluate for abdominal proces\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and CD4 less than 50. CMV colitis, Cryptosporidium,\n esoph. candidiasis, C. diff colits.\n REASON FOR THIS EXAMINATION:\n Pt has very high Alk Phos. Pls evaluate for abdominal process. U/S has to be\n done in room. Pls follow Scabies and TB precautions!!!!\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with HIV, CD4 less than 50, CMV colitis,\n cryptosporidiosis and esophageal candidiasis. Patient now with elevated\n alkaline phosphatase. Evaluate.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: The liver parenchyma is normal in echotexture. A few\n scattered areas of increased echogenicity near the right liver dome likely\n represent biliary hamartomas. No focal nodules or masses are detected. There\n is no intrahepatic biliary ductal dilatation. A moderate amount of sludge is\n seen within a non-distended gallbladder. The gallbladder wall is slightly\n thickened at 3 mm. The common bile duct dilated at 8 mm. The right kidney\n measures 9.3 cm. The left kidney measures 8.9 cm. A 10 x 6 x 8 mm cyst is\n seen within the interpolar, lateral left kidney. No hydronephrosis, stones,\n masses are seen bilaterally. The spleen is not enlarged at 9.0 cm. The\n pancreas and aorta are poorly visualized secondary to overlying bowel gas.\n\n IMPRESSION: Minimal thickened gallbladder wall with intraluminal sludge and\n slightly dilated common bile duct. These constellation of findings are\n concerning for HIV cholangiopathy.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-02 00:00:00.000", "description": "Report", "row_id": 1452478, "text": "NPN 7a-7p\nNeuro: Pt. alert and oriented-able to communicate needs. Pt. verbalilzed he understands DNR/DNI.\n\nResp: On 4L NC with sats 96-98%. CXR shows RML pna. Has congested cough but unalbe to cough sputum out. Breath sounds clear bilaterally. Was seen by ENT who obtained culture swabs. Thought tissued looked \"healthy\" but dry.\n\nCV: Unable to wean pressors-remains on dopa 20mcg levo 0.15 with BP 80-90/60 MAP 60's. Has had 4 L LR. Will be switching maintenance IVF. K 2.7, repeat 4.5 but was possibly contaminated by IVF running in. Will repeat. Was repleted with 40KCL and K phos and Mag.\n\nGI: Hypoactive bowel sounds. Had 3 episodes of diarrhea-stool for c-diff sent. TPN on hold.\n\nGU: Foley intact. Urine output 50-100cc/hr.\n\nEndo: insulin per ss\n\nID: Temp increased to 95. Bear hugger on. On broad spectrum antibiotics and isolation precautions for WBC 0.4. Antiretrovirals restarted.\n\nSkin: Scabies rash with some oozing of serosanquinous drainage.\n\nSocial: Family in to visit most of the day. Trying to get pt's mother here from .\n\nPlan\n-check k\n-monitor BP wean pressors as tolerated\n-IVF as ordered\n-monitor plts and replete as needed\n-stool sample to be sent for chem.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452479, "text": "micu-west npn 1900-0700\n*Code status: DNR/DNI\n\nAllergies: Iodine\n\nPrecautions: Contact for Scabies/Droplet for ?TB\n\nin Brief: A 40 yo male w/ PMH: HIV; CD4=17. Also, significant for cryptosporidium, CMV colitis, C-Dif, esophogeal Yeast, malnutrition, Abnormal TFTs, H/o pancreatitis, scabies, anal candylomata, and panocytopenia/anemia - came to initially f0r treatment for anemia, FTT, and Panocytopenia (PLT < 7) thought to be caused by HAART medication. On pt. condition worsened becoming hypotensive while on floor, sbp 40s and tx w/ Dopamine and 3 L IVF w/ bump to sbp 60s, and this time pt. was transferred to MICU for maintenance of BP/?TB vs viral laryngitis.\n\nNeuro: Pt. is pleasant, able to follow commands, alert and oriented to person, place, and time, pupils pearl 2mm brisk, able to move all four extremeties on bed, gross muscle atrophy present in extremeties, pt. complains of weakness. Pt. sips H20 and swallows crushed meds.\n\nResp: Pt. is on 2L NC, O2 sats 98-100%, LS clear in upper lobes and diminished in lower lobes, occasional dry cough, CXR shows right mid-lobe PNA, ENT consult : multiple samples sent, no nodules visualized indicating doubtful of TB, although pt. remains on droplet precautions at this time.\n\nCV: Pt. received on Dopamine @ 20mcg/kg/min and Levophed @ 0.15mcg/kg/min w/ sbp=88-94, Map=58-70 and HR 110-140s. Around 0400, pt. Dopamine decreased to 10mcg/kg.hr and Levophed increased to 0.28mcg/kg/hr. Pt. sbp 95-106 and HR 125-135 NSR, no ectopy. Pulses palpable in all four extremties, though extremeties cool and dry. Right PICC Line - double lumen currently infusing D5W 1/2NS w/ 50mEq NaHCO3 @ 100cc/hr for 1 Liter. 4gm Ca+Glu repleted today for ICa+=0.9. K+ repletion HELD for K+ of 4.5. Peripheral IV WNL. Blood Cult- growing gram neg rods/pos cocci.\n\nGU/GI: Abd soft/firm/nontender, BS hypoactive, TPN on HOLD since , loose green stool x 4 medium amounts, Foley drainng 50-100cc/hr yellow/sediment urine.\n\nID: Pt. WBC =0.4, Lactic Acid=3.4, receiving steroids, Temp 95-97.5, bair hugger applied as needed, Abx Flagyl for C.Dif/Vanco/Cefepime.\n\nSkin: Pt. has highly contagious scabies from head to toe, tx. w/ Permetherine @ 00:00 and has patches of severe dry skin, tx w/ Eucerin @ .\n\nEndo: FSBS 130-150, follow SS\n\nSocial: Dr. met w/ pt. and pt. code status changed from Full Code to DNR/DNI tonight, cousins visited tonight, and family is coming from , will be here in about a week.\n\nPlan: Please obtain stool sample/C. Dif?\n Follow-up on morning labs ie: electrolyte repletion\n TPN?/ address nutrition needs\n TB? Need for Droplet precautions\n Follow-up on sputum cultures/blood cult\n Wean Dopamine/Levophed keeping MAPS>60.\n Await Enfuvurtide - arriving this evening\n Wash off premetherine this AM\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452480, "text": "NPN MICU-7 7AM-7PM\nEVENTS: PLT-9, started with lrge amts dark brown watery stool this AM, that advanced to BRB watery stool that required a recatl tube placed, and rec'd several blood products. Able to wean of Dopa Gtt but continues on Levo. Gtt.\n\nC/V: pt on Dopa and Levo Gtts, able to wean and d/c Dopa, but Levo continues @ 0.232 mcq/min/kq down from .280mcq. BP-86-96/60's, HR has come down from 140's ST to 98-105's with Dopa being off. K+-3.5, rec'd 40mEq KCL, and Mag+ repletion.\n\nRespir: Remains on 2-3L NP's with O2 sats 97-100%, but with RR 30-40's, appears to be tiring. Does not have an aline. Has no cough, remains on repsir precautions.\n\nGI:HEME; PLT Ct-9, is in DIC, INR-1.9, had dark red watery stool this AM but has advanced to BRB watery stool late morning. Rec'd 2 units PLT's, and 1 FFP, to rec PC's one unit when available from BB. No N/V noted. Rectal bag was placed but had to have a mushroom cath placed. Still having lrge amts Melena well over a 1200cc noted. Will transfuse with PC's then repeat levels. Is NPO.\n\nGU: U/O 50-70cc/hr with Bun/CRE-46/1.0. IVF's D5W with 3 amps Bicarb @50cc/hr started this afternoon.\n\nID: Temps 97-95.6 PO heating Bair hugger blanket was off for some of the day, but will be replaced this evening. WBC-0.4, continues on several IV antibx's which times have needed to be re-scheduled due to IV access difficulty. Still awaiting arrival of Enfurvirtide from Pharmacy.\n\nSkin: As MD's skin is improved, still on contact precautions. Applying skin cream's as ordered. Has two skin tears on buttocks, duoderms were applied.\n\nNeuro: A&Ox3, is very pleasant and cooperative is aware of how grave is prognosis is.\n\nIV access: Only has double lumen PICC line in place is difficult to administer all IV's, as ordered, has discussed with team the issue, but with PLT of 9 and bleeding cannot place an additional line.\n\nA/P: Continue to attempt to wean pressors, follow u/o. Assess bleeding and monitor HCT's,PLT Ct and administer blood products as needed. Assess lytes and replete as needed. Continue with IV antibx's, monitor temps use bair hugger blanket to keep temp 97 po.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452481, "text": "NPN ADDENDUM 7AM-7PM\nS/O: SOCIAL: Code Status was disussed with pt and with HCP and with Cousin was questions about reverseing the DNR/DNI status but after discussing the situation with the pt and family members adn fully explaining his grave condition pt dicided to remain a DNR/DNI. Will continue full aggressive treatment and will hopefully make it until his mother and brother arrive in a few days.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-04 00:00:00.000", "description": "Report", "row_id": 1452482, "text": "micu west 1900-0700 npn\n*Code status: dnr/dni\nAllergy: Iodine\n* Precautions: Contact for Scabies and Droplet for question TB\n\nSignificant Events: Pt. received TOTAL 3 units PRBCS for HCt=19 @ 1900, 1 unit FFP, and 1 unit Platlets for PLT=10. Also, total 60mEq of Potassium was repleted for K+=2.5.\n\nNeuro: Pt. is alert and oriented,able to follow commands and verbalize needs, voice hoarse, and pt. tires during effort to speak, pupils 3mm brisk, able to move all four extremeties on bed, although weak w/ gross muscle wasting, cough is very weak secondary to fatigue.\n\nResp: Pt. is on 2-3L NC, 02sats 98-100%, LS clear to diminshed in bases, cough effort is very weak/nonproductive, pt does not/is unable to expectorate any sputum.\n\nCv: Pt. is currently receiving Levophed 0.235 mc/kg/hr, sbp 90-115, MAP>60, HR 90-140 NS/ST no ectopy, HR decreasing from 140 to 100 since IVF and blood products infusing, suggesting need for hydration/volume, Dopamine OFF now for 24 hrs. Pt. received 1 L of D5W w/ 50mEq BiCarb, IVF was switched, and D5W is currently infusing @ rate of 200cc/hr for 1 L.\n\nGu/Gi: Foley draining yellow to drk yellow sediment urine 35-100cc/hr, urine sent for PH to determine Bicarb levels, abd soft/nontender, BS present, Mushroom cath draining increasing gross bloody liquid stool.pt has been NPO for 24hrs, does not take PO meds due to gross bloody liquid stool/GU bleed, TPN needed but there is currently no designated port available as Abx and Blood products are infusing via LICC -double lumen. Access has not been obtained as of now due to decreased PLT.\n\nId: Temp 95.7-99.5 for shift, Bair Hugger adjusted accordingly, Vanco Dc'd, ABX: Cefepime/Flagyl/Levofloxacon/Veroconizole\n\nEndo: FSBS covered per SS\n\nSkin: Applied Eucerin on dry areas/neck, coccyx abrasion/breakdown protected w/ duoderm, Scabies present on skin.\n\nSocial: Friends visited today/Health Care Proxy came and will visit tomorrow morning, Dr. met w/ pt. and discussed code status and disease process.\n\nPlan: Access for TPN needed/check PLT count/consider Precautions and pt. tenous condition before any transport\n Monitor PLT/HCT/K+/Mg; replete blood product/electrolytes as\n needed\n Monitor INR/bleeding\n Wean Levophed, maintaining Maps>60\n Social work consult today to discuss end of life issues\n One more sputum needed to r/o TB\n Permetherine (skin ointment) due Thursday\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-04 00:00:00.000", "description": "Report", "row_id": 1452483, "text": "Nursing Note:0700-1900\n\nCode Status:DNR/DNI\nAllergies:Iodine\nPrecautions: Scabies and Droplet question of TB.\n\n40 yo M with a hx of AIDSon salvage HAART admitted for tx of anemia, FTT, pancytopenia. On pt's condition worsened;hypotensive, SBP:40's. Transferred to MICU. Last night\npt. recieved 3units PRBC's bumping up HCT to 28.2 and recieved KCL repletion. Potassium 2.7.\n\nNeuro:A&Ox3, articulates well, follows commands, PERRL, labored MAE, cachectic, weak cough.\n\nResp: LS cta dim @ bases,SpO2:97-100%,RR 30's,weak, nonproductive cough, Sputum sent for 3rd TB.\n\nCV:Pt. recieved of Norepinephrine 0.235 mcg/kg/hr weaned to 0.093 mcg/kg/hr.\nTolerated well. D5W 200 ml/hr continuous. HR82-107 bpm, SBP:95-122,\nTemp:96-96.3, Pt requested removal of bearhugger.Potassium down to\n2.6 from 2.7/to be repleted.\n\nID:Temp:96-96.3,Bear hugger refused, ABX;Cipro q12h, Cefepime,Voriconazole. Levofloxacin D/C'd. Pt unable to swallow PO meds and cannot take HAART meds including subcut. unless all meds are administered, Dr notified.\n\nGI/GU:Foley draining adequate amount of clear amber urine. Mushroom cath draining liquid bloody stool/GI Bleed. Pt unable to take PO meds and all antiviral meds. Nutrition consult:Diet chg'd to Full Liquids; supplement, boost resource fruit beverage B/L/D. Pt continues to obsess about caloric intake/TPN/boost, he prefers the dietary chg to a more invasive procedure.\n\nEndo:Insulin SS protocol.\n\nAccess:PICC R ac. Dressing chg'd, patent.\n\nInteg:Scabies throughout body. Cream applied to neck and underarms.\nAbrasion breakdown on coccyx area, replaced 2 Duoderms. Skin flakes off. Frequent bed changes.\n\nSocial:Discussed end of life issues. Pt. is \"at peace\" and has come to an acceptance of disease process.\nFamily and friends visiting throughout the day. Very supportive.\nSocial work in to meet with pt and family. Pt.'s mother coming from on Thursday.\n\nPlan:Monitor patient for internal hemorrhage/INR/PLT. Replete blood products with HCT of 21. Current HCT 28. Monitor electrolytes.\nReplete prn.Continue to wean levophed. Ivermectin due .\nPermethrin due .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-05 00:00:00.000", "description": "Report", "row_id": 1452484, "text": "micu west 1900-0700 npn\nCode Status: DNR/DNI\nAllergy: Iodine\nPrecuations: Droplet for question TB and Contact for scabies\n\nSignificant Events: Pt. received (two) infusions of 60mEqKCl in 1 Liter D5W, for a K+ of 2.6 and received 150mEq Bicarb in 1 Liter D5W.\nAlso, anti-retroviral medications DC'd.\n\nNeuro: Pt. is alert and oriented, pupils 3m brisk, pt. is very weak w/ gross atrophy, but able to move extremeties well on bed. Pt. cough is weak, gag reflex impaired. Pt. is able to sip water, but is NOT taking the majority of his PO medication, but is able to sip medication crushed in water. Of note: Antiretrovirals are rendered inactive when crushed/ in addition all the anti-retrovirals must be taken for effectiveness/also, pt has not been very responsive to anti-retrovirals for some time, so Dr. and pt. agreed to D'C anti-retroviral mediction as effectiveness and absorption is in question. Pt voice is much stronger/less hoarse than previous, and pt. appears to be less lethargic since RBC/PLt/FFP transfusion.\n\nResp: Pt. received on 2L NC, O2 sat=98-100%, around 00:00 was able to D'C the NC w/ O2 sat=94-98%. Pt. cough is increasing in productivity, last sputum to r/o TB was sent , but lab cancelled specimen. Pt. does not complain of SOB, RR=20-30, decreased from 40s, and becoming more regular rather than shallow.\n\nCV: HR 75-90 NSR, Levophed has been weaned from 0.93 to 0.75 w/ sbp maintaining 90-115 MAp>65 (goal >60). Pt. received 1 Liter D5W w/ 150MEq Bicarb, and is currently receiving D5W @ 200cc/hr for maintenance fluid (continue for total 4L). In addition, pt. has received 1 L D5W w/ 60mEq K+Cl for K+=2.6 and an additional 1 L D5W w/ 60mEq K+Cl is currently infusing. Hct 28 (@2200) goal HCt>21.\n\nGU/GI: Foley draining 100-300cc/hr yellow/sedimenty urine, abd is firm, nontender, BS present, Mushroom cath draining large volumes of brown liquid stool, red tinged but significantly less frank blood than previous. Pt. is able to sip water and able to take Boost/Fruit nectar for calorie.\n\nID: Temp 95.7 Bair Hugger on, Levofloxacin DC'd/Cipro added/Flagl Dc'd\nBlood Culture for Psuedomonas.\n\nEndo: FSBS covered according to SS.\n\nSocial: Friend called tonight and informed pt/nurse that pt's mother will visit Thursday morning as well as four colleuges/friends from where pt. received PhD.\n\nPlan: Permetherine Ointment due/Ivermectin due as well\n cont. to monitor K+ and replete\n PLT=11 (trending down) Goal?\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-05 00:00:00.000", "description": "Report", "row_id": 1452485, "text": "NPN 7a-7p\nEVENTS: Levophed weaned off since 1100. MAPs>60. Pt has received total of 100mEq KCL and will get 60mEq more. Pt also received 2g Mg. Plts dropped to 8, and received 1u Plts-post plt count 53.\n\nNEURO: Pt is A@O, very pleasant man. Pt seems to be somewhat depressed today, anxious about his mother coming tomorrow and fears about what he looks like. Emotional support provided. Social worker also spoke with pt. Pt very weak, needing help moving around in bed. Pt refusing PO meds.\n\nCV: NSR 60s-90s. BP 80s-108/60s-70s, MAPs>60. Levophed off, as stated above. PM lytes to be checked @ MN.\n\nRESP: LS coarse upper, diminished @ bases. Pt has nonproductive cough. 3rd AFB pnding, 2 smears negative. Sats>96% on RA. RR 20s-30s.\n\nGI/GU: ABD is firm, +BS. Mushroom cath draining green liquid stool, guiac +. No visual blood. Pt taking occas sips of water and boost. 1500cc stool out @ 1200. Foley draining ample urine, 140-480cc/hr. D5W maintenance @100cc/hr-on 3rd out of 4L.\n\nENDO: BS have been 200s-300s, D5W. On humalog SS.\n\nID: Tmax 96.3, bear-hugger on most of day. +pseudomonas in blood. Pt also has scabies.\n\nSOCIAL: Pt has had many visitors today, including relatives. Pts mother will be flying in from tomorrow.\n\nPLAN: Continue to monitor BP, support as needed to maintain MAP>60. Continue skin care with creams and ointments for scabies. F/U with pm labs, replete lytes prn. Goal plts 10. Monitor for bleeding.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-06 00:00:00.000", "description": "Report", "row_id": 1452486, "text": "micu west npn 1900-1077\nDNR/DNI\n\nallergy: Iodine\n\nPrecaution: Contact for Scabies/Droplet for ?TB\n\nEvents: Pt. met w/ DSr. and has decided take PO medication, including HAART meds (anti-retrovirals), Pt. repleted 60mEq K+Cl for K+=3.5 and 15mmol Phosp repleted for Phos=1.7, and 500cc FB for sbp 90 and HR 120-140s, HR decreased to 9\\85-93 w/ FB.\n\nNeuro: Pt. is alert and oriented, given 2 tab Percocet for anxiety w/ good effect, pt. able to sleep for remainder of the night. Pt. is bale to move all extremeties on bed, despite complaints of weakness, gross muscle atrophy present in all four extremeties. Pupils 3mm brisk, cough weak, nonproductive and gag reflex intact, pt. is able to swallow pills whole and sip boost w/ no coughing.\n\nResp: Pt. LS are coars to clear in upper lobes and diminshed in bases, O2 sats 97-98% RA, RR was in 40s earlier this evening, but settled to 20-30 following fluid bolus, no complaints of SOB or difficulty breathing. Sputum 3 of 3 for ACB came back negative.\n\nCV: At 2100 pt. appeared to becoming more tachycardic/tachypneic, HR 110-120, 500cc FB given and HR decreased to 80-95 and RR decreased from 40 BPM to 20-30 BPM. Currently, HR 85-100 NSR, sbp 90-100 MAP.60.. Pt. has been off Levophed since @ 1100am. Pulses are palpbale in all four extremeties, 2+ edema noted in LE. K= 3.5 tx w/ 60MEqKCl in 1L D5W repletion, Phos=1.7 tx w/ 15mmol/20mEq K+Phos in 500ml D5W. 4 of 4 Liters D5W @ 100cc/hr IN @ 0600.\n\nHEME: hct 28/PLT 27 (post 1 unit PLT infusion )\n\nGU/GI: Foley draining 50-300cc/hr amber/yellow sediment urine, abd firm/slight tenderness noted on exam, mushroom cath draining approx 2L of brown to tan liquid stool, appearing tan following several sips of boost and PO medication. Pt has decided to take HAART medications as well as other PO medications, and has swallowed PO medication/Boost successfully.\n\nSkin: applied at midnight (dose 2 of 2).\n\nID: t=95-97.5, bair hugger on, ABX: Cefepime/Cipro\n\nEndo: FSBS covered SS\n\nSocial: Friends visited last night, will return this AM for rounds, mother to come today from , and health care proxy may come today as well. Pt. provided emotional support this evening, as he was deciding whether or not to take HAART medication. Ultimately, pt. decided to continue w/ HAARTs.\n\nPlan: Monitor BP, FB w/ NS for MAP>90\n Monitor PLT (GOAL>10), currently 27.\n Monitor electrolytes and replete as necessary\n PSYCH CONSULT for support\n Please START HAART medications in AM, as pt. requested taking them @ 0800\n Please rinse OFF pt. skin and apply Eucerin\n Allow friends/family visit, providing rest for pt per his request\n Cont. Potassium Phosphate infusion, running @ 80cc/hr\n Maintenance fluids?\n Please encourage BOOST/high calorie intake as tolerated by pt.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-06 00:00:00.000", "description": "Report", "row_id": 1452487, "text": "Nursing Note:0700-1900\n\nCode Status:DNR/DNI\nPrecautions:Contact and \nAllergies:Iodine\n\nNeuro:Calm, Cooperative Male,A&Ox3,PERRL,Pt OOB to Chair with\n2 assists; tolerated well. Pt. in good spirits today. MAE; pt at risk for falls, very weak. Pt. denies pain.Emotional support provided.\n\nResp:Coarse to clear LS dim at bases, weak cough effort. RR 26-38,\nSpO2:96-99%. Respiratory Precautions D/C'd. CO2-14\n\nCV:HR:89-111 ST/NSR, SBP:100-111,Mean:73-95,\nFluid goal 1 to 1 1/2 L positive, pedal pulses positive.\nCalcium Gluconate repletion. Ionized calcium:1.11\nPotassium 2.7, HCT 28.3, Hgb 10.2, Plt's 23, RBC's 3.27.\nPotassium to be repleted.Pending labs\n\nGI/GU:Pt has thrush and is being treated with antifungal, Vericonazole. Diet;full liquids, boost. Abd firm to palpation, bs+,\nMushroom catheter no longer in place, sphincter muscle has lost tone,\nunable to place rectal bag d/t continue flow of stool. Pt has padding and diaper on; chg'd q1hr. Urine specimen sent. Foley draing adequate\namounts of clear yellow urine. Lg quantity of liquid,brown stool outputfor shift\n\nEndo:Insulin SS protocol.\n\nInteg:Breakdown coccyx area, duoderms replaced multiple times d/t\ncontinual stooling.Breakdown on neck and underarms treated with Urea cream throughout day.\n\nSocial: multiple visitors and phone calls all day. very supportive family. Mother to arrive tomorrow. pt happy to be out of bed and into a chair today for visitors. Pt cousin, is contact person. Please refer callers and visitors to her for information.\n\nDispo: continue to replete lytes prn\nMonitor labs closely, Fluid goal 1 1/2 L positive,\ncontinue treating skin with urea cream.\ncont. to assess bp,temp. Monitor FS\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-07 00:00:00.000", "description": "Report", "row_id": 1452488, "text": "NURSING NOTES: 1900-0700\n40Y/O MALE ADMITTED FOR THROMBOCYTOPENIA\n\nPMH: HIV/AIDS \n CRYPTOSPIRIDIUM, CMV COLITIS, CDIFF COLITIS\n ESOPHAGEAL CANDIDIASIS, MALNUTRITION, ABNORMAL TFTS\n PANCREATITIS, SCABIES, ANAL CONDYLOMATA, PANCYTOPENIA, ANEMIA\n\nDNR/DNI\n\nIODINE ALLERGY.\n\nSIGNIFICANT EVENTS: LYTES REPLETION.\n\nNEURO. PATIENT REMAINS TO BE ALERT AND ORIENTED X3. MAE.3MM PERRLA/BSK. DENIES ANY PAIN. NO SEIZURE ACTIVITY NOTED ON THIS SHIFT.\n\nCV. NSR TO ST WITH HR BETWEEN 76-105 NO ECTOPY NOTED. SBP BETWEEN 102-112. PALPABLE PULSES NOTED ON ALL EXTREMETIES. HCT 30.4 FROM 28.3. K OF 2.7 REPLETED WITH 80 MEQS OF IV KCL AND 20MEQS PO KCL. K IN AM WAS 3.3 WILL REPLETE WITH 60MEQS MORE IV KCL. MG 1.7 TO BE REPLETED WITH 4 GMS OF MAGNESIUM SULFATE IV. NA 141 DOWN FROM 150 POST WATER BOLUSES. LAST PLATELET WAS 23.\n\nRESP. ON ROOM AIR SATTING BETWEEN 98-100% WITH CLEAR BIL BREATH SOUNDS WITH SLIGHTLY DIM BS AT THE BASES. EUPNEIC AT 26-30 NOT IN DISTRESS.\n\nGI/GU. HYPERACTIVE BOWEL SOUNDS. STILL DRAINING LARGE AMT OF LIQUID STOOLS. DIAPER IN PLACE. PATIENT NOT ON PPI AS PPI INCREASE CHANCE OF THROMBOCYTOPENIA PER DR. . FOLEY CATH DRAINING TO 50-200CC/HR CLEAR YELLOW URINE.\n\nID. TMAX 96.2 ON RETROVIRAL MEDS, CEFTRI AND CEFEPIME LAST WBC 11.3.\n\nSKIN. DRY/SCALY/FLAKING SKIN. STILL WITH SCABBIES. TOPICAL OINTMENTS APPLIED.\n\nACCESS. RT PICC LINE WNL.\n\nPLAN. MONITOR LYTES AND REPLETE IF NECESSARY. GOAL TO BE 1.5L POSITIVE. PLT GOAL OF >10. MONITOR FOR HYPOTENSION AND FLUID BOLUS IF NECESSARY. CHECK Q1-2 HOUR AND CHANGE DIAPER AS NECESSARY.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-09 00:00:00.000", "description": "Report", "row_id": 1452493, "text": "micu Nursing note \n\nNeuro pt awake and alert this am, at 1400 woke pt to turn was confused didn;t understand why i was turning him even after explaining it to pt took 10 min to reorient pt to what we were doing, pt follows commands but seem to have periods on confusion.\n\nCv pt through most of the day hr 70-90 sr at 1400 pt turned hr ^ 130 st called resident Bp stable at the time pt boluses with 500 cc n/s , hr dropped back to the 80's while getting bolus then after bolus finished hr back up into 120's Ivf changed to 1/2 ns at 150 hr, labs sent at that time ( and pending ) now\n\nGi abd soft nontender, pt still has flexflow rectal tube system passing green lig stool 800 cc this shift pt continues on octotide and opium for loose stool, pt taking poor intake incouraged to eat and drink but still has poor po intake,\n\n pt passing clear yellow urine via foley 100-200 cc hr.\nId pt hypothermic again was in bear hugger x5 hr pt remain on iv antibiotics and antivirals hct 27, wbc 14 plt 38 this am\nSkin pt still picking at skin pulling off scabs on neck and head told that he must stop because skin below and is bleeding , scalp washed andcream applied to head and body, scale covered with cap in order to remind pt not to pick at skin, pt remains on multi skin creams for dry skin and scabes,\n\nSocial spoke with family today about pt and that he does have periods of confusion they would like to speak with hiv specialist tomorrow to have a time line about therapy of new drug, also we need social service andcase worked to see pt about what type of care will be needed and if pt should be dischaged back to a long term care facility or a medical floor, at present pt talking a large amount of nursing time for care and would be to much care for nursing on floor, with need for lyte replacement and nutrition support and dirrehea control along with the fact pt will need a privite room, Right now is the time we need to balance the needs of the psycosocial along with medical, have the most amount of freedom and least restrictive enviornment, with the need for medical care will address this again with house staff tomorrow and also need to speak with id about long term needs, for isolation,\n\nA/p follow up with social services, care worked, Hiv and id, follow up with labs tonight may need replacement lytes and now looks to need more iv fluids, follow mental status and would talk with hiv speicalist about mental status and what meds may be part of making pt more confused\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452494, "text": "MICU 7 1900-0700 NPN\n\nPlease see flowsheet for objective data.\n\nNeuro: Patient's mental status fluctuates. When asked yes/no questions he answers appropriately, yet when RN administer's care he presents with confusion not understanding why care is being done even though POC has been explain previously. Early and Late in shift patient was lethargic. He was able to answer questions but did not take an interest in completing his oral medications. Upper and lower extremities are very weak and was not able to help in his turns.\n\nCV: Patient continues to be ST with no ectopy. 250cc bolus given and HR recovered to NSR. 60mEq PO of KCL, and 40mEq IV of KCL were ordered for correction of a Potassium level of 2.9. However patient would only take 20mEq of the PO KCL. need to replete remaining PO KCL via IV.\n\nResp: Patient continues to maintian >95% O2 sats on RA. Lung sounds remain clear throughout. Increased work of breathing and RR noted late in shift. 250 cc FB given, RR decreased to low 20's with occassional jumps to high 30's. Patient cough remains weak and patient states that he is not moving secretions.\n\nGI/GU: Patient remains on soft diet. No appetite noted this shift. Bowel sounds present, and flexitube inplace and draining green liquid stool. There is some leaking at rectum around tube, placed new kurlex and pads to absorb leakage and applied double guard cream to buttocks to protect skin. Patient continues to be on opium to correct excessive output of liquid stool. Foley is intact and draining large amounts of clear yellow urine. Urine output has significantly increased in the last 24 hours from 30cc/hr to 100-200cc/hr.\n\nID: Remains on contact precautions for scabies. Skin continues to be treated with multiple skin creams at bedside. Skin is very fragile at head and neck. Patient continues with bear hugger therapy due to low temps.\n\nSocial: Family into visit at 0000 after patient placed call to family.\n\nPlan: Continue to monitor hemodynamic status, follow electrolytes and replete when appropriate. Monitor fluid balance, team wants patient to be positive. ? mental status changes, is it r/t hemodynamic status, medications, or both. ? Long term plan for patient and plan for HIV MD consult requested by family.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452495, "text": "MICU 7 1900-0700 Addendum\n\n0600 FS 24, Amp of D50 given. At 0630 FS was up to 189. Very Lethargic this AM. Unable to take PO medication. D5 started at 100cc/hr. PICC port was clotted off, 1 cc of TPA was given with good effect.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452496, "text": "Micu Nursing note \n\nNeuro to very lathargic this am when bp 80/50 pt fluid boluses with 1l n/s and 1 liter Bp improved over an hr pt became more responsive when sbp > 100/. pt required multi lyte replacements durring the day and still passing lg amount of lig green stool hem pos, > 2 liters of stool this shift , u/o 400-500 cc hr. Family called in this am because pt was doing poorly.\nThis afternoon pt asked to speak with me in reguards to his care, after 45 min dicussion where pt was very clear, he stated that he didn't want this type of care any more would like to go home. wanted to be cmo,\nCall had aready been placed to Dr his Hiv md who did come in this evening also the icu fellow was called and informed about pt decision case mannagement was called and told of pt decision, a fmily discussion with DR , myself the family and the icu fellow. The family's concern is should go home with hospice or to a nursing home with hospice decause of the amount of nursing care,\n again verbalized to family his wishes for cmo, and case mannagement will work on dischage planning tomorrow,\nPlan is for pt to be transfered out to home /nh on hospice\nwill provide supportive care for pt and family\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452497, "text": "NURSING NOTE \nPT HAD VERBALIZED CONCERNS REGARDING WILL. PAGE TO AT SOCIAL SERVICES MADE IN AN ATTEMPT TO FIND OUT PROPER CHANNELS FOR MAKING ARRANGEMENTS- ADVISED TO GET IN TOUCH WITH LEGAL COUNSEL- DISCUSSED CASE WITH FROM LEGAL WHO INFORMED THIS RN THAT UNFORTUNATELY, THE HOSPITAL IS UNABLE TO REPRESENT PT IN REGARDS TO THESE MATTERS AND TO ADVISE PT TO MAKE ARRANGEMENTS WITH FAMILY AND HCP REGARDING HIRING PRIVATE COUNSEL AND AT THE HAVING HCP WRITE DOWN WISHES AND SIGN PAPER UNTIL LEGAL PREPARATIONS HAVE BEEN MADE. WILL DISCUSS AT LENGTH WITH THE PATIENT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-11 00:00:00.000", "description": "Report", "row_id": 1452498, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nCODE STATUS: CMO\n\nTHIS IS A 39 Y/O M WITH , NORWEGIAN SCABIES, END STAGE AIDS, CHORNIC DIARRHEA CRYPTOSPORIDIUM, C-DIFF AND CMV COLITIS, PANCYTOPENIA, ELECTROLYTE ABNORMALITIES WHO WAS ADMITTED FROM CC7 FOR HYPOTENSIVE CRISIS WITH SBP IN THE 40'S. AFTER A LONG, DETAILED DISCUSSION WITH PT, DR. (PRIMARY ID PHYSICIAN) AND MICU PT HAS ADVANCED CODE STATUS TO CMO AS OF AT 6PM.\n\nNEURO: PT IS BECOMING MORE SLEEPY THROUGH THE SHIFT. HAD BEEN ALERT AND ORIENTED X 3- LUCID AND NEUROLOGICALLY INTACT ENOUGH TO TAKE CARE OF LAST WILL AND TESTAMENT WHICH WAS WITNESSED AND NOTARIZED AT THE BEDSIDE. PT HAS BEEN VERY ANXIOUS ABOUT HIS COMFORT NEEDS AS HE BECOME MORE LETHARGIC, CONFUSED AND UNABLE TO VERBALIZE HIS PAIN MEDICATION NEEDS. SPOKE WITH THE PATIENT AT LENGTH ASSURING HIM THAT HE IS BEING CLOSELY MONITORED AND THAT COMFORT IS OUR PRIMARY ISSUE WITH HIM. PT HAS AN ORDER FOR PRN MORPHINE 2-10MG Q 1 HOUR AS NEEDED. AFTER LENGTHY DISCUSSION AND PT HAS BEEN VERY COMFORTABLE AND ABLE TO REST. PT HAS VERBALIZED THAT HE \"DOES NOT WANT TO PROLONG HIS LIFE AT ALL\". PERRLA, 3/BRISK. PT C/O CONSTANTLY BEING COLD- CURRENTLY HAS BAIR HUGGER ON FOR COMFORT. NO SEIZURE ACTIVITY NOTED. SPEECH REMAINS CLEAR AND HE IS FOLLOWING COMMANDS WITHOUT ANY DIFFICULTY.\n\nRR: PT CURRENTLY O2L NC. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES. PT C/O OF SOME SOB AT TIMES WHICH IS RELIEVED BY MORPHINE. SP02 > OR = TO 95%. BILATARAL CHEST EXPANSION NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-80'S WITH NO SIGNS OF ECTOPY. SBP > OR = TO 100. WEAKLY PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT IS STILL RECEIVING BICARB GTT AT 200CC/HR BUT AS PER DR. - WE ARE NOT TREATING ELECTROLYTES.\n\nGI: PT CONTINUES TO HAVE MASSIVE DIARRHEA- GREEN, LIQUID STOOL NOTED. PT HAS SECURE AND INTACT FECAL INCONTINENCE BAG. SOME SEEPAGE AROUND SITE- BUT FOR THE MOST PART STOOL IS CONTAINED. PT WOULD LIKE TO KEEP BAG ON.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: PT KNOWN TO HAVE NORWEGIAN SCABIES. CARE PROVIDERS AND ANY VISITORS MUST WEAR SHOE COVERS, CAP, GOWN AND GLOVES PRIOR TO ENTERING. PT NOTED TO HAVE DRY, SCALY SKIN THROUGHOUT BODY.\n\nSOCIAL: LARGE AMOUNTS OF FAMILY IN TO VISIT. PT ALSO ABLE TO TAKE PHONE CALLS. MOM AT BEDSIDE. ALL QUESTIONS ANSWERED.\n\nPLAN: CMO. D/C TO HOSPICE ASAP. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2150-08-08 00:00:00.000", "description": "Report", "row_id": 1452491, "text": "MIcu Nursing note \n\nNeuro pt is awake and alert following commands, this morning pt sent for head ct which was neg for a bleed, they felt his mental staus was slighly off, pt knows place sometimes is unable to state month.\n\nCv pt hemeodymanically stable, pulses weak but palp, bilaterally, pt\nhad 2 episodes where hr down in the 40's when asleep, bp stable at that time. pt remains on d5w at 100/hr Na still ^, pt still havving large amounts of loose brown which has now turned yellow this afternoon, pt needing lyte replacment , repeat lytes this afternoon K 3.0 and cal 7.2 house staff to put in orders to replace lytes.\n\nResp pt on Ra sats 96-100% lungs cta. pt has slight cough non productive.\n\nGi pt started on brat diet tonight, has been given 2 doses of opium po for loose stool bsx4, flexflow system patent,\n\nGu u/o low 10-20 cc hr amber urine\nId pt hypothermic placed on bearhugger this afternoon at 1500 temp 95.6 blood culture sent of picc today\nendo bs 148-152 requiring coverage at 6 pm 2 units reg sq.\nskin neck scalp with crusty scabs, and open areas because is picking skin told nt to pick scabs because underneight is very frigile and will try to wash scaple tomorrow.\n\nsocial asked pt today if he still wanted full treatment he said yes , told him that we need to treat dirrehea and that, if he wanted to be treated that this issue must be addressed and stated that the opium kills his appetite told hiwe understand but that liguid still in the amounts he has must be treated. her agreed to take opium tonight.\n\nA/P opium q6, repleat lytes , uncourage po's and continue with brat diet.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-09 00:00:00.000", "description": "Report", "row_id": 1452492, "text": "MICU 1900-0700 NPN\n\nPlease refer to flowsheet for all objective data.\n\nNeuro: Patient A/O x3 for most of shift. At times patient seemed confused when RN would respond to call bell. However patient could be reoriented quickly. MAE's, but stregnth is weak.\n\nCV: HR has been ST with no ectopy this shift. Pedal pulses are palpable bilaterally. 60 mEq of KCL was given for a potassium of 3.4. 2 grams of calcium gluconate was given to correct for a calcium of 7.1. Morning labs still pending.\n\nResp: Patient continues to sat at 95-100% on RA. Cough remains weak and nonproductive.\n\nGI/GU: Patient continues to have no appetite. Has requested water several times tonight. BS are present. Fecal bag remains intact and draining clear liquid stool. Foley remains intact and is draining amber colored urine.\n\nID: Remains on contact precautions for scabbies. Tmax this shift was 98.3. Patient continues to require bear hugger at times for hypothermia.\n\nSocial: Patients family was in to visit at the start of shift.\n\nPlan: Continue to monitor hemodynamic status. Continue contact precautions and topical ointments for skin. Follow lytes and replete when appropriate. ? call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-07 00:00:00.000", "description": "Report", "row_id": 1452489, "text": "NPN MICU-7 7AM-7PM\n41 YO MALE WITH +HIV/AIDS, WITH Cryptospiridum, CMV Colitis, C-diff Colitis, Esophageal Cnadidiasis, Anal Condylomata, Pancytopenia, Anemia, S/P Sepsis, and Scabies.\n\nEvents: Not as Alert today, and poor PO's.\n\nNeuro: Alert but extremely tired and sleepy, but easily arousable. Appears mildly confused @times, but is aware of time.date and place. Did not want to get out of bed today.\n\nC/V: BP stable to 98-110/60, HR 70's-80's SR with no ectopy noted. AM K+-3.3, rec'd 60mEq IV, Ca 7.5, MagS+ 1.7, was repleted. Repeat Lytes sent are PND.\n\nHEME: HCT-stable @ 30.4, PLT-29, PT/PTT 14/30.0 INR- 1.2. No s/s bleeding, no transfusions needed.\n\nGI: Continues having copious amts brown Liquidy stool, Flexi-seal stool bag was placed but is still leaking around the rectal area, but is better contained. Is very tired today not wanting any PO's today except for OJ this AM. T Bili-6.8. Was ordered for U/S but has not been done as yet.\n\nRESPIR: Remains on RA with O2 sats 98-100%, RR 24-28, L/S clear.\n\nGU: U/O 60-80cc/hr, BUN/CRE 37/0.8. Rec'ing IVF- NS 125cc/hr, Na+-141, T CO2-19.\n\nID: Temp 96-95.6, WBC-11.3. Continues on several IV antibx's and anti-virals.\n\nSkin: Seen by Derm. skin appears to be improving, rec'ing creme's as ordered. Has duoderm on two open areas on buttocks. Head and neck and back still with flaking off skin in lrge amts.\n\nSocial: Mother and Brother arrive from today, have been in/out visiting today. Dr discussed issues with the family.\n\nA/P: Continue to replete Lytes as needed, and continue IVF's as ordered. Assess GI output, and assess for re-bleeding, check HCT, and PLT's . Apply skin cream's, as ordered. Monitor I&O's, as replete fluids as needed. Continue IV antibx's. Update family as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-08 00:00:00.000", "description": "Report", "row_id": 1452490, "text": "NURSING NOTES 1900-0700\n39 Y/O MALE ADMITTED FOR DIAGNOSIS OF THROMBOCYTOPENIA\n\nPMH: HIV/AIDS \n CRYPTOSPIRIDIUM, CMV COLITIS\n CDIFF COLITIS, ESOPHAGEAL CANDIDIASIS,\n MALNUTRITION, ABNORMAL TFTS, H/O OF PANCREATITIS, SCABIES,\n ANAL CONDYLOMATA, PANCYTOPENIA, ANEMIA.\n\nINITIAL ADMISSION CC7 FOR TX OF ANEMIA, FTT AND PANCYTOPENIA (PLT DOWN TO 7), THOUGHT TO BE MYELOSUPPRESSION FROM HAART MEDS AND MALNUTRITION. ON PT. WORSENING HYPOTENSION SBPS 40'S, DOPA AND 3L OF IV FLUID ADMINISTERED WHICH BROUGHT SBP TO 60'S, HENCE ADMIT TO MICU.\n\nDNR/DNI\n\nALLERGY: IODINE\n\n\nSIG EVENTS: LYTES REPLACEMENT, PATIENT SPOKE WITH MOTHER. VERBALIZED WANTING TO TALK WITH SOCIAL SERVICES AND ETHICS COMMITTEE, ALLOWED TO SLEEP FOR 4-5HRS WITH PLANNED CARE INTERRUPTIONS.\n\n\nNEURO. REMAINS ALERT AND ORIENTED X 3 WITH GENERAL WEAKNESS. MAE. PERRLA 3MM/BSK. DENIES OF ANY PAIN OR DISCOMFORT. NO SEIZURE ACTIVITY NOTED. PATIENT WAS ASSURED THAT HE HAS AN ADVOCATE THROUGH HIS NURSES IF HE EVER FEELS ALONE. PT OPEN TO SUGGESTION TO TALKING WITH SOCIAL SERVICES AND ETHICS COMMITTEE.\n\n\nCV. NSR HR BETWEEN 78-97 WITH NO ECTOPY NOTED. STRONG PALPABLE PULSES NOTED ON ALL EXTREMETIES. SBP 97-111. K=3.2 REPLACED TOTAL OF 100MEQS OF KCL, CO2=20 REPLACED WITH 100MEQS OF BICARB IN 1L OF D5W. HCT STABLE AT 30.1. LYTES RESULTS PENDING POST REPLETION.\n\n\nRESPI. ROOM AIR SATTING BETWEEN 95-100% EUPNEIC WITH RR BETWEEN 18-30. CLEAR BIL BREATHSOUNDS NOTED ON AUSCULTATION. OCCASSIONAL COUGHING NOTED, ENCOURAGED PATIENT TO TURN MORE OFTEN, AMENABLE.\n\nGI/GU. ON FULL LIQUID DIET. PLS ENCOURAGE. HYPERACTIVE BOWEL SOUNDS NOTED ON AUSCULTATION.PATIENT CONTINUES TO OOZE GREENISH LIQUID STOOL VIA FLEXI SEAL BAG. SYSTEM INTACT, FLEXI SEAL BALLOON REINFORCED WITH ADDTL 15CC SALINE TOT 45CC. TOTAL OF 1L EMPTIED IN LESS THAN 12 HOURS. PATIENT STARTED ON OCTREOTIDE, OPIUM TINCTURE AND LOPERAMIDE BUT REFUSED LOPERAMIDE AND OPIUM TINCTURE DESPITE OF ENCOURAGEMENT. FOLEY CATH DRAINING TO OF 30-100CC/HR..\n\nENDO. FSS COVERED BY SLIDING SCALE \n\nSKIN. DRY FLAKY SKIN. TOPICAL OINTMENTS ADMINISTERED. ENCOURAGED NOT TO SCRATCH. HAS NOWRWEGIAN SCABIES WHICH IS BEING TREATED WITH PERMETHRINE OINMENT ONCE EVERY 2 WEEKS. POSITIVE SKIN BREAKDOWN IN COCCYX.\n\nID. TMAX 95.9 BAIR HUGGER AND WARM PACKS OFFERED BUT REFUSED. EXTRA BLANKETS PROVIDED. WBC 14.1. PT CONTINUES TO BE ON RETROVIALS AND ANTIBIOTICS.\n\nPLAN. MAINTAIN PLT >10, CONT TO MONITOR LYTES AND REPLETE IF NECESSARY. HAVE SOCIAL WORKER AND ETHICS COMMITTEE TOUCH BASE WITH PATIENT. START CALORIE COUNT. PROVIDE EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452501, "text": "NURSING NOTES 0700-1900\n39 Y/O MALE PT WITH END STAGE AIDS, NORWEGIAN SCABBIES, CHRONIC DIARRHEA, CMV COLITIS, CDIFF,CRYPTOSPORIDIUM AND ELECTROLYTE ABNORMALITIES. INITIALLY ADMITTED AT CC7 FOR ANEMIA, FTT AND PANCYTOPENIA HAD HYPOTENSIVE CRISIS WITH SBP IN THE 40'S THUS TRANSFER TO MICU.\n\nPATIENT HAS DECIDED HIMSELF TO BE ON COMFORT MEASURES LAST /O6. PATIENT IS CURRENTLY ON MORPHINE DRIP AT 5MG/HR REQUIRING RESCUE DOSES AT TIMES FOR PAIN/GEN DISCOMFORT MOSTLY FROM HIS COCCYX. HE IS LUCID, LETHARGIC BUT VERY MUCH ORIENTED X 3.\n\nPATIENT HAS BEEN ST WITH HR RATE IN THE 120'S WITH SBP BETWEEN 85-90'SMMHG.\n\nCONTINUES TO BE ON ROOM AIR, EUPNEIC RR IN THE 20'S SATTING BETWEEN 95-100%.\n\nOF NOTE PATIENT HAS A PHD DEGREE IN ECONOMICS AND IS VERY MUCH LOVED BY A LOT OF FRIENDS AND FAMILY. MOTHER AND BROTHER FLEW IN FROM . PATIENT VALUES A LOT THAT HIS WISHES WOULD NOT BE REVERSED WHEN HE IS NOT LUCID ANYMORE AND THAT HE WOULD DIE WITH DIGNITY.\n\nPLEASE PROVIDE PATIENT AND FAMILY EMOTIONAL/SPIRITUAL SUPPORT DURING THE DYIN/GRIEVING PROCESS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452502, "text": "NURSING NOTES ADDENDUM 0700-1900\nPT AT 140S WITH SATS AROUND THE 80'S WITH LABORED BREATHING, TALKED WITH PATIENT, REQUESTING FOR FAMILY TO BE AROUND, WAS ABLE TO SPEAK WITH (COUSIN), THEY WILL BE IN ASAP. NURSE WITH PATIENT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452503, "text": "Transfer to the floor is on hold.\nAgonal breathing, sats in the 60's. Morphine gtt was increased to 10 mg/h at 1715.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452504, "text": "PT PASSES AWAY AT ON , DR PRONOUCED. FAMILY AWARE, PT'S BELONGES SENT WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-11 00:00:00.000", "description": "Report", "row_id": 1452499, "text": "Nsg Progress Note 0700-1900\n\nCV - Pt hemodynamically stable. IVF dc'd. HR NSR with no ectopy although it is becoming slightly irregular.\n\nResp - No O2. O2sats excellent on RA and no c/o SOB or difficulty breathing. BS cl bilat. Dry spont cough. Pt did have 3 short episodes of nose bleed from left nares only. Bleeding stopped spontaneously. No episodes since 1300.\n\nGI - Pt has no interest in eating. Abd soft with positive BS. Mushroom cath placed for large amt green liquid stool.\n\nGU - foley cath draining mod - large amt clear yellow urine. Urine is occasionally blood tinged but clears on its own.\n\nNeuro - Pt very awake in the morning and able to help with turns and care. A&O x3 and very aware of surroundings. Pt requesting more pain med and as the day progressed - he is sleeping more and takes longer to orient self to place and time. He is still oriented and appropriate and stated that he just wants to sleep and not be awake anymore.\n\nSocial - Mother, brother and in all day. They have been updated on condition by attending and case manager and social worker. They are all in agreement with patient's wishes. They would prefer to keep patient in hospital if death looks imminent but they are also comfortable with patient being transferred to hospice if necessary.\n\nCode status - Pt remains a CMO and antibiotics and IVF's have been dc'd. Pt receiveing MSO4 as requested to keep him comfortable. He responds well to 5 mg IVP q 3-4 hours.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452500, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM DAY SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVRIONMENT SECURED FOR SAFETY.\n\nTHIS IS A 39 Y/O MALE W/ NORWEGIAN SCABIES, END STAGE AIDS, CHRONIC DIARRHEA CMV COLITIS, C-DIFF AND CRYPTOSPORIDIUM, PANCYTOPENIA AND ELECTROLYTE ABNORMALITIES THAT WAS INITIALLY ADMITTED FROM CC7 IN HYPOTENSIVE CRISIS; SBP 40-60'S. AFTER A LONG, DETAILED DISCUSSION WITH FAMILY, PRIMARY CARE- DR. AND MICU PT ADVANCED HIS CODE STATUS TO CMO AS OF . SOCIAL SERVICES IS ACTIVELY ATTEMPTING TO ARRANGE PLCMT INTO HOSPICE NH.\n\nPT HAS BEEN COMFORTABLE FOR MOST OF SHIFT. CURRENTLY RECEIVING IVP OF 10MG MORPHINE Q 2-3 HOURS FOR COMPLAINTS OF GENERALIZED DISCOMFORT. REMAINS LUCID- ORIENTED X 3- LETHARGIC AT TIMES. PROVIDING CONSTANT REASSURANCE THAT HIS DISCOMFORT WILL NOT GET OUT OF CONTROL. MOTHER HAS BEEN SPENDING THE NIGHT AT THE BEDSIDE. PLAN IS FOR PLCMT IN HOSPICE NH- AND MANAGING DISCOMFORT WITH MORPHINE DURING TRANSITION. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n" } ]
8,988	192,643	On hospital day number one, the intra-aortic balloon pump remains in place. The patient is stable. He had a head CT scan which showed chronic lacunar infarcts and cisterna magna. Cardiology was consulted who agreed with the patient's therapy and also recommended the cardiac surgery consultation for possible coronary artery bypass graft in the future. Neurology was consulted for the patient's finding on the CT scan. Neurology's opinion was that the patient's findings were due to old long-standing hypertension and there were no clinical signs or symptoms concerning for embolic ischemic cerebrovascular disease at the time of examination. The patient had some signs and symptoms of Parkinson's, however, that was not an acute issue and would not warrant any evaluation at that time. On hospital day number three, the patient had carotid Duplex Doppler which was within normal limits. The patient was taken to an Operating Room on , where a coronary artery bypass graft times three with saphenous vein graft to left anterior descending, left internal mammary artery to diagonal and saphenous vein graft to obtuse marginal was performed. The operation went without complications. Pacing wires as well as mediastinal and pleural tubes were placed. Postoperative day number one, the patient had to be bolused a few times to keep his cardiac index in an acceptable range. The patient was weaned off Propofol and was alert and arousable. On postoperative day number two, intra-aortic balloon pump was removed; the patient was extubated. He had an episode of atrial fibrillation which responded to Amiodarone bolus. The patient was started on an Amiodarone drip which was discontinued later in the morning. Electrophysiology Service was consulted who suggested that the patient may need a pacer at some point in the future. On postoperative day number three, the patient had episodes of bradycardia arrhythmia and a couple of episodes of atrial fibrillation which responded to Amiodarone boluses as well. The chest tube was successfully removed. On postoperative day number four, the patient continued to go in and out of atrial fibrillation. When he is in atrial fibrillation his rate is about 90. When the patient is in normal sinus rhythm, his rate is anywhere from 60 to 70. On postoperative day number five, the patient had a few episodes of rate controlled atrial fibrillation converted spontaneously, so it was decided not to start the patient on Lopressor or Amiodarone due to the possibility of a block. He was started on anti-coagulation for his atrial fibrillation. Postoperative day number six, the patient continues to go in and out of rate controlled atrial fibrillation. On postoperative day number seven, again rate controlled atrial fibrillation. The patient was transferred to the floor in stable condition. On the floor overnight, the patient had a six second asystolic episode when transitioned from rate controlled atrial fibrillation to normal sinus rhythm. The patient was asymptomatic at that time. His blood pressure remained stable. He was seen again by Electrophysiology Service who at this point recommended a pacemaker placement. The patient's warfarin and heparin were held overnight. On postoperative day number eight, Lopressor was discontinued. He continues going in and out of atrial fibrillation, rate controlled, and had a couple of episodes of brady arrhythmia which resolved spontaneously. On postoperative day number nine, the patient was taken to Electrophysiology Laboratory where a dual chamber rate responsive pacemaker was placed. The patient had some blood loss and it was recommended by Electrophysiology Service to hold all his anti-coagulation for a few days. The patient was also started on a few doses of Cefazolin per Electrophysiology Service protocol. Also, on postoperative day number five, urinalysis was done which showed a urinary tract infection for which the patient was treated with a five day course of Ciprofloxacin. At this point, the patient has no complaints, no active issues. The issue of anti-coagulation will be decided between the Cardiothoracic and the Electrophysiology Services before the patient is discharged and will be discussed with him and his family.	LUNGS CLEAR - COARSE AFTER TCDP AND INSENTIVE SPEROMETRY. There is a hazy opacity involving the left base consistent with a pleural effusion. Small left sided pleural effusion with associated atelectatic changes. Right bundle-branch block with left anterior fascicular block.Compared to the previous tracing of no significant change.TRACING #1 I believe this finding represents a so-called cisterna magna, as opposed to a retrocerebellar cyst. 3) Minimal nonspecific hazy increased density persists in both lung bases. Left atrial abnormality. Note is made of a small hiatal hernia. There is a right apical opacity as well as a patchy opacity within the right middle lobe. The left lung demonstrated a small left sided pleural effusion with associated atelectatic changes. The trachea is deviated to the right of the chest and there is effusion versus pleural thickening most marked at the right apex and to a lesser degree at the left apex. There are bibasilar parenchymal opacities, unchanged from prior study. Rightbundle-branch block with left anterior fascicular block. Note is made of a calcified granuloma in the left upper lobe. 2) Left sided pleural effusion. There is right apical and right middle lobe opacity probably representing atelectasis and/or scarring. The prominence in the chest radiograph most likely represented a tortuous ectatic aorta. Additionally, there is a very large cerebrospinal fluid space posterior to the cerebellum, but without apparent mass effect. There is ectasia of the aorta with calcification consistent with atherosclerotic disease. There is coronary calcifications. However, there are multiple tiny areas of low density within the head of the left caudate nucleus, the right lentiform nucleus and the cerebellar hemispheres bilaterally, consistent with chronic lacunar infarcts. FINDINGS: Duplex and color Doppler demonstrate normal carotid systems bilaterally. There is a dual lead left sided pacemaker with leads appropriately positioned. Sinus rhythm. Sinus rhythm. Sinus rhythm. Since the previoustracing of ST-T wave changes are decreased. Right bundle-branch block with leftanterior fascicular block. Sinus rhythm- borderline first degree A-V blockRBBB with left anterior fascicular blockST-T changes consider ischemiaQRS changes in lead V3 - ? The previously noted endotracheal tube, Swan Ganz catheter, NG tube, and chest tubes have been removed. There are sternal wires and clips overlying the cardiac silhouette consistent with a previous CABG. There are bilateral pleural effusions. The right lung is decreased in volume. There is still minimal nonspecific increased density in both lung bases. LS DIMINISHED AT BASES. Cardiac and mediastinal contours are unchanged. RA=91%.ABD SOFT WITH + BS. DUODERMS INTACT ON BACK/COCCYX.2+PEDAL EDEMA.SKIN EXTREMELY DRY/FLAKY. The ET tube, bilateral chest tubes, right swan ganz catheter, and numerous mediastinal clips and wires are essentially unchanged in position. This other mediastinal drain are less likely a right chest tube terminating adjacent to the right mediastinum. A right cordis remains in place, its tip in the distal right internal jugular vein. The aorta is tortuous and a radiopaque marker of the intra-aortic balloon pump is 7.3 cm below the most superior aspect of the aortic arch. PT DOES APPEAR COMF EXTUB. PT UPDATE PT IS S/P CABG X3 YEST. BILOUS DRG. Reversing paralytics currently.GU: UOP very low in OR. C/O naseau once, Zofran given. Resp: O2 on at 1L NC. Nursing Note 7A-7PNeuro: Arouses to voice, awake oriented to person, place, disoriented to time or day. REMAINS ON NTG (SEE FLOW SHEET FOR EXACT DOSEAGES). CXR-IABP placement better per , PA. 1st units PRBC going in now. UOP improving currently.GI: OG to LCWS, bilious drainage. Lungs clear.NEURO: Propfol still infusing. During day, pt stated place was , , Sitchuit. POST-EXT. HEPARIN GTT CONT. IABP 1:1, poor wave form, fling, team notified, attempted to fix. Will vpace 100%, but CO still low. R IJ IABP CONT. Passing gas, requested bedpan once but no BM.ENDO: BG wNL.SKIN: Arms still edematous, cordis in place. Iapb on 1:1 all night with good augmentation.GI: ogt patent drianing bilious fluid.GU: urjine outputs adequate.skin: incisions clean and dry no drainage. TO HAVE GOOD DIASTOLIC AUGMENTATION AND SYS UNLOADING, SEE FLOW SHEET FOR EXACT #'S. IN TO ASSESS PT A FEW MINUTES AGO AND WANTS PT MORE AWAKE TO EXTUB. Ntg gtt started for HTN at that time. DOPPLERABLE PULSES BILT., FEET COOL TO TOUCH.RESP: BS CLEAR BILT., O2 WEANED DOWN TO 2L NP WITH SAT'S >95%.GI/GU: HOURLY URINES CONT. GI: OGT-LCWS. GIVEN 1 DOSE OF MAGSO4 (2GM'S), K LEVEL WNL. SHIFT UPDATE.PT. SHIFT UPDATE.PT. TO BE IN NSR WITH AT TIMES PERIODS OF 1 DEGREE AV BLOCK WITH PR INTERVALS OF >.24, MULTIFOCAL PVC'S NOTED THRU-OUT NIGHT. EXTUB. IV Lasix given, good diuresis.GI: Hypo bowel sounds. Epicardial pacing wires attached to pacer, back up rate of 60 set.PULM: Wean off O2, room air now with good sats. TO OOZE VERY SM. SX FOR OLD BL. CV: At beginning of shift, junctional vs CHB. CV: NSR, occass to rare PVC's. REPOSITIONED, U/O IMPROVING. TINGE-SCANT AMT. BS CLEAR, DECREASED IN BASES. BP stable. IABP advanced by , PA, waiting CXR results.PULM: CT's draining sanginous fluid, no airleak. Giving reversal agents presently. pt presented to csru- awake, alert,pleasant, on iv ntg and integrilin. HCT STABLE-28. BP stable at this time but CO low. When pacer turned down, NSR rate 70's. NODAL B/P STABLERESP CONTINUES TO REQUIRE FREQ ENCOURAGMENT TO LEAVE O2 ON DEEP BREATHING AND COUGHING WELL COARSE BS WITH SOME UPPER AIRWAY CONGESTIONLABS K COVERED X2 WITH 20MEQ IV KCL BS 121 NO COVERAGEGU/GI GOOD U/O WITH DECEASING AMTS IN AM MD AWARE NO PO FLUIDS MOUTH CARE FREQPLAN CONTINUE TO MONITOR EKG FOR CHANGES MAINTAIN WORKING PACER AMT, DSG CHANGED AND NEW PRESSURE DSG APPLIED. Extremely labile BP initially, treated with 3L LR and one unit PRBC so far. d/c iapb later today. CI 1.8-1.9 range, also treated with the fluid so far. EP consulted. IABP 1:1. Will tx low CI with 2 units PRBC.	35	[ { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 765678, "text": " 6:26 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate ? anterior mediastinal mass\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man pre-op CABG\n REASON FOR THIS EXAMINATION:\n evaluate ? anterior mediastinal mass\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Question anterior mediastinal mass.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the upper abdomen. 100 cc of optiray were given because of patient's\n debility. There are no previous examinations available for comparison.\n\n A chest X-ray performed on was used.\n\n There is ectasia of the aorta with calcification consistent with\n atherosclerotic disease. The heart is normal in size. There is coronary\n calcifications. There is no paracardial effusion. A filling defect is seen\n throughout the descending aorta consistent with the intraaortic balloon pump.\n There is no mediastinal or hilar lymphadenopathy. No mediastinal mass is\n identified. There is a right apical opacity as well as a patchy opacity\n within the right middle lobe. This is suggestive of atelectasis and/or\n scarring. The right lung is decreased in volume. There is no evidence of\n lung resection. There is evidence of pleural thickening at the right base, as\n well. There are right posterior rib fractures. The left lung demonstrated a\n small left sided pleural effusion with associated atelectatic changes. No\n nodules or masses are identified. Note is made of a calcified granuloma in\n the left upper lobe.\n\n Note is made of a small hiatal hernia. There is a simple right renal cyst\n that measured 3.4 x 3.2 cm. The patient has a appropriately positioned IVC\n filter.\n\n IMPRESSION:\n\n There is no anterior mediastinal mass or lymphadenopathy. The prominence in\n the chest radiograph most likely represented a tortuous ectatic aorta.\n\n There is right apical and right middle lobe opacity probably representing\n atelectasis and/or scarring. This causes decreased volume within the entire\n right lung.\n\n Small left sided pleural effusion with associated atelectatic changes.\n\n (Over)\n\n 6:26 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate ? anterior mediastinal mass\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 765636, "text": " 10:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pt with vagues h/o dizziness and needs CABG. Please eval for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD, HTN\n REASON FOR THIS EXAMINATION:\n Pt with vagues h/o dizziness and needs CABG. Please eval for presence of\n strokes/other lesions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dizziness; preoperative for coronary artery bypass.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no intracranial hemorrhage or shift of normally midline\n structures.\n\n However, there are multiple tiny areas of low density within the head of the\n left caudate nucleus, the right lentiform nucleus and the cerebellar\n hemispheres bilaterally, consistent with chronic lacunar infarcts.\n\n Additionally, there is a very large cerebrospinal fluid space posterior to the\n cerebellum, but without apparent mass effect. I believe this finding\n represents a so-called cisterna magna, as opposed to a retrocerebellar\n cyst. Considering patient age, there is only minor involutional change of the\n brain identified.\n\n CONCLUSION: Multiple chronic lacunar infarctions. cisterna magna.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765760, "text": " 3:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/IABP check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/IABP check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG and intraaortic balloon placement.\n\n Status post CABG. The chest is markedly rotated to the right. Endotracheal\n tube is 6 cm above carina. The tip of Swan-Ganz catheter overlies main\n pulmonary artery segment. Because of the rotation tip of intraaortic balloon\n is not clearly identified on this film. NG tube is present with distal end\n also not localized. Chest tube is present in the left lower hemithorax. No\n pneumothorax. There is biapical pleural thickening/effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765602, "text": " 2:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate IABP placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n REASON FOR THIS EXAMINATION:\n Evaluate IABP placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease with intra-aortic balloon pump.\n\n FINDINGS: There are no old films available for comparison. The trachea is\n deviated to the right of the chest and there is effusion versus pleural\n thickening most marked at the right apex and to a lesser degree at the left\n apex. The aorta is tortuous and a radiopaque marker of the intra-aortic\n balloon pump is 7.3 cm below the most superior aspect of the aortic arch.\n This other mediastinal drain are less likely a right chest tube terminating\n adjacent to the right mediastinum. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 765648, "text": " 12:39 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: CAD, DIZZINESS\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Coronary artery disease, dizziness.\n\n FINDINGS: Duplex and color Doppler demonstrate normal carotid systems\n bilaterally. There is also normal antegrade flow in both vertebral arteries.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 766533, "text": " 10:35 AM\n CHEST (PA & LAT) Clip # \n Reason: check lead placement and rule out pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CABG, and new pacemaker on left side\n REASON FOR THIS EXAMINATION:\n check lead placement and rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New pacemaker placement.\n\n Two views of the chest are compared to a previous study dated .\n\n There is a dual lead left sided pacemaker with leads appropriately positioned.\n There are sternal wires and clips overlying the cardiac silhouette consistent\n with a previous CABG. There is no pneumothorax. There is a hazy opacity\n involving the left base consistent with a pleural effusion. There is\n significant tortuousity of the aorta and enlargement of the heart. The\n patient is status post right upper lobectomy with staples in the hilar region.\n The right lung is otherwise clear.\n\n IMPRESSION:\n\n 1) Appropriately positioned left sided dual lead pacemaker.\n 2) Left sided pleural effusion.\n 3) No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765769, "text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check IAB placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n\n REASON FOR THIS EXAMINATION:\n check IAB placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89 y/o man with coronary artery disease status post intra aortic\n balloon pump placement.\n\n Portable AP supine view of the chest performed at 17:56 hours.\n Comparison film performed same day at 15:34 hours.\n\n Multiple lines and tubes overlie the visualized chest and abdomen. The ET\n tube, bilateral chest tubes, right swan ganz catheter, and numerous\n mediastinal clips and wires are essentially unchanged in position. An intra\n aortic balloon pump is not clearly visualized. There are bilateral pleural\n effusions. There are bibasilar parenchymal opacities, unchanged from prior\n study.\n\n IMPRESSION:\n\n 1. An intra aortic balloon pump is not clearly visualized. A follow up repeat\n radiograph with good positioning, removal of the overlying wires and tubes,\n and good inspiration should be performed for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765983, "text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man s/p cabg and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal.\n\n PORTABLE CHEST: Comparison is made to film from two days earlier. The\n previously noted endotracheal tube, Swan Ganz catheter, NG tube, and chest\n tubes have been removed. A right cordis remains in place, its tip in the\n distal right internal jugular vein. Cardiac and mediastinal contours are\n unchanged. There is stable pleural-based density in both lung apices, with no\n change in a more vertically oriented band-like density which projects over the\n left apex medially. There is no evidence of pneumothorax. There is still\n minimal nonspecific increased density in both lung bases.\n\n IMPRESSION:\n\n 1) Status post removal of all tubes and catheters as described, with a right\n Cordis now in place.\n\n 2) No evidence of pneumothorax.\n\n 3) Minimal nonspecific hazy increased density persists in both lung bases.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2148-08-23 00:00:00.000", "description": "Report", "row_id": 136683, "text": "Tracing taken with a magnet. Sinus rhythm. Right bundle-branch block with left\nanterior fascicular block. Intermittent paced beats.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-08-23 00:00:00.000", "description": "Report", "row_id": 136684, "text": "Sinus rhythm. Right bundle-branch block with left anterior fascicular block.\nCompared to the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 136685, "text": "Sinus rhythm. Left atrial abnormality. Marked left axis deviation. Right\nbundle-branch block with left anterior fascicular block. Since the previous\ntracing of ST-T wave changes are decreased.\n\n" }, { "category": "ECG", "chartdate": "2148-08-11 00:00:00.000", "description": "Report", "row_id": 136686, "text": "Sinus rhythm\n- first degree A-V block\nRBBB with left anterior fascicular block\nProbable anterior infarct - age undetermined\nLateral T wave changes offer additional evidence of ischemia\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 136687, "text": "Sinus rhythm\n- borderline first degree A-V block\nRBBB with left anterior fascicular block\nST-T changes consider ischemia\nQRS changes in lead V3 - ? position\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-18 00:00:00.000", "description": "Report", "row_id": 1380969, "text": "Pt. alert and answers all questions appropriately. Needs orientation to day but otherwise has good recall of recent events.\nPt. having several episodes of incontinence despite having penile appliance on. Pt. had episode of afib at 0400. that was reported to Dr. . HR <100 with good bp. K+ with a.m. labs was 3.3. kcl 20 meq po given. Nsr restored without intervention.Pt. swallowing with some discomfort in his throat. Says that his throat is sore.\nPlan: monitor rhythm; keep electrolytes wnl. slowly increase po diet as tol. OOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-18 00:00:00.000", "description": "Report", "row_id": 1380970, "text": "NEURO ALERT ORIENTED GOOD EQUAL STRENGHTS NO DEFECITS NOTED\n\nC/V NSR NO ECT UNTIL 1810 CONVERT TO AFIB HR 90S B/P 98/47 NO C/O MD AWARE NO TREATMENT AT THIS TIME\n\nRESP NC 1L SATS 99% RA SATS 92-94% LUNGS CLEAR\n\nGU/GI URINARY POUCH REAPPLIED GOOD U/O BAG INTACT ABD SOFT POSITIVE FLATUS TOL PO FAIR C/O SORE THROAT MD AND SOFT FOODS GIVEN\n\nACTIVITY OOB TO CHAIR X2 ASSISTS TOL WELL GOOD WEIGHT BEARING\n\nPLAN INCREASE ACTIVITY AS TOL MONITOR EKG CHANGES\n" }, { "category": "Nursing/other", "chartdate": "2148-08-19 00:00:00.000", "description": "Report", "row_id": 1380971, "text": "8-11/11P-7A\n\nNEUROLOGICALLY INTACT. FOLLOWING COMMANDS.MAE, ALTHOUGH VERY STIFF.NSR WITH STABLE BP. LS DIMINISHED AT BASES. 1.5LNC SATS=97%. RA=91%.\nABD SOFT WITH + BS. URINE COLLECTION POUCH INTACT AND WORKING GREAT. CLOUDY YELLOW URINE. DUODERMS INTACT ON BACK/COCCYX.2+PEDAL EDEMA.\nSKIN EXTREMELY DRY/FLAKY. -OIL APPLIED ALL OVER.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-19 00:00:00.000", "description": "Report", "row_id": 1380972, "text": " 7a-7p Addendum to transfer note:\nOn transfer but no beds available.\nStable with improvement to bp 100-140's/50-59; Sats 97-98% on 1.5 via nc. DB&C / IS encouraged. OOB to chair with improving mobility. Eating small amts from meal trays. Total 575 cc cloudy urine (7a-7p).\n" }, { "category": "Nursing/other", "chartdate": "2148-08-20 00:00:00.000", "description": "Report", "row_id": 1380973, "text": "D PATIENT ALERT AND ORIENTED MOVING ALL EXTREMETIES NSR MOST OF THE SHIFT BUT WENT INTO AFIB WITH A HR OF 90 -120 TOLERATED WELL CONVERTED BACK TO NSR ON OWN AT PRESENT WITH OUT ECTOPI. PATIENT UNABLE TO SUCCESSFULLY USE THE URINAL. A URINE POUCH WAS PUT IN PLACE TO COLLECT THE URINE. CLEAR YELLOW URINE. ABD SOFT WITH BOWEL SOUNDS. LUNGS CLEAR - COARSE AFTER TCDP AND INSENTIVE SPEROMETRY. MOVING . SAT REMAIN >94. ON 1.5 L NC. TURNED FREQUENTLY .\n SKIN INTEGRITY DRY WITH POOR TURGER. LOTION APPLIED TO LEGS. DOUDERM REMAINS ON BACK AND COCCYX PRESSER SITES .\nA PATIENT STABLE. HAS PERIODS OF AF WHICH HE TOLERATEDS WELL.SKIN INTEGRITY IS POOR.\nR TURN FREQUENTLY. INCOURAGE TCDP AND INSENTIVE SPEROMETRY.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380957, "text": "89 y.o. male readmitted to CSRU after CABG x 3 using the LIMA and SVG. Difficult intubation in OR due to limited range of motion of neck. Received 3 units PRBC in OR. Otherwise uneventful OR time. Extremely labil BP first 3 hours in unit but now stabilizing.\n\nCV: NSR, long PR interval, rate 60's. Apaced, rate 80 currently. 2Atrial and 2Ventrical epicardial wires attached to pacer. Still warming. Extremely labile BP initially, treated with 3L LR and one unit PRBC so far. CI 1.8-1.9 range, also treated with the fluid so far. Waiting for team to decide on latest CI. IABP 1:1, poor wave form, fling, team notified, attempted to fix. IABP advanced by , PA, waiting CXR results.\n\nPULM: CT's draining sanginous fluid, no airleak. Lungs clear.\n\nNEURO: Propfol still infusing. Reversing paralytics currently.\n\nGU: UOP very low in OR. UOP improving currently.\n\nGI: OG to LCWS, bilious drainage. No bowel sounds.\n\nENDO: BG WNL so far.\n\nSKIN: Right fem IABP site not bleeding, dsg changed. Multiple central lines/alines.\n\nPLAN: Waiting for team to view CXR, decide on tx for low CI. Giving reversal agents presently.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380958, "text": "Will tx low CI with 2 units PRBC. CXR-IABP placement better per , PA. 1st units PRBC going in now.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380959, "text": "Neuro: propofol weaned off pt wakes with stimulation, following commands nodding head to questions but still sleepy.\nResp: Pt remained vented overnight, good abg's weaning vent at present with plans to extubate this am with anesthesia present 2nd to difficult intubation.Chest tubes patent draining serous sanguinious fluid.\nC/V: pt a paced underlying rhythm sinus with rat in the low 70's but bp dips with this rhythm. pt required 2 units of pc's 2u ffp and 1l hespan for volume 2nd to low cardiac index. svo2 prior to volume 71 but ci 1.7 post volum index >2. Iapb on 1:1 all night with good augmentation.\nGI: ogt patent drianing bilious fluid.\nGU: urjine outputs adequate.\nskin: incisions clean and dry no drainage. Iabp no oozing. pt heels reddened.\nPlan wean to extubate ? d/c iapb later today.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380954, "text": "SHIFT UPDATE.\nHOURLY URINES DROPPING TO 10CC X3/HR'S, CCU RESIDENT NOTIFIED AND AWAITING TO EVALUATE PT. NO INTERVENTION GIVEN AT THIS TIME. VSS CONT. TO BE STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380955, "text": "CV: NSR, occass to rare PVC's. AFebrile. IABP 1:1. Balloon alarming gas leakage almost constantly this a.m. Team notified, while preparing pt to go to cath lab to change out balloon, alarm quit. Decided not to change it. Only change had been in pt's position. Site is oozing blood, hematoma present but unchanged from previous shift.\n\nPULM: 2L/NC, sats 98%. Strong cough. Lungs clear. Pt going to CAT scan for CT of chest now for \"mass seen on mediastinum\" NP.\n\nNEURO: Alert, oriented. No c/o CP today. Agrees to CABG tomorrow. CT of head and doppler of carotids done today.\n\nGU: 250cc fluid bolus and MIVF restarted due to low UOP. UOP seems to increase when BP is higher. Small amt bloody drainage from catheter.\n\nGI: Ate 75% breakfast, 25% lunch. C/O naseau once, Zofran given. No CP at that time.\n\nPLAN: CT scan of chest now.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380956, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, OR PROCEDURE REVIEWED WITH PATIENT. APPEARS TO BE UNDERSTANDING POST-OPERATIVE BYPASS SURGERY. GIVEN 5MG PO AMBIEN AT BEDTIME, PT. SLEEPING ALL NIGHT, EASILY AROUSABLE BUT AT TIMES DID APPEAR TO BE CONFUSED BUT EASILY RE-ORIENTED BACK TO PLACE AND TIME. LOG ROLLED SIDE TO SIDE BUT D/T IABP CONSISTENTLY GAS LEAKAGE WHILE ON SIDES PT. LEFT ON BACK AND FLAT IN BED.\nCARDIAC: CONT. TO BE IN NSR WITH OCCASSIONAL PVC'S, LABS CHECKED AND TREATED AS NEEDED. R GROIN IABP CONT. TO OOZE FROM AROUND SITE, PRESSURE DSG'S CHANGED X2, SITE CONT. TO HAVE A HEMATOMA NOTED BUT HAS NOT EXPANDED PAST MARKER OUTLINE. DOPPLERABLE PULSES, FEET COOL TO TOUCH. CONT. TO HAVE GOOD DIASTOLIC AUGMENTATION AND SYS UNLOADING, SEE FLOW SHEET FOR EXACT #'S. NTG GTT REMAINS ON AT 100MCG/MIN KEEP SYS ~90-120 WITH MAP'S IN THE 70'S. HEPARIN GTT CONT. TO BE TITRATED TO KEEP PTT AROUND 60'S, PREVIOUS PTT IN THE 70'S AND GTT DECREASED TO 700U/HR, PTT PENDING. IVF D/C'D AT 2200PM.\nRESP: BS SLIGHTLY DIMINISHED IN BASES, O2 ON AT 2L NP WITH SAT'S >96%.\nGI/GU: HOURLY URINES ACCEPTABLE, CONT. TO HAVE DRAINAGE FROM AROUND MEATUS, CLEANED SEVERAL TIMES, STAT U/A SENT LAST EVENING. + BS THRU-OUT, TOLERATING SUPPER AND PT. MADE NPO AFTER MN.\nSOCIAL: SON AND INTO VISIT, UPDATES GIVEN REGARDING PENDING SURGERY AND QUESTIONS ANSWERED REGARDING CXRAY FINDINGS (MASS NOTED IN MEDIASTINUM) AND FOLLOW UP CHEST CT (WHICH RESULTS STILL PENDING), PT. ALSO AWARE OF CXRAY FINDINGS.\nSURGERY: UA SENT, BATH SCRUB DONE AND TYPE AND SCREEN SENT TO BB. ALSO FULL CHEM 7, COAGS, CBC/DIFF SENT TO LAB THIS AM, PRE-OP CHECK LIST ALSO STARTED.\nPLAN: CABG THIS AM WITH DR. , RESULTS OF CHEST CT, PTT LEVEL.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-16 00:00:00.000", "description": "Report", "row_id": 1380965, "text": "NEURO ALERT CONFUSED TO PLACE AND TIME AWARE OF PERSON ONLY MOVES ALL EXTREMTIES NO WEAKNESS NOTED INCREASE AGITATION DURING NOC PULLING AT LINES EKG CABLES WHEN ATTEMTED TO ORIENT PT \"GO JUMP IN A \" HALDOL 2MG GIVEN WITH GOOD EFFECT DECREASE AGITATION SLEEPING IN NAPS\n\nC/V NSR WITH PACS B/P INCREASE AT TIMES RESPONDS WELL TO IV NITRO ON AND OFF DURING NOC GOOD DOPPLER PULSES EPI WIRES INTACT BACKUP RATE OF 60 NOT NEEDED\n\nRESP NC4L WITH SATS 98-99% LUNGS CLEAR MUCH IMPROVED PRODUCTIVE FOR SMALL AMTS CLEAR SECRETIONS\n\nPLAN CONTINUE TO MONITOR CARDIAC STATUS MAINTAIN CURRENT STATUS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-16 00:00:00.000", "description": "Report", "row_id": 1380966, "text": "CV: NSR, no ectopy. Approx 1430, pt in and out of afib, highest rate seen is 111. BP stable. Hydralazine po ordered but not given yet due to parameters set for med. AFebrile. Epicardial pacing wires attached to pacer, back up rate of 60 set.\n\nPULM: Wean off O2, room air now with good sats. Lungs clear.\n\nNEURO: Disoriented to place, answers year correctly every time and knows people. Pt very drowsy today. Woke up to eat breakfast but asleep since. Wakes to noxious stimuli. No pain meds given. OOB with max assitance x 2, pt barely moves feet.\n\nGU: Pt pulled on Foley, urine became bloody and had clots in it. Irrigated catheter, urine now clear with small amt bloody sediment. IV lasix as scheduled.\n\nGI: Ate half of breakfast, no lunch. Passing gas, requested bedpan once but no BM.\n\nENDO: BG wNL.\n\nSKIN: Arms still edematous, cordis in place. Waffle boots on while in bed. Duoderm on coccyx.\n\nPLAN: Monitor rhytm, BP. No pain meds due to drowsiness. Will stay in ICU until rhythm settles and more alert.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-17 00:00:00.000", "description": "Report", "row_id": 1380967, "text": "Neuro: pt easy to arouse, able to state year, place and some events but thinks he is in . slept well through night.\nResp: Breath sounds clear, on 1l np with sats 96-98%\nC/V: pt heart rate most of night sinus with intermittent bouts of afib controlled rate 90-105. pt converts back to sinus rhythm on own. Presently in afib. blood pressure stable on hydralazine.\nGi: tolerat ing water with pills without issues.\nGU: foley sluggish with minimal drainage and leaking around cath. area cleansed and tube reposition and balloon reinflated with improvement in urine output.\nSkin: Heels reddened, duoderm present on coccyx.\nPlan: ? transfer to floor this weekend if rhythm remains stable.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-17 00:00:00.000", "description": "Report", "row_id": 1380968, "text": "Nursing Note 7A-7P\nNeuro: Arouses to voice, awake oriented to person, place, disoriented to time or day. PERL, moves all extremities. C/V: NSR rate in the 70's no ectopy noted. Pacer wires remain attached rate set at 60. Resp: O2 on at 1L NC. Lung sounds clear. Sat=96-98%. GU: Foley D'cd (see flow sheet). Voiding in urinal in small amts. GI: Positive BS, no stools. Diet taken well. Activity: OOB to chair X2 for Bkft and lunch. Skin: Duoderm ramains on coccyx removed from back. Social: Family members visited and updated to patients status. Plan: Continue to monitor cardiac status, transfer to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-11 00:00:00.000", "description": "Report", "row_id": 1380952, "text": "post cath\nD: pt adm with csru post cath on CCU service- pt ccu- results noted in history- iabp placed as well as pacing wire due to pt r/I for ant mi- severe 3 vessel dx- surgery consulted- surgery request pt have head ct , and doppler studues of carotids prior to surgery- pt no going to or tomorrow thus tests to be performed monday am.\n pt presented to csru- awake, alert,pleasant, on iv ntg and integrilin. site of iabp/and fem-arterial and venous sheath ozzing with bright red blood- cath team aware as well as ccu team. site out line over hardened area on groin.\nA: integrilin d/c and changed to heparin per ccu team- initial ptt >70- thus heparin started at 600u without a bolus.\nR: eventually ozzing subsided, no inc in hardened area over right fem.\nD: pt denies c/o pain except in right fem area when turning, c/o nausea- given protonix and zofran with some relief, tol sips of ginger ale.\nsocial: pt married with 4 children- wife and he live alone in situate- daughter in .\nplan: pt for possible CABG on tues- after ct and doppler studies okayed.--keep iabp\n\naddem; pt sbp intially 130-145/70 with map >100- inc iv ntg until map <75- iv ntg up to 160mcq/min.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380953, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, C/O \"NOT BEING ABLE TO GET COMFORTABLE\" TURNED AND REPOSITIONED FREQUENTLY. GIVEN 5MG PO AMBIEN WITH GOOD EFFECT. PT. ABLE TO SLEEP IN LONG NAPS. MOVING ALL EXTREMITIES TO COMMANDS. DENIES ANY CHEST PAIN.\nCARDIAC: CONT. TO BE IN NSR WITH AT TIMES PERIODS OF 1 DEGREE AV BLOCK WITH PR INTERVALS OF >.24, MULTIFOCAL PVC'S NOTED THRU-OUT NIGHT. GIVEN 1 DOSE OF MAGSO4 (2GM'S), K LEVEL WNL. R IJ IABP CONT. TO HAVE FAIR DIASTOLIC AUGMENTATION AND GOOD SYS UNLOADING, WAVE FORM TIMMING DIFFICULT ESPECIALLY IF PT. HAVING FREQUENT PVC'S, SLIGHTLY DAMPENED WAVE FORM. R IJ GROIN SITE, CONT. TO OOZE VERY SM. AMT, DSG CHANGED AND NEW PRESSURE DSG APPLIED. R FEMORAL HEMATOMA SITE CONT. TO BE STABLE FROM PREVIOUS OUTLINE MARK, NO PROGRESSION NOTED, SITE REMAINS TENDER TO PALPATION, HCT STABLE. REMAINS ON NTG (SEE FLOW SHEET FOR EXACT DOSEAGES). HEPARIN GTT TITRATED TO KEEP PTT ~60, CURRENTLY AT 800U/HR, WILL PLAN ON RECHECKING IN AM. V-WIRE ATTACHED BUT PACER OFF. DOPPLERABLE PULSES BILT., FEET COOL TO TOUCH.\nRESP: BS CLEAR BILT., O2 WEANED DOWN TO 2L NP WITH SAT'S >95%.\nGI/GU: HOURLY URINES CONT. TO BE AROUND 25CC, INITIALLY URINE CLOUDY WITH LOTS OF SEDIMENT, FOLEY IRRIGATED X1, FOR 1/HR OF MINIMAL URINE, PT. REPOSITIONED, U/O IMPROVING. PT. ALSO NOTED TO HAVE SOME BLOODY DISCHARGE FROM AROUND MEATUS. + BS THRU-OUT, TOLERATING SIPS OF LIQUIDS WELL, ABLE TO TAKE PO PILLS WITHOUT DIFFICULTY.\nPLAN: KEEP PTT AROUND 60, MONITOR U/O AND HEMODYNAMICS, PLAN FOR CABG POT. ON TUESDAY. IAPB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380963, "text": "NEURO REMAINS ALERT LETHARGIC EASILY AROUSABLE MOVES ALL EXTREMETIES\n\nC/V CO/CI WHILE V PACED 2.02 TO 1.84 IMPROVED WITH CONVERT TO NSR 70S CI INCREASE TO 2.4 ATTEMPTED TO A IN NSR UNABLE TO CAPTURE WITH A WIRES BACKUP VWIRES AT 60 TOL WELL 615AM CONVERT AFIB FLUTTER WITH EPISODES OF HR 30S V WIRE NON CAPTURE WITH PATIENT ON L SIDE MA INCREASE TO 16 FOR CAPTURE HR 30S AMIODERONE BOLUS REPEATED REMAINS IN AFIB FLUTTER PACER SET TO 45 MD WITH FREQUENT EPISODES OF PACED 45 ? NODAL B/P STABLE\n\nRESP CONTINUES TO REQUIRE FREQ ENCOURAGMENT TO LEAVE O2 ON DEEP BREATHING AND COUGHING WELL COARSE BS WITH SOME UPPER AIRWAY CONGESTION\n\nLABS K COVERED X2 WITH 20MEQ IV KCL BS 121 NO COVERAGE\n\nGU/GI GOOD U/O WITH DECEASING AMTS IN AM MD AWARE NO PO FLUIDS MOUTH CARE FREQ\n\nPLAN CONTINUE TO MONITOR EKG FOR CHANGES MAINTAIN WORKING PACER\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380964, "text": "CV: At beginning of shift, junctional vs CHB. BP stable at this time but CO low. Apacing not capturing 100%. Will vpace 100%, but CO still low. Dr. wants pt AV paced, which does capture 100% and CO good. Ntg gtt started for HTN at that time. EP consulted. When pacer turned down, NSR rate 70's. Stayed in NSR until evening when he started flipping between controlled afib rate 80's, junctional 40's, NSR 80's, this is his current rhythm. EP at beside during this episode, will watch rhythm for 72 hours then reevaluate. Pt has 2atrial and 2 vent epicardial pacing wires. Afebrile.\n\nPULM: Decreased to 2L/NC, sats 97%. Strong cough, able to raise thin, tan sputum, very small amts. Lungs clear. CT's draining small amts serosang fluid, no airleak.\n\nNEURO: Lethargic all day. Confusion increased during day. In morning, pt oriented except to year. During day, pt stated place was , , Sitchuit. Has not gotten year correct. OOB to chair with max assistance. On way back to bed, almost had to total lift pt to bed. No pain meds today.\n\nGU: Foley. IV Lasix given, good diuresis.\n\nGI: Hypo bowel sounds. Ate small amts jello at lunch and half of custard at dinner and drank mighty shake. No swallowing problems. bm.\n\nSKIN: Red area on coccyx, turned pt side to side as tx. Heels red, waffle boots bil. Cordis in, no PIV, arms too swollen.\n\nPLAN: Watch rhythm for 72 hours then decide on perm pacer. Pulm toilet. OOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380960, "text": "PT UPDATE\n PT IS S/P CABG X3 YEST.\n\n NEURO: PT HAS BEEN OFF PROP SINCE 12MN. HAS RECEIVED NO SEDATION TODAY. PT WAS VERY DROWSY THIS AM. PT IS MORE AWAKE THIS AFTERNOON-BUT NEEDS TO BE MORE AWAKE TO EXTUB. MAE, AND FOLLOWING COMMANDS CONSISTENTLY. APPEARS TO UNDERSTAND WHAT IS SAID TO HIM.\n\n RESP: PT HAS BEEN ON CPAP SINCE 0600. ABG GOOD. FIO2 DOWN TO 40% THIS AM WITH SATS 98-99. BS CLEAR, DECREASED IN BASES. SX FOR OLD BL. TINGE-SCANT AMT. PT WAS A DIFFICULT INTUB. IN TO ASSESS PT A FEW MINUTES AGO AND WANTS PT MORE AWAKE TO EXTUB.\n\n CARDIAC: IABP WEANED DOWN TO 1:3 THIS AM AND D/C'D. CI REMAINS EXCELLENT-3.0 AT 1330. PT REMAINS AP 80-VERY LITTLE RHYTHM UNDERNEATH. BP STABLE OFF ALL PRESSORS. SOMEWHAT HIGHER AT THIS TIME AS PT IS MORE AWAKE AND SEEMS A LITTLE ANXIOUS.\n\n GU: PT RECEIVED LG AMTS VOLUME (BLD PRODUCTS AND CRYST) OVERNIGHT. WEIGHT UP 10 KG. U/O MARGINAL. GIVEN 20MG IVP LASIX JUST NOW.\n\n GI: OGT-LCWS. BILOUS DRG.\n\n LAB: K 4.2-HAS NOT NEEDED K OR CA REPLACEMENT TODAY. HCT STABLE-28. RECEIVING SS INSULIN AS PER PROTOCOL.\n\n OTHER: PT HAS PULSES PT/DP BILAT. RT FOOT COOLER THAN LEFT THIS AM-STILL SLIGHTLY COOLER; BUT WARMER THAN EARLIER TODAY. RT GROIN DSD INTACT FROM IABP SITE-NO OOZING.\n\n WIFE AND SON IN TO VISIT TODAY. WIFE IS ANXIOUS FOR PT TO BE EXTUB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380961, "text": "PT UPDATE\n PT MORE AWAKE THIS AFTERNOON. EXTUB. AT 1500. PT STILL SOMEWHAT LETHARGIC WHEN LEFT ALONE. POST-EXT. ABG GOOD. SATS 98. BS SOMEWHAT COARSE. PT ENCOURAGED TO COUGH AND DEEP BREATH. PT TURNED SIDE TO SIDE AND GIVEN CPT-DID NOT TOL TOO WELL. PT NEEDS MUCH ENCOURAGEMENT TO TAKE A DEEP BREATH-NOW AFTER CPT, HAS HAD A FEW GOOD COUGHS. ATTEMPTED TO HAVE PT USE I.S.-BUT PT SEEMS UNABLE TO DO IT. MED WITH SMALL DOSE SC MSO4 FOR INCISIONAL PAIN TO ASSIST IN PT'S ABILITY TO COUGH. PT DOES APPEAR COMF EXTUB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380962, "text": "NEURO LETHERGIC AWAKE AT TIMES EASILY AROUSABLE ORIENTED X3 MOVES ALL EXTREMETIES EQUAL STRENGHTS\n\nRESP LUNGS COARSE ALL FIELDS DEEP BREATHING AND COUGHING WITH ENCOURAGMENT WITH SOME CLEARING OF CONGESTION REMOVES AEROSAL MASK FREQUENTLY WITH SATS DECREASING TO 90 NC 4L ON TO MAINTAIN SATS WHEN MASK REMOVED WITH GOOD EFFECT SATS 96-99% MOUTH BREATHS BENEFITS FROM MASK WITH MIST\n\nC/V MP A PACED 80S AT 8PM OCC NON CAPTURED BEAT UNDERLYING INITIALLY DIFFICULT TO ASSESS DUE TO POOR SENSING OF A WIRES AND CONTINUED PACING WITH LOWER RATE HR 30S TO 40S ? SB 10PM WHILE MOVING AND BED AND COUGHING A WIRES NON CAPTURE WITH PAUSE OF APPROX 3 SECONDS ? UNDERLYING PATTERN AFIB UNABLE TO APPROPRIATLY OR CAPTURE WITH WIRES MD AWARE V PACING WITH GOOD CAPTURE AND SENSING AMIODERONE 150MG BOLUS GIVEN WITH GOOD EFFECT UNDERLYING PATTERN SB 30-40 HOWEVER STILL UNABLE TO A NONCAPTURE AT FULL MA CONTINUES TO SENSE INAPPROPRIATELY POLARITY CHANGED WITH NO EFFECT PT CONTINUED TO MD DECREASE WITH INDEX 2.02 B/P STABLE\n\nPLAN CONTINUE TO MAINTAIN HEMODYNAMICS CLOSE MONITOR OF EPICARDIAL WIRES FOR EFFECTIVE HR\n" } ]
22,901	137,227	1. Congestive heart failure - The patient with significantly volume overloaded on admission with severe lower extremity edema from volume overload seen on chest x-ray. The patient was aggressively diuresed with Lasix initially on admission. Initially Foley catheter was placed to monitor ins and outs and creatinine was followed very closely. The crackles in the left lobe were improved and the patient had evidence of becoming dry with an increase in creatinine by . At that time his Lasix was held as his pulmonary status was stable. However, on , the patient became hypotensive which continued to be a problem over the next 24 hours. This was possibly secondary to urosepsis and required large fluid boluses to maintain his blood pressure. In the setting of this increased intravenous fluid, the patient's congestive heart failure worsened and he was transferred to the Intensive Care Unit. In the Intensive Care Unit, the patient was once again aggressively diuresed using Lasix and prn Metolazone. On , the patient was able to return to the floor for continued care. He was diuresed throughout the remainder of this hospital stay with a good result. His creatinine has remained stable during this time. hose were applied to the legs bilaterally and his legs and right arm were kept elevated. The patient will be discharged on a standing Lasix dose. 2. Coronary artery disease - The patient was found to have a new right bundle branch block on admission. Laboratory data revealed an elevated MB index and slightly elevated troponin 0.4 to 0.6. These findings were thought to be most likely ___________related. The patient was monitored on telemetry without _________________during the early parts of admission. An echocardiogram was repeated to evaluate for new wall defect and provide further ______________ regarding the patient's congestive heart failure. Echocardiogram on showed in left ventricular function of greater than 55 percent. The left and right atrium are moderately dilated. There is symmetric left ventricular hypertrophy with a normal ventricular cavity size. Regional and ventricular wall motion was normal. Mild aortic valve stenosis, periventricular and preventricular, mild 1+ mitral regurgitation. Mild tricuspid regurgitation 1+, mild pulmonary _____________________. The patient was continued on aspirin and beta blocker throughout her admission. 3. Atrial fibrillation - The patient is on Coumadin for anticoagulation at home and a beta blocker for rate control. On admission, his INR was supertherapeutic at 3.6. Therefore his Coumadin was held to allow the INR to trend down. His Coumadin was then restarted with goal INR ranged between 2 and 3. The patient is therapeutic at this time. He continues on beta blocker with good rate control. 4. Infectious disease - The patient showed no evidence of infection on admission. However, on , he became hypotensive with a systolic blood pressure of 70. This was responsive to intravenous fluids. The patient was pancultured and was found to have urosepsis with 10:100,000 of Enterobacter ACA grown on culture. The patient required transfer to the Intensive Care Unit on for blood pressure support and diuresis consistent with congestive heart failure. Thereupon he was started on a course of Ciprofloxacin and will complete a ten day course for his urosepsis. Blood cultures have been negative during admission. At this time he is afebrile with a normal white blood cell count. 5. Renal - The patient had acute and chronic renal failure at the time of presentation. His creatinine was followed closely as he diuresed. During admission, he did have an increase in creatinine during which time his Lasix was held. However, his Lasix was now trended down and he is tolerating daily diuresis with a creatinine below his baseline. 6. Myeloid dysplastic syndrome - The patient is pancytopenic at baseline thought to be secondary to myeloid dysplastic syndrome, although this has not been confirmed with a bone marrow biopsy. On admission, he was transfused three units of packed red blood cells. His hematocrit and platelets have been fairly stable within the range since that time. His hematocrit has been followed closely with a goal transfusion for hematocrit less than or equal to 28. 7. Rehabilitation - Physical therapy has been working extensively with the patient. They have recommended discharge to a rehabilitation facility. 8. Code - The patient is full code.	Vanco stopped.Heme: Pt with stable hct this AM and plt count 90. Pts LLE > in edema than R. Adequate u/o. head CT at 2200 negative.RESP: B/L BS diminished, occasional I wheeze relieved w/ nebs. MSICU NSG COVERAGE 0700-1100Periods of lethargy alt w/periods on being barely arousable. remains intubated overnoc on A/C. PT does desat to high 70's when O2 removed. Pt in ARF, BUN/Cr is 71/1.9.HEM: HCT/HGB down from 33.7/9.7 to 30.2/8.7. Mg=2.0.GI: NPO sec to lethargy. Cardiac: Remains in af..100-110.no vea. Hypotensive at start of shift, SBP in 80's; resolved spon. Lytes repleated.Resp: Pt extubated on .4 FT. BS clear bilaterally, pts cough weak. +BM (small), +BS, abd tender upon palpation.GU: Pt anasarcic. NPO sec to lethargy. PLT 83 sec to chronic condition.ID: afebrile, WBC down to 12. on abx.HEM: 1U PRBC tx for HCT 28, tol well, no s/s of reaction. +glaucoma, R exothalmosis. Awaiting AM labs.GI: Abd distended, soft, +BSX4. B/L BS present, coarse, w/rales. Pt became hypotensive, Neo restarted at 0.50mcq/kg/min. Pt has R nare NGT placed. MAE.CV- HR 100-116, afib, no ectopy. AM ABG: 7.31/74/66/6/39. Resp Care,Pt. Abd soft, distended, +ventral hernia. GI: Taking liqs well started on soft solids..tolerated ok Neuro: Alert,orientated able to follow commands..limited rom d/t edema. NPNMICUPLEASANT YR OLD MALE ADM WITH CHF,AFIB AND UROSEPSIS....HOSP COURES C/B HYPOXIA AND HYPERCAPNEA ..REQUIRING INTUBATION ..AND BRIEF PRESSOR SUPPORT ..S NO COMPLAINTSO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATACV REMAINS IN AFIB ..RATES IN THE 110-120'S...AMIODARONE INFUSION DECREASED TO .5MG/KG...LOPRESSOR RESTARTED AT LOWER RATE ..SBP 110-130'S/60'S..VIA RIGHT RADIAL ALINE ..CVP 10-12RESP RIGHT >LEFT PLEURAL EFFUSION..PER CXR ON ..NON-PROD COUGH ..RR 22-24..UNLABORED ...LUNGS CLEARGI TOLERATING SIPS OF CLEAR LIXS..COUGH WITH SWALLOWING ..GU ..URINE OUTPUT 30-40 CC Q1 ...REMAINS 3RD SPACED ...ID ON CEFTRIAXONE FOR UROSEPSIS ...RIGHT IJ TLC ..FLUSHED AND INTACT ...A HEMODYN STABLENEEDS BETTER RATE CONTROLDIURESISHEPARIN VS COUMADIN FOR AFIBPT CONSULT AM ABG: 7.38/56/115/6/34/97.8. BS coarse w/ rales bibasilar. Awaiting CXR, cont to follow w/ team.GI- Abd soft and distended, +BS, sm BM. Weaned neo to off. lungs essentially clear on auscultation but diminished at the bases . Pt remains lethargic this AM though arouses at time to voice, tactile, and localizes. O2 sat 97-98%.GI: Pt remains NPO except for meds. BP remains 110-130 on neo drip at .75mcg/kg/min. NPN 1900-0700NEURO: AXOX3, DIFFACULT TO UNDERSTAND , ACCENT AND SPEECH IMPAIRED BY WHAT APPEARS TO BE OLD FACIAL CVA DEFECEIT.RESP: LCTA, DIMINISHED AT BASES, 02 2L W/ SATS MID 90'SC/V: AFIB, AMIODORONE DECREASED TO .5MG /MIN .RECIEVED 80MG LASIX BOLUS,W/ BRISK EFFECT. No fentanyl needed today.Cardiac: Pt remains in AF, HR 106-120, CVP 3-6, lopressor dc'd, Neo weaned off, started on amio gtt at 1mg/min unitl 2100, minimal effect on HR or BP. pt transfered top 11r. No c/o pain.RESP: B/L BS diminished w/ rales, coarser at L base. Lopressor 5mg IV X1 w/ no effect. +dry cough. BP tolerated dose. ABG sent, results 7.26/78/69/4/37. IMPRESSION: 1) Stable appearance of LV failure with a left pleural effusion. IMPRESSION: Left ventricular failure with small pleural effusions. There is mild symmetric left ventricular hypertrophy. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. A left pleural effusion is present.Conclusions:1. There is mild aorticvalve stenosis. There ismild aortic valve stenosis. There is a moderate amount of periventricular and subcortical white matter hypoattenuation consistent with chronic small vessel ischemia and gliosis. PATIENT/TEST INFORMATION:Indication: Left ventricular function.BP (mm Hg): 108/70HR (bpm): 78Status: InpatientDate/Time: at 15:42Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is a persistent left lower lobe opacity consistent with atelectasis or consolidation. CHEST AP: There is cardiomegaly with small bilateral pleural effusions. Trace aortic regurgitation is seen.4. Note is made of prominent soft tissue edema. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is interval placement of a right IJ central line with the tip in the low SVC. There is mild pulmonary artery systolic hypertension.6. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is a trivial/physiologic pericardial effusion.GENERAL COMMENTS: Compared with the findings of the prior study, there hasbeen no significant change. Sinus rhythmFirst degree A-V blockRBBB with left anterior fascicular blockInferior T wave changes are nonspecificLow QRS voltages in limb leadsSince previous tracing, atrial fibrillation absent; inferior T wave changesnoted IMPRESSION: Findings consistent with mild CHF. Small, old lacunar infarcts and chronic small vessel ischemic gliosis. Distribution of the pulmonary vascularity and the septal lines consistent with an interval worsening of CHF or fluid overload. There are persistent bibasilar infiltrates/atelectasis and small bilateral pleural effusions. There is a trivial pericardial effusion.7. Worsening of CHF, or fluid overload. A left pleural effusion remains present. If a nasogastric tube has indeed been placed, it may be within the oro- and hypopharynx ( regions which are not included on this study). IMPRESSION: 1) Endotracheal tube in satisfactory position. Regional left ventricular wall motion isnormal. Patchy atelectasis in both lower lobes. The left atrium is moderately dilated.2. FINDINGS: There are low lung volumes. There are degenerative changes of the thoracic spine which are unchanged when compared to the previous study. There are bilateral small pleural effusions. Compared with the findings of the prior report (tape unavailable forreview) of , tricuspid regurgitation is less. There is calcification of the aorta. Degenerative changes are noted in the thoracic spine. Left ventricular systolic function is hyperdynamic (EF>75%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are moderately thickened. Mild (1+) mitralregurgitation is seen.5. Again demonstrated are bilateral pleural effusions, right greater than left. Again seen is a left lower lobe opacity. Query worsening of CHF. Left lower lobe atelectasis/consolidation. Compared to the previous tracing of rightbundle-branch block patterning was previously present and is no longer present.Arrhythmia persists as before.	30	[ { "category": "Nursing/other", "chartdate": "2160-03-26 00:00:00.000", "description": "Report", "row_id": 1562063, "text": "MSICU NSG ACCEPTANCE/PROGRESS NOTE\n\n yo man,w/ h/o MDS and new urosepsis, transferred from 11R w/hypoxia/hypercapnea,hypotention and CHF.\n\nLethargic/fatigued but follows commands (very HOH). No episodes of hypotention upon arrival and given 80mg Lasix and started on low-dose IV NTG. BP remained stable. Given 5mg IV Lopressor. Foley cath inserted. Initial urine pale yellow. Now it is sl pink at times.He is currently ~700cc neg since ICU admit. On 50% neb FT his O2sats are mid 90s. No further ABGs drawn. Denies pain. No c/o SOB. Family in with pt all day. NPO except for meds as he is lethargic. ?more Lasix this eve. MD to re-evaluate.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 1562064, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Lethargic at start of shift. More alert as night progressed. Did not sleep. Very HOH. +glaucoma, R exothalmosis. Ointment and gtt at bedside. PERRLA, 2 brisk. MAE, generalized weakness, X4. Mostly russian speaking. Able to communicate approp w/ limited english. O X3. Speech slurred at times, baseline. No c/o pain.\n\nRESP: B/L BS diminished w/ rales, coarser at L base. +dry cough. Pt tachhypneic, no other s/s of distress. O2 sat 95-100% O2 weaned to 2L NC, tolerating. O2 sat 100%.\n\nCV: A-Fib, no ectopy. Accelerated throughout night, 100-120. No s/s of cardiac distress. HO aware. Started on PO lopressor 25mg TID. Lopressor 5mg IV X1 w/ no effect. No additional interventions. Nitro at 0.25mcq/hr to decrease preload. SBP 100-140. +anasarca, pitting, +. +PP. Slightly hyperkalemic at 5.2 sec to ARF, HO aware. Mg=2.0.\n\nGI: NPO sec to lethargy. Able to swallow pills w/ pudding when more awake. Aspiration precaution. Abd soft, distended, +ventral hernia. Small Bm X3, brown, soft, guiac neg.\n\nGU: Foley catheter w/ no urine at start of shift. Catheter and meatus w/ scant amt of serosanguinous drainage. Flushed catheter w/ no effect, irrigant dispelled from urethral meatus. D/C'd foley, blood clots evident at tip. Attempted to insert 16 Fr w/ no effect. Met no resistence upon insertion, but yielded no urine. Bladder scan w/ portable device, no urine in bladder. Lasix 60mg IV as per HO, yielded no results. Urology consulted by Ho. Ho attempted to insert Coude catheter w/o effect, inserted w/ no resistence, though resistence met during inflation of balloon. As per urology, apply condom catheter, and monitor for bladder distention, will come in AM. Passing small amts of blood clots, HO aware. No discomfort nor bladder distention throughout shift. As per ultrasound, bladder w/ 300cc of urine at 0500. Pt in ARF, BUN/Cr is 71/1.9.\n\nHEM: HCT/HGB down from 33.7/9.7 to 30.2/8.7. PLT 83 sec to chronic condition.\n\nID: afebrile, WBC down to 12. On abx.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562067, "text": "MSICU NSG COVERAGE 0700-1100\n\n\nPeriods of lethargy alt w/periods on being barely arousable. SBP 77 after being turned and remained low despite IVB. ABG 7.30 PCO2 71 PaO2 83 on Bipap. Intubated for airway protection d/t alt mental status. BP required Neo post intubation and additional IVBs. SBP appears to be stabilizing. Plan to wean Neo as tol.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-30 00:00:00.000", "description": "Report", "row_id": 1562075, "text": " 4 ICU nursing progress note:\n Respiratory: RR 20's..sats 98% changed to 2l nc..sats mid 90's. No cough. Decreased BS.\n Cardiac: Remains in af..100-110.no vea. Given 150mgm amioderone bolus this am...gtt increased to 1mgm/min for next 24hrs. Also given 80 lasix late this afternoon...45cc out thus far. Has 3+ pitting edema in lower extremites.\n GI: Taking liqs well started on soft solids..tolerated ok\n Neuro: Alert,orientated able to follow commands..limited rom d/t edema.\n Lines: RIJ and R radial aline..peripheral ivs dc'd...day #3\n Social: Multiple family members in to visit..updated on pt condition.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 1562065, "text": "PMICU Nursing Progress Note 7a-7p\nEvents\n\n Pt did not make urine all morning, cont only to have a few bloody clots out until a new cath placed. At 1300, urologist placed 20 F coude double lumen cath. Pt immediately put out 450 cc dark red urine. Cath was then manually flushed until return was pink, light and clear. Pt then recieved 80 mg of lasix to assist w/ diuresis for CHF. Following cath placement, pt fell asleep. He became increasingly lethargic as afternoon went on. HO notified as pt became more difficult to arouse. ABG sent, results 7.26/78/69/4/37. Pt then placed on BIPAP in attempt to improve ventilation. Family at bedside throughout, updated on status by nsg and team.\n\nReview of Systems\n\nNeuro- Changes in MS mentioned above, this am pt was alert and oriented x2 which according to Pt's daughter (also his HCP) is his baseline. Denied pn throughout day when asked. MAE.\n\nCV- HR 100-116, afib, no ectopy. SBP 105-150, lopressor increased to 37.5 PO. Cont on Nitro gtt @ .25 mcg/kg/min. Unable to take evening cardiac meds for afib due to lethargy, HO notified. Evening labs checked, K 4.7, Na 143, Ion Ca 1.20, lactic acid 1.2, HCT 28.\n\n Pt presently on BIPAP 10/5, TV 200-400 (problems w. leaking- RT presently working on), sats 98%, RR 18-20. LS coarse, diminished bases. Pt had insp wheeze this am, recieved atrovent nebs q 4 hrs today, improvement noted. PT does desat to high 70's when O2 removed. Awaiting CXR, cont to follow w/ team.\n\nGI- Abd soft and distended, +BS, sm BM. NPO until pt is more awake.\n\nGU- Current FB - 920, goal - 1 L. Urine yellow and clr, plan to manually flush if output decreases or it darkens.\n\nID- Afebrile, cont on Vanco and ceftriaxone IV. Pt does have gram neg rods in urine.\n\nPlan- Cont supportive medical care.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562068, "text": "NPN 11AM-7PM:\nNeuro: Pt initially agitated after intubation requiring fentanyl 25-50mcg IV Q1hr times two. Since then pt is able to be awake without too much agitation/discomfort and has received small doses of fentanyl 25mcg IV PRN. Pt now seems alert and interactive with family, nodding yes and no to simple questions and assisting with turns and position changes. Tolerating suctioning/turning well. MAE\n\nCV: Remains in RAF rates 110-120 and due to hypotension has not been able to get lopressor doses. Required neo drip to maintain SBP goal of 120 or above. Currently at .75mcg/kg/min infusing via new central line inserted after intubation. Pt also has a-line with good waveform, draws easily. Pt received 1 liter NS IVF boluses after intubation and after central line insertion was given additional 500cc's for CVP3-5. Currently CVP 6-7.\n\nResp: Pt intubated for airway protection and hypercarbia and hypotension. Remains on AC 20, TV 500, FIO2 40% with 5cm peep with good sats. Lungs coarse with deminished sounds at bases. Bronch done at bedside and washings sent for culture.\n\nID: Afebrile. Some antibiotic changes done. Vanco stopped.\n\nHeme: Pt with stable hct this AM and plt count 90. No s/s bleeding noted. Given dose of procrit as ordered.\n\nGI: OGT inserted for meds. Pt has +BS small oozing of soft brown stool.\n\nGU: Foley draining clear yellow urine in adequate amts.\n\nIV access: Pt has two PIV's flushed with NS and new triple lumen central line in right IJ.\n\nSkin: Looks to be in good shape. Heels slightly reddened bilaterally as well as coccyx. No open areas noted.\n\nSocial: Family are aware of the intubation and line placements. Have been at his bedside talking to him for most of the afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562069, "text": "Patient intubated due to bad ABG mental status change. Bronchoscopic procedure done today lung tissue appears normal. ABG improves patient slightly more alert will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-31 00:00:00.000", "description": "Report", "row_id": 1562076, "text": "NPN 1900-0700\n\nNEURO: AXOX3, DIFFACULT TO UNDERSTAND , ACCENT AND SPEECH IMPAIRED BY WHAT APPEARS TO BE OLD FACIAL CVA DEFECEIT.\n\nRESP: LCTA, DIMINISHED AT BASES, 02 2L W/ SATS MID 90'S\n\nC/V: AFIB, AMIODORONE DECREASED TO .5MG /MIN .RECIEVED 80MG LASIX BOLUS,W/ BRISK EFFECT. STARTED ON LASIX GTT . CURRENTLY 1200CC NEG FOR 24HRS. CONT TO HAVE + EDEMA OF HANDS AND FEET.\n\nF/E/N: NA+ STILL ELEVATED @ 146, CONT TO HAVE FREQUENT THIRST. UO NOW DOWN TO ~ 200CC /HR.SMEARS OF STOOL OVERNOC. ??INCREASE BOWEL REGIMEN?\n\nPLAN: CONT AMIODODRNE GTT FOR AFIB, CONT LASIX GTT W/ GOAL OF 1.5 LITERS NEG FOR 24/HR.MONITOR LYTES.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-31 00:00:00.000", "description": "Report", "row_id": 1562077, "text": "d: pt a&o x3 . follows simple commands appropriately. o2 at 2l/m nc with o2 sats> 95%. lungs essentially clear on auscultation but diminished at the bases . hemodynamically very stable. remains in afib with hr in the 80's. amioderone gtt at 0.5 mg/hr d/c'd and pt changed to amioderone 200 mg po tid. abd soft and nontender with pos bowel sounds on auscultation. no sotol output today, pt takin free water wll. will continue to gently diures pt with goal of i& o to be neg about 500cc's. r arm more swollen then l. medical team aware and to have u/s done to r/o dvt. also plan to restart pt on po coumadin. pt transfered top 11r. will continue with present medical management. pt's daughter at bedside and was updated by nursing staff.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562066, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Pt found stuperous at start of shift. Unresponsive since 1600 sec to hypercapnea. Pt remains lethargic this AM though arouses at time to voice, tactile, and localizes. Able to make eye contact when aroused. Incomprehensible sounds. Generalized weakness, equal strength throughout. R eye glaucoma, exothamosis, pupil 1, slugg, L pupil 2, slug. No s/s of pain. head CT at 2200 negative.\n\nRESP: B/L BS diminished, occasional I wheeze relieved w/ nebs. BS coarse w/ rales bibasilar. Weaned O2 to 2L mask when off Bipap. ABG improved at 2100. Placed on Bipap post head Ct. Tol well, sats upper nineties on 30% Rate 18 PS 10 PEEP 5. AM ABG: 7.31/74/66/6/39. More hypercapneic and hypoxic. PEEP increased to 8, FIO2 to 40% as per HO. Tol well.\n\nCV: A-Fib, accelerated rate, 110-120. Hypotensive at start of shift, SBP in 80's; resolved spon. Lopressor 5mg, then 7.5mg IV given as per HO w/ 2-3 hr effect, rate 90-105. Anasarca. PP palp. ECG done, unchanged. Awaiting AM labs.\n\nGI: Abd distended, soft, +BSX4. NPO sec to lethargy. +BM, mod brown, neg.\n\nGU: Foley C/D/I. +hematuria, pink tinged, sediment. No clots. Patent. Adequate amts/hr. Pt I/O -1618 for shift.\n\nID: afebrile. on abx.\n\nHEM: 1U PRBC tx for HCT 28, tol well, no s/s of reaction. HCT 35.2 this AM.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562070, "text": "MICU NPN Addendum 7PM-11PM:\nPt's vital signs remain unchanged. Pt remains in RAF 110-130. Pt given 5mg IV lopressor to try to control rate without much effect. BP tolerated dose. BP remains 110-130 on neo drip at .75mcg/kg/min. UO remains 45-60/hr. CVP 6-8. Hematology results this eve are unchanged from this AM and ABG is good on current vent settings. Pt slightly restless at times and treated with small doses of IV fentanyl with good effect. Decision made to hold off on starting tube feeds due to possibility of trying to extubate if vital signs are stable tomorrow. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562071, "text": "NPN SHIFT 2300-0700: Assessment unchanged since picking up pt at 2300. See previous notes. Weaned neo to off. Cardizem 10mg IV given as per HO for RAF, rate 110-130. Rate controlled to 80-90, but improvement in HR did not improve BP. Pt became hypotensive, Neo restarted at 0.50mcq/kg/min. SBP 90-120. HCT stable at 32. No s/s of bleed. PLT= 90 sec to MDS. Afebrile. WBC=3.54. Na+=152, HO made aware, no interventions. K=3.6, no repletion sec to ARF. Mg+=1.8. Phos=2.6. BUN/Cr=65/1.3. I/O=pos 683.8. Good urine output. B/L BS present, coarse, w/rales. No cough, scant secretions. No resp distress. AM ABG: 7.38/56/115/6/34/97.8. Satting 100%. +BS, no BM, kept NPO as MD.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562072, "text": "Resp Care,\nPt. remains intubated overnoc on A/C. No vent changes this shift. RSBI not obtained due to apnea. Maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562073, "text": "M/SICU Nursing Progress Note\nNeuro: PT A&O x3. MAE, weak however. Pt c/o pain on palp in RLQ of abd. No fentanyl needed today.\n\nCardiac: Pt remains in AF, HR 106-120, CVP 3-6, lopressor dc'd, Neo weaned off, started on amio gtt at 1mg/min unitl 2100, minimal effect on HR or BP. BP stable 110-120 sys. Lytes repleated.\n\nResp: Pt extubated on .4 FT. BS clear bilaterally, pts cough weak. O2 sat 97-98%.\n\nGI: Pt remains NPO except for meds. Pt has R nare NGT placed. +BM (small), +BS, abd tender upon palpation.\n\nGU: Pt anasarcic. Pts LLE > in edema than R. Adequate u/o. Pt started on 250cc q3 free H2O bolus for hypernatremia.\n\nID: Pt remains afebrile on ceftriaxone.\n\nSocial: Multiple family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-30 00:00:00.000", "description": "Report", "row_id": 1562074, "text": "NPN\nMICU\nPLEASANT YR OLD MALE ADM WITH CHF,AFIB AND UROSEPSIS....HOSP COURES C/B HYPOXIA AND HYPERCAPNEA ..REQUIRING INTUBATION ..AND BRIEF PRESSOR SUPPORT ..\nS NO COMPLAINTS\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV REMAINS IN AFIB ..RATES IN THE 110-120'S...AMIODARONE INFUSION DECREASED TO .5MG/KG...LOPRESSOR RESTARTED AT LOWER RATE ..SBP 110-130'S/60'S..VIA RIGHT RADIAL ALINE ..CVP 10-12\nRESP RIGHT >LEFT PLEURAL EFFUSION..PER CXR ON ..NON-PROD COUGH ..RR 22-24..UNLABORED ...LUNGS CLEAR\nGI TOLERATING SIPS OF CLEAR LIXS..COUGH WITH SWALLOWING ..\nGU ..URINE OUTPUT 30-40 CC Q1 ...REMAINS 3RD SPACED ...\nID ON CEFTRIAXONE FOR UROSEPSIS ...\nRIGHT IJ TLC ..FLUSHED AND INTACT ...\nA HEMODYN STABLE\nNEEDS BETTER RATE CONTROL\nDIURESIS\nHEPARIN VS COUMADIN FOR AFIB\nPT CONSULT\n" }, { "category": "Echo", "chartdate": "2160-03-21 00:00:00.000", "description": "Report", "row_id": 60382, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 108/70\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 15:42\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Left ventricular systolic function is hyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmild aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Compared with the findings of the prior study, there has\nbeen no significant change. A left pleural effusion is present.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%).\n3. The aortic valve leaflets are moderately thickened. There is mild aortic\nvalve stenosis. Trace aortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is mild pulmonary artery systolic hypertension.\n6. There is a trivial pericardial effusion.\n7. Compared with the findings of the prior report (tape unavailable for\nreview) of , tricuspid regurgitation is less.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824815, "text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with new fever and increased hypoxemia. Evaluate\n for infiltrate.\n\n AP single view of the chest is compared to .\n\n FINDINGS: There are low lung volumes. The cardiac and mediastinal contours\n are unchanged. There is calcification of the aorta. Distribution of the\n pulmonary vascularity and the septal lines consistent with an interval\n worsening of CHF or fluid overload. Patchy opacity in the left lower lobe but\n could represent pneumonia or atelectasis.\n\n IMPRESSION:\n 1. Worsening of CHF, or fluid overload.\n 2. Patchy opacity in the left base could represent pneumonia or atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825110, "text": " 7:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval volume status\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n eval volume status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever with increased oxygen requirement. Evaluate for pulmonary\n edema or infiltrate.\n\n COMPARISON: .\n\n CHEST AP: There is cardiomegaly with small bilateral pleural effusions. Again\n seen is a left lower lobe opacity. The mediastinal contours are unremarkable.\n\n Degenerative changes are noted in the thoracic spine.\n\n IMPRESSION: Left ventricular failure with small pleural effusions. Left lower\n lobe atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 824342, "text": " 4:14 PM\n CHEST (PA & LAT) Clip # \n Reason: SOB ? WORSENING chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with\n REASON FOR THIS EXAMINATION:\n SOB ? WORSENING chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old male with shortness of breath. Query worsening of CHF.\n PA and lateral views of the chest are compared to .\n\n The heart is increased in size consistent with cardiomegaly, but no\n significantly unchanged in the interval. The aorta is tortuous and calcified.\n The mediastinal and hilar contours are unchanged. There is upper zone\n redistribution of the pulmonary vascularity which is consistent with mild CHF,\n but there is no overt pulmonary edema. There are bilateral small pleural\n effusions. No focal consolidations to suggest pneumonia. There are\n degenerative changes of the thoracic spine which are unchanged when compared\n to the previous study.\n\n IMPRESSION:\n Findings consistent with mild CHF.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825289, "text": " 5:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with new fever and increased O2 requirement.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared to\n the previous study of yesterday.\n\n The NGT is coiled within the pharynx.\n\n There is increased congestive heart failure with cardiomegaly and bilateral\n pleural effusions. There is increased patchy atelectasis in both lower lobes.\n The patient has been extubated. The right jugular IV catheter remains in\n place.\n\n IMPRESSION:\n 1) Coiling of the NGT in the pharynx.\n 2) Increased congestive heart failure with cardiomegaly and small bilateral\n pleural effusions. Patchy atelectasis in both lower lobes.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825190, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check for R IJ central line placement & NG tube placement\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n check for R IJ central line placement & NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A -year-old man with new fever and increased oxygen\n requirement. Now status post right IJ central line placement and NG tube\n placement.\n\n AP semi-upright single view of the chest is compared to .\n\n FINDINGS: There is an ET tube located in good position unchanged when compared\n to the previous study. There is interval placement of a right IJ central line\n with the tip in the low SVC. There is no evidence of pneumothorax. There has\n been placement of a feeding tube with the tip extending beyond the limits of\n the diaphragm in the stomach.\n\n IMPRESSION: Right IJ central line and feeding tube are in satisfactory\n position. Otherwise, unchanged appearance of the chest x-ray when compared to\n the study done two hours earlier on the same day.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824925, "text": " 9:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulm edema\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n Evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New fever and hypoxia.\n\n COMPARISON: .\n\n FINDINGS: AP portable semi-upright view. Cardiomegaly with congestive heart\n failure is again noted, and changed since the prior status. A left pleural\n effusion remains present. There is a persistent left lower lobe opacity\n consistent with atelectasis or consolidation. Degenerative changes are noted\n within the thoracic spine.\n\n IMPRESSION:\n\n 1) Stable appearance of LV failure with a left pleural effusion.\n 2) Stable left lower lobe atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 825074, "text": " 1:25 PM\n RENAL U.S. PORT Clip # \n Reason: r/o hydroneprhosis\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with MDS, diastolic dysfunction, CRF now w/ no urine outpt x 10\n hours w/ minimal UO despite new foley\n REASON FOR THIS EXAMINATION:\n r/o hydroneprhosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MDS, diastolic dysfunction, no urine output for 10 hours.\n\n FINDINGS: The left kidney measures 10.4 cm. The right kidney measures 11.0.\n There is a 2.3 cm simple cyst within the lower pole of the left kidney. There\n is also a 2.5 cm simple cyst in the upper pole of the left kidney. The\n bladder is collapsed with a Foley in place.\n\n IMPRESSION: No evidence of hydronephrosis or stones.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825393, "text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval fluid status\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n please eval fluid status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever and increasing oxygen requirement.\n\n AP UPRIGHT CHEST: Compared with , there is slightly better lung\n inflation. There are persistent bibasilar infiltrates/atelectasis and small\n bilateral pleural effusions. Persistent vascular congestion and cardiomegaly.\n No pneumothorax. The right central venous catheter is unchanged.\n\n IMPRESSION: 1) Persistent CHF. 2) Slight improvement in the bibasilar\n infiltrate/atelectasis, which could represent pneumonia if clinically\n consistent.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-31 00:00:00.000", "description": "R US EXTREMITY NONVASCULAR RIGHT", "row_id": 825448, "text": " 2:14 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: RUE SWELLING, R/O DVT\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new RUE edema w/ R. radial a-line and R. IJ TLC\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper extremity edema with right radial A-line and right\n internal jugular catheter.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the\n right internal jugular, subclavian, axillary, brachial, basilic and cephalic\n veins were performed. Normal flow, compressibility, augmentation, and wave\n forms are demonstrated. No intraluminal thrombus is identified. Note is made\n of prominent soft tissue edema.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825176, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS ETT PLACEMENT, FAILED NGT PLACENET\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n assess ETT placement and NGT placement in y/o male now intubated for\n hypotension decreased ms\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to previous study of one day earlier.\n\n CLINICAL INDICATION: Evaluate endotracheal tube and nasogastric tube\n position.\n\n An endotracheal tube is in satisfactory position. No nasogastric tube is\n identified. Cardiac and mediastinal contours appear stable in the interval.\n Again demonstrated are bilateral pleural effusions, right greater than left.\n There is persistent left retrocardiac opacity, not significantly changed.\n\n IMPRESSION:\n\n 1) Endotracheal tube in satisfactory position.\n\n 2) No nasogastric tube identified. If a nasogastric tube has indeed been\n placed, it may be within the oro- and hypopharynx ( regions which are not\n included on this study).\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 825113, "text": " 8:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute change in mental status, h/o CVA, chronic afib, coumad\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with chf, uti, afib\n REASON FOR THIS EXAMINATION:\n acute change in mental status, h/o CVA, chronic afib, coumadin has been held in\n house\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: CHF, A fib, acute mental status changes.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial noncontrast head CT.\n\n CT HEAD WITHOUT CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalus, shift of normally midline structures or edema. There is a\n moderate amount of periventricular and subcortical white matter\n hypoattenuation consistent with chronic small vessel ischemia and gliosis.\n Small lacunar infarcts are also identified within bilateral basal ganglia,\n and there is a small left parietal chronic infarction.\n\n The paranasal sinuses are well aerated. There is proptosis on the right with\n an irregular contour to the globe posteriorly.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n 2. Small, old lacunar infarcts and chronic small vessel ischemic gliosis.\n 3. Proptosis of the right orbit with an irregular configuration to the\n posterior portion of the right globe. This may represent previous trauma to\n the globe with rupture. Clinical correlation is recommended.\n\n\n\n" }, { "category": "ECG", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 107770, "text": "Atrial flutter-fibrillation. Axis minus 30 degrees. ST segment elevations in\nleads V2-V3 (probably early repolarization). Low voltage in the limb leads and\nprecordial leads. Compared to the previous tracing of right\nbundle-branch block patterning was previously present and is no longer present.\nArrhythmia persists as before.\n\n" }, { "category": "ECG", "chartdate": "2160-03-21 00:00:00.000", "description": "Report", "row_id": 107771, "text": "Possible atrial flutter (P in lead V1) with variable block versus atrial\nfibrillation\nLeft axis deviation\nBorderline left anterior fascicular block\nRight bundle branch block\nSince previous tracing, atrial flutter present\n\n" }, { "category": "ECG", "chartdate": "2160-03-20 00:00:00.000", "description": "Report", "row_id": 107772, "text": "Sinus rhythm\nFirst degree A-V block\nRBBB with left anterior fascicular block\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing, atrial fibrillation absent; inferior T wave changes\nnoted\n\n" } ]
97,243	129,107	Pt was admitted to neurosurgery service and underwent a right frontal craniotomy for tumor resection on . Pt tolerated this procedure very well with no complications. Post operatively he was transferred to the ICU for continued care including q1 neuro checks and strict blood pressure control. On post op exam he is AOx3, following commands and moving all ext with full strength, he has no change from his baseline. A post op head ct showed good resection of lesion with no acute hemorrhage. Pt was transferred to the floor on , his diet was advanced, his foley was removed and he was sdeemed fit for discharge on the morning of as he was ambulatory in the hallways without assistance. He as given instructions for followup and discharged on the afternoon of	Imaged portion of paranasal sinus and mastoid air cells appear within normal limits. Limited study for a preoperative planning demonstrates stable appearance of bifrontal enhancing lesions with surrounding vasogenic edema, left greater than right. Note is again made of a T1 hyperintense subcutaneous nodule, which is unchanged in size and most consistent in imaging appearances with lipoma. The right frontal enhancing mass appears unchanged. Again seen is an enhancing right frontal focus with an apparent necrotic component. The enhancing lesion seen in the right frontal lobe, 2:22, is better evaluated on last MR. CONCLUSION: Status post resection of left frontal lobe mass with expected post-operative changes. Again identified is a right occipital scalp lipoma. There is stable mass effect on the frontal of the left lateral ventricle. T1 hyperintense well-circumscribed subcutaneous nodule over the right occiput, most consistent with lipoma. TECHNIQUE: MP-RAGE, coronal T1, sagittal T1, axial T1 images were acquired. FINDINGS: Again seen are bifrontal metastases with marked surrounding vasogenic edema, left greater than right. FINDINGS: The patient is status post a left frontal craniotomy for resection of the previously demonstrated parenchymal mass. Again seen is extensive left frontal edema. no large acute hemorrhage. Sagittal MP-RAGE imaging was performed and reformatted in axial and coronal orientations. Enhancing lesion at the right frontal lobe better evaluated on recent MRI. Post-surgical changes at the left frontoparietal region with expected pneumocephalus and tiny blood products. The ventricles and sulci are normal in size and configuration. FINAL REPORT HISTORY: Left parietal lesion; status post craniotomy for resection. COMPARISON: Multiple prior MRIs, most recently . IMPRESSION: 1. IMPRESSION: 1. Fiducial markers are in place over the scalp. The dural venous sinuses are patent. Comparison to brain MRs and . Please obtain between 2130 and 2230 No contraindications for IV contrast WET READ: IPf FRI 9:18 PM post-surgical changes at the left frontal lobe. Overall, this appears slightly improved since the pre-operative study. Elsewhere -white differentiation is preserved. There is persistent soft tissue edema in the left frontoparietal white matter, 2:20. The orbits are normal in appearance. Sagittal and axial short TR, short TE spin echo imaging was performed through the brain. FINDINGS: Status post resection of left parietal mass with post-surgical changes at the surgical bed, with pneumocephalus and tiny blood products. The ventricles are stable in size. There is stable 2-mm shift of midline structures, 2:15. COMPARISON: MR . No new lesions are detected. No new lesions are detected. Persistent vasogenic edema at the left frontal lobe. The globes are intact. No new foci are appreciated. Evaluate postoperative change. Following the administration of contrast. TECHNIQUE: Contiguous axial images were obtained through the brain. The visualized paranasal sinuses are unremarkable. No new enhancing foci are seen. Note that the high intensity of the hemorrhage will somewhat limit detection of small amounts of enhancing tumor. These are similar in size compared with the prior with the largest on the left measuring approximately 1.8 x 1.6 cm. There is no large acute hemorrhage or large acute territorial infarction. 2. 2. No intravenous contrast administered. After administration of 16 cc of Magnevist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, long TR, long TE fast spin echo, short TR, short TE spin echo, and diffusion technique. There is hemorrhage at the surgical site, with no evidence of residual enhancing tumor. 9:19 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change in patient with left craniotomy Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: MAGNEVIST Amt: 16CC MEDICAL CONDITION: 79 year old man with left parietal lesion s/p craniotomy for resection REASON FOR THIS EXAMINATION: evalaute for post-op change in patient with left craniotomy for resection No contraindications for IV contrast FINAL REPORT MR HEAD WITHOUT AND WITH CONTRAST HISTORY: Status post left parietal craniotomy for tumor resection. 7:47 PM CT HEAD W/O CONTRAST Clip # Reason: evalaute for post-op change. 3. Please obtain between 2130 and Admitting Diagnosis: BRAIN TUMOR/SDA MEDICAL CONDITION: 79 year old man with left parietal lesion s/p craniotomy for resection REASON FOR THIS EXAMINATION: evalaute for post-op change. 12:12 PM MR HEAD W/ CONTRAST Clip # Reason: for surgical mapping Contrast: MAGNEVIST Amt: 17 MEDICAL CONDITION: 79 year old man with brain tumor REASON FOR THIS EXAMINATION: for surgical mapping No contraindications for IV contrast FINAL REPORT CLINICAL INFORMATION: A 79-year-old male with history of melanoma and brain metastasis.	3	[ { "category": "Radiology", "chartdate": "2147-03-10 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1176429, "text": " 12:12 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: for surgical mapping\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with brain tumor\n REASON FOR THIS EXAMINATION:\n for surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: A 79-year-old male with history of melanoma and brain\n metastasis.\n\n COMPARISON: Multiple prior MRIs, most recently .\n\n TECHNIQUE: MP-RAGE, coronal T1, sagittal T1, axial T1 images were acquired.\n Following the administration of contrast.\n\n FINDINGS: Again seen are bifrontal metastases with marked surrounding\n vasogenic edema, left greater than right. These are similar in size compared\n with the prior with the largest on the left measuring approximately 1.8 x 1.6\n cm. No new foci are appreciated. Elsewhere -white differentiation is\n preserved. The ventricles and sulci are normal in size and configuration.\n Fiducial markers are in place over the scalp. Note is again made of a T1\n hyperintense subcutaneous nodule, which is unchanged in size and most\n consistent in imaging appearances with lipoma. The orbits are normal in\n appearance. The visualized paranasal sinuses are unremarkable. The dural\n venous sinuses are patent.\n\n IMPRESSION:\n 1. Limited study for a preoperative planning demonstrates stable appearance\n of bifrontal enhancing lesions with surrounding vasogenic edema, left greater\n than right. No new enhancing foci are seen.\n\n 2. T1 hyperintense well-circumscribed subcutaneous nodule over the right\n occiput, most consistent with lipoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-03-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176507, "text": " 7:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalaute for post-op change. Please obtain between 2130 and\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left parietal lesion s/p craniotomy for resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change. Please obtain between 2130 and 2230\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf FRI 9:18 PM\n post-surgical changes at the left frontal lobe. no large acute hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left parietal lesion; status post craniotomy for resection.\n Evaluate postoperative change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast administered.\n\n COMPARISON: MR .\n\n FINDINGS: Status post resection of left parietal mass with post-surgical\n changes at the surgical bed, with pneumocephalus and tiny blood products. The\n enhancing lesion seen in the right frontal lobe, 2:22, is better evaluated on\n last MR. There is persistent soft tissue edema in the left frontoparietal\n white matter, 2:20. There is stable mass effect on the frontal of the\n left lateral ventricle. There is stable 2-mm shift of midline structures,\n 2:15.\n\n The ventricles are stable in size. There is no evidence of hydrocephalus.\n There is no large acute hemorrhage or large acute territorial infarction.\n Imaged portion of paranasal sinus and mastoid air cells appear within normal\n limits. The globes are intact.\n\n IMPRESSION:\n 1. Post-surgical changes at the left frontoparietal region with expected\n pneumocephalus and tiny blood products.\n 2. Persistent vasogenic edema at the left frontal lobe.\n 3. Enhancing lesion at the right frontal lobe better evaluated on recent MRI.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-03-12 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1176657, "text": " 9:19 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change in patient with left craniotomy\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 16CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left parietal lesion s/p craniotomy for resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change in patient with left craniotomy for resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST \n\n HISTORY: Status post left parietal craniotomy for tumor resection.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. After administration of 16 cc of Magnevist intravenous contrast,\n axial imaging was performed with gradient echo, FLAIR, long TR, long TE fast\n spin echo, short TR, short TE spin echo, and diffusion technique. Sagittal\n MP-RAGE imaging was performed and reformatted in axial and coronal\n orientations. Comparison to brain MRs and .\n\n FINDINGS: The patient is status post a left frontal craniotomy for resection\n of the previously demonstrated parenchymal mass. There is hemorrhage at the\n surgical site, with no evidence of residual enhancing tumor. Note that the\n high intensity of the hemorrhage will somewhat limit detection of small\n amounts of enhancing tumor. Again seen is extensive left frontal edema.\n Overall, this appears slightly improved since the pre-operative study. Again\n seen is an enhancing right frontal focus with an apparent necrotic component.\n No new lesions are detected.\n\n Again identified is a right occipital scalp lipoma.\n\n CONCLUSION: Status post resection of left frontal lobe mass with expected\n post-operative changes. No new lesions are detected. The right frontal\n enhancing mass appears unchanged.\n\n\n" } ]
29,488	147,767	Cardiac catherterization showed 99% LM, IABP was placed, and she was taken emergently to the operating room where she underwent a CABG x 2. She was transferred to the ICU in critical but stable condition. She was extubated and her IABP was removed on POD #1. She was transferred to the floor on POD #3. She did well postoperatively, she was seen by PT and was ready for discharge home on POD #5.	There is an RSR' pattern in lead V1 which is probably normal.Non-specific anterior and anterolateral ST-T wave changes. given percocet 1tab po w/sip of h2o->n/v shortly after. d/c CTs in am. Normal ascending aorta diameter. Percoets d/c'd and Darvocet given this am. percocet 1 tab given x2 w/good effect. PATIENT/TEST INFORMATION:Indication: CAD, unstable angina,Height: (in) 66Weight (lb): 130BSA (m2): 1.67 m2BP (mm Hg): 100/40HR (bpm): 72Status: InpatientDate/Time: at 18:07Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is a right internal jugular central venous line in place terminating within the expected region of the cavoatrial junction. SINGLE VIEW CHEST, AP UPRIGHT: The cardiac size is on the upper limits of normal. cxray done. The mitral valveappears structurally normal with trivial mitral regurgitation. The endotracheal and left chest tube have been removed in the interim. Normal aortic arch diameter. There are simple atheroma in the descendingthoracic aorta. ct's & epicardial wires d/c'd. Normal RV systolic function.Mild improvement in previously hypokinetic apical anterior and anteroseptalsegments.Minimal MR and minimal TR. vent weaned. PP palpable.RESP: Pt on 4L NC. o2 weaned to 2l nc. FINAL REPORT PROCEDURE: Chest portable line placement on . iabp weaned tolerated well->d/c'd by dr . wean ntg as tolerates. ntg restarted d/t sbp>130 by aline, nibp 10pt lower. Neuro: pt oriented following commands.Resp: pt on 2 L NP tolerating well with O2 sats 95-98%C/V: vss pt in sinus rhythm with stable BP . There is mild regional left ventricular systolic dysfunctionwith focalities in the apical anteroseptal and anterior wall. zofran order/more freq reglan order. There is asmall pericardial effusion. Plan to place on Cpap wean for possible extubation.C/V: pacer turned down, pt in sinus rhythm rate 70-80's no ectopy. Hct 31.1. tolerating po lopressor. Mild regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - hypo; anterior apex - hypo; septal apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. CT draining min amt serosang fluid. The patient is status post median sternotomy and CABG. The patient is status post median sternotomy and CABG. I ABP inserted and pt sent to OR. abd soft +bs. +palp pp bilat.resp: lungs clear but dim in bases. Thepatient appears to be in sinus rhythm. 6am lasix dose held d/t low cvp, given at 11a per team w/fair diuresis.endo: fs treated w/ssri per protocol.id: last dose of vanco given. sat's>94%.gi/gu: og->lws w/billious drainage, d/c'd w/extubation. Lytes repleated prn.SKIn: Skin WDI, afebrile, t-max 98.6.PLAN: Monitor VS, resp status, CT and u/o. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). n/v as noted above. +pp bilat. Left ventricular wall thicknesses arenormal. Baseline postop examination showing a new left lower lobe atelectasis and small left pleural effusion. pacer placed on a demand of 60. pt became hypertensive nitro started and titrated up to 3 with MAP staying up in the 90's and SBP by IABP 130's. The cardiac silhouette remains at the upper limits of normal. a&o x3 post extubation. CVP 0-3 most of shift, MD aware. There is improved aeration of the left base associated with partial interval resolution of the left basilar atelectasis noted on the prior examination. +bs. Sinus rhythm. Sinus rhythm. c/o nausea w/pain med & requesting reglan w/pain med->nauseous dispite med zofran given w/good effect. oob->chair w/assist of 2 tol well.cv/skin: nsr. Normal LV cavity size. FINDINGS: In the interim, a new endotracheal tube has been placed with distal tip terminating approximately 3 cm above the carina bifurcation. c/o incisional pain medicated w/morphine->n/v x1 reglan given. team aware of ^'d need of ntg, to order lopressor. Arrived here on Propofol and Neo 0.2mcg pt 100% apaced on arrival. shift update:neuro: oriented x3. shift update:neuro: , , follows commands. Cannot rule out myocardialischemia. k+, ca & magnesium repleted. LS clear, diminshed in bases. tolerating sips of clears. Focal calcifications in aorticarch. FINDINGS: A single portable image of the chest was obtained and compared to the prior examination dated . Neo weaned off.Neuro: pt sedated with propofol overnight. magnesium repleted.resp: lungs clear but dim in bases. pt reports n/v from morphine. Focal calcifications inascending aorta. FINDINGS: A single portable image of the chest is compared to the prior examination dated . The left ventricular cavity size is normal. Wake and wean vent good diuresis after lasix.endo: insulin gtt per protocol. reglan x1. -airleak/crepitus.GI/GU: +BS, pt nauseous/-vomitting: given reglan Q6; pt requesting more often ? zofran?CV: pt in NSR 70s-80s, with no ectopy noted. Note is made of bilateral humeral head replacements. Cont with pulmonary toileting. Radial aline tracing with fling SBP up to 160's. pt given reglan Q6 for nausea-> ? sat's>94. There are focalcalcifications in the aortic arch. encouraged to cdb & use is, cough weak & only able to get is to 250.gi/gu: abd soft. The heart size is mildly enlarged expected from a postoperative procedure. IMPRESSION: 1. A line d/c'd after lost waveform and could not draw off; NIBP 100s-120s, MAP 60s-70s. Comfort and support pt. Foley to be d/c'd in am.Skin: Incisions clean and dry no drainage or redness noted.Pain: pt complains of incision pain requesting percocet and something for nausea at same time. The right hemithorax is clear. The cardiomediastinal silhouette is stable. The cardiac silhouette is grossly unchanged. sbp stable. dr aware, no new orders. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Focal calcifications inaortic root. ^ diet and activity as tol by pt.	13	[ { "category": "Radiology", "chartdate": "2122-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002592, "text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p urgent CABG\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: A 72-year-old status post urgent CABG.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . The endotracheal and left chest tube\n have been removed in the interim. In addition, the nasogastric tube has been\n removed. Otherwise, no significant interval change. The patient is status\n post median sternotomy and CABG. Persistent left basilar streaky opacities\n are seen likely reflect underlying atelectasis, difficult to exclude\n pneumonia. The right hemithorax is clear. The cardiac silhouette is grossly\n unchanged. The cardiac silhouette remains at the upper limits of normal.\n There is a right internal jugular central venous line in place terminating\n within the expected region of the cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1002419, "text": " 8:41 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumotnorax.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumotnorax.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable line placement on .\n\n Chest radiograph from at 14:21.\n\n HISTORY: 72-year-old woman with CABG, evaluate for effusion, edema or\n tamponade.\n\n FINDINGS: In the interim, a new endotracheal tube has been placed with distal\n tip terminating approximately 3 cm above the carina bifurcation. A new right\n IJ central line terminating at the atrial/caval junction. A new feeding tube\n is placed terminating in the stomach. There is an intraaortic balloon pump at\n a distance of 8 cm from the superiormost portion of the aortic arch. A new\n left lower lobe atelectasis with a small left pleural effusion is also noted\n on today's examination. The right lung is clear. The patient is status post\n cardiothoracic surgery with multiple sternotomy wires with no associated wire\n complication. The heart size is mildly enlarged expected from a postoperative\n procedure.\n\n IMPRESSION:\n\n 1. Baseline postop examination showing a new left lower lobe atelectasis and\n small left pleural effusion.\n\n 2. Lines and tubes and catheters are in appropriate location as described\n above.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002452, "text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72F severe left main dz s/p emergent CABGx2\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 72-year-old female with severe left main disease status\n post emergent CABG x2.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination dated . The patient is status post median sternotomy and\n CABG. The supporting lines are stable and in satisfactory positions. There\n is improved aeration of the left base associated with partial interval\n resolution of the left basilar atelectasis noted on the prior examination. No\n new focal opacities are seen. The cardiomediastinal silhouette is stable.\n\n\n" }, { "category": "Echo", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 76251, "text": "PATIENT/TEST INFORMATION:\nIndication: CAD, unstable angina,\nHeight: (in) 66\nWeight (lb): 130\nBSA (m2): 1.67 m2\nBP (mm Hg): 100/40\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 18:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. No left ventricular\naneurysm is seen. There is mild regional left ventricular systolic dysfunction\nwith focalities in the apical anteroseptal and anterior wall. Right\nventricular chamber size and free wall motion are normal. There are focal\ncalcifications in the aortic arch. There are simple atheroma in the descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is a\nsmall pericardial effusion. Dr. was notified in person of the results\non patient .\n\nPost_Bypass:\nLVEF 50%.\nThoracic aortic contour is intact. Normal RV systolic function.\nMild improvement in previously hypokinetic apical anterior and anteroseptal\nsegments.\nMinimal MR and minimal TR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-02-23 00:00:00.000", "description": "Report", "row_id": 1644511, "text": "Neuro: pt oriented following commands.\nResp: pt on 2 L NP tolerating well with O2 sats 95-98%\nC/V: vss pt in sinus rhythm with stable BP . CVP 2-4. palpable pedal pulses.\nGI: pt having intermittent bouts of nausea associated with pain medication treated with Zofran 4mg with fair relief but not lasting more then several hours. IV Reglan given with good effect.\nEndo: blood sugars treated with sliding scale insulin.\nGU: pt receiving lasix 10mg ivp with fair response. Foley to be d/c'd in am.\nSkin: Incisions clean and dry no drainage or redness noted.\nPain: pt complains of incision pain requesting percocet and something for nausea at same time. pt given Zofran and percocet 1 tab but developed dry heaves several hours later.Pt stated that she gets nauseous after taking percocets. Percoets d/c'd and Darvocet given this am. Pt sleeping at present.\nPla: Remove floey, increase activity and transfer to floor when bed available\n" }, { "category": "Nursing/other", "chartdate": "2122-02-22 00:00:00.000", "description": "Report", "row_id": 1644509, "text": "NEURO: Pt A&Ox3, MAE and follows commands. Pt c/o severe () pain @ CT site. Given 0.50mg Dilaudid IV Q4, with min effect, however pt falls asleep. Pt c/o nausea most of shift, especially when given pain medicine (immediate nausea). pt given reglan Q6 for nausea-> ? zofran?\n\nCV: pt in NSR 70s-80s, with no ectopy noted. Epicardial wires: 2As/2Vs, Vs do not sense or capture appropriately. A line d/c'd after lost waveform and could not draw off; NIBP 100s-120s, MAP 60s-70s. CVP 0-3 most of shift, MD aware. Given 250cc NS fluid bolus for low u/o and CVP. Hct 31.1. PP palpable.\n\nRESP: Pt on 4L NC. LS clear, diminshed in bases. Pt not C&DB well. Uses IS<250. CT draining min amt serosang fluid. -airleak/crepitus.\n\nGI/GU: +BS, pt nauseous/-vomitting: given reglan Q6; pt requesting more often ? zofran order/more freq reglan order. Standing order Lasix 10mg TID with + diuresis for few hours. Give 250cc NS bolus for low u/o-->?hold lasix in am. ^ diet as pt tol, pt refused PM meds, food & H2O d/t N/V.\n\nENDO: Lasix gtt off d/t BS 76; BS WNL since, will tx prn with SC insulin. Lytes repleated prn.\n\nSKIn: Skin WDI, afebrile, t-max 98.6.\n\nPLAN: Monitor VS, resp status, CT and u/o. Comfort and support pt. ^ diet and activity as tol by pt. Cont with pulmonary toileting. ? d/c CTs in am. OOC to chair\n" }, { "category": "Nursing/other", "chartdate": "2122-02-22 00:00:00.000", "description": "Report", "row_id": 1644510, "text": "shift update:\n\nneuro: oriented x3. mae. c/o incisional pain on scale 1-10. dilaudid 0.5mg ivp x1 given w/reglan per pt request w/fair effect per pt, but pt found sleeping. percocet 1 tab given x2 w/good effect. oob->chair w/assist of 2 tol well.\n\ncv/skin: nsr. no vea. sbp stable. tolerating po lopressor. ct's & epicardial wires d/c'd. cxray done. +pp bilat. magnesium repleted.\n\nresp: lungs clear but dim in bases. o2 weaned to 2l nc. sat's>94. encouraged to cdb & use is, cough weak & only able to get is to 250.\n\ngi/gu: abd soft. +bs. c/o nausea w/pain med & requesting reglan w/pain med->nauseous dispite med zofran given w/good effect. tolerating sips of clears. 6am lasix dose held d/t low cvp, given at 11a per team w/fair diuresis.\n\nendo: fs treated w/ssri per protocol.\n\nid: last dose of vanco given. afebrile.\n\nsocial: niece into visit & update given.\n\nplan: pain management. cont to monitor vs, labs, i&o. encourage pulmonary toilet. increase activity & diet as tolerates. transfer to 6 when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644507, "text": "pt arrived last evening around from the OR s/p Cabg x2 done emergently after found to have tight left main. I ABP inserted and pt sent to OR. Arrived here on Propofol and Neo 0.2mcg pt 100% apaced on arrival. Pt had been oozy in OR chest tubes draining small amounts Fibrogen 128 pt received Cryoprecipitate on arrival. Neo weaned off.\nNeuro: pt sedated with propofol overnight. This am opening eyes with stimulation, moving all extremities and following commands.\nResp: pt on CMV overnight with good ABG's Fio2 weaned down to 40%. Peep increased to 8 last night after chest xray showed lower left based possible collaspse. Plan to place on Cpap wean for possible extubation.\nC/V: pacer turned down, pt in sinus rhythm rate 70-80's no ectopy. pacer placed on a demand of 60. pt became hypertensive nitro started and titrated up to 3 with MAP staying up in the 90's and SBP by IABP 130's. Radial aline tracing with fling SBP up to 160's. Monitoring BP by fiberoptic and Iabp aline. CVP 8-9 pt given lopressor total 5mg ivp for elevated BP with out effect, hydralazine 5mg ivp given with good effect Map down below 85 and nitro weaned off. IABP on 1:1 all night with good augmentation and unloading. Pedal pulses palpable in bilateral feet, warm to touch.\nGI: OGT draining dark bilious fluid overnight. no bowel sounds heard as of yet.\nEndo: Insulin gtt started for BS of 150's off this am.\nGU: adequate urine output.\nSkin: Dsg clean and dry no drainage.\nPain: pt given morphine 2mgs ivp for perceived pain through ight. pt nods yes to pain this am after turning.\nPlan: wean IABP prepare for possible remaoval. Start lasix. Wake and wean vent\n\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644508, "text": "shift update:\n\nneuro: , , follows commands. c/o pain medicated w/morphine 2mg at 0800 w/good effect. a&o x3 post extubation. c/o incisional pain medicated w/morphine->n/v x1 reglan given. pt reports n/v from morphine. given percocet 1tab po w/sip of h2o->n/v shortly after. dr aware, no new orders. remains on bedrest until 1830 per cardiology d/t iabp d/c'd.\n\ncv/skin: nsr->st w/rare pac's. ntg restarted d/t sbp>130 by aline, nibp 10pt lower. iabp weaned tolerated well->d/c'd by dr . team aware of ^'d need of ntg, to order lopressor. pacer set for ademand at 60, sensing & capturing appropriately. ct drainage minimal. k+, ca & magnesium repleted. +palp pp bilat.\n\nresp: lungs clear but dim in bases. vent weaned. extubated to 50% oft->weaned to 4lnc. sat's>94%.\n\ngi/gu: og->lws w/billious drainage, d/c'd w/extubation. n/v as noted above. reglan x1. abd soft +bs. good diuresis after lasix.\n\nendo: insulin gtt per protocol. see flowsheet for details.\n\nsocial: niece into visit, updated. niece requesting that her phone number be given out to anyone calling to check on pt.\n\nplan: pain management. bedrest until 1830. ?start po lopressor. wean ntg as tolerates. cont to monitor vs labs & i&o. increase diet as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644506, "text": "Respiratory care note:\nPt received from OR around 7:30 PM on A/C 550/12/5 with 100%. X-ray revealed some atelectasis, peep increased to 8. Good ABGs, FiO2 and peep weaned to 40% and 5.\nPlan: Continue to monitor.\nRSBI=69.5\n" }, { "category": "Radiology", "chartdate": "2122-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002376, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest pain resolved\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n chest pain resolved\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n COMPARISONS: None.\n\n SINGLE VIEW CHEST, AP UPRIGHT: The cardiac size is on the upper limits of\n normal. There are no focal pulmonary opacities and the pulmonary vasculature\n is within normal limits. There is no pneumothorax or definite pleural\n effusion. Note is made of bilateral humeral head replacements.\n\n IMPRESSION: No acute cardiopulmonary disease.\n\n\n" }, { "category": "ECG", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 185883, "text": "Sinus rhythm. There is an RSR' pattern in lead V1 which is probably normal.\nNon-specific anterior and anterolateral ST-T wave changes. Compared to the\nprevious tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 185884, "text": "Sinus rhythm. Anterolateral ST-T wave changes. Cannot rule out myocardial\nischemia. Compared to the previous tracing of anterolateral\nST-T wave changes are new. Clinical correlation is suggested.\n\n" } ]
1,747	109,552	MICU transfer: 42 yo alcoholic male with h/o DTs and withdrawal seizures who initially admitted to medicine serivice on after a witnessed tonic-clonic seizure secondary to EtOH withdrawal. Per reports, the seizure lasted a few minutes and the patient was post-ictal and incontinent of urine upon arrival to ED. On arrival to ED T 101.8, HR 120, BP 113/69, RR 18, O2 sat 95%. Blood alcohol level of 80. In ED he received IV hydration with D5NS, thiamine, and ativan per CIWA scale for withdrawl. He denied hallucinations, CP, SOB, Fever, Chills, N/V/D, belly pain, HA, nightsweats. Reports chronic minially productive cough, no hemoptysis. . After arrival to the floor, the patient was managed with Valium initially at 10 mg po q1-2 hrs per CIWA protocol and Haldol prn for agitation. On the evening of the day of admission, code purple was called after the patient started ripping his IV and attempting to leave AMA. The patient was delirius and did not have decisional capacity to leave AMA. . He received a total of over 170 mg of Valium since arrival to medical floor. The patient was transferred to MICU today for management of EtOH withdrawal in the setting of high benzodiazepine requirement and increasing agitation. Psychiatry was concerned re: paradoxical reaction to Benzodiazepines. At the time of transfer, the patientn is delirius and is unable to provide hitory. History is obtained from the chart review. . On admission to the MICU, the patient was started on an aggressive CIWA scale with 20mg Ativan q10 minutes initially as needed for a CIWA scale greater than 10. The patient initially required frequent dosing and large requirements, recieving int he first 12 hours 240mg of Diazepam. The patient appeared o respond well with decreased agitation and decreased benzo needs. An attempt was made to control the patient's agitation with increased Haldol and less benzo's, but patient responded with increased agitation again, indicating that the patient had large and ongoing Benzodiazepine requirements for ETOH withdrawal. Since admission to the MICU the patient has remained afebrile and had no additional seizures. He has been maintained with a 1:1 sitter as needed and required ongoing point restraints for agitation and attempts to get out of bed. . 1. EtOH withdrawl/seizure. He reports last drink was 1 day PTA but had negative serum EtOH in ED. Suspect that seizure due to withdrawl. LFTs c/w EtOH abuse (AST > AlT). - CIWA scale with valium was continued after transfer from MICU. Patient did not require more than 3 doses overnight after transfer. - thiamine, folate were continued throughout the hospitalization. - Does not report a history of cirrhosis and no ascites on exam. - 1 day after transfer from MICU, patient decided to leave the hospital AMA, and was in the opinion of the housestaff and medical attending capable of making that decision for himself. The patient left the hospital against medical advice.	1:1 sitters d/c'd.cv: monitor shows sb-nsr with rare pvc noted.resp: ls coarse throughout. NEW IV PLACED RL POSTERIOR ARM.DISPO- REMAINS IN MICU FOR DT TX.PLAN- VALIUM 10-20MG IV Q 10MIN PRN CIWA > 10. diaphoritic at times with DT'S. adequately sedated from previous shift(s) IV Valium doses. labs pending.Resp: on RA, pulse ox 96-99%, lungs clear.GI/ENDO: abd soft,nontender,nondistended. +bs noted. uo marginal...dr aware. Baseline artifactSinus tachycardiaOtherwise normal ECGNo previous tracing available for comparison Pt medicated as ordered with 10-30mg Valium IV according to CIWA scale. micu note 2300-0700S; incomprehensible, mumbling.O; Please see carevue for VS and objective dataNeuro; Pt. +perrla noted. bowel sounds +, no BM on this shift. BS CLEAR.CARDIAC- HR 100-ONE TWENTIES. HE FEELS HE IS IN A MONITORED SETTING WITH GOOD O2 SATS ON RA. Valium20 ivp given, total of at least 240mg ivp q shift. Arrived in EW post ictal and had urinary incontinence. PERL, 2mm, sluggish. tol sips of clears.gu: foley intact and patent. MICU team aware of level of sedation and last dose Valium. 1:1 sitter this shift.CVS; Hemodynamically stable with HR 50-60's, NSB/NSR. Treated w/IVF and IV ativan in EW, had - head CT and tox screen had zero ETOH level. PATIENT HAD 1:1 SITTER THIS AM. HALDOL GIVEN 5MG IV X1. WAS CALLED AND A SITTER WAS REINSTITUTED. SBP 130-160'S. CIWA scale still >10.Cardiac: ST 100-110's, no ectopy. FOCUS; NURSING PROGRESS NOTE42 YEAR OLD GOING THROUGH ETOH WITHDRAWAL.REVEIW OF SYSTEMS-NEURO- PATIENT IS ORIENTED TO PERSON ONLY. Received 160mg valium until he became somulent. BP ranges 109-130's/60-70.Resp; Room air sats 97-100%, Lungs clear bil. neuro: a+o to person and place. MICU NPN Neuro: pt sedated, has recieved 280mg Valium IV today, last dose at 1830. motehr called x1. Abdomen soft with active bowel sounds, no stool this shift. Last dose 11/3 1830. initially extremely agitated and medicated with prn valium x2 for ciwa scale >10 with +efffect. CIWA scale 3 most of shift. HE BECAME QUITE AGGITATED WHEN VALIUM WAS HELD TO TRY HALDOL. AND THINKS IT IS 'S. He tried to leave AMA overnight and Code Purple was called. Foley to drainage with clear, amber urine, u/o 30-45cc/hour.ID; afebrileA: adequately sedated from previous shift IV Valium while in acute DTs.P: Cont to monitor neuro and CIWA scale, assess for further DTs, IV Valium as needed by CIWA. remains in 3 point restraints. DR HERE AT THE TIME AND WANTS THE PATIENT TO CONT ON VALIUM 10-29MG Q 10MIN PRN FOR CIWA > 10. ?IV: #18 in right AC. REPEAT TO BE DRAWN AT 1700.GI- ABD SOFT WITH POS BS. #20 angio placed on left hand and medicated w/Valium. K+ 3.4, received 40meq ivpb on this shift. Opened eyes briefly to nailbed pressure. +mae noted. RESP 16-21. MG WAS 1.8 TX WITH 2GMS MAG. LOWEST CIWA HAS BEEN 8.RESP- ON RA SATS HAVE BEEN 98-99%. fingersticks q 6hr. Arousable to name and sternal rub with a mumbling of incomprehensible sounds only. 35-50ml/hrSkin/ID: intact, afebrile. HE IS NPO. TX WITH 40MEQ IV KCL. CIWA scale remains >10 when awoken to assess CIWA scale. shift note 1900-700Events: Pt continues to withdrawal and active DT's, hallucinating, discorieted and aggitated. had witnessed seizure on admission in EW, no seizure activity this shift. denies sob or resp distress.gi: abd soft and nontender. Pt. Sitter present in room.CV: HR 54-60's SB/NSR, BP 108-130/60.ID: afebrile.A/P: Pt without need for further Valium over past 4 hrs, cont to monitor. Pt initially medicated w/5mg IM haldol as IV on right lower arm was infiltrated. remains on ra. DOWN TO THE 90'S WHEN CIWA 8. HE WAS ON VALIUM IV FOR CIWA > THAN 10 THIS AM. NEW IV PLACED THIS AM IN LEFT HAND WHICH PATIENT WAS ABLE TO GET OUT. pt updated on status and plan of care. Follow up with am labs, IVF when banana bag complete, remains NPO. cough/gag intact. VSS. HAS BEEN REORIENTED A NUMBER OF TIMES THIS AM. REPEAT 3.6. No vea noted. THINKS HE IS . oriented to self. replete electrolytes as needed. PSYCHE WAS BY AND FELT HE WAS BENZO TOXIC. SBP 140-150's. mouthcare x 2, but difficulty to do mouthcare, which pt needs. THE PATIENT HAS IN TOTAL RECEIVED 160MG OF VALIUM IV TODAY. NPO.GU: foley with clear amber urine. RR 16-20, sats 98% on RA, occ coughing. eye care given x 2, may have conjuntivitis? OLD ECCHYMOSIS ON LEFT THIGH. D5 1/2ns with 20 kcl infusing @ 120 cc/hr.i-d: afebrile.psy-soc: c/o medical floor awaiting bed. ON PPI.GU- FOLEY PATENT DRAINING AMBER CLEAR URINE AT 30-100CC/HR.SKIN- SKIN INTACT. Comfort and emotional support to Pt. K THIS AM WAS HEMOLYZED AT 5.5. pt non-complient and uncoorperative. Snoring at intervals.GI;GU; NPO, IVF with banana bag from previous shift at 100cc/hour. sedated, no N/V, tremors/seizures, no diaphoresis. Please see FHPA for further details. HE WAS SEDATED FOR A SHORT TIME AFTER THIS BUT 1.5 HOURS AFTER RECEIVING NO VALIUM HE HAD A CIWA OF 21. No cough. No N/V. lethargic most of shift but easily arousable. sitter at bedside.Neuro: confused and disoriented to event,place,time. Pt has had sitter at bedside since.Pt arrived to MICU via ambulance accompanied by sitter, disoriented, combative, profusly diaphoretic with auditory and visual hallucinations. receiving banana bag at 100ml/hr, and then d51/2 at 100ml/hr.Plan: continue to monitor for DT's, sedation PRN for pt's safety. SITTER WAS DC'D BY AS THIS NURSE HAD ONE PATIENT AND PATIENT WAS RELATIVELY CALM WHEN SHE WAS HERE. No audible or visual hallucinations noted. no stools this shift. no Nausea or vomiting. Not following commands. SHE STATES HE HAS WITHDRAWAL SEIZURES MULTIPLE TIMES IN THE PAST. NO STOOL TODAY. Pt in EW 21 hours then transfered to floor where he received large doses of valium as well as intermittent haldol to control his withdrawal symptoms of agitation, tremulousness, tachycardia and hypertension. no seizure activity.	7	[ { "category": "ECG", "chartdate": "2175-09-27 00:00:00.000", "description": "Report", "row_id": 202249, "text": "Baseline artifact\nSinus tachycardia\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284190, "text": "shift note 1900-700\nEvents: Pt continues to withdrawal and active DT's, hallucinating, discorieted and aggitated. Valium20 ivp given, total of at least 240mg ivp q shift. no seizure activity. remains in 3 point restraints. sitter at bedside.\n\nNeuro: confused and disoriented to event,place,time. oriented to self. hallucinating, seeing people in room, thinks he is at work,in the car, at the bar, ect. aggitated, but increasing becoming easier to communicate with patient and listens more throughout shift. unable to comprehend whereabouts and unable to keep oriented. speech comprehensible but slurred, will use profanity. had witnessed seizure on admission in EW, no seizure activity this shift. CIWA scale still >10.\n\nCardiac: ST 100-110's, no ectopy. SBP 140-150's. Replete MG on days with 4 grams, which bumped his mg level to 2.5. K+ 3.4, received 40meq ivpb on this shift. labs pending.\n\nResp: on RA, pulse ox 96-99%, lungs clear.\n\nGI/ENDO: abd soft,nontender,nondistended. bowel sounds +, no BM on this shift. fingersticks q 6hr. no Nausea or vomiting. NPO.\n\nGU: foley with clear amber urine. 35-50ml/hr\n\nSkin/ID: intact, afebrile. mouthcare x 2, but difficulty to do mouthcare, which pt needs. pt non-complient and uncoorperative. diaphoritic at times with DT'S. eye care given x 2, may have conjuntivitis??\n\nIV: #18 in right AC. receiving banana bag at 100ml/hr, and then d51/2 at 100ml/hr.\n\nPlan: continue to monitor for DT's, sedation PRN for pt's safety. replete electrolytes as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284191, "text": "FOCUS; NURSING PROGRESS NOTE\n42 YEAR OLD GOING THROUGH ETOH WITHDRAWAL.\nREVEIW OF SYSTEMS-\nNEURO- PATIENT IS ORIENTED TO PERSON ONLY. THINKS HE IS . AND THINKS IT IS 'S. HAS BEEN REORIENTED A NUMBER OF TIMES THIS AM. HE WAS ON VALIUM IV FOR CIWA > THAN 10 THIS AM. PSYCHE WAS BY AND FELT HE WAS BENZO TOXIC. HALDOL GIVEN 5MG IV X1. HE WAS SEDATED FOR A SHORT TIME AFTER THIS BUT 1.5 HOURS AFTER RECEIVING NO VALIUM HE HAD A CIWA OF 21. DR HERE AT THE TIME AND WANTS THE PATIENT TO CONT ON VALIUM 10-29MG Q 10MIN PRN FOR CIWA > 10. HE FEELS HE IS IN A MONITORED SETTING WITH GOOD O2 SATS ON RA. THE PATIENT HAS IN TOTAL RECEIVED 160MG OF VALIUM IV TODAY. LOWEST CIWA HAS BEEN 8.\nRESP- ON RA SATS HAVE BEEN 98-99%. RESP 16-21. BS CLEAR.\nCARDIAC- HR 100-ONE TWENTIES. DOWN TO THE 90'S WHEN CIWA 8. SBP 130-160'S. K THIS AM WAS HEMOLYZED AT 5.5. REPEAT 3.6. TX WITH 40MEQ IV KCL. MG WAS 1.8 TX WITH 2GMS MAG. REPEAT TO BE DRAWN AT 1700.\nGI- ABD SOFT WITH POS BS. NO STOOL TODAY. HE IS NPO. ON PPI.\nGU- FOLEY PATENT DRAINING AMBER CLEAR URINE AT 30-100CC/HR.\nSKIN- SKIN INTACT. OLD ECCHYMOSIS ON LEFT THIGH.\n MOTHER CALLED AND WAS UPDATED BY THIS NURSE. SHE STATES THAT THE PATIENT HAS BEEN DRINKING SINCE AGE 13. IF HE IS WORKING HE DOES WELL IF HE ISN'T WORKING HE DRINKS HEAVILY. SHE STATES HE HAS WITHDRAWAL SEIZURES MULTIPLE TIMES IN THE PAST. PATIENT HAD 1:1 SITTER THIS AM. SITTER WAS DC'D BY AS THIS NURSE HAD ONE PATIENT AND PATIENT WAS RELATIVELY CALM WHEN SHE WAS HERE. HE BECAME QUITE AGGITATED WHEN VALIUM WAS HELD TO TRY HALDOL. HE WAS ATTEMPTING TO CRAWL OOB. SWINGING LEGSOVER THE SIDERAIL. WAS CALLED AND A SITTER WAS REINSTITUTED. SITTER PRESENTLY AT BEDSIDE.\nPATIENT ALSO HAS SAFETY DEVICES ON WRISTS TO PREVENT HIM FROM PULLING AT TUBES AND LINES.\nACCESS- HAS RIGHT ANTECUB IV. NEW IV PLACED THIS AM IN LEFT HAND WHICH PATIENT WAS ABLE TO GET OUT. NEW IV PLACED RL POSTERIOR ARM.\nDISPO- REMAINS IN MICU FOR DT TX.\nPLAN- VALIUM 10-20MG IV Q 10MIN PRN CIWA > 10.\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284192, "text": "MICU NPN \nNeuro: pt sedated, has recieved 280mg Valium IV today, last dose at 1830. Pt has been sleeping, snorring. RR 16-20, sats 98% on RA, occ coughing. Sitter present in room.\nCV: HR 54-60's SB/NSR, BP 108-130/60.\nID: afebrile.\nA/P: Pt without need for further Valium over past 4 hrs, cont to monitor. VSS.\n" }, { "category": "Nursing/other", "chartdate": "2175-09-29 00:00:00.000", "description": "Report", "row_id": 1284193, "text": "micu note 2300-0700\nS; incomprehensible, mumbling.\nO; Please see carevue for VS and objective data\nNeuro; Pt. adequately sedated from previous shift(s) IV Valium doses. Last dose 11/3 1830. CIWA scale 3 most of shift. Pt. sedated, no N/V, tremors/seizures, no diaphoresis. No audible or visual hallucinations noted. PERL, 2mm, sluggish. Arousable to name and sternal rub with a mumbling of incomprehensible sounds only. Opened eyes briefly to nailbed pressure. Not following commands. MICU team aware of level of sedation and last dose Valium. Soft hand restraints remain in place for safety of IVs. 1:1 sitter this shift.\nCVS; Hemodynamically stable with HR 50-60's, NSB/NSR. No vea noted. BP ranges 109-130's/60-70.\nResp; Room air sats 97-100%, Lungs clear bil. No cough. Snoring at intervals.\nGI;GU; NPO, IVF with banana bag from previous shift at 100cc/hour. Abdomen soft with active bowel sounds, no stool this shift. No N/V. Foley to drainage with clear, amber urine, u/o 30-45cc/hour.\nID; afebrile\nA: adequately sedated from previous shift IV Valium while in acute DTs.\nP: Cont to monitor neuro and CIWA scale, assess for further DTs, IV Valium as needed by CIWA. Follow up with am labs, IVF when banana bag complete, remains NPO. Comfort and emotional support to Pt. and family\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-29 00:00:00.000", "description": "Report", "row_id": 1284194, "text": "neuro: a+o to person and place. initially extremely agitated and medicated with prn valium x2 for ciwa scale >10 with +efffect. lethargic most of shift but easily arousable. pt with increased alertness this afternoon and more appropriate than in am. +mae noted. cough/gag intact. +perrla noted. 1:1 sitters d/c'd.\ncv: monitor shows sb-nsr with rare pvc noted.\nresp: ls coarse throughout. +prod cough thick yellow secretions. remains on ra. denies sob or resp distress.\ngi: abd soft and nontender. +bs noted. no stools this shift. tol sips of clears.\ngu: foley intact and patent. uo marginal...dr aware. D5 1/2ns with 20 kcl infusing @ 120 cc/hr.\ni-d: afebrile.\npsy-soc: c/o medical floor awaiting bed. motehr called x1. pt updated on status and plan of care.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-27 00:00:00.000", "description": "Report", "row_id": 1284189, "text": "Nursing Admit\n42 yo man w/history of alcohol abuse with history of DTs w/withdrawal seizures presents to MICU from 12 with escalating drug requirements for ETOH withdrawal.\nPt presented to EW via ambulance after witnessed seizure. Arrived in EW post ictal and had urinary incontinence. Treated w/IVF and IV ativan in EW, had - head CT and tox screen had zero ETOH level. Pt in EW 21 hours then transfered to floor where he received large doses of valium as well as intermittent haldol to control his withdrawal symptoms of agitation, tremulousness, tachycardia and hypertension. He tried to leave AMA overnight and Code Purple was called. Pt has had sitter at bedside since.\nPt arrived to MICU via ambulance accompanied by sitter, disoriented, combative, profusly diaphoretic with auditory and visual hallucinations. Pt initially medicated w/5mg IM haldol as IV on right lower arm was infiltrated. #20 angio placed on left hand and medicated w/Valium. Pt medicated as ordered with 10-30mg Valium IV according to CIWA scale. Received 160mg valium until he became somulent. CIWA scale remains >10 when awoken to assess CIWA scale. Please see FHPA for further details.\n\n" } ]
5,877	172,786	She was admitted to on for a Whipple Procedure. This was complicated by a Portal Vein injury with an estimated 2000cc blood loss. She received 6 Units of PRBCs. She was admitted to the SICU post-operatively and remained intubated. She was stable post-op and extubated the next morning.	Resp Care,Pt. Left lower lobe atelectasis is noted. FRONTAL CHEST RADIOGRAPH: Right IJ line is terminating in distal SVC. Nasogastric tube is seen terminating in the left upper quadrant. ABG WNL, see carevue. IMPRESSION: Tubes and lines as described above. Plan to extubate this am. Placed on SBT. Three small radiodense opacities in the upper abdomen, probably representing clips. Three small linear densities are seen, probably representing surgical clips. Drainage tube is noted, overlying the mid abdomen. Drainage tube is noted overlying the left upper quadrant. Nasogastric tube is coursing down below the left hemidiaphragm, with the tip in left mid quadrant. Cardiac and mediastinal contours are within normal limits. T wave abnormalities.Since the previous tracing of the rate is somewhat slower. TECHNIQUE: Portable abdominal radiograph. Comparison is made with the prior abdominal CT dated . Sinus tachycardia.. Borderline low limb lead voltage. Clinicalcorrelation is suggested. admitted from OR intubated #7.5 taped at 21@lip. Endotracheal tube is terminating 3 cm above the carina. TheQRS voltage is decreased and T wave abnormalities are more marked. IMPRESSION: Somewhat limited study. Tol well. 6:47 PM ABDOMEN (SUPINE ONLY) IN O.R. follows commandsCARDIO:hr 100-110'S; On neo for a short period, now off since 4am and SBP>100EKG unchanged post-opRESP:weaned to extubation by 4am; RSBI 25. pt awake and wanting tube outvery ready for extubation.GI/GU:good urine outsPOC:EXTUBATECONTINUE TO FOLLOW PATHWAY The evaluation is somewhat limited on this film which does not include the peripheral portion of the left abdomen. Clip # Reason: MISSING MATERIALS ? BS clear. awoke calm and moves all extremities. 8:16 PM CHEST PORT. Admitting Diagnosis: PANCREATIC CA/SDA FINAL REPORT INDICATION: 63-year-old woman with question missing material. No other radiodense foreign body. No other radiodense material is noted. No evidence of pneumothorax. condition updateS/P WHIPPLE PROCEDURE W/PORTAL BLEED.NEURO:sedated on propofol, given 2 doses of pain med and shut off propofol around 2am for more thorough neuro exam and vent wean. 4am RSBI 25, awake and alert. No evidence of pneumothorax is noted on this radiograph.	5	[ { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1339245, "text": "condition update\nS/P WHIPPLE PROCEDURE W/PORTAL BLEED.\nNEURO:\nsedated on propofol, given 2 doses of pain med and shut off propofol around 2am for more thorough neuro exam and vent wean. awoke calm and moves all extremities. follows commands\nCARDIO:\nhr 100-110'S; On neo for a short period, now off since 4am and SBP>100\nEKG unchanged post-op\nRESP:\nweaned to extubation by 4am; RSBI 25. pt awake and wanting tube out\nvery ready for extubation.\nGI/GU:\ngood urine outs\nPOC:\nEXTUBATE\nCONTINUE TO FOLLOW PATHWAY\n" }, { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1339246, "text": "Resp Care,\nPt. admitted from OR intubated #7.5 taped at 21@lip. BS clear. 4am RSBI 25, awake and alert. Placed on SBT. Tol well. Plan to extubate this am. ABG WNL, see carevue.\n" }, { "category": "ECG", "chartdate": "2103-09-27 00:00:00.000", "description": "Report", "row_id": 201016, "text": "Sinus tachycardia.. Borderline low limb lead voltage. T wave abnormalities.\nSince the previous tracing of the rate is somewhat slower. The\nQRS voltage is decreased and T wave abnormalities are more marked. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2103-09-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 934240, "text": " 8:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: sp whipple\n Admitting Diagnosis: PANCREATIC CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with panc ca\n REASON FOR THIS EXAMINATION:\n sp whipple\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with pancreatic cancer, status post Whipple\n procedure.\n\n FRONTAL CHEST RADIOGRAPH: Right IJ line is terminating in distal SVC.\n Endotracheal tube is terminating 3 cm above the carina. Nasogastric tube is\n coursing down below the left hemidiaphragm, with the tip in left mid quadrant.\n Drainage tube is noted, overlying the mid abdomen. No evidence of\n pneumothorax is noted on this radiograph. Cardiac and mediastinal contours\n are within normal limits. Left lower lobe atelectasis is noted.\n\n IMPRESSION: Tubes and lines as described above. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-27 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 934228, "text": " 6:47 PM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: MISSING MATERIALS ?\n Admitting Diagnosis: PANCREATIC CA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with question missing material.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n Comparison is made with the prior abdominal CT dated . The\n evaluation is somewhat limited on this film which does not include the\n peripheral portion of the left abdomen. Nasogastric tube is seen terminating\n in the left upper quadrant. Drainage tube is noted overlying the left upper\n quadrant. Three small linear densities are seen, probably representing\n surgical clips. No other radiodense material is noted.\n\n IMPRESSION: Somewhat limited study. Three small radiodense opacities in the\n upper abdomen, probably representing clips. No other radiodense foreign body.\n\n\n" } ]
55,973	164,256	Primary Reason for Hospitalization: 60F with PMH pancreatic and renal transplants, DM type II, diastolic CHF, HTN, and hypothyroidism, recently admitted for CHF exacerbation who presents with weakness, fevers, and hypotension suggestive of urosepsis.	Moderateregional LV systolic dysfunction. There is moderate regional left ventricular systolic dysfunction withakinesis of the apex and hypokinesis of the distal segments of the LV. There is a trivial/physiologicpericardial effusion. No echocardiographicsigns of tamponade.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium is mildly dilated. Traceaortic regurgitation is seen. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Left atrial abnormality. There is moderatepulmonary artery systolic hypertension. The left ventricular cavity is mildlydilated. Compared to tracing #1 sinustachycardia is absent.TRACING #2 Left bundle-branch block.Compared to the previous tracing of ST segment depression is lesspronounced in lead V6.TRACING #1 Possible left atrial abnormality. Mildly dilated LV cavity. INDICATION: Urosepsis with poor IV access. : (in) 67Weight (lb): 138BSA (m2): 1.73 m2BP (mm Hg): 86/43HR (bpm): 90Status: InpatientDate/Time: at 10:20Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is continued perihilar haziness with vascular indistinctness compatible with mild pulmonary edema. Moderate to severe (3+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Patchy opacities at the lung bases likely reflect atelectasis. Sinus tachycardia. Sinus tachycardia. Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH This is a power pick FINAL REPORT (Cont) The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cannot exclude LV mass/thrombus. The main renal artery and vein are patent with normal waveforms. Sinus rhythm. IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions, similar compared to the prior study. Perinephric fluid or hydronephrosis. OPERATORS: Drs. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Small bilateral pleural effusions are similar when compared to the prior study. The mediastinal and hilar contours are unchanged. Incorrectly transcribed PFI. Incorrectly transcribed PFI. The mitral valve leaflets are mildly thickened.Moderate to severe (3+) mitral regurgitation is seen. Under aseptic conditions and son guidance, a micropuncture needle was placed in the right basilic vein. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. The diameters ofaorta at the sinus, ascending and arch levels are normal. Mild to moderate [+] TR.Eccentric TR jet. IMPRESSION: 1. Resistive indices in the upper, mid and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively, previously ranging from 0.78 to 0.81. UPRIGHT AP VIEW OF THE CHEST: The heart size remains mildly enlarged. Timeout was performed as per protocol. The left atrium is elongated. FINAL REPORT PICC PLACEMENT. Tissue Doppler imagingsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Left bundle-branch block. Pulmonary pressures are worse. COMPARISON: . COMPARISON: . Leftventricular wall thicknesses are normal. Bibasilar air space opacities likely reflect atelectasis. REASON FOR THIS EXAMINATION: Please place PICC line. Wire was removed and sheath peeled away. Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH This is a power pick ******************************* CPT Codes ****************************** * PICC W/O PORT * * * **************************************************************************** MEDICAL CONDITION: 60 year old woman s/p pancreas and renal transplant w/ dCHF and CAD, p/w with urosepsis, and poor IV access. No AS. A 0.018 caliber wire was placed via the needle and advanced into the IVC. Appropriate dressing was applied. Appropriate measurements were made. , , and . Otherwise,no significant change. The tricuspidregurgitation jet is eccentric and may be underestimated. There are no echocardiographic signs of tamponade.Compared with the findings of the prior study (images reviewed) of ,the focal left ventricular dysfunction described above is new. Hypotension, fever. Rightventricular chamber size and free wall motion are normal. CONTRAST: None. A PICC was attempted to be placed over the wire via the peel-away sheath; however, we were unsuccessful in passing the catheter past the axillary - subclavian vein junction. 2. 2. 2. 2. 2. Status post pancreas and renal transplant. The degree ofmitral regurgitation has increased slightly. No acute osseous abnormalities are seen. TDI E/e'>15, suggesting PCWP>18mmHg. SEDATION: None. (Over) 2:23 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line.	8	[ { "category": "Radiology", "chartdate": "2181-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1202157, "text": " 9:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: The heart size remains mildly enlarged. The\n mediastinal and hilar contours are unchanged. There is continued perihilar\n haziness with vascular indistinctness compatible with mild pulmonary edema.\n Small bilateral pleural effusions are similar when compared to the prior\n study. Patchy opacities at the lung bases likely reflect atelectasis. No\n pneumothorax is present. No acute osseous abnormalities are seen.\n\n IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions,\n similar compared to the prior study. Bibasilar air space opacities likely\n reflect atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-08-06 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1202962, "text": " 2:23 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line.\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n This is a power pick\n ******************************* CPT Codes *****************************\n PICC W/O PORT \n \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p pancreas and renal transplant w/ dCHF and CAD, p/w with\n urosepsis, and poor IV access.\n REASON FOR THIS EXAMINATION:\n Please place PICC line.\n ______________________________________________________________________________\n FINAL REPORT\n PICC PLACEMENT.\n\n OPERATORS: Drs. , , and . Dr.\n , attending physician was present throughout the procedure.\n\n INDICATION: Urosepsis with poor IV access. Status post pancreas and renal\n transplant.\n\n SEDATION: None.\n\n CONTRAST: None.\n\n PROCEDURE: Patient was placed supine on the imaging table in the\n interventional suite. Procedure was explained to the patient. Timeout was\n performed as per protocol.\n\n Under aseptic conditions and son guidance, a micropuncture needle was\n placed in the right basilic vein. A 0.018 caliber wire was placed via the\n needle and advanced into the IVC. The needle was exchanged over the wire with\n a peel-away sheath. Appropriate measurements were made. A PICC was attempted\n to be placed over the wire via the peel-away sheath; however, we were\n unsuccessful in passing the catheter past the axillary - subclavian vein\n junction. Multiple attempts were made with various catheters. Venogram was\n not performed due to renal insufficiency. We were subsequently successful in\n advancing a 4-French 34 cm Glidecath into the lower SVC. Wire was removed and\n sheath peeled away. Glidecath port was secured to the skin by a StatLock.\n Appropriate dressing was applied. The patient tolerated the procedure well\n and no immediate post-procedure complications were seen.\n\n IMPRESSION: Successful placement of a 34 cm 4-French C2 Glidecath via the\n right basilic vein with its tip in the lower SVC. Please note that multiple\n attempts were made to pass a standard 4-French PICC but were unsuccessful.\n Results were discussed with Dr. at around 5:10 p.m. on\n .\n (Over)\n\n 2:23 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line.\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n This is a power pick\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2181-08-01 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1202282, "text": " 3:00 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ?hydronephrosis\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hx DMI s/p renal tx/pancreatic tx, urosepsis, fever\n REASON FOR THIS EXAMINATION:\n ?hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): WED 9:13 PM\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n\n Incorrectly transcribed PFI. Correct read discussed with Dr. at 9 pm\n on via telephone.\n PFI VERSION #1 WED 4:39 PM\n 1. Perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with history of diabetes, status post renal\n transplant, urosepsis and fever.\n\n COMPARISON: .\n\n RENAL ULTRASOUND: The transplanted kidney measures 11.3 cm. No evidence of\n hydronephrosis or perinephric fluid collection. The main renal artery and\n vein are patent with normal waveforms. Resistive indices in the upper, mid\n and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively,\n previously ranging from 0.78 to 0.81.\n\n The bladder is collapsed about the Foley and could not be well evaluated in\n this study.\n\n IMPRESSION:\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n Findings discussed with Dr. at 9 pm on via telephone\n\n" }, { "category": "Radiology", "chartdate": "2181-08-01 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1202283, "text": "2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78. Page: 2\n\n , F 60 () \n , MED 3:00 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ?hydronephrosis\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hx DMI s/p renal tx/pancreatic tx, urosepsis, fever\n REASON FOR THIS EXAMINATION:\n ?hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n\n Incorrectly transcribed PFI. Correct read discussed with Dr. at 9 pm\n on via telephone.\n\n" }, { "category": "Echo", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 63959, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension, fever.\n: (in) 67\nWeight (lb): 138\nBSA (m2): 1.73 m2\nBP (mm Hg): 86/43\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nregional LV systolic dysfunction. Cannot exclude LV mass/thrombus. TDI E/e'\n>15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nakinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nEccentric TR jet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is mildly\ndilated. There is moderate regional left ventricular systolic dysfunction with\nakinesis of the apex and hypokinesis of the distal segments of the LV. The\nremaining segments contract normally (LVEF = 35-40 %). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. The tricuspid\nregurgitation jet is eccentric and may be underestimated. There is moderate\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe focal left ventricular dysfunction described above is new. The degree of\nmitral regurgitation has increased slightly. Pulmonary pressures are worse.\n\n\n" }, { "category": "ECG", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 125673, "text": "Sinus rhythm. Left bundle-branch block. Compared to tracing #1 sinus\ntachycardia is absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 125674, "text": "Sinus tachycardia. Possible left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing of ST segment depression is less\npronounced in lead V6.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2181-07-31 00:00:00.000", "description": "Report", "row_id": 125675, "text": "Sinus tachycardia. Left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing of heart rate is increased. Otherwise,\nno significant change.\n\n" } ]
20,680	166,134	1) Rhythm - The patient was shocked twice to convert him to A fib rhythm. He was put on a lidocaine drip at 2 mg/min and transferred to . His rhythm spontaneously converted to bradycardic sinus rhythm within 6 hours of arrival, and the lidocaine drip was discontined. He was put on heparin 6 hours post cardiac catheterization but this was discontinued within 6 hours as well, as the sinus rhythm continued. He remained borderline sinus bradycardic during the remainder of hospitalization, with rates from 45-60, but was asymptomatic. He was transferred to the VA for pacer/AICD placement. 2) Pump - Initial EF during catheterization was calculated at 28%. He was monitored overnight with a swan-ganz catheter, which showed slightly increased RA and pulmonary pressures (see cath report). This was removed in the morning before extubation. His EF was 35% by echocardiogram, which also showed a dilated LV. He was put on captopril 6.25 TID which can be titrated as tolerated. His BP was stable at 110's-130's the day of discharge. A CHF workup can be pursued at the VA including TSH, iron studies, SPEP/UPEP, and an HIV test. 3) Coronaries - He has no coronary artery disease by cardiac catheterization. 4) Neurological - His short term memory was decreased immediately post extubation, but improved gradually during hospitalization. It is presumably due to the transient cerebral hypoxia. It should be followed up. His long term memory was intact. 5) Respiratory - The patient was intubated by the EMS, and extubated the morning after admission without incident.	There is moderateglobal left ventricular hypokinesis. There is moderate global leftventricular hypokinesis. follows commands, otherwise neuro status per baseline.resp: 2l nc o2 to ra tol well, o2 sats stable. denies sob/distress.cv: hr in nsr to sinus brady, couple rare episodes of ectope, pvc's noted. Right ventricular chamber size is normal.There is borderline global right ventricular free wall hypokinesis. cont in sr w/good bp.p- cont. fx/pt updated on pt progress, yesterday's events and plan.a- s/p arrest with clean cs on cath, low ef. +BPPP. Extubated yesterday and hemodynamically stable since.EPS possibly todayPossible call out to floor k- 3.7, mg 1.9 both replaced. CLEAR SECRETIONS.CARDIAC: ON ADM. TO CCU HR 50-53 AFIB, NO ECTOPY. Foley patent and draining adequate amounts of CYU. 1/2NS 100CC/HR X5HRS GIVEN FOR POST-CATH FLUIDS.GI: NPO. ccu npno- id- afebrile to 99.1po.cv- hr 50-60s sr, occ 40s, no vea. SX FOR MIN. OGT IN PLACE FOR MEDS. PLACEMENT CONFIRMED BY CXR. BS CLEAR BUT DIMINISHED AT BASES. safety prec prn. VS stable upon transfer HR 40-60 SR SB. S/P VF arrest.Height: (in) 66Weight (lb): 160BSA (m2): 1.82 m2BP (mm Hg): 117/94HR (bpm): 60Status: InpatientDate/Time: at 10:58Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. bs present, belly soft, nt/nd. pulses palp dp/pt bilat. The patient has been extubated in the interval. Sinus bradycardiaLeft bundle branch blockSince pervious tracing, no significant change to monitor hr, bp, ryhthm. BS+. ~0430 BECAME HYPOTENSIVE WITH SBP 77. nursing prog. Left ventricular wall thicknesses arenormal. ABG 7.42/39/166/26 99%. hct 32.7. aline d/c'd this pm. FINDINGS: Single portable AP view of the chest shows successfully placed ETT in good position. Cardiomegaly with slight cardiac failure. Improved cardiomegaly. TO BE SEEN BY EP->PACER/AICD. about 1000cc day.gi- abd soft, no pain, pos. Hemodynamically stable overnight. Pt to CCU intubated, fully vent supported. HR 50-57 SB, NO ECTOPY.BP 97-129/55-76. Overall left ventricular systolic function ismoderately depressed.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. There is minimal linear atelectasis in the left retrocardiac region. NG tube is noted with its tip and side port past the GE junction. Denies difficulty breathing. Denies chest pain dizziness, or lightheadedness. venous sheath d/c'd this pm by fellow, r groin d+i. BP m120-130/40-60. Otherwise neuro intact. The leftventricular cavity is mildly dilated. VENOUS SHEATH & SWAN IN R. GROIN WHICH IS D&I. There is mild pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. DISTENDED. RSBI this am 25 when sedation decreased. The left ventricular cavity is mildly dilated. Groin CDI with palpable pulses distal. Sinus bradycardiaLeft bundle branch block ADMISSION NOTEMR. The mitral valve leaflets are structurally normal.There is mild pulmonary artery systolic hypertension. Overall left ventricular systolicfunction is moderately depressed. Since the previous tracingof no significant change. bowel sounds. LIDO 2MG GTT.PAD 15->10, C0 4.4->4.3, CI 2.2->2.15. Sinus bradycardia. The aorticvalve leaflets (3) appear structurally normal with good leaflet excursion andno aortic regurgitation. IMPRESSION: Successful placement of ETT. MAEs. U/O 100-200CC/HR->5-40CC/HR. Cuff leak present prior to extubatation. Little changes overnoc on vent, remained sedated. There is left ventricular enlargement with slight upper zone redistribution of pulmonary vascular markings. RR 12/12. Low grade temps. NOT FOLLOWING COMMANDS.RESP: ON VENT: 40%/TV 600/AC 12/PEEP 5. no residual effect from hypoxemia other than noted short term memory deficit. note significant short term memory deficit, becoming apparent throughout morning with pt. ABD. SL. npo after 12am.ms- forgetful, oriented to person, date, occ. ls clear bilat and to bases. Breath sound clear. O2 SAT 100%. NSR/SB with no ectopy noted. PATIENT/TEST INFORMATION:Indication: Left ventricular function. bp 120-140s/ this pm. TO BE SEEN BY EP.NEURO: SEDATED ON PROPOFOL 10-20MCG/KG. See flowsheet for further pt data.Plan: Extubate. Left bundle-branch block. Follow simple commands. O2 sat on RA 100%. CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier. reorient prn, repeat teaching as needed. repeats self in converstaion topics. "SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSsO-A/O/X/3. R. GROIN ARTERIAL SHEATH D/C'D BY FELLOW SHORTLY AFTER COMING TO CCU. Resp CarePt extubated with no stridor noted tol well with spo2 in the upper 90s on 50% coo aerosal. This may indicate slight cardiac failure. bp slightly hypertensive this am, pt refused dose of captopril this am, after discussion w/ Dr. pt willing to take med, given at 1500. trace edema to ble.gi/gu: had remained npo for tentative aicd placement, currently restarted on low sodium diet, tol well at present. had liquids, pudding, to solids, tol well. OFF BRIEFLY, MAE & EXTREMELY AGITATED. There is mild cardiac enlargement which has improved since the prior study. RESPIRATORY CARE:61 yo m adm to CCU s/p cath (after vfib arrest in field). HR DOWN TO 45.500CC NS BOLUS & ATROPINE .5MG GIVEN->SBP 90'S & HR 55. IMPRESSION: No evidence of congestive heart failure. noteneuro: alert, oriented x3, moving all extrem. MVO2 65->60%. The lungs are otherwise clear. GIVEN NS BOLUS FOR HYPOTENSION, & WATCHING U/O.ID: ABEBRILE.AM LABS PENDING.PLAN: WEAN->EXTUBATE(WILL HAVE TO BE DONE QUICKLY--VERY AGITATED WHEN AWAKE). PLEASE SEE FHP FOR DETAILS OF PMH & EVENTS OF CURRENT ADMISSION. NO STOOL.GU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. Tolerating POs well with good intake. Denies SOB chest discomfort over sternum probably due to defibrillation, chest compressions. No repeative questions or response noted. heparin/lido d/c'd in am.resp- propofol d/c'd and extubated this am to 50% face tent with bag 7.38,41,81. sats 95-100. u/o adeq, i+o pos. NPO after MN for possible EP study in morning. O2Sats > 95% on 2LNP.	13	[ { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533761, "text": " 1631\n\nPt transfered to hospital for evaluation and placement of AICD. Transfered via ALS ambulance crew. VS stable upon transfer HR 40-60 SR SB. BP m120-130/40-60. O2 sat on RA 100%. Denies SOB chest discomfort over sternum probably due to defibrillation, chest compressions. Denies chest pain dizziness, or lightheadedness. PG 1,2 Discharge summary and cath reports sent with ambulance crew to hospital. Patient aware of transfer and happy with plan.\n" }, { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533759, "text": "CCU NPN:\nS:\"I am very interested in research!\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSs\n\nO-A/O/X/3. Pleasant and cooperative with care. Asking appropriate questions. No repeative questions or response noted. Follow simple commands. MAEs. Otherwise neuro intact. Hemodynamically stable overnight. NSR/SB with no ectopy noted. Groin CDI with palpable pulses distal. Breath sound clear. O2Sats > 95% on 2LNP. Denies difficulty breathing. Foley patent and draining adequate amounts of CYU. Tolerating POs well with good intake. NPO after MN for possible EP study in morning. Low grade temps. On no current abx treatment.\nSister visiting for most evening going home. Contact numbers for daughter and sister in room.\n\nA/P: 61 yo s/p vf arrest with defibrillation times two to NSR and intubated. Extubated yesterday and hemodynamically stable since.\n\nEPS possibly today\nPossible call out to floor\n" }, { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533760, "text": "nursing prog. note\nneuro: alert, oriented x3, moving all extrem. note significant short term memory deficit, becoming apparent throughout morning with pt. follows commands, otherwise neuro status per baseline.\n\nresp: 2l nc o2 to ra tol well, o2 sats stable. ls clear bilat and to bases. denies sob/distress.\n\ncv: hr in nsr to sinus brady, couple rare episodes of ectope, pvc's noted. bp slightly hypertensive this am, pt refused dose of captopril this am, after discussion w/ Dr. pt willing to take med, given at 1500. trace edema to ble.\n\ngi/gu: had remained npo for tentative aicd placement, currently restarted on low sodium diet, tol well at present. bs present, belly soft, nt/nd. foley patent for concentrated yellow urine, qs, catheter d/c'd at 1500.\n\nendo: bg stable, no insulin coverage needed.\n\nid: afebrile, wbc stable.\n\nsocial: daughter present, friends in to visit. case mgmt in to discuss plans for transfer to VA facility this afternoon/evening if bed available, insurance/veterans benefits situation resolved.\n\na/p: pt s/p vf arrest, doing well at present. no residual effect from hypoxemia other than noted short term memory deficit. continue monitoring as per protocol, plan for aicd placement at va facility within next couple days after hopeful transfer tonight.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533755, "text": "ADMISSION NOTE\nMR. IS A 61 YR OLD SELECTMAN WHO HAD A VFIB ARREST AT THE TOWN MEETING LAST EVENING. PLEASE SEE FHP FOR DETAILS OF PMH & EVENTS OF CURRENT ADMISSION. DIRECT ADMISSION TO CATH LAB->NL CORONARIES WITH EF~30%. TO BE SEEN BY EP.\n\nNEURO: SEDATED ON PROPOFOL 10-20MCG/KG. OFF BRIEFLY, MAE & EXTREMELY AGITATED. NOT FOLLOWING COMMANDS.\n\nRESP: ON VENT: 40%/TV 600/AC 12/PEEP 5. ABG 7.42/39/166/26 99%. MVO2 65->60%. RR 12/12. O2 SAT 100%. BS CLEAR BUT DIMINISHED AT BASES. SX FOR MIN. CLEAR SECRETIONS.\n\nCARDIAC: ON ADM. TO CCU HR 50-53 AFIB, NO ECTOPY. ~0145 HAD ~4.5 SEC.\nPAUSE, THEN CONVERTED TO SR AT RATE OF 50. HR 50-57 SB, NO ECTOPY.\nBP 97-129/55-76. ~0430 BECAME HYPOTENSIVE WITH SBP 77. HR DOWN TO 45.\n500CC NS BOLUS & ATROPINE .5MG GIVEN->SBP 90'S & HR 55. LIDO 2MG GTT.\nPAD 15->10, C0 4.4->4.3, CI 2.2->2.15. R. GROIN ARTERIAL SHEATH D/C'D BY FELLOW SHORTLY AFTER COMING TO CCU. VENOUS SHEATH & SWAN IN R. GROIN WHICH IS D&I. NO EVIDENCE BLEEDING/HEMATOMA. +BPPP. 1/2NS 100CC/HR X5HRS GIVEN FOR POST-CATH FLUIDS.\n\nGI: NPO. OGT IN PLACE FOR MEDS. PLACEMENT CONFIRMED BY CXR. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 100-200CC/HR->\n5-40CC/HR. GIVEN NS BOLUS FOR HYPOTENSION, & WATCHING U/O.\n\nID: ABEBRILE.\n\nAM LABS PENDING.\n\nPLAN: WEAN->EXTUBATE(WILL HAVE TO BE DONE QUICKLY--VERY AGITATED WHEN AWAKE).\n TO BE SEEN BY EP->PACER/AICD.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533756, "text": "RESPIRATORY CARE:\n\n61 yo m adm to CCU s/p cath (after vfib arrest in field). Pt to CCU intubated, fully vent supported. Little changes overnoc on vent, remained sedated. RSBI this am 25 when sedation decreased. See flowsheet for further pt data.\nPlan: Extubate.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533757, "text": "Resp Care\nPt extubated with no stridor noted tol well with spo2 in the upper 90s on 50% coo aerosal. Cuff leak present prior to extubatation.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533758, "text": "ccu npn\no- id- afebrile to 99.1po.\ncv- hr 50-60s sr, occ 40s, no vea. bp 120-140s/ this pm. k- 3.7, mg 1.9 both replaced. hct 32.7. aline d/c'd this pm. venous sheath d/c'd this pm by fellow, r groin d+i. pulses palp dp/pt bilat. echo done in am, ef 35%, etc. heparin/lido d/c'd in am.\nresp- propofol d/c'd and extubated this am to 50% face tent with bag 7.38,41,81. sats 95-100. u/o adeq, i+o pos. about 1000cc day.\ngi- abd soft, no pain, pos. bowel sounds. no n/v, no bm. had liquids, pudding, to solids, tol well. npo after 12am.\nms- forgetful, oriented to person, date, occ. hard time remembering what hospital he is in. repeats self in converstaion topics. mae.\nsocial- fx in, sister, then dtr and her fx. fx/pt updated on pt progress, yesterday's events and plan.\na- s/p arrest with clean cs on cath, low ef. cont in sr w/good bp.\np- cont. to monitor hr, bp, ryhthm. reorient prn, repeat teaching as needed. safety prec prn. npo after 12am, ?eps, ?icd tomorrow.\n\n" }, { "category": "Echo", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 76911, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P VF arrest.\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nBP (mm Hg): 117/94\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:58\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. There is moderate global left\nventricular hypokinesis. Overall left ventricular systolic function is\nmoderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. There is moderate\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is moderately depressed. Right ventricular chamber size is normal.\nThere is borderline global right ventricular free wall hypokinesis. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve leaflets are structurally normal.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841047, "text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for acute cardiopulmonary process\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p V.fib arrest, clean coronary arteries with increased sob\n\n REASON FOR THIS EXAMINATION:\n assess for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P VIFB arrest with increased shortness of breath.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier.\n The patient has been extubated in the interval. The Swan-Ganz catheter has\n also been removed as has the nasogastric tube. There is mild cardiac\n enlargement which has improved since the prior study. There is minimal linear\n atelectasis in the left retrocardiac region. The lungs are otherwise clear.\n There is no evidence of congestive heart failure.\n\n IMPRESSION: No evidence of congestive heart failure. Improved cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2112-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 840862, "text": " 11:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate tube placement, for infiltrate, CHF\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p V.fib arrest, clean coronary arteries\n REASON FOR THIS EXAMINATION:\n please evaluate tube placement, for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P V-FIB arrest, evaluate tube placement.\n\n COMPARISON: None.\n\n FINDINGS: Single portable AP view of the chest shows successfully placed ETT\n in good position. There is left ventricular enlargement with slight upper zone\n redistribution of pulmonary vascular markings. This may indicate slight\n cardiac failure. A transfemoral Swan-Ganz catheter is seen with its tip in the\n pulmonary artery trunk. NG tube is noted with its tip and side port past the\n GE junction. The osseous structures are unremarkable.\n\n IMPRESSION: Successful placement of ETT. Cardiomegaly with slight cardiac\n failure.\n\n" }, { "category": "ECG", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 183989, "text": "Sinus bradycardia. Left bundle-branch block. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 183990, "text": "Sinus bradycardia\nLeft bundle branch block\nSince pervious tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 183991, "text": "Sinus bradycardia\nLeft bundle branch block\n\n" } ]
13,457	103,720		The tube was sutured in place with 0-Prolene. Mild (1+) mitral regurgitationis seen. Mild(1+) aortic regurgitation is seen. The right brachial vein was selected for venipuncture. Focal calcifications in aortic root.Mildly dilated ascending aorta. Atrial fibrillation with a controlled ventricular response. The intravascular length of the catheter was determined. Borderline PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. The catheter and puncture access site were overlaid with a Tegaderm occlusive dressing. Ultrasound was used to identify right brachial vein, which was patent and compressible. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 68Weight (lb): 150BSA (m2): 1.81 m2BP (mm Hg): 150/76HR (bpm): 62Status: InpatientDate/Time: at 15:52Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The ascending aorta is mildly dilated. Underlying rhythm is atrial fibrillation. Catheter is ready to employ. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Atrial fibrillation. Probable underlying atrial fibrillation.Compared to the previous tracing of no diagnostic change. There isborderline pulmonary artery systolic hypertension. Under ultrasound guidance, right brachial vein was punctured, and 0.018-guidewire was inserted over the needle. The mitral valve leaflets are mildlythickened. Mild thickening of mitral valve chordae. The aortic root ismoderately dilated. Right upper arm was prepped and draped in usual sterile fashion. Pre- and post-ultrasound images obtained. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's anterior abdominal wall was prepped and draped in a sterile fashion. Calcified tipsof papillary muscles. The guide wire was advanced by way of the access needle and steered to the superior vena cava under fluoroscopic visualization. Tip position is in caudal superior vena cava. Atrial fibrillation with underlying left bundle-branch block and secondaryST-T wave abnormalities. Once satisfactory positioning was confirmed, both lumens of the catheter were flushed and heparin locked. Mild mitralannular calcification. This demonstrated the gastric remnant to be of decent size and directly below the anterior abdominal wall. Baseline artifactVentricular paced rhythmUnderlying atrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change The catheter was tailored at the 37-cm mark and delivered using modified Seldinger technique to the level of the caudal superior vena cava. Insufflation of the patient's current NG tube was performed in conjunction with review of a recent CT scan. NURSING VSS, AFEBRILE OVERNIGHT. 11:18 AM PICC LINE PLACMENT SCH Clip # Reason: please place PICC Admitting Diagnosis: ILEUS,ABDOMINAL PAIN ******************************* CPT Codes ****************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. OPERATORS: , M.D. A catheter or pacing wire isseen in the RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Compared to theprevious tracing of ventricular pacing is no longer present. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root. Once the above were accomplished, the patient was positioned in supine fashion on a special procedures/angiography table with the right arm abducted and externally rotated. Bipap weaned to off, and placed on face mask and 02 weaning. The right arm in turn was prepped and draped from the axilla to the antecubital fossa. The proximal port which is for gastric aspiration, was left within the gastric remnant, the distal port, 80 cm in the efferent limb for tube feeding. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF 60%). The line was finally StatLocked. Focal calcifications in ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Final catheter length is 37 cm. Normal tricuspidvalve supporting structures. Uneventful one- wall venipuncture was achieved under ultrasound guidance using a 21-gauge micropuncture needle. The final fluoroscopic image was obtained to confirm the location of the line. Left bundle-branch blockwith secondary ST-T wave abnormalities. wire and Kumpe catheter were used to manipulate into the patient's efferent loop. Atrial sensed ventricular pacedNo previous tracing available for comparison Needs PICC and TPN. Needs PICC and TPN. FINAL REPORT HISTORY: Gastric outlet obstruction in a patient with a Billroth II procedure. MD aware of 5.4 K. skin intact. MORPHINE GTT STARTED, ANTIBIOTICS DC'D, VENODYNES REMOVED, O2 APPLIED WITH NASAL CANNULA FOR PATIENT COMFORT. K 5.4 (up from ), kayexalate given as ordered. , M.D. DR. IV access required for TPN and blood draws. TITRATE MORPHINE GTT TO PATIENT COMFORT. bolused x2, lasix given on floor. Atrial sensed ventricular pacedSince previous tracing of , no significant change Atrial fibrillation with a rapid ventricular response. Responsive only to pain and with transfer to bed. IN AND SPOKE WITH PATIENTS HEALTH CARE PROXY. This loop was confirmed both with contrast and passage of a 150-cm wire. The catheter-wire combination were manipulated approximately 100 cm into the efferent limb, after which the wire was exchanged for an Amplatz wire. Underlying leftbundle-branch block and secondary ST-T wave abnormalities. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Please place GJ tube. Tourniquet was applied to the upper arm. REASON FOR THIS EXAMINATION: please place GJ tube tube with G port to vent stomach & J port into efferent jejnual limb for tube feedings... Needle was exchanged with peel-away sheath, and 31 cm 5 French double lumen PICC line was inserted over the wire using flouroscopic guidance, with the tip terminating in distal SVC. IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this patient's gastric remnant, proximal port within the remnant, distal port approximately 80 cm within the efferent limb in this patient who is status post a Billroth II procedure. REASON FOR THIS EXAMINATION: Please place PICC FINAL REPORT PROCEDURE: 5 French dual-lumen PICC line placement via right brachial vein approach.	18	[ { "category": "Echo", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 105314, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 150\nBSA (m2): 1.81 m2\nBP (mm Hg): 150/76\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 15:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Mild to moderate [+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 60%). No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2189-09-08 00:00:00.000", "description": "Report", "row_id": 309881, "text": "Ventricularly paced rhythm at 60 beats per minute with probable underlying\natrial fibrillation. Compared to the previous tracing of the\nventricular pacing is new.\n\n\n" }, { "category": "ECG", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 309882, "text": "Atrial fibrillation with underlying left bundle-branch block and secondary\nST-T wave abnormalities. No change compared to the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2189-08-31 00:00:00.000", "description": "Report", "row_id": 309883, "text": "Atrial fibrillation with a controlled ventricular response. Underlying left\nbundle-branch block and secondary ST-T wave abnormalities. Compared to the\nprevious tracing of ventricular pacing is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2189-09-22 00:00:00.000", "description": "Report", "row_id": 309877, "text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch block\nwith secondary ST-T wave abnormalities. Compared to the previous tracing\nof no change.\n\n" }, { "category": "ECG", "chartdate": "2189-09-18 00:00:00.000", "description": "Report", "row_id": 309878, "text": "Atrial fibrillation. Left bundle-branch block. Compared to the previous tracing\nthe paced rhythm is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2189-09-14 00:00:00.000", "description": "Report", "row_id": 309879, "text": "Baseline artifact\nVentricular paced rhythm\nUnderlying atrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2189-09-13 00:00:00.000", "description": "Report", "row_id": 309880, "text": "Ventricular paced rhythm. Underlying rhythm is atrial fibrillation. Compared to\nthe previous tracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2189-08-28 00:00:00.000", "description": "Report", "row_id": 310092, "text": "Ventricularly paced rhythm, rate 60. Probable underlying atrial fibrillation.\nCompared to the previous tracing of no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2189-08-28 00:00:00.000", "description": "Report", "row_id": 310093, "text": "Atrial fibrillation with ventricular pacing, rate 60. Since the previous\ntracing of the technical artifacts are improved. Positional changes are\nnoted, particularly over the lateral precordium.\n\n" }, { "category": "ECG", "chartdate": "2189-08-27 00:00:00.000", "description": "Report", "row_id": 310094, "text": "Atrial sensed ventricular paced\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2189-08-26 00:00:00.000", "description": "Report", "row_id": 310095, "text": "Atrial sensed ventricular paced\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2189-09-17 00:00:00.000", "description": "GUID WIRES INCL INF", "row_id": 930437, "text": " 2:32 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please place GJ tube tube with G port to vent stomach & J po\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 30CC\n ******************************* CPT Codes *****************************\n PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE \n CATHETER, DRAINAGE C1769 GUID WIRES INCL INF \n C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER \n C1894 INT.SHTH NOT/GUID,EP,NONLASER \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86M s/p bilroth 2, with delayed gastric emptying & need for feeding tube.\n REASON FOR THIS EXAMINATION:\n please place GJ tube tube with G port to vent stomach & J port into efferent\n jejnual limb for tube feedings...\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gastric outlet obstruction in a patient with a Billroth II\n procedure. Please place GJ tube.\n\n TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's\n anterior abdominal wall was prepped and draped in a sterile fashion.\n Insufflation of the patient's current NG tube was performed in conjunction\n with review of a recent CT scan. This demonstrated the gastric remnant to be\n of decent size and directly below the anterior abdominal wall. Hence, after\n insufflation, two T-fasteners were placed along the greater curvature of the\n stomach, after which the Seldinger technique was used to place a 5 French\n sheath within the gastric remnant lumen. wire and Kumpe catheter\n were used to manipulate into the patient's efferent loop. This loop was\n confirmed both with contrast and passage of a 150-cm wire. The catheter-wire\n combination were manipulated approximately 100 cm into the efferent limb,\n after which the wire was exchanged for an Amplatz wire. -Coons\n gastrojejunostomy tube was shortened (regularly 100 cm, shortened to\n approximately 80 cm) with additional sideholes placed and then advanced into\n the efferent limb after tract dilatation. The proximal port which is for\n gastric aspiration, was left within the gastric remnant, the distal port, 80\n cm in the efferent limb for tube feeding. The tube was sutured in place with\n 0-Prolene. As well, it contains a mushroom tip for internal anchoring.\n\n IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this\n patient's gastric remnant, proximal port within the remnant, distal port\n approximately 80 cm within the efferent limb in this patient who is status\n post a Billroth II procedure. No complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-08-27 00:00:00.000", "description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)", "row_id": 927850, "text": " 11:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: POOR ACCESS, NEEDS TPN AND LAB DRAWS\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ***************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with poor nutrition for 14 days. Needs PICC and TPN.\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC line placement via right brachial vein\n approach.\n\n CLINICAL HISTORY: 86-year-old man with poor nutrition. IV access required\n for TPN and blood draws.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were accomplished, the patient was positioned in\n supine fashion on a special procedures/angiography table with the right arm\n abducted and externally rotated. The right arm in turn was prepped and draped\n from the axilla to the antecubital fossa. Tourniquet was applied to the upper\n arm. Ultrasound was used to assess the veins of the upper arm. The right\n brachial vein was selected for venipuncture. The skin was infiltrated with\n approximately 2-3 cc of 1% Xylocaine for local anesthesia. Uneventful one-\n wall venipuncture was achieved under ultrasound guidance using a 21-gauge\n micropuncture needle. (Hard copy son images of the venipuncture were\n obtained in hard copy fashion.) The guide wire was advanced by way of the\n access needle and steered to the superior vena cava under fluoroscopic\n visualization. The intravascular length of the catheter was determined. The\n catheter was tailored at the 37-cm mark and delivered using modified Seldinger\n technique to the level of the caudal superior vena cava. Once satisfactory\n positioning was confirmed, both lumens of the catheter were flushed and\n heparin locked. The catheter was statlocked and positioned for security. The\n catheter and puncture access site were overlaid with a Tegaderm occlusive\n dressing. The patient tolerated the procedure well. No immediate\n complications were encountered. Estimated blood loss was minimal.\n\n IMPRESSION:\n 1. Status post successful placement of 5 French dual-lumen PICC line via\n right brachial vein approach. Final catheter length is 37 cm. Tip position\n is in caudal superior vena cava. Catheter is ready to employ.\n\n\n\n (Over)\n\n 11:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: POOR ACCESS, NEEDS TPN AND LAB DRAWS\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)", "row_id": 928586, "text": " 11:18 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC \n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ***************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with poor nutrition for 14 days. Needs PICC and TPN.\n\n REASON FOR THIS EXAMINATION:\n please place PICC \n ______________________________________________________________________________\n FINAL REPORT\n\n 1\n INDICATION: 86-year-old male with poor nutrition.\n\n RADIOLOGIST: Drs. and , the attending\n radiologist, who was present throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography table.\n Right upper arm was prepped and draped in usual sterile fashion. Ultrasound\n was used to identify right brachial vein, which was patent and compressible.\n Pre- and post-ultrasound images obtained. Under ultrasound guidance, right\n brachial vein was punctured, and 0.018-guidewire was inserted over the needle.\n Needle was exchanged with peel-away sheath, and 31 cm 5 French double lumen\n PICC line was inserted over the wire using flouroscopic guidance, with the tip\n terminating in distal SVC. Peel-away sheath is removed, the wire is removed.\n The line was flushed, capped, and heplocked. The line was finally StatLocked.\n The final fluoroscopic image was obtained to confirm the location of the line.\n The patient tolerated the procedure without any immediate complication. The\n line is ready for use.\n\n IMPRESSION: Successful placement of 31 cm 5 French double lumen PICC line\n with the tip terminating in distal SVC from right brachial vein. The line is\n ready for use.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-22 00:00:00.000", "description": "Report", "row_id": 1437453, "text": "nursing note\nPt admitted from 10 after being found unresponsive and nt suctioned for fecal contents. Pt admitted and placed on bipap mask secodnary to o2sat's in 80's. Responsive only to pain and with transfer to bed. LS coarse, suctioned for thick brown fecal smelling contents. Bipap weaned to off, and placed on face mask and 02 weaning. o2 sat 97% on 80%fio2. , NGT to lws with brown fecal smelling contents. abd soft,nt. JT clamped, GT to gravity with brown fecal smelling output. foley patent dark yellow urine, minimal output, urine lytes sent. bolused x2, lasix given on floor. K 5.4 (up from ), kayexalate given as ordered. MD aware of 5.4 K. skin intact. Family spoke with MD and reiterated DNR/DNI, plan to await rest of family beofre making further decisions.\n\nPLAN:Bipap prn, wean o2, monitor I+O, DNR/DNI, monitor lytes.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-23 00:00:00.000", "description": "Report", "row_id": 1437454, "text": "NURSING\n VSS, AFEBRILE OVERNIGHT. FAMILY IN ATTENDENCE ALL NIGHT AT BEDSIDE. ALL GRANDCHILDREN ARRIVED BY MIDNIGHT. DR. IN AND SPOKE WITH PATIENTS HEALTH CARE PROXY. DNR/ CHANGED TO CMO STATUS AT MIDNIGHT. MORPHINE GTT STARTED, ANTIBIOTICS DC'D, VENODYNES REMOVED, O2 APPLIED WITH NASAL CANNULA FOR PATIENT COMFORT. PATIENT HAD COMPLAINED OF PAIN PRIOR TO GTT BEING STARTED, GTT STARTED AT 5 MG/HR. CURRENTLY REMIANING AT 5. APPEARS COMFORTABLE, MINIMAL RESPONSE TO STIMULI, OPENS EYES WHEN TURNED. PACER CONTINUES TO PACE A NORMAL SINUS RHYTHM WITH FREQUENT PACED BEATS AND OCCASIONAL PAC'S.PACER IS ATRIAL SENSED, VENTRICULAR PACED, SET AT A RATE OF 60.\n CONTINUE TO PROVIDE COMFORT MEASURES, SUPPORT TO FAMILY. TITRATE MORPHINE GTT TO PATIENT COMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-23 00:00:00.000", "description": "Report", "row_id": 1437455, "text": "Pt expired with family at bedside. Emotional support was given throughout the shift.\n" } ]
12,838	189,264	1. GI: The patient presented with coffee ground emesis. She was initially guaiac negative in the Emergency Room but on transfer to the floor developed melena. On the following morning she was found to be with persistent melena and hypotensive with a blood pressure to 60/40, heart rate was 80 and her mental status had declined. She was transfused and then transferred to the MICU for further management and discussion of GI work-up. The GI team was consulted and it was decided that she would undergo an EGD when hemodynamically stable. Later that evening she developed acute respiratory distress. Chest x-ray showed an opacification in the left lung. Her arterial blood gases were consistent with a severe respiratory acidosis. The patient had stated clearly, prior to this event, that she wished to be DNR, DNI and the situation was also discussed with her power of attorney, who was in at the time. C-PAP was attempted but did not lead to an improvement in her symptoms. After discussions between the MICU team and the patient's daughter, it was decided to move to comfort measures only. The patient subsequently passed away on at 1:50 a.m. , M.D. Dictated By: MEDQUIST36 D: 13:53 T: 16:47 JOB#:	A nasogastric tube has been removed in the interval. There is interval removal of NG tube. Interval removal of NG tube. Sinus rhythmPossible inferior infarct, age indeterminateSince last ECG, increased anterolateral ST-T abnormalities There is some patchy alveolar opacity in the left mid lung zone centrally. FINAL REPORT HISTORY: Acute ventilatory failure. There is interval worsening of consolidation in the left base, obscuring the left hemidiaphragm. Sinus rhythmPossible inferior myocardial infarctInferolateral ST-T abnormalities less markedSince last ECG, , no significant change CLINICAL INDICATION: Decreased oxygen saturation. There is interval decrease in diffuse granular opacities throughout both lungs and slight interval decrease in bilateral pleural effusions. 3) Probable small left pleural effusion. HR/BP dropping quickly and pronounced by resident at 0120. grandaughter called. out of sync with mask vent and placed on NRB. dopa d/c'd. The distal most aspect of the intramedullary nail is not imaged. The right lung is clear except for discoid atelectasis at the right base. Diffuse pulmonary edema is resolved. However, a focal area of consolidation in the left mid lung is unchanged. stat CXR done, ABG 6.86/PO2 47. pt. There has been interval development of complete collapse of the left lower lobe. IMPRESSION: 1) Interval development of complete collapse of left lower lobe. at 2230 slightly less responsive but still with good air movement, responding to name. Minimal scarring or linear atelectasis in the right base. less responsive again, brady to 50, BP drop to 60/. Right internal jugular central venous catheter is again noted. taken off mask vent. There is moderate prominence of ventricles and sulci consistent with moderate brain atrophy. The cardiomediastinal silhouette is within normal limits. IMPRESSION: Moderate brain atrophy, otherwise negative study. discussed with resident, taken off mask to NRB for comfort. and ambu bag , given NS IVB. Pts O2 sat decreasing, abg very poor, Pt placed on bipap with 20 PS; causing Pts BP to drop. Question aspiration pneumonia in LLL.GI: Pts abd con't to be firm, with melena stool'sGU: Poor urine ouptutID: Pt started on Levo and flagyl for ? attending aware and in agreement.- at 0100, MSO4 gtt started at 2mg/hr. ABG on NRB: 7.18/46/101 at 2200. check on pt. Noted is dextroscoliosis of the thoracic spine, associated with degenerative disc disease of thoracic spine. 1:38 PM CT HEAD W/O CONTRAST Clip # Reason: s/p fall with injury to hip. Today while being disimpacted, passed large black tarry stool and dropped bp to 60/40, given 2L bolus of NS and 1U prbc and bp ^ 85 sys. mental status changes FINAL REPORT CLLINICAL INFORMATION: Status post fall with hip injury now with mental status changes. Recommend repeat film to exclude injury involving the distal aspect of nail. also given .2mg flumazenil IV in case of prolonged effects of sedation given earlier today. NBP found to be 10-15pts > than aline: 90/50 MAP 66. dopa weaned to 17mcq.ABG on 15 PS/5peep: 7.24/42/91. The aorta is calcified and tortuous. IMPRESSION: Healing right intertrochanteric fracture. Status post transfusion, assess for pulmonary edema. decesion made to place back on PS.- at 2300, placed back on CPAP , pt. Pt started on Dopa @ 4mcg with a bp ^ high 80-90;s.Pt then had CVL and ALINE placed which thereafter scoped at bedisde. patient with oxygen decompensation not a candidate for intubation placed on face-mask 15/5-1.0. Suspect pneumonia (vs. less likely atelectasis) in the left mid lung and left lung base. Dopa in creased to 12mcg, currently.Pt is DNR/DNI.PLAN:Continue to monitor BP and resp statusEGD showed "Kissing duodenal ulcer" plan for tx IV protonix and serum H-pyloriSerial H/H q6h HR 70's SR, BP 60-80's/50. 11:11 PM CHEST (PORTABLE AP) Clip # Reason: poor air movement and desaturation on CPAP MEDICAL CONDITION: 89 year old woman with above, requesting CXR for further eval REASON FOR THIS EXAMINATION: poor air movement and desaturation on CPAP FINAL REPORT Portable chest obtained compared to previous study earlier the same day. Pt to continued to pass tarry stools which then turned maroon in color and transferred here for bp support.PMH: NHL (s/p Xrt to neck),HTN, Hyperthyroidism, R hip fx w/ hip screw placement x 1 MONTH AGOCCU COURSE: Pt tx to CCU alert and confused but following commands. There is probably a small left pleural effusion present as well. 12:18 AM CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # Reason: 89 yo female with acute ventilatory failure. During procedure given 0.5mg of versed intially and another 0.5mg as pt became more agitated. pneumonia. DR. . Addendum to CCU Admittion noteNeuro: Pt becoming much more awake and aggitated.Cardiac: Pt remains on 12 mcg dopa to keep maps >60. Serial H&H, next at .Resp: Pt Remains on bipap with ABG's greatly improving! ABG metabolic acidosis will switch patient intermittently from mask ventilation to non rebreathe mask.	11	[ { "category": "ECG", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 298536, "text": "Sinus rhythm\nPossible inferior myocardial infarct\nInferolateral ST-T abnormalities less marked\nSince last ECG, , no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-11-07 00:00:00.000", "description": "Report", "row_id": 298750, "text": "Sinus rhythm\nPossible inferior infarct, age indeterminate\nSince last ECG, increased anterolateral ST-T abnormalities\n\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430943, "text": "Addendum to CCU Admittion note\nNeuro: Pt becoming much more awake and aggitated.\n\nCardiac: Pt remains on 12 mcg dopa to keep maps >60. Serial H&H, next at .\n\nResp: Pt Remains on bipap with ABG's greatly improving! Question aspiration pneumonia in LLL.\n\nGI: Pts abd con't to be firm, with melena stool's\n\nGU: Poor urine ouptut\n\nID: Pt started on Levo and flagyl for ? pneumonia.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430944, "text": "patient with oxygen decompensation not a candidate for intubation placed on face-mask 15/5-1.0. ABG metabolic acidosis will switch patient intermittently from mask ventilation to non rebreathe mask.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-09 00:00:00.000", "description": "Report", "row_id": 1430945, "text": "CCU NPN 1900-\nO: SBP 70/40 initially via radial aline at 1900. per team, dopa increased up to 20mcq to maintain MAPS >60. NBP found to be 10-15pts > than aline: 90/50 MAP 66. dopa weaned to 17mcq.\nABG on 15 PS/5peep: 7.24/42/91. pt. awake and moaning, appearing uncomf. with mask on. discussed with resident, taken off mask to NRB for comfort. pt. awake, speaking with garbled speech. saying name. RR ~ 20. responding to name. ABG on NRB: 7.18/46/101 at 2200. check on pt. at 2230 slightly less responsive but still with good air movement, responding to name. decesion made to place back on PS.\n- at 2300, placed back on CPAP , pt. less responsive again, brady to 50, BP drop to 60/. taken off mask vent. and ambu bag , given NS IVB. HR/BP coming up within ~ 5min. resident called. stat CXR done, ABG 6.86/PO2 47. pt. out of sync with mask vent and placed on NRB. HR 70's SR, BP 60-80's/50. also given .2mg flumazenil IV in case of prolonged effects of sedation given earlier today. no effect.\n- during this time, resident calling and speaking to fellow oncall as well as attending. in addition, calls/messages left with family, proxy. granddaughter(proxy in ) ~ 0030 and updated on condition, she agreed with idea for comfort only. attending aware and in agreement.\n- at 0100, MSO4 gtt started at 2mg/hr. dopa d/c'd. HR/BP dropping quickly and pronounced by resident at 0120. grandaughter called.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430942, "text": "CCU Nsg Admission Note\nCC: 87 yo was admitted to hospital on after being found down in facility covered in \"coffee ground emesis.\" Pt admitted to floor and followed by team. Today while being disimpacted, passed large black tarry stool and dropped bp to 60/40, given 2L bolus of NS and 1U prbc and bp ^ 85 sys. Pt to continued to pass tarry stools which then turned maroon in color and transferred here for bp support.\n\nPMH: NHL (s/p Xrt to neck),HTN, Hyperthyroidism, R hip fx w/ hip screw placement x 1 MONTH AGO\n\nCCU COURSE: Pt tx to CCU alert and confused but following commands. BP 70 sys, given 500x 2 Ns bolus and addt'l unit of prbc with a bp ^ 80's, BS present abd firm and passing lagre melana stools. U/O 10 -20cc/hr, amber in color and clear. Pt started on Dopa @ 4mcg with a bp ^ high 80-90;s.Pt then had CVL and ALINE placed which thereafter scoped at bedisde. During procedure given 0.5mg of versed intially and another 0.5mg as pt became more agitated. Pts O2 sat decreasing, abg very poor, Pt placed on bipap with 20 PS; causing Pts BP to drop. Dopa in creased to 12mcg, currently.Pt is DNR/DNI.\n\nPLAN:\nContinue to monitor BP and resp status\nEGD showed \"Kissing duodenal ulcer\" plan for tx IV protonix and serum H-pylori\nSerial H/H q6h\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 744703, "text": " 1:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p fall with injury to hip. mental status changes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with injury to hip. mental status changes\n ______________________________________________________________________________\n FINAL REPORT\n CLLINICAL INFORMATION: Status post fall with hip injury now with mental\n status changes.\n\n Contiguous axial images.\n\n No priors.\n\n FINDINGS:\n\n There is no mass, hemorrhage, diplacement of normally midline structures or\n extraaxial accumulation. There is moderate prominence of ventricles and sulci\n consistent with moderate brain atrophy. The bone images show no definite\n evidence fo calvarial fracture and the visualized paranasal sinuses are clear.\n\n IMPRESSION: Moderate brain atrophy, otherwise negative study.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-07 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 744705, "text": " 1:46 PM\n PELVIS (AP ONLY) Clip # \n Reason: s/p fall with injury to hip\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with injury to hip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89 year old female status post fall with hip pain.\n\n COMPARISON: .\n\n SINGLE AP PELVIS: A compression screw and intramedullary nail in the right\n femur is unchanged with no evidence of hardware failure proximally. There is\n increased callus formation about the fracture site. The distal most aspect of\n the intramedullary nail is not imaged. The sacroiliac joints, pubic\n symphysis, and left hip are normal.\n\n IMPRESSION: Healing right intertrochanteric fracture. No evidence of new\n fracture. However, distal aspect of intramedullary nail is not imaged.\n Recommend repeat film to exclude injury involving the distal aspect of nail.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744746, "text": " 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement, check placement, actively GI bleeding s/p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above\n REASON FOR THIS EXAMINATION:\n s/p NGT placement, check placement\n actively GI bleeding s/p 4 units fluid please assess for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post NG tube placement in this patient with active GI\n bleeding. Status post transfusion, assess for pulmonary edema.\n\n Single frontal view of the chest: Comparison is made to film obtained 9 hours\n ago. Right internal jugular central venous catheter is again noted. There is\n interval removal of NG tube. The cardiomediastinal silhouette is within\n normal limits. The aorta is calcified and tortuous. There is interval\n decrease in diffuse granular opacities throughout both lungs and slight\n interval decrease in bilateral pleural effusions. However, a focal area of\n consolidation in the left mid lung is unchanged. There is interval worsening\n of consolidation in the left base, obscuring the left hemidiaphragm. No\n pneumothorax is seen. Noted is dextroscoliosis of the thoracic spine,\n associated with degenerative disc disease of thoracic spine.\n\n IMPRESSION: Consolidation in the left mid lung and worsening consolidation in\n the left base are suspicious for pneumonia. Diffuse pulmonary edema is\n resolved. Interval removal of NG tube.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744788, "text": " 12:18 AM\n CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: 89 yo female with acute ventilatory failure.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above, requesting CXR for further eval\n REASON FOR THIS EXAMINATION:\n 89 yo female with acute ventilatory failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute ventilatory failure.\n\n SINGLE FRONTAL VIEW OF THE CHEST. Comparison is made to film obtained 1 hour\n ago. There has been no significant interval change. There is no pneumothorax.\n\n IMPRESSION: No significant change from film obtained 1 hour ago. Suspect\n pneumonia (vs. less likely atelectasis) in the left mid lung and left lung\n base. Minimal scarring or linear atelectasis in the right base.\n\n DR. . \n" }, { "category": "Radiology", "chartdate": "2197-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744786, "text": " 11:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: poor air movement and desaturation on CPAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above, requesting CXR for further eval\n REASON FOR THIS EXAMINATION:\n poor air movement and desaturation on CPAP\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest obtained compared to previous study earlier the same\n day.\n\n CLINICAL INDICATION: Decreased oxygen saturation.\n\n A central venous catheter remains in satisfactory position. A nasogastric\n tube has been removed in the interval.\n\n The heart size is within normal limits for technique. There has been interval\n development of complete collapse of the left lower lobe. There is probably a\n small left pleural effusion present as well. There is some patchy alveolar\n opacity in the left mid lung zone centrally. The right lung is clear except\n for discoid atelectasis at the right base.\n\n IMPRESSION:\n\n 1) Interval development of complete collapse of left lower lobe.\n\n 2) Persistent alveolar opacity in the left perihilar region, which may\n relate to pneumonia.\n\n 3) Probable small left pleural effusion.\n\n" } ]
19,408	106,880	The patient was admitted to , where he was transferred from an outside institution. He was initially started on oral Levaquin and Flagyl for his toe ulceration. Angiogram was scheduled for the day after admission and he was subsequently hydrated gently overnight. He was given the Mucomyst protocol. The Glucophage and Lasix were held prior to angiogram. The creatinine was 1.6. The hematocrit at that time was noted to be 25. On hospital day #1, noninvasive studies were also obtained. These revealed a limited study due to the examination being technically difficult as the patient declined having the cups placed for the volume recordings at any location other than the ankles. EBIs were noted to be inaccurate due to extensive vessel compressibility. The angiogram revealed no significant proximal inflow disease from the level of the renal arteries to the knee. The anterior tibial artery was the only continuously patent leg vessel and it was severely stenosed in its first and few centimeters. A patent dorsalis pedis artery was noted. No plantar arteries were opacified. Based on this information the patient was taken to the operating room on , where a left superficial femoral to dorsalis pedis artery bypass was performed with the use of nonreverse saphenous vein graft. At that time a left fourth toe open amputation was also performed. Details of this procedure are dictated in a separate operative note. The patient did fairly well hemodynamically, postoperatively and was transferred up to the Vascular Intensive Care Unit. PA catheter was placed, which revealed significant pulmonary hypertension. This was noted on preoperative echocardiogram. These were obtained from the Medical records. A Cardiolite imaging study revealed a large fixed hypoperfusion defect involving the inferior apical and inferolateral regions. It was suggestive of an area of prior myocardial infarction with no significant residual ischemia. On gated images the left ventricle was moderately enlarged with moderately reduced systolic function due to wall-motion abnormalities. The right ventricle was also noted to be enlarged. The pulmonary was noted to be approximately 56 mmHg and a left ventricular ejection fraction was noted to be approximately 30%. On postoperative day #2, the patient's pulmonary artery catheter was pulled out to monitor CVP. He was able to get out of bed to a chair and he was started on a regular diet. He did have some nausea, which was relieved with Reglan and Compazine. Consultation was sought by his medical internist, Dr. at that time. On postoperative day #3, the CVP line was changed over to central-venous catheter. He was transferred to the floor and he started to ambulate with physical therapy. After that time, he did extremely well and progressed very rapidly. His wound was left open, however, it did continue to show evidence of healing with pink granulation tissue. He had a palpable dorsalis pedis graft pulse. He was seen by the Department of Physical Therapy routinely throughout the hospital stay and he was eventually cleared for discharge home. He was sent home with a walker and he was only going to need VNA care for his left fourth toe amputation site. On postoperative day #4, he did have some nausea, while on the floor. However, an EKG was obtained and revealed no significant changes from previous EKGs. On postoperative day #5, the patient was discharged to home on PO Keflex. It was to be continued for approximately ten days. The patient was instructed by Dr to followup in his office in ten days to two weeks.	Please Contrast: OPTIRAY Amt: 210 FINAL REPORT (Cont) On the left, the left superficial femoral artery is patent. Pull back pressures were measured at the level of the distal aorta, left common iliac and left external iliac arteries. At the foot level, the dorsalis pedis artery is patent and shows a tortuous course. The left peroneal artery is occluded in its middle third and reconstitutes distally. With the catheter in the left external iliac artery, serial arteriograms covering the entire left lower extremity were obtained. It presents, however, significant stenosis in its first and last few centimeters. The catheter was pulled down into the infrarenal aorta and an oblique pelvic arteriogram was acquired. Please Contrast: OPTIRAY Amt: 210 ******************************* CPT Codes ****************************** * INTRO AORTA FEM/AXIL ABDOMINAL A-GRAM * * EXT UNILAT A-GRAM IV CONSCIOUTIOUS SEDATION PRO * * NON-IONIC 200 CC SUPPLY * **************************************************************************** MEDICAL CONDITION: 66 year old man with gangrene of left foot X 2weeks. A 0.035 guidewire was inserted through the needle and advanced up to the abdominal aorta. An AP abdominal aortogram was obtained. Manual compression of the left groin was applied until hemostasis was achieved. Patent dorsalis pedis artery. The needle was exchanged for a 4-French straight multi- sidehole catheter which was advanced to the suprarenal aorta. FINDINGS: The right and left renal arteries are widely patent. 225 ml of nonionic contrast intra-arterially. Diffuse ST-T waveabnormalities consistent with conduction abnormality. Sinus bradycardiaMarked left axis deviationIntraventricular conduction defect Anterolateral inferior ST elevation consider related to Intraventricularconduction delay or injury Lateral T wave changes may be due to myocardial ischemiaClinical correlation is suggested Sinus rhythmMarked left axis deviationIntraventricular conduction defectDiffuse nonspecific ST-T abnormalitiesSince previous tracing, no significant change After sterile draping and prepping, local anesthesia was administered in the left groin and the left common femoral artery was punctured by using a 19 gauge needle. The internal and external iliac arteries and the common femoral arteries are patent on both sides. There are several narrowings in branches of the left profunda femoris artery, two of which are moderate-to-severe. MEDICATIONS: Lidocaine 1% for local anesthesia. The anterior tibial artery is the only continuously patent leg vessel and is severely stenosed in its first and last few centimeters. Sinus rhythm. DR. D' Please due left leg with runuff and AP and LAT views of foot. The left popliteal artery shows several short mild-to- moderate narrowings in its above-knee portion, all of which appear to be less than 50% reductions in diameter. Incomplete left bundle-branch block. Please do left leg runoff with AP and Lat views of foot. RADIOLOGISTS: Drs. The patient was then transferred to the recovery room and the catheter was removed. There is mild tortuosity of the infrarenal aorta and common iliac arteries, without significant narrowing at those levels. No significant proximal inflow disease from the level of the renal arteries to the knee. 30 mg of papaverine were injected intraarterially for vasodilation when imaging the distal leg and foot. The left anterior tibial artery is the only leg artery which is patent in its entirety. (Over) 7:52 AM UNI-LAT FEMORAL Clip # Reason: 66 yr old male with gangrene of left foot X 2weeks. A total of 2.5 mg of Versed and 125 micrograms of fentanyl were administered intravenously in divided doses under continuous hemodynamic monitoring for conscious sedation. REASON FOR THIS EXAMINATION: 66 yr old male with gangrene of left foot X 2weeks. 7:52 AM UNI-LAT FEMORAL Clip # Reason: 66 yr old male with gangrene of left foot X 2weeks. It supplies at least four different intermetatarsal arteries. Compared to the previoustracing of no interval change. No posterior tibial artery nor plantar arteries can be opacified, even after intraarterial injection of 30 mg of papaverine. CONCLUSIONS: 1. As mentioned above, no plantar artery can be opacified, even after pharmacologic vasodilation test. FINAL REPORT INDICATION: Nonhealing ulcer and gangrene of the fourth left toe for three weeks in a 66 year old male patient. Dr. , the staff radiologist, was present for the whole procedure. 2. PROCEDURE/TECHNIQUE: The procedure with its potential risks and benefits were explained to the patient and informed signed consent was obtained. No plantar artery opacified. 3. and .	4	[ { "category": "ECG", "chartdate": "2130-02-06 00:00:00.000", "description": "Report", "row_id": 175441, "text": "Sinus rhythm. Incomplete left bundle-branch block. Diffuse ST-T wave\nabnormalities consistent with conduction abnormality. Compared to the previous\ntracing of no interval change.\n\n" }, { "category": "ECG", "chartdate": "2130-02-05 00:00:00.000", "description": "Report", "row_id": 175442, "text": "Sinus rhythm\nMarked left axis deviation\nIntraventricular conduction defect\nDiffuse nonspecific ST-T abnormalities\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2130-02-01 00:00:00.000", "description": "Report", "row_id": 175443, "text": "Sinus bradycardia\nMarked left axis deviation\nIntraventricular conduction defect\n Anterolateral inferior ST elevation consider related to Intraventricular\nconduction delay or injury\n Lateral T wave changes may be due to myocardial ischemia\nClinical correlation is suggested\n\n" }, { "category": "Radiology", "chartdate": "2130-02-01 00:00:00.000", "description": "ABDOMINAL A-GRAM", "row_id": 751522, "text": " 7:52 AM\n UNI-LAT FEMORAL Clip # \n Reason: 66 yr old male with gangrene of left foot X 2weeks. Please\n Contrast: OPTIRAY Amt: 210\n ******************************* CPT Codes *****************************\n INTRO AORTA FEM/AXIL ABDOMINAL A-GRAM \n EXT UNILAT A-GRAM IV CONSCIOUTIOUS SEDATION PRO \n NON-IONIC 200 CC SUPPLY \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with gangrene of left foot X 2weeks. Please do left leg runoff\n with AP and Lat views of foot.\n REASON FOR THIS EXAMINATION:\n 66 yr old male with gangrene of left foot X 2weeks. Please due left leg with\n runuff and AP and LAT views of foot.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nonhealing ulcer and gangrene of the fourth left toe for three\n weeks in a 66 year old male patient.\n\n RADIOLOGISTS: Drs. and . Dr. \n , the staff radiologist, was present for the whole procedure.\n\n MEDICATIONS: Lidocaine 1% for local anesthesia. 225 ml of nonionic contrast\n intra-arterially. A total of 2.5 mg of Versed and 125 micrograms of fentanyl\n were administered intravenously in divided doses under continuous hemodynamic\n monitoring for conscious sedation. 30 mg of papaverine were injected\n intraarterially for vasodilation when imaging the distal leg and foot.\n\n PROCEDURE/TECHNIQUE: The procedure with its potential risks and benefits were\n explained to the patient and informed signed consent was obtained. After\n sterile draping and prepping, local anesthesia was administered in the left\n groin and the left common femoral artery was punctured by using a 19 gauge\n needle. A 0.035 guidewire was inserted through the needle and advanced up to\n the abdominal aorta. The needle was exchanged for a 4-French straight multi-\n sidehole catheter which was advanced to the suprarenal aorta. An AP abdominal\n aortogram was obtained. The catheter was pulled down into the infrarenal aorta\n and an oblique pelvic arteriogram was acquired. Pull back pressures were\n measured at the level of the distal aorta, left common iliac and left external\n iliac arteries. With the catheter in the left external iliac artery, serial\n arteriograms covering the entire left lower extremity were obtained. The\n patient was then transferred to the recovery room and the catheter was\n removed. Manual compression of the left groin was applied until hemostasis was\n achieved.\n\n COMPLICATIONS: No immediate complication occurred.\n\n FINDINGS: The right and left renal arteries are widely patent. There is mild\n tortuosity of the infrarenal aorta and common iliac arteries, without\n significant narrowing at those levels. The internal and external iliac\n arteries and the common femoral arteries are patent on both sides.\n\n (Over)\n\n 7:52 AM\n UNI-LAT FEMORAL Clip # \n Reason: 66 yr old male with gangrene of left foot X 2weeks. Please\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n On the left, the left superficial femoral artery is patent. There are several\n narrowings in branches of the left profunda femoris artery, two of which are\n moderate-to-severe. The left popliteal artery shows several short mild-to-\n moderate narrowings in its above-knee portion, all of which appear to be less\n than 50% reductions in diameter.\n\n The left anterior tibial artery is the only leg artery which is patent in its\n entirety. It presents, however, significant stenosis in its first and last few\n centimeters. The left peroneal artery is occluded in its middle third and\n reconstitutes distally. No posterior tibial artery nor plantar arteries can be\n opacified, even after intraarterial injection of 30 mg of papaverine.\n\n At the foot level, the dorsalis pedis artery is patent and shows a tortuous\n course. It supplies at least four different intermetatarsal arteries. As\n mentioned above, no plantar artery can be opacified, even after pharmacologic\n vasodilation test.\n\n CONCLUSIONS:\n 1. No significant proximal inflow disease from the level of the renal arteries\n to the knee.\n 2. The anterior tibial artery is the only continuously patent leg vessel and\n is severely stenosed in its first and last few centimeters.\n 3. Patent dorsalis pedis artery. No plantar artery opacified.\n\n DR. D' \n" } ]
23,199	116,771	He was given 10 cc per kilogram normal saline for poor perfusion and pallor. 1. RESPIRATORY: The baby's initial chest x-ray showed low volume and hazy lung fields consistent with surfactant deficiency. He was intubated and given a total of three doses of surfactant with excellent response. He was transitioned to CPAP and subsequently to nasal cannula by day of life number four. He subsequently weaned to room air on . He has had no apnea and bradycardia.	NPN DAYSRESP DISTRESS:REMAINS IN RA, MAINTAINS O2 SATS IN MID 90'S.LUNGS CLEAR, RR 40-60'S WITH OCCASIONAL MILD SUBCOASTALRETRACTIONS. NPN 1900-0730#1 Problem resolved, lungs clear and well aerated to baseswith mild baseline SC retractions. P: Continue to monitor andsupport developmental needs.REVISIONS TO PATHWAY: 7 Hyperbilirubinemia; resolved MOM INDEPENDENT WITHBF. Mom agreeable to VNA. CONTINUE CURRENTFEEDING PLAN. REVIEWED SOME D/CTEACHING. UPDATED AT BEDSIDE. NPN 7a-1215p, discharge note is a former 37 1/7wk infant now DOL 10, corrected at 38 4/7wks. 10:46 PM BABYGRAM (CHEST ONLY) Clip # Reason: ? Is NPO, maintaining d/s's. PLEASE SET UP VNATOMORROW PRIOR TO D/C. Dr. did speak with pedi and gave update. BP stable. TYLENOLGIVEN AFTER CIRC. Capgas 7.36, pCo2 45 26/0. Mom very . NPN 1900-0730#1 Lungs are clear and well aerated to bases with mildtachpnea and little/no WOB. Waking ~q4hrs for feeds. CONTINUE TOMONITOR RESP STATUS CLOSELY FOR ANY DESATS. NOEPISODES OF APNEA OR BRADYCARDIA OR DESATS. SHE IS INDEPENDENTWITH CARES AND BF. HEARING SCREEN PASSED THIS MORNING. RRR, without murmur, pulses 2+ and symmetrical. asking appropriate questions, were updated oninfant's continued required vent support. Infant is s/p circ. RR 50's-70's, mild intercostalretractions. P: Continue to update and support.FEN: BW= 3625kg, CW= 3345kg ^5gms. 24h lytes139/4.5/105/19. Lytes 143/4.6/110/20. Updated on pt condition.A=Involved.P= Support.#4 F/N- Abd soft,+bs no loops.Remains NPO. A:NPO,dstick stable. alert with cares, settlesbetween cares.Font. BSclear. 99.1-99.4 swaddled. LSclear, SC retractions present. To treat for 48h. Abdomen bneign. P: Continueantibiotics as ordered. Bilirubin 8.1/0.3. received intubated on SIMV, 22/6, rate of 18.Pt. BS present. Comfoprtavble appearing. completed transfusion of PRBC after critof 22.2 with retic of 8.2. O: Wt. Remains in NCo2. WIll repeat this am. O:Pt. O:Pt. O: pt. O: Pt. extubated and placed on prong CPAp around 0300 afterCBG, 7.38/32. Mild SC retractions. maintaining temp. TF at 80 cc/k/d. swaddled on offwarmer, temp. P:Cont to support and update.#4 O: NPO. A: AGA. Dstick 103. A:Weaning rate today. No bradys.A:Weaned toCPAP.P: Continue to monitor resp. Pt. Pt. Pt. Hct 37. Abdomen benign; voiding 3.0cc/kg/h in 12h. NeonatologyDoing well. Bili 3.5/0.2/3.3. HC stable at 35.5cm; isnoted at 35 at time of delivery. NPN#1 Resp- Remains on Prong CPAP of 7cms in 30-38% o2. LS clear and=. Soft belly with + BS. status.#2Potential sepsis. Initial CBCwithout shift. BC - todate. continue to monitor/wean O2 as tolerated.3. Initial Hct 35. A: NPO. BP in good range. RR 40-60s since placed on CPAP, FiO2 35-40. Will continue on cpap and follow. On IV dextrose. Respiratory CareBaby continues on cpap 7, fio2 32-40%, Bs clear, rr 40-70's. DS 133, 68 when PIV turnedoff to let PRBC's infuse through it. Neonatology AttendingDay 3Remains on CPAP with fio2 0.28-0.32. P: Cont to monitor.#2 O: Infant remains on amp and gent as ordered. NoA&B's noted. Ptreceived Survanta x 1. Pt continues with IC/SubC retractions. Continue to wean O2 as pt.tolerates.#3. CBG after intubation was7.37/43/28/26. CXR c/w mild RDS per Dr. . Respiratory O: Pt. P-Cont to assess resp needs.#2 O/A- CBC DONE AT 1220 WITH PEDING REULTS.aMPI AND GENT AT1320 AFTER BC SENT.tEMP STABLE. Abdomen benign.Ad feeds being tolerated.Hct 49.5Will discuss possibility of retrotx with . UPDATED ATBEDSIDE. P: Continue tomonitor respiratory status. Admitted to NICU at 1120 viaincubater with blby02. He isvoiding/ stooling QS. P: Cont tomonitor.G&D: Temps 99.1-99.9 on open warmer, warmer weaned x 1. LS clear/=, mild SC retractions. IVF is D10W via PIV. A/P: Cont tomonitor resp status.3. P-Cont to assess cv needs.#1O/AReceived with 100% blby 02 with cpap 7 at 1140 with abgat 1320 of 7.39,39 c02,35 p02.Dr. NPN#1 cont in NC O2. Cap refill secs. SPoek with primary pedi who has priviledges at NWH. STOOL GUIAC NEG. Nursing NICU Note#1. He is currently on low flow NC, 100cc flow, Fio2100%. A: Pt. A: Pt. He has begun towean back from 100cc flow now. A-Cv needs wnl with paoloron admission. POa BM/E20. Weaning to RA. On BM ad . NeonatologyIn NCo2 at 100% 1oo cc. Bp 71/49 mean 61. aware of above withno changes in setting .Chest x ray at 1230 with reverealedMild RDS from Dr. . Nrsg Addendum Note-1818 remains with f102 25-30 % on npcpap 7 with rr 40-70-'s with occassional retractions with gd aeration noted. P: Cont to monitor.G&D: Temps stable in , pt dressed/swaddled. d/t PrematurityP:Cont. Nosupplement given. Amp and gent d/c'd. Updated on pt condition. Stable on CPAP cont to follow P: Cont tomonitor and wean from NC as tolerated.FEN: Birth wgt was 3625g. soft,pos bs,noloops or spits.Voiding and stooling guiac negativestool.A:Stable P:Cont. Off antibiotics, very active withhandling, appearing comfortable once settled. R to L shunting). in Resp. to assess resp. Neonatology fellow noteAwake and alert, NADAFOF, mildly jaundicedRRR, I/VI SEMOn NC, CTA bilaterally, good air entry, no retractionsAbd soft, active bowel sounds, fullWWP, MAEE, good tone Updated atbedside. A: Remainingin NC o2. LS = and clear,still exhibiting poor "reserve". p= Support.#4 F/N- Abd soft,+bs, no loops.Remains NPO. LS clear/=.No retractions. Neonatology fellow noteSleeping, NADAFOF, mildly jaundicedRRR, no murmursCTA bilaterally on CPAP, good aeration, mild retractionsAbd soft, active bowel sounds, non-distendedWWP, MAEE, good tone Settles well withpacifier or feeding. A: AGA.P: Cont to support development.#7 O: Coloring jaundiced. to support growth and dev.Hyperbili:Infant appears jaundice.Bili level sent awaitingresults. Med spit x 1. held awhile and were updated. Wgt tonight is 3430g, down 120g.Pt is ad lib feeding BM20/PE20, needing to be woken Q4hr toeat. LS clear and=. Respiratory CareBaby continues on cpap 7, fio2 28-31%, bs clear, rr 40-60's. Lungs fairly well aerated bilaterally despite grunting, heart RRR s murmur, abd soft s HSM. P: Contto monitor.#5 O: Infant maintaining temp in . WIll wean further today as tolerated. Mild retractions.RR= 40-70's.#3 Mom called x1.	63	[ { "category": "Radiology", "chartdate": "2154-05-02 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 791926, "text": " 12:04 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: eval lung fields, heart size\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress, O2 req s/p c-s at 37 wks\n REASON FOR THIS EXAMINATION:\n eval lung fields, heart size\n ______________________________________________________________________________\n FINAL REPORT\n CHEST DATED \n\n CLINICAL INDICATION: Infant with respiratory distress. Evaluate lung fields.\n\n FINDINGS: Lung volumes are small. The chest has a slight bell-shape,\n suggesting a slightly small thorax. Please correlate clinically. Hazy\n opacifications throughout both lungs suggest surfactant deficiency. No focal\n pulmonary parenchymal process. The study is otherwise unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2154-05-02 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 791978, "text": " 10:46 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ? ETT position; evaluate lungs\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, 37 weeks, now intubated\n REASON FOR THIS EXAMINATION:\n ? ETT position; evaluate lungs\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n HISTORY: Infant with RDS.\n\n FINDINGS: The film is submitted for interpretation on . The baby has\n been intubated. The tip of ETT is 1 cm above carina. The lungs are hazy in\n keeping with hyaline membrane disease. The lung volumes are greater than on\n film number 1. There is no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2154-05-04 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 792117, "text": " 1:08 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: 37 week infant with RDS, persistent respiratory distress\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above.\n REASON FOR THIS EXAMINATION:\n 37 week infant with RDS, persistent respiratory distress\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST \n\n HISTORY: 37 week infant with RDS. Persistent respiratory distress.\n\n FINDINGS: Since the study performed , the endotracheal tube has been\n removed. The lung aeration is normal. The minimal granular opacities\n consistent with hyaline membrane disease appear similar. The heart and\n mediastinal contours are normal. The pulmonary blood flow is within normal\n limits.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992293, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992294, "text": "NPN DAYS\n\n\nALT IN RESP:RECEIVED BABY IN NASAL CANNULA O2, 100%, 75CC.\nBABY WEANED OUT OF O2 AT10AM THIS MORNING WHILE BF. HE HAS\nREMAINED IN RA ALL DAY. MAINTAINS O2 SATSIN MID 90'S. NO\nEPISODES OF APNEA OR BRADYCARDIA OR DESATS. CONTINUE TO\nMONITOR RESP STATUS CLOSELY FOR ANY DESATS. RETURN TO NASAL\nCANNULA IF HE DOES NOT MAINTAIN O2 SATS 94% OR GREATER.\n\nALT IN NUTRITION:TOL FEEDS WELL, ON AD DEMAND SCHEDULE\nOF BM20. HE BF WITH MOM AT 9:30AM FOR 1HR AND BOTTLED 30CC,\nAND ALSO AT 1PM. AT 5PM HE BF FOR 1HR AND FELL ASLEEP, DID\nNOT NEED BOTTLE. ABD EXAM BENIGN, NO LOOPS, NO SPITS.\nVOIDING AND STOOLING WELL. STOOL GUIAC NEG. CONTINUE CURRENT\nFEEDING PLAN. MOM WILL NOT BE HERE TONIGHT, BOTTLE AD .\n\nALT IN GROWTH AND DEVELOPMWNT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WLL BTW FEEDS. WAKES AND DEMANDS ABOUT Q4HRS.\nMAINTAINS TEMP IN OPEN CRIB. NEEDS HEARING SCREEN AND CAR\nSEAT TEST, AND CIRC SOON.\n\nALT IN PARENTING:MOM IN TO VISIT ALL DAY. SHE IS INDEPENDENT\nWITH CARES AND BF. UPDATED AT BEDSIDE. REVIEWED SOME D/C\nTEACHING. CONTINUE TO SUPPORT AND UPDATE. MOM WILL BRING IN\nCAR SEAT TOMORROW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992295, "text": "NPN 1900-0730\n\n\n#1 Lungs are clear and well aerated to bases with mild\ntachpnea and little/no WOB. RR's 50-70's. Sats are\ngenerally >95% in RA with rare drifts to 92 while sleeping.\nWill cont to follow exam closely and offer supplemental O2\nas needed.\n\n#3 Mom called x1 for update, pleased with his progress and\nthat he's remained out of oxygen. No new questions or\nconcerns voiced. She plans to be in around 0830 for\nfeeding.\n\n#4 Weight up 65gms to 3385 on full enteral feeds of BM20 ad\n demand. Took 112cc/k/d plus breastfeeding yesterday.\nVoiding and stooling well with benign abdominal exam.\nWaking every four hours or so to eat, taking 120cc each\ntime.\n\n#5 Temps remain stable in open crib dressed and swaddled.\nWaking for feeds as above. Alert and active with cares,\nsettles off quickly to sleep. Needs help bringing hands to\nface and enjoys snug swaddling. will cont to support growth\nand development as able.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992296, "text": "Neonatology Attending\nDOL 10\n\nHas been in room air for 24 hours. No apneas/bradycardias/desaturations.\n\nNo murmur.\n\nWt 3385 (+65) on breastfeeding during the day and bottling well overnight. Voiding and stooling normally.\n\nPassed hearing screen.\n\nA&P\n37-1/7 infant with resolved surfactant deficiency\n-We will monitor respiratory status for another 24 hours then consider discharge home\n-Car seat testing today\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992297, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and slightly jaundiced. Abd benign, no HSM. active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992298, "text": "NPN DAYS\n\n\nRESP DISTRESS:REMAINS IN RA, MAINTAINS O2 SATS IN MID 90'S.\nLUNGS CLEAR, RR 40-60'S WITH OCCASIONAL MILD SUBCOASTAL\nRETRACTIONS. NO EPISODES OF APNEA OR BRADYCARDIA OR DESATS,\nEVEN WHILE BOTTLING OR BREASTFEEDING. CONTINUE TO MONITOR\nRESP STATUS CLOSELY FOR DESATS.\n\nALT IN NUTRITION:TOL FEEDS WELL ON AD DEMAND SCHEDULE OF\nBM20. BABY BF WITH MOM AT 10AM FOR 1HR. NO SUPPLEMENT. AT\n1:30-2:30PM BABY BOTTLED 120CC. AT 6PM MOM BF FOR 40MINS AND\nHE BOTTLED 30CC. ABD EXAM BENIGN, NO LOOPS, NO SPITS.\nVOIDING AND STOOLING WELL. STOOL GUIAC NEG. CIRC COMPLETED\nBY DR. AT 8PM USING INJECTED LIDOCAINE. TYLENOL\nGIVEN AFTER CIRC. NO BLEEDING. CONTINUE CURRENT FEEDING\nPLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. WAKING AND DEMANDING Q3-4HRS.\nMAINTAINS TEMP IN OPEN CRIB. CAR SEAT TEST PASSED THIS\nAFTERNOON. HEARING SCREEN PASSED THIS MORNING. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 10AM. THEY ARE\nINDEPENDENT WITH CARES. BATH DONE. MOM INDEPENDENT WITH\nBF. BABY IS READY FOR D/C TOMORROW. PLEASE SET UP VNA\nTOMORROW PRIOR TO D/C. MOM KNOWS TO MAKE PEDI APPOINTMENT\nFOR WEDNESDAY. CONTINUE TO REVIEW D/C TEACHING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992299, "text": "NPN 1900-0730\n\n\n#1 Problem resolved, lungs clear and well aerated to bases\nwith mild baseline SC retractions. Transient tachypnea to\nthe upper 60's at times with sats >97% in RA.\n\n#3 Mom called x1 for update, very excited to bring \nhome today. No new questions or concerns voiced.\n\n#4 Weight up 25gms to 3410 on full enteral feeds of BM20 ad\n demand. Took 126cc/k/d yesterday plus BF'ing. Belly is\nunremarkable, voiding and stooling well. Taking >4oz. every\nfour hours.\n\n#5 Temps are stable in open crib, waking Q4-5hrs to eat.\nAlert and active with cares, settles easily to sleep. Circ\nsite is clean with scant blood tinged drainage on gauze.\nTylenol given every six hours for pain with good relief\nseen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992300, "text": "Neonatology Attending Progress Note\n\nNow day of life 10 for this 37 week gestation infant.\n\nRR 40-70s - now in RA for 2 days.\nNo apnea and bradycardia.\nHR 130-140s\nBP 78/44 54\n\nWt. 3410gm up 25gm on ad demand feedings of breastmilk\n Baby is also taking bottle feedings well.\nTotal yesterday 126cc/kg/d plus breastfeeding.\n\nCirc healing well - performed yesterday.\n\nAssessment/plan:\nVery nice progress continues.\nWill plan on discharge to home today.\nVNA to be set up.\nAppointment with pediatrician to be set up within 2 days.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992301, "text": "Neonatology fellow note\nWell-appearing, crying but consolable, NAD\nAFOF, pink\nred reflex ou, palate intact\nRRR, no murmurs, 2+ femoral pulses\nCTA bilaterally, no retractions\nAbd soft, good bowel sounds, non-distended, no HSM\nCirc'd male, testes descended bilaterally\nPatent anus, no dimple\nHips stable, WWP\nMAEE, reflexes intact, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992302, "text": "NPN 7a-1215p, discharge note\n is a former 37 1/7wk infant now DOL 10, corrected at 38 4/7wks. Infant has been in RA since Sat , easily maintaining sats >/=95%. RR stable 40-60. No retractions noted. BBS cl/=. No apnea/brady spells noted. Hr stable- 140-160. No murmur. BP stable. Infant remains pink and well perfused. Current wt 3410. Has been ad demand feeding BM20. Waking ~q4hrs for feeds. Mom in this am and breastfed infant for over 45mins. Infant has strong suck, and feeds very well. Mom did offer supplemental bottle of 35cc to settle infant. No spits. Abd soft, +, no loops. Voiding and stooling. Infant is s/p circ. Tip of penis is red, no active bleeding noted. Sm spot of pink noted on gauze this am. Vaseline applied to tip of penis and front of diaper. Sm bruise noted on upper left base of penis r/t injection site from circ. Mom aware and will monitor for changes at home. No difficulty voiding. Tylenol given x1 for pain this am. Mom discussed Tylenol with Dr. and will follow her recommendations. Reviewed circ care with Mom and written info given. also conts to maintain stable temps while swaddled in an open crib. He is alert and active with cares. Waking on own for feeds. Settles easily. MAE. Fonts soft/flat. He has passed his hearing screen and carseat tests. Reviewed proper positioning of infant in carseat, and gave Safe Travels handout. Dad did put infant in carseat correctly. Mom spoke with pedi, Dr. and will be taking infant to pedi office upon d/c from NICU per pedi's request. Dr. did speak with pedi and gave update. Fellow to have d/c summary faxed to pedi. VNA referral called in and faxed. Will be seen by Care Group VNA tomorrow. Mom agreeable to VNA. Reviewed all d/c teaching with . Mom plans to exclusively breastfeed. Will cont to pump and give bottles of BM20 at times, as needed. Mom very . with care of infant and feeding. did not have L&D tags on them, but both provided positive MA ID's. D/C exam done and order in chart. Infant d/c'ed home with in carseat.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992285, "text": "npn 1900-0730\n\n7 Hyperbilirubinemia\n\nRESP: Recieved infant on 50cc of 100% FiO2, currently infant\nweaned down to 25cc of 100% FiO2. Sats=>94%, with no desats\nnoted. RR=40-60'S, with mild baseline subcostal retractions.\nLSC/=. No s/s of increased WOB noted thus far. No spells\nthus far. P: Continue to monitor respiratory status and\ncontinue to wean O2 as tolerated.\n\nPAR: No contact from thus far, unable to assess\nfuther at this time. P: Continue to update and support\n.\n\nFEN: BW= 3625kg, CW= 3345kg ^5gms. Infant is an ad \ndemand feeder, waking 2-3.5hrs bottling 75-90cc of BM/E20.\n also BF during the day, when mom is in to visit.\nInfant tolerating po feeds well, no spits. TF for past\n24hrs= 64cc/kg/d + volumes from Breast feeding. Abd benign,\nsoft, no loops, +BS. Voiding and stooling, guiac negative.\nP: Continue w/ current feeding plan and monitor wt gain.\n\nDEV: Temp stable in , while infant dressed and swaddled.\nInfant wakes for feeds. Alert and active with cares. Sucks\non pacificer vigorously. Brings hands to side of face to\ncomfaort himself. Brings hands to mouth and midline. \ncan become irritiable at times but calms easily w/ pacificer\nor being held. MAE. AFSF. AGA. P: Continue to monitor and\nsupport developmental needs.\n\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992259, "text": "NPN 7A-7P\n\n\n#1 Infant remains on CPAP 7, Fi02 35-40%. Has Sa02 drifts\nwith irritability/crying and slowly returns to baseline once\ncalmed. LS = clear. RR 50's-70's, mild intercostal\nretractions. CRX done earlier in day, no changes made. Cap\ngas 7.36, pCo2 45 26/0. Will con't to monitor respiratory\nstatus closely for increased respiratory distress.\n\n#2 Remains on map and gent, blood cultures negative to date.\nStill requiring CPAP support, will determine length of\nantibiotic course tomorrow.\n\n#3 in to visit x 2 today, also brought in visitors.\n asking appropriate questions, were updated on\ninfant's continued required vent support. Mom informed of\nprobability that ifnant will not be discharged with her to\nhome on Monday and was appropriately teary but is glad that\nhe somewhat improved. Will con't to update and support. Plan\nfor Family Meeting on Monday prior to mom's discharge from\npost-partum.\n\n#4 Remains NPO, PIV infusing well, D/S:74. Is slightly\nedematous, voiding well, no stool this shift but has mec\nlast evening. Con't to assess respiratory status to\ndetermine start of feeds.\n\n#5 Three day old 37 weeker still requiring vent support for\nRDS. Is NPO, maintaining d/s's. Active with handling but\nsettling well. On antibiotics, voiding and stooling. Con't\nto monitor closely.\n\n#6 Is pink, repeat Hct today 37.5. BP 60/39 m:47. Problem\nd/c'd.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992260, "text": "6 Alteration in CV status\n\nREVISIONS TO PATHWAY:\n\n 6 Alteration in CV status; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992261, "text": "RESPIRATORY CARE NNOTE\nBaby received on Prong CPAP 7 FiO2 30-38%. RR 40-70's breath sounds are clear. Suctioned orally for mod amt of white secretions. Baby looks comfortable on CPAP will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992262, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 7cms in 30-38% o2. BS\nclear. Mild retractions.RR= 40-70's.\n#2 Sepsis- Remains on Amp+ Gent.\n#3 Mom here to visit x1. Updated on pt condition.A=\nInvolved.P= Support.\n#4 F/N- Abd soft,+bs no loops.Remains NPO. PIV patent\ninfusing at 80cc/kg/day.Voiding in adeq amts.Sm stool x1.Wt\ndown 5 gms.Lytes=143/4.6/110/20.\n#5 Dev- Alert+ active w/cares. Sleeping in between.Swaddled\non off open warmer w/adeq temps.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992263, "text": "Neonatology Attending\n\nDay 3\n\nRemains on CPAP with fio2 0.28-0.32. Clear breath sounds. Blood gas 7.35/45. Doesn't tolerate being off CPAP. HR 130-50s. BP mean 46. Hct 37. Weight 3615 gms (-5). TF at 80 cc/kg/d. On IV dextrose. Lytes 143/4.6/110/20. Blood glucose 85. Bilirubin 8.1/0.3. Stable temperature on warmer.\n\nResolving hyaline membrane disease. Will continue to wean CPAP as allowed. Monitoring cardio-respiratory status closely. Metabolically fine. Physiologic bilirubin. Will follow. Plan to stop antibiotics today. Hct is fine now. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992256, "text": "NPN 1900-0700\n\n\n#1Resp. O:Pt. received intubated on SIMV, 22/6, rate of 18.\nPt. extubated and placed on prong CPAp around 0300 after\nCBG, 7.38/32. RR 40-60s since placed on CPAP, FiO2 35-40. LS\nclear, SC retractions present. Pt. suctioned with cares for\nmoderate white secretions via ett. Maintaining sat 90 and\nabove with occasional drifts to 80s. No bradys.A:Weaned to\nCPAP.P: Continue to monitor resp. status.\n\n#2Potential sepsis. O:Pt. maintaining temp. swaddled on off\nwarmer, temp. 99.1-99.4 swaddled. MAP BP 45 and 54. Pt.\ncontinues on ampicillin and gentamycin as ordered. BC - to\ndate. A: No increasing signs of sepsis noted. P: Continue\nantibiotics as ordered. Check blood culture results, monitor\nfor increasing signs of sepsis.\n\n#3Parenting. O: Mom here during evening for visit, updated\nat bedside. Mom has called for updates during night.\nA:Involved family. P: Continue to update and support family.\n\n#4Fen. O: Wt. 3620, up 5 gms, currently at BW. Pt NPO, on TF\nof 80cc/kg/day receiving D10 with lytes via PIV at\n12.1cc/hr. Dstick 103. Abd. soft, active bowel sounds, no\nloops, voiding with each care, meconium stool x1. A:NPO,\ndstick stable. P: Continue to monitor I/O, monitor dstick.\n\n#5Dev. O: pt. initially on open warmer set at lowest setting\nof 34 degrees, temp. 99.5-100 on warmer. Warmer now off, pt.\nswaddled and maintaining temp. Pt. alert with cares, settles\nbetween cares.Font. soft and flat, MAE.A: AGA. P: Support\ndevelopmental needs.\n\n#6CV status. O: Pt. completed transfusion of PRBC after crit\nof 22.2 with retic of 8.2. Pt. pale pink, brisk cap refill\nafter transfusion. HR 150-160. BP 77/43, MAP 54. No murmur\nnoted. A: Post transfusion for low crit, poor perfusion.\nP:Monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992257, "text": "Neonatology Attending Progress Note:\n\nDOL #2\nextubated last pm to CPAP 6 increased to 7 this am. FiO2=40%\nRR=40-80's\ncrit=37.5%\nmean BP=45\nbili=3.5\nwt=3620g\nNPO\ndstx=74\nurine output > 2 cc/kg/hr\n\nPE: moderate respiratory distress on CPAP, active, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mod ic/sc retx, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: x-37 week infant s/p blood loss at time of delivery, HMD--continuing with respiratory distress, and r/o sepsis.\n--obtain ABG\n--CXR in setting of persistent respiratory distress\n--to decide course of antibiotics depending on CXR\n--may need to reintubate if persistent\n--lytes and bili in am.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992258, "text": "Respiratory Care\nBaby continues on cpap 7, fio2 32-40%, Bs clear, rr 40-70's. Cpap increased to 7, for increased fio2 requirements. CXR with good lung expansion, cbg drawn 7.36/45. Will continue on cpap and follow.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992284, "text": "1. remains in nasal cannula 100% weaned to 50cc flow\nthis am, sats>95, RR 40-70, mild sc retractions, BBS clear,\nequal. continue to monitor/wean O2 as tolerated.\n3. Mom here all day, breast feeding, learning temp taking,\nindependent with diaper changes, spoke with Neo fellow, has\ndecided to stay here vs transfer to community hospital.\ncontinue to provide updates and offer support.\n4. E20/BM /breast feeding ad . BF well plus 30cc BM at\n1000, abd soft, active bowel sounds, no loops, no spits,\nvoiding and passing loose yellow stool. continue to monitor.\n5. wakes ~q4-5h, active and alert, temps stable swaddled in\nopen crib. continue to support growth and development.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992250, "text": "Neonatology fellow note\nSleeping, NAD\nAFOF, pale pink\nRRR, no murmurs\nCTA bilaterally, good aeration, moderate retractions, tachypneic\nAbd soft, good bowel sounds, non-distended\nNl male genitalia, testes descended bilaterally\nno sacral dimple\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992251, "text": "Neonatology\nIntubated last night for increasing distress has received two dose of surfactant. CXR lung fields c/w RDS, but low lung voluems with bell shaped thorax. Ribs appear normal. Consideration to be given to third dose of surf based on clinical status and net settings.\nBP in good range. No evidence of PDA.\n\nPale this am. Initial Hct 35. WIll repeat this am. Not jaundiced. No signs of external losses except minimal phlebotomy.\n\nNo sepsis risk factors, will rx with 48 h r/o but given clincial course and GA will consider treating with extended course of abx over weekend..\n\nWt 3260 down 15. TF at 80 cc/k/d. Abdomen bneign. BS present. Will plan to start feeds as tolerated via gavage this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992252, "text": "Neonatology\nREpeat HCT this am shows HCT of 22. No evdinec of blood loss. Neuro exam non-focal and age appropriate. No sig bogginress of skull. Abdomen soft non-distened. BP in good range. Liver just below RCM. Not enlarged.\n\nSpokje with Dr . Anterior placenta with accretta. ? blood loss at time of delivery.\n\nWill Transfuse with 20 cc/k PRBCs and monitor response. If evidence of ongoing losses will evaluate further including perhaps HUS, abd US.\n\nSpoke with Father at bedside\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992253, "text": "NPN 0700-1900\n\n6 Alteration in CV status\n\n#1 O: Received infant intubated on vent settings of 22/6\nrate 20; weaned to rate of 18 after CBG of 7.38/42. Fio2\n21-40%. RR 40's-90's; very tachypneic at times. LS clear and\n=. Suctioned for lg amounts of thick white secretions from\nETT q 2-3h. Mild SC retractions. No spells but having desats\nto 60's and 70's after being disturbed or while sucking on\npacifier. Received third dose of surfactant;given by RRT. A:\nWeaning rate today. P: Cont to monitor.\n#2 O: Infant remains on amp and gent as ordered. Initial CBC\nwithout shift. To treat for 48h. Bl cx remain neg to date.\nA: No obvious s/s of sepsis. P: Cont to monitor.\n#3 O: Dad in numerous times throughout day; asking a lot of\nappropriate questions. Mom in later today; very sleepy and\nweak. Signed consent for blood transfusion. A: Involved. P:\nCont to support and update.\n#4 O: NPO. TF= 80cc/kg/d. Infant receiving IV fluids of D10\ntoday (added lytes this eve at 1700). Receiving 12.1cc/h via\nPIV. Abdomen benign; voiding 3.0cc/kg/h in 12h. No stool\nthis shift. Soft belly with + BS. DS 133, 68 when PIV turned\noff to let PRBC's infuse through it. 24h lytes\n139/4.5/105/19. Bili 3.5/0.2/3.3. A: NPO. P: Cont to\nmonitor.\n#5 O: Infant noted to be warm this am while on servo mode.\nTaken off servo and switched over to air for a while.\nSheepskin also removed today. Placed prone for most of day\nwith boundaries in place. Infant very agitated throughout\nday having desats when upset. Sucks on pacifier when offered\nbut sometimes also desats with this. HC stable at 35.5cm; is\nnoted at 35 at time of delivery. A: AGA. P: Cont to\nsupport development.\n#6 O: Infant had a repeat Hct drawn at 24 h old today;\nresult was 22.2. Infant was given first transfusion of\nPRBC's of 35cc's over 2h from 1500-1700 today. Second\ntransfusion to be started shortly. BP means 44-52. Pale\ncoloring prior to transfusion; starting to pink up since\nreceiving first transfusion. Poor perfusion noted. To\nttransfuse 2nd aloquot of PRBC's of 35cc's over 2h.\n\nREVISIONS TO PATHWAY:\n\n 6 Alteration in CV status; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992254, "text": "Respiratory Care\nPt recieved on SIMV, rate of 20, pressures of 22/6, with the fio2 23 to 45%. Pt weaned down on ventilator rate from 20 to 18 with good blood gas results. Pt given 3rd dose of surfactant of 14cc, tolerated. Pt to recieved blood. Plan is to follow, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992255, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 22/6 Rate 18 FiO2 28-30%. Suctioned ETT for mod amt of white secretions. Cap gas PO2 35 Co2 45 PH 7.42 30 3. Baby was extubated at 3am and placed on Prong CPAP 6 FiO2 35%. Baby looks comfortable on CPAP will cont to wean FiO2 as tolerated. Cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992286, "text": "NICU nursing note\nThis RN has assessed pt and agrees with above note.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992287, "text": "Neonatology fellow note\nAwake and alert, crying but consolable\nAFOF, mild jaundice\nRRR, no murmurs\nCTA bilaterally, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992288, "text": "Neonatology\nDoing well. Remains in NCo2. Comfoprtavble appearing. SLowl,y weaning flow. No spells. murmur.\n\nWt 3335 down 5. Took in 63 cc/k/d yesterday with multiple good breast feeds. DOing well from BF.\n\nNeeds hearing screen\nCar seta tes\nNeeds car seat test.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992289, "text": "NPN DAYS\n\n\nALT IN RESP:REMAISNIN NASAL CANNULA O2, 100%. RECEIVED BABY\nIN 25CC. WEANED TO 13CC THIS MORNING, AND HAS REMAINED\nIN 13CC ALL DAY, EVEN WHILE BF. MAINTAINS O2 SATS 94-96%.\nLUNGS CLEAR, RR 40'S WITH MILD SUBCOASTAL RETRACTIONS. NO\nEPISODES OF APNEA OR BRADYCARDIA THIS SHIFT. CONTINUE TO\nMONITOR RESP STATUS CLOSELY AND WEAN O2 AS TOL.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TMEP IN OEPN CRIB.\nCONTINUE DEVELOPMENTAL CARES. WILL ARRANGE HEARING SCREEN\nTHIS WEEKEND, AND POSSIBLE CIRC. WILL DO CAR SEAT TEST WHEN\nBABY IS OUT OF O2.\n\nALT IN PARENTING:MOM IN TO VISIT AT 9AM, AND HAS BEEN HERE\nALL DAY. SHE IS INDEPENDENT WITH CARES, AND BF. UPDATED AT\nBEDSIDE. SHE IS HAPPY THAT IS WEANING DOWN ON HIS O2.\nCONTINUE TO SUPPORT AND UPDATE. BEGIN REVIEWING D/C TEACHING\nWHEN BOTH ARE HERE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992290, "text": "NPN DAYS CONTINUED\nALT IN NUTRITION: IS ON BM20, AD DEMAND SCHEDULE. HE BOTTLED AT 6:30AM. AT 10AM HE WOKE AND MOM BF HIM FOR 1HR. SHE DID NOT SUPPLEMENT WITH A BOTTLE. AT 12PM HE WOKE AGAIN AND HE BF FOR ANOTHER 20MINS. HE SLEPT UNTIL 4PM AND BF FOR AN HOUR AGAIN, AND THEN BOTTLED 30CC OF BM. HIS ABD EXAM IS BENIGN, NO LOOPS, NO SPITS. VOIDING AND STOOLING WELL. STOOL GUIAC NEG. CONTINUE CURRENT FEEDING PLAN. BOTTLE THROUGH THE NIGHT WHEN MOM IS NOT HERE.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992291, "text": "NPN\n\n\n#1 cont in NC O2. He had some drifting to 70's & 80's\nearly in shift and needed his O2 increased. He has begun to\nwean back from 100cc flow now. LS clear and equal with mild\nSCR noted and slight nasal stuffiness, color pink. A: cont\nto require O2 P: wean as able\n#3 no contaact with family thusfar in shift.\n#4 cont on demand feeds, is waking between 4-5 hrs and\nbottles well taking 105-115 cc BM. Abd benign, soft, no\nloops or distention, vdg qs, no stool. Weight own 25 grams\nA: feeds well P: no change at present\n#5 Stable in open crib, wakes for feeds, sleeps well\nbetween. Sucks some on pacifier. A: AGA P: cont to support\ndevelopment\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992292, "text": "Neonatology Attending\n\nDOL 8 CGA 38 2/7 weeks\n\nIn NCO2 75 cc then weaned to RA this morning. R 40s-60s. No A/B.\n\nOn BM/E20 ad demand. Feeds well taking 80-115 cc per bottle or breastfeeding. Voiding. Stooling. Wt 3320 grams (down 25).\n\nHct 49.5 on .\n\nMother visiting and up to date.\n\nA: Stable. Weaning to RA. Feeding well.\n\nP: Monitor\n Home when stable in RA\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992278, "text": "Neonatology\nDoing well. Slightly increase Fio2 requirement. No spells. generally comfortable apeparing. No evidence of PDA, Comfortable appearing\n\nWt 3330 down 100. TF at ad lib feeds and doing well.\nAbdomen benign. Will offer pc supplements with BM or formula.\n\nBili in 12 range. Following bili.\n\nAwaiting weaning from O2 and improvem,ent in feeding quantity.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992279, "text": "Neonatology fellow note\nAwake and alert, looking around\nAFOF, mild jaundice\nRRR, no murmur\nCTA bilaterally, no retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992244, "text": "Nrsg Admission Note-0700-1900\n\n1 Term Respiratory Distress\n2 Infant with Potential Sepsis\n3 PARENTING\n\n (male ) born to a 37 y.o G4 now P4 Mom with\nknown acreda. Repeat c section for 37 week gestation male\nborn at 1051 with apgars 7&8. Admitted to NICU at 1120 via\nincubater with blby02. O2 sat 80 (placed on rt ft) and cv\nleads placed.\nCv status- Ap 150 ,rr 70. Bp 71/49 mean 61. Palor noted with\npoor perfusion. Cap refill secs. piv inserted into lt\nhand with nc 10 cc/kg bolus administered over 20 minutes\nwith perfusion improved to 4 secs at 1155 am and color\nremaining pale.Pink at 1200 with bp means ranging 46-61. cbc\nobtained at 1220 with hct 35.9, Dr. aware of above. No\nmurmur noted with ap 140-150's. A-Cv needs wnl with paolor\non admission. P-Cont to assess cv needs.\n#1O/AReceived with 100% blby 02 with cpap 7 at 1140 with abg\nat 1320 of 7.39,39 c02,35 p02.Dr. aware of above with\nno changes in setting .Chest x ray at 1230 with reverealed\nMild RDS from Dr. . Grunting initally with intercostal\nmild retractiosn.occasionally grunts with rr 40-70's.\nAeration gd with color pink from 1200-present. F102 33-50%.1\ndesat to 55 after abg draw. A-Resp needs with chest x ray\nreflective of RDS. P-Cont to assess resp needs.\n#2 O/A- CBC DONE AT 1220 WITH PEDING REULTS.aMPI AND GENT AT\n1320 AFTER BC SENT.tEMP STABLE. A-NO OVERT SEPSIS NEEDS.\n#3o/aMom and dad both visited with complete update\ngiven.Aware of possible intubatioN.Dr. spoke with\nparents. A-Parents aware of status.P-COnt to assess parental\nneeds.\n\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 2 Infant with Potential Sepsis; added\n Start date: \n 3 PARENTING; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992245, "text": "Respiratory Care Note\nThis 37 wk GA male was placed on prong CPAP +7, O2 28% (currently) for grunting and retracting. CXR c/w mild RDS per Dr. . BS clear. Pt continues with IC/SubC retractions. CBG on CPAP 7.39/39.Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992246, "text": "Nrsg Addendum Note-1818\n remains with f102 25-30 % on npcpap 7 with rr 40-70-'s with occassional retractions with gd aeration noted. Dstix 133 at 1800 with d 10w remaining at 80 cc's/kg .Npo status with lge mec x1.DTV. Moving all extrem well with fussiness soothed with sucking on fingers. No plans for repeat chest x ray. No other cbg or abg obtained with Dr. to be notified should fi02 increase to 40 %. Dad and Mom with complete update with both parents aware that adm could be several days in the NICU.( Parents expected 1-2 days in NICU). Plans for report at 1900.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992280, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. received on NC O2 300cc flow Fio2\n~ 40-60%. He is currently on low flow NC, 100cc flow, Fio2\n100%. RR ~30-70's. LS clear/=. No increase work of\nbreathing noted. He has mild SC retractions noted. No\nA&B's noted. A: Pt. is stable on NC O2. P: Continue to\nmonitor respiratory status. Continue to wean O2 as pt.\ntolerates.\n\n#3. O: Mom in throughout the day. She was\nupdated at bedside on pt's current status and daily plan of\ncare. Mom active and independent in cares. A: \n and involved. P: Continue to update, support and\neducate.\n\n#4. FEN O: Pt. is ad lib demand, breastfeeds well.\nAbdomen is soft, pink, +BS, no loops/spits noted. He is\nvoiding/ stooling QS. A: Pt. is tolerating current\nnutritional plan. P: Continue w/ current feeding plan.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. He is alert and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopmet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992281, "text": "NPN NIghts\n\n\n1. O: Received pt on NC 100% 100cc flow. Desats to 80cc with\ndecreased flow. RR 40-70's. Mild subcostal retractions. Occ\ndesats to 80's which QSR. No spells. Ls clear. A/P: Cont to\nmonitor resp status.\n\n3. O: MOm called X1. MOm asking appropriate questions. Rn\nupdated Mom. A/P: Cont to educate and support .\n\n4. O: Wt 3340gms, up 10. POa BM/E20. Pt took 50+ 110cc\nthus far this shift. Voiding and stooling G-. No spits. +bs.\nA/P: Cont to monitor wt, abd, and po intake.\n\n5. O: Temp stable swaddled in open crib. Alert and active\nwith cares. Waking for feeds. A/P: Cont to monitor temp.\nCont to cluster cares.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992282, "text": "Neonatology\nIn NCo2 at 100% 1oo cc. Generally comfortable apeparing but with some desats.\n\nWt 3340 up 10. On BM ad . Abdomen benign.\nAd feeds being tolerated.\n\nHct 49.5\n\nWill discuss possibility of retrotx with . SPoek with primary pedi who has priviledges at NWH. interested in , but given lability in O2 wouls suggest either staying here or transfer to level2.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992283, "text": "Neonatology fellow note\nWell-appearing, active, NAD\nAFOF, mild jaundice\nRRR, no murmur\nCTA bilaterally, good air entry, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992247, "text": "4 FEN\n5 Development\n\nREVISIONS TO PATHWAY:\n\n 4 FEN; added\n Start date: \n 5 Development; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992248, "text": "1900-0730 NPN\n\n\nRESP: Received pt on Prong CPAP of 7 with FiO2 22-25%. D/T\ncontinuous grunting, pt was placed on SIMV with settings\n22/6, rate of 20. FiO2 on SIMV has been 24-60%. Pt\nreceived Survanta x 1. CBG after intubation was\n7.37/43/28/26. See flow sheet for further details. RR\n33-74, O2 sats >92%. LS clear/=, mild SC retractions. Pt\nsuctioned x 2 for lg cloudy secretions via ETT and no\nsecretions orally. No A/B spells. Desats x 2, requiring\nincrease in O2, see flow sheet for details. P: Cont to\nmonitor and wean vent settings as tolerated.\n\nSEPSIS: Cont on IV Ampicillin and Gentimicin for 48hr r/o.\nBlood cx pending. VSS, no s/s of infection. P: Cont to\nmonitor for s/s of infection and await blood cx results.\n\nFEN: Birth wgt was 3620g. Current wgt is 3615g, down 5g.\nTF=80cc/kg/d. Pt is NPO. IVF is D10W via PIV. D-stick was\n139. Abdominal girths stable at 30.5-31cm. Abdomen soft,\nround, BS active, no loops. Pt is vdg, unable to assess\nurine output this shift d/t lg mec stools x 2. P: Cont to\nmonitor.\n\nG&D: Temps 99.1-99.9 on open warmer, warmer weaned x 1. Pt\nis nested on sheepskin. MAE, alert/active with cares.\nSleeps between cares, with irritability at times. Sucks\npacifier and brings hands to face for comfort, settles well\nwith hand containment. Fontanels soft/flat, sutures smooth.\nAGA. P: Cont to support growth and development.\n\nPARENTING: Mom called x 1, updated by RN, asking\nappropriate questions. P: Cont to support/educate parents.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992249, "text": "Respiratory care\nBaby received on cpap 7 fio2 ranged from 25-60% when agitated.Decision made to intubate for ^ wob,resp distress.intubated with 4.0 ett @ 10cm with good tube placement , confirmed by cxr.Initial settings r 20 22/6 fio2 as above.Received 2 doses of surf,14 cc,tol well.Sx prior to surf for mod cldy secs.cbg 7.37/43 tried to wean R to 18 but baby became , ^ back to R 20.will follow with rpt gas.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992276, "text": "NPN 0700-1900\n\n7 Hyperbilirubinemia\n\n#1 O: Receeived infant in NC 02 300cc's of flow at 30-50%\nwhere he currently remains while at rest. Needing up to 60%\nwith BF earlier in shift but more recently 40%. LS clear and\n=. RR 40's-70's. No retractions or increased WOB'ing noted.\nO2 sats have been maintained 91-97%. No spells. A: Remaining\nin NC o2. P: Cont to monitor.\n\n#3 O: Both in for family meeting this afternoon.\nThis RN and fellow present. asking appropriate\nquestions and seeming to understand infant's status.\nDiscussed Hep B, car seat test and hearing to all be done\nprior to infant going home. signed consent for circ\nbut aware will not be done until off o2. Mom plans to stay\nover tonight in parent room to be able to BF infant. A:\nInvolved, . P: Cont to support and update.\n\n#4 O: Infant continues on an ad lib demand feeding schedule\nwaking now q 2 1/2-4h and breastfeeding well both sides. No\nsupplement given. Abdomen benign; voiding, no stool. No\nspits. DS this am at 79. A: Tolerating feeds well. P: Cont\nto monitor.\n\n#5 O: Infant maintaining temp in . Awake and alert with\ncares; sleeping well between. Awoke on own for feeds today.\nSwaddled in blanket; sucks on pacifier when offered. A: AGA.\nP: Cont to support development.\n\n#7 O: Coloring jaundiced. Bili to be checked tomorrow am. A:\nHyperbili. P: Cont to monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992277, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant cont's in NC FIO2 40-60%,flow rate\n300cc's/min.RR 48-80 with mild sc retractions.LS remain\nclear and equal b/l.Infant with no spells thus far.Drifts in\nsats titrating o2 as needed.A:Alt. in Resp. d/t Prematurity\nP:Cont. to assess resp. status and titrate o2 as needed.\n\nParenting:Mom in this eve very and invested.Staying\nin Family Room,does plan to go home tomorrow.Verbalized how\ndifficult it will be leaving her infant.A/P:Cont. to\nsupport,update and educate.\n\nF/E/N:Infant cont's on ad lib demand shedule.Infant BF most\nfeeds.At 2200 mom into BF infant latches on very well.Mom\nskipped following feed to rest prior to going home.Infant\nbottled and took 90cc's of E20 with a Nuk\nnipple.Weight=3.330kg down 100 grams.Abd. soft,pos bs,no\nloops or spits.Voiding and stooling guiac negative\nstool.A:Stable P:Cont. to assess tolerance of feeds.\n\nDEV:AFSF.Infant alert and active with cares.Sleeping quietly\nb/t cares.Infant remains in open crib;presently swaddled\nwith nested boundaries.Bringing hands to face and mouth and\nsucking on pacifier.A:AGA P:Cont. to support growth and dev.\n\nHyperbili:Infant appears jaundice.Bili level sent awaiting\nresults.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992243, "text": "Admission Note\n37 wk male admitted at ~1.5 hr of age with respiratory distress.\nDelivered via elective repeat c/s this am. EDC \nMom is 37yo G4 P3-4 (1st 3 children are girls); A+/Ab-/RPR NR/RI/GBS ?.\n\nNo fever. ROM at delivery.\nPlacenta accreta noted at delivery; maternal blood loss/transfusion by report\n\nBwt 3625g (LGA); Apgars 7&8. NICU team called for persistent grunting post delivery. Arrived to find pt in RA, pale pink/sl mottled, grunting/flaring/retracting. Pt admitted to NICU for further evaluation/management.\n\nHR 160s, RR 50s (G/F/R), BP mean 50s, T 97.9, sat 100% with 60% BBO2\nD-stick 90\nPE pale pink, active, sl decreased but symmetrical tone. AFOF; no molding. Lungs fairly well aerated bilaterally despite grunting, heart RRR s murmur, abd soft s HSM. Cord clamp noted to have been secured over small amt of skin - removed and replaced. GU AGA male. hips stable.\n\n10cc/kg NS bolus given IV for poor perfusion/pallor\nCBC/Bcx sent\n\nImp/ 37 wk LGA male with resp distress s/p elective c-s - most likely retained fetal lung fluid; possible infection. Pain from cord-clamped skin may have contributed to symptoms (mild incr BP, incr HR, incr glucose, O2 requirement ? R to L shunting). Maternal placenta accreta/blood loss unlikely to have affected baby.\n\nPlan/\ncontinue to monitor cvr status;\nO2 and NCPAP to support resp;\nCXR to evaluate lung fields/heart size;\nABG if distress persists/worsens on CPAP;\nIV amp/gent if indicated by CBC, CXR, or clinical status;\nnpo on IV fluid pending resolution of respiratory symptoms; follow blood sugar given LGA status.\n\nPrimary pedi = ( Medical); in house coverage to be determined by preference of OB \n\nParents updated by in OR.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992271, "text": "NPN/0700-1900\n\n\n#1 RESP: Received infant on prong CPAP 6 with FiO2 ~26%.\nDecreased to 5cm this AM, and then trialed to NC ~2hrs\nlater. Infant remains on 300cc flow NC, 40-50% at rest, ^\nto 60% with breastfeeding. RR 40-60's. LSC/= with no ^\nWOB. Cont. to monitor. Wean O2 as able.\n\n#3 : Mom visiting throughout the day. Updated at\nbedside. Breastfed infant x2 this afternoon. Both mom and\ninfant did well with feedings. Dad and grandparents\nvisiting this afternoon. Very loving towards infant. Mom\nremains in house. Will be up for feeding.\n\n#4 FEN: Received infant NPO with D10 ^ at 100cc/k/d.\nIVF weaned and then dc'd as breastfeeding continued well.\nInfant breastfeeding well Q4hrs. Voiding qs/no stools.\nAbd. benign. DS=82 (on 50cc/k of IVF). Cont. with\nbreastfeeding/ad lib feeds.\n\n#5 DEVELOPMENT: Infant swaddled on off warmer with temps\nstable. Active/irritable with cares. Settles well with\npacifier or feeding. AFOF. AGA. Cont. to support\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992272, "text": "2 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 2 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992273, "text": "1900-0730 NPN\n\n\nRESP: Cont on NC 300cc flow, 30-50% FiO2 (increased to 60%\nfor PO feeding). RR 30's-50's, O2 sats >91%. LS clear/=.\nNo retractions. No A/B spells or desats. P: Cont to\nmonitor and wean from NC as tolerated.\n\nFEN: Birth wgt was 3625g. Wgt tonight is 3430g, down 120g.\nPt is ad lib feeding BM20/PE20, needing to be woken Q4hr to\neat. Pt BF > 10 mins at , and at 2400 took 30cc by\nbottle. D-stick 82. Med spit x 1. Abdomen benign. Pt is\nvoiding, no stool yet this shift. P: Cont to monitor.\n\nG&D: Temps stable in , pt dressed/swaddled. MAE,\nalert/active with cares. Sleeps between cares, not yet\nwaking independently for feeds. Sucks pacifier and brings\nhands to face for comfort. Fontanels soft/flat. AGA. P:\nCont to support growth and development.\n\nPARENTING: Mom in to visit, BF infant. Mom also called x\n1. Mom updated at bedside, asking appropriate questions.\nMom is and invested. P: Cont to support/educate\n.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992274, "text": "Neonatology fellow note\nAwake and alert, NAD\nAFOF, mildly jaundiced\nRRR, I/VI SEM\nOn NC, CTA bilaterally, good air entry, no retractions\nAbd soft, active bowel sounds, full\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992275, "text": "Neonatology Attending\nDOL 5\n\nIn NC 300cc/min with no apneas/bradycardias.\n\nNo murmur.\n\nWt 3430 (-120) on ad lib feeds. Voidign and stooling normally.\n\nTemperature stable in open crib.\n\nA&P\nPreterm infant with resolving surfactant deficiency\n-Continue to await resolution of oxygen requirement\n-Monitor for adequacy of enteral intake on ad lib feeds.\n-Otherwise continue current management as above.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992264, "text": "NPN 7A-7P\n\n\n#1 Remains on CPAP 7, Fi02 30% (Fi02 increased with\ncrying/irritability to 40% but able to wean. LS = and clear,\nstill exhibiting poor \"reserve\". Sao2's low-mid 90's. Con't\nto wean Fi02 as tolerated.\n\n#2 Blood culture remains neg, CBC w/ diff unremarkable for\ninfection. Amp and gent d/c'd. Will con't to monitor general\nstatus for S&S of sepsis.\n\n#3 in to visit along with infant's three sisters.\n held awhile and were updated. Will con't to\nsupport. Plan for a Family Meeting tomorrow prior to mom's\ndischarge.\n\n#4 TF remain at 80cc/k/d. Is NPO, abdomen soft and pink with\npositive bowel sounds and likes to suck on pacifier. Is\nvoiding well, no stool. Will remain NPO until respiratory\nstatus improves.\n\n#5 Three day old 37week gestation infant boy on CPAP with\noxygen requirement and poor reserve. Fi02 decreased somewhat\nover the past 24 hrs. Off antibiotics, very active with\nhandling, appearing comfortable once settled. Is swaddled on\n\"off\" warmer (too big for crib. Will con't present\ninterventions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992265, "text": "Respiratory Care\nBaby continues on cpap 7, fio2 28-31%, bs clear, rr 40-60's. Will continue to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992266, "text": "Neonatal NP-exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infnat active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992267, "text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 7 FiO2 28-32%. RR 40-70's breath sounds are clear. Baby looks comfortable on CPAP. Plan to wean CPAP and transition to nasal cannula soon. Stable on CPAP cont to follow\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992268, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 6 weaned from 7cms in\n26-32%. BS clear. Mild retractions.RR= 40-70's.\n#3 Mom called x1. Updated on pt condition. A=\nInvolved. p= Support.\n#4 F/N- Abd soft,+bs, no loops.Remains NPO. PIV patent\ninfusing at 80cc/kg/day. D/S=85.Voiding+ stooling in adeq\namts.Mec stool x1.Wt down 65gms.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992269, "text": "Neonatology\nDOwn on CPAP from 7 to 6. WIll wean further today as tolerated. Generally comfortable. No murmur.\n\nWT down 65. TF to be increased to 100 cc/k/d.\nAbdomen benign.\n\nHct stable over wekeend.\n\nWIll advance feeds rapidly as tolerated given GA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992270, "text": "Neonatology fellow note\nSleeping, NAD\nAFOF, mildly jaundiced\nRRR, no murmurs\nCTA bilaterally on CPAP, good aeration, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" } ]
78,814	105,817	77 yo M with history of coronary artery disease s/p CABG , PCI native left circumflex , systolic heart failure, and multiple sclerosis, presented with melena from . Found to be having massive upper GI bleed as well as cholangitis and pneumonia. Suspected source of bleeding was from recent biliary stenting where he had bled in the past. He urgently went to ERCP where he was seen to be bleeding near the duodenal papilla at the site of a prior spincterotomy and bleed. Sclerosis and ligation were unsuccessful at ERCP. IR was called and he went to angio. At angio the gastroduodenal artery was identified as the bleeding source. Embolization was unsuccessful. Surgery was following throughout. After IR could not embolize the source of bleeding, surgery was urgently called to the bedside. Surgery felt the patient was an extremely high operative risk given his CHF, PNA, Afib, MS, and cholangitis on top of his GI bleed. His wife was by surgery and she agreed to defer surgery. The patient was made DNR at that point. He continued to massively hemorrhage. Again his wife was and he was made . He expired shortly thereafter from exsanguination.	Presented in early for bleed at sphincterotomy site which was treated endoscopically as OSH. PPX: -DVT ppx with pneumoboots -Bowel regimen assessment once out of window of GI bleed . PPX: -DVT ppx with pneumoboots -Bowel regimen assessment once out of window of GI bleed . Has had repeated bouts of cholangitis, deemed to be non operative candidate for cholecystectomy, most recently had ERCP in for exchange of stent. ERCP was aborted and trauma line was plaed by anesthesia in ERCP suite prior to patient being transferred back to for stabilization. ERCP was aborted and trauma line was plaed by anesthesia in ERCP suite prior to patient being transferred back to for stabilization. Transfused one unit of PRBC and transferred to for further care. Likely bleeding source is duodenal papilla at site of prior sphincterotomy. Likely bleeding source is duodenal papilla at site of prior sphincterotomy. Of note, patient had a recent admission to from to for elective ERCP during which he had removal of CBD stones as well as a biliary stent placed. Of note, patient had a recent admission to from to for elective ERCP during which he had removal of CBD stones as well as a biliary stent placed. A Trauma line was placed in the right IJ and pt had a left radial aline. A Trauma line was placed in the right IJ and pt had a left radial aline. Selective common hepatic arteriogram. That hospital course was complicated by atrial fibrillation with RVR. That hospital course was complicated by atrial fibrillation with RVR. Based on both clinical and radiologic findings, decision was made to attempt cannulization and embolization of the gastroduodenal artery. Of recurrent bleeding from previous sphincterotomy site. ACCESS: PIV's, trauma line . ACCESS: PIV's, trauma line . Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 160 FINAL REPORT (Cont) notified immediately, including surgical attending Dr. . Per report was taken for ERCP and a large amt of blood was seen in the duodenum with active bleeding noted but visualization was limited and pt was referred to Interventional radiology. Per report was taken for ERCP and a large amt of blood was seen in the duodenum with active bleeding noted but visualization was limited and pt was referred to Interventional radiology. Pt arrived sedated with HR= 110 Afib with occasional PVCs, BP 90-110/60s, intubated and sedated. Pt arrived sedated with HR= 110 Afib with occasional PVCs, BP 90-110/60s, intubated and sedated. Hypoxia: Patient noted in ED to have hypoxia to 70s on room air and was subsequently placed on a non-rebreather. Hypoxia: Patient noted in ED to have hypoxia to 70s on room air and was subsequently placed on a non-rebreather. GI, hepatology, and ERCP were consulted. GI, hepatology, and ERCP were consulted. - Appreciate GI, ERCP, surgery, IR recs - Maintain two large IVs and trauma line - Massive transfusion protocol active - Has anti-E antibodies, so will have to transfuse until the anti-E is consumed by hemolysis - Will continue to trend CBC, coags, and T and S - IR was able to identify bleeding from a branch of the gastroduodenal artery but unable to embolize it. - Appreciate GI, ERCP, surgery, IR recs - Maintain two large IVs and trauma line - Massive transfusion protocol active - Has anti-E antibodies, so will have to transfuse until the anti-E is consumed by hemolysis - Will continue to trend CBC, coags, and T and S - IR was able to identify bleeding from a branch of the gastroduodenal artery but unable to embolize it. He then proceeded to Holy hospital, where he received one unit of blood and ~1 L IVF. He then proceeded to Holy hospital, where he received one unit of blood and ~1 L IVF. Patient's ABG on NRB was 7.46/48/77, indicating a significant A-a gradient. Patient's ABG on NRB was 7.46/48/77, indicating a significant A-a gradient. TITLE: MICU Nursing Critical event note: Pt is a 77yo male adm to ICU with GI bleed and proceeded to ERCP where a bleeding source was visualized but required possible . GI attending in ED felt that source of bleed was likely to be sphincterotomy site as patient had an ERCP in , which was complicated by ulcerative bleed around stent. GI attending in ED felt that source of bleed was likely to be sphincterotomy site as patient had an ERCP in , which was complicated by ulcerative bleed around stent. He was then urgently transferred to for suspected upper GI bleed related to his history of multiple ERCPs. He was then urgently transferred to for suspected upper GI bleed related to his history of multiple ERCPs. Surgery deferred managment decisions to GI and ERCP team. Surgery deferred managment decisions to GI and ERCP team.	14	[ { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507265, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male initially adm to ICU via ED from OSH with\n C/O acute abd. pain and melanotic stool. Pt with sig. PMH for COPD,\n IDDM, mult. GIB---mult ERCP for stent placements at sphincterotomy\n site, arrhythmias, CAD, ischemic cardiomyopathy with EF= 25%, CHF, HTN,\n multiple sclerosis, s/p CABG in . Pt with allergies to\n Levofloxacin and quinolones.\n Per report was taken for ERCP and a large amt of blood was seen in the\n duodenum with active bleeding noted but visualization was limited and\n pt was referred to Interventional radiology. During ERCP pt required\n total of 2 units of FFP and 5 units of pRBC via emergency transfusion\n protocol. A Trauma line was placed in the right IJ and pt had a left\n radial aline. BP was reported between 70-120/50-80\ns and IV\n Neosynephrine was infusing at 0.7 mcgs/kg/min. Pt was intubated for\n the ERCP and sedated on Propofol gtt at 33mcgs/kg/min. Pt transferred\n to MICU-6 via ACLS ambulance. Pt arrived sedated with HR= 110 Afib\n with occasional PVC\ns, BP 90-110/60\ns, intubated and sedated. Upon\n arrival to MICU-6 the pt was immediately transported to the IR suite.\n During angiogram a large bleed was seen in a large vessel but all\n attempts by IR team were unsuccessful to embolize or coil the bleed.\n Pt required multiple transfusions during the procedure---transfused\n with total of 3 units pRBC\ns and 1 bag of platelets during IR\n procedure. Neosynephrine gtt was titrated up to 1.0 mcgs/kg/min for\n transient BP dips to 80\ns/60\ns. IV Propofol was increased to\n 50mcgs/kg/min for increased agitation during the case and pt also\n received 2 doses of IV Fentanyl 50mcgs with good effect.\n Returned to MICU-6 and surgical team evaluated pt. Pt not a candidate\n for surgery due to multiple co-morbidities and unstable hemodynamic\n status. Pt bolused with total of 2 liters NS, received 2 more units of\n pRBC\ns ( for a total of 10 units), received 2 more units FFP ( for a\n total of 4 units) and received another bag of platelets (for a total of\n 2 units). Neosynephrine titrated up to 1.2 mcgs/kg/min to maintain\n MAP\ns>60, pt received antibx as ordered, Hct 29, pt passing huge amts\n of melanotic stool and large amts of bright red blood per rectum, color\n ashen with some mottling noted, cool to touch. MICU team and surgical\n teams spoke with pt\ns wife and pt made DNR and then . ALL\n transfusions stopped at 0330, Neo gtt stopped at 0330, bolused with 4\n mg. IV Morphine x 1 and IV Morphine gtt initiated and titrated up to 4\n mg/hr, pt restless/tachypneic/and ? seizing----received 4 mg. IV versed\n x 1 with no effect. Pt received another 4 mg. IV versed bolus dose\n with good effect.\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507268, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male initially adm to ICU via ED from OSH with\n C/O acute abd. pain and melanotic stool. Pt with sig. PMH for COPD,\n IDDM, mult. GIB---mult ERCP for stent placements at sphincterotomy\n site, arrhythmias, CAD, ischemic cardiomyopathy with EF= 25%, CHF, HTN,\n multiple sclerosis, s/p CABG in . Pt with allergies to\n Levofloxacin and quinolones.\n Per report was taken for ERCP and a large amt of blood was seen in the\n duodenum with active bleeding noted but visualization was limited and\n pt was referred to Interventional radiology. During ERCP pt required\n total of 2 units of FFP and 5 units of pRBC via emergency transfusion\n protocol. A Trauma line was placed in the right IJ and pt had a left\n radial aline. BP was reported between 70-120/50-80\ns and IV\n Neosynephrine was infusing at 0.7 mcgs/kg/min. Pt was intubated for\n the ERCP and sedated on Propofol gtt at 33mcgs/kg/min. Pt transferred\n to MICU-6 via ACLS ambulance. Pt arrived sedated with HR= 110 Afib\n with occasional PVC\ns, BP 90-110/60\ns, intubated and sedated. Upon\n arrival to MICU-6 the pt was immediately transported to the IR suite.\n During angiogram a large bleed was seen in a large vessel but all\n attempts by IR team were unsuccessful to embolize or coil the bleed.\n Pt required multiple transfusions during the procedure---transfused\n with total of 3 units pRBC\ns and 1 bag of platelets during IR\n procedure. Neosynephrine gtt was titrated up to 1.0 mcgs/kg/min for\n transient BP dips to 80\ns/60\ns. IV Propofol was increased to\n 50mcgs/kg/min for increased agitation during the case and pt also\n received 2 doses of IV Fentanyl 50mcgs with good effect.\n Returned to MICU-6 and surgical team evaluated pt. Pt not a candidate\n for surgery due to multiple co-morbidities and unstable hemodynamic\n status. Pt bolused with total of 2 liters NS, received 2 more units of\n pRBC\ns ( for a total of 10 units), received 2 more units FFP ( for a\n total of 4 units) and received another bag of platelets (for a total of\n 2 units). Neosynephrine titrated up to 1.2 mcgs/kg/min to maintain\n MAP\ns>60, pt received antibx as ordered, Hct 29, pt passing huge amts\n of melanotic stool and large amts of bright red blood per rectum, color\n ashen with some mottling noted, cool to touch. MICU team and surgical\n teams spoke with pt\ns wife and pt made DNR and then . ALL\n transfusions stopped at 0330, Neo gtt stopped at 0330, bolused with 4\n mg. IV Morphine x 1 and IV Morphine gtt initiated and titrated up to 4\n mg/hr, pt restless/tachypneic/and ? seizing----received 4 mg. IV versed\n x 1 with no effect. Pt received another 4 mg. IV versed bolus dose\n with good effect. Pt extubated and appeared comfortable and expired at\n approx. 0430. MICU resident notified pt\ns family, MICU attending, and\n medical examiner. Medical examiner declined autopsy. Pt has a gold\n watch and eyeglasses and a t-shirt---all to be sent with him to the\n morgue as no family will be coming to the hospital.\n" }, { "category": "Nursing", "chartdate": "2126-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507173, "text": "Pt. presented to OSH with acute onset of sharp abd. Pain this morning\n following episode of maroon stool. Transfused one unit of PRBC and\n transferred to for further care. Surgery, GI teams consulted. Pt.\n has hx. Of recurrent bleeding from previous sphincterotomy site. VSS at\n this time. HR 110\ns-120\ns A-fib, BP 110\ns/60\n Pt. with LLL pna per Xray in ED. On 100% NRB with O2 sat at 99-100%.\n LS with rhoncki with congested cough.\n Abd. Large obese with BS+ hypoactive. No stool while in MICU. NGT in\n place.\n Pt. to go to ERCP tonight.\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Death Note", "row_id": 507259, "text": "TITLE: Death note\n Mr. was made CMO after consultation between his HCP / wife\n . subsequently had pressors discontinued and he was extubated.\n He passed away from exsanguination due to an upper GI bleed. He was\n given morphine and midazolam prior to death to ease his symptoms.\n His case was referred to the Medical Examiner who declined the case. An\n autopsy was refused by his wife/HCP.\n MD\n" }, { "category": "General", "chartdate": "2126-12-07 00:00:00.000", "description": "ICU Event Note", "row_id": 507177, "text": "Clinician: Attending\n 77 yo man with Multiple sclerosis, chronic Afib, h/o CAD, h/o CHF with\n ischemic cardiomyopathy (LVEF 25%), DM2, COPD. Has had repeated bouts\n of cholangitis, deemed to be non operative candidate for\n cholecystectomy, most recently had ERCP in for exchange of stent.\n Presented in early for bleed at sphincterotomy site which was\n treated endoscopically as OSH. Presents now with SOB, abdominal pain,\n maroon stools. Was recently told he has PNA, but has not started\n abtx. Had elevated LFTs in ED with increased alk phos and bili. CXR\n with LLL infiltrate. Also noted to be significantly hypoxemic.\n Transferred to for ERCP. Currently feels mildly SOB. No\n abdominal pain.\n o/e\n dry oropharynx\n no LAD\n lungs: bronchial BS at left base\n CV: irreg, tachy\n abd: soft NT\n ext: no edema, left toe amputations\n Labs:\n ALT: 47 AST: 80 AP: 554 Tbili: 2.7 Lip: 109 INR: 1.3\n A/P:\n cholangitis with intraductal bleed: best explains picture with signs\n of biliary obstruction, and GIB. To get ERCP.\n respiratory distress, hypoxemia: basline long time smoker, COPD, with\n LLL PNA. continue Unasyn for cholangitis plus azithro for LLL PNA.\n Will be intubated for procedure. Hydrate as necessary to support BP\n and urine output.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2126-12-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507229, "text": "TITLE:\n Chief Complaint: abdominal pain, marroon colored stools\n HPI:\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from . Of note,\n patient had a recent admission to from to for\n elective ERCP during which he had removal of CBD stones as well as a\n biliary stent placed. That hospital course was complicated by atrial\n fibrillation with RVR. He then presented on to for additional ERCP to have his previously placed biliary\n stent removed. At time of that procedure, ERCP team\n reported some blood from around the stent at the ampulla, which they\n cauterized to gain hemostasis. Patient was discharged from \n and reports that he was not feeling like he ws back to his baseline at\n any point in . This morning at 0600, he awoke with severe\n mid-abdominal pain and then had urgency to have bowel movement, which\n was described as \"mahagony-colored\". He then proceeded to Holy \n hospital, where he received one unit of blood and ~1 L IVF. Due to poor\n respiratory status, he received furosemide. He was then urgently\n transferred to for suspected upper GI bleed related to his\n history of multiple ERCPs.\n .\n Of note, patient has had upper respiratory sypmtoms for the last 3 to 4\n weeks and presented to his primary care physician several days prior to\n coming in for his acute complaint at this admission. He was prescribed\n an antibiotic of which he does not recall the name. Regardless, he\n never filled the prescription. He notes his breathing is a bit labored\n and though denies acute complaints, later admits that he has had\n increased cough and sputum production in last week.\n .\n Vitals upon presentation to the ED were: T 98, HR 120, BP 100/74, RR\n 16, O2Sat 100% on NRB. Once arriving at , ED obtained NG lavage,\n which failed to clear of blood and noted large amounts of melena.\n Additionally, U/A which showed moderate bacteria and positive nitrite,\n but was without WBCs. Urine culture and blood cultures are pending.\n Patient was given pantoprazole IV as only medical intervention. Patient\n was maintained on a non-rebreather throughout his stay in the ED and\n sats were 100%. He was noted to be in atrial fibrillation with RVR and\n HR was in the 110s to 120s throughout his ED stay with no intervention\n performed. GI, hepatology, and ERCP were consulted. GI attending in ED\n felt that source of bleed was likely to be sphincterotomy site as\n patient had an ERCP in , which was complicated by ulcerative\n bleed around stent. Surgery deferred managment decisions to GI and ERCP\n team. Patient was then transferred to the prior to signout of the\n patient to the admitting medicine ICU team due to need for emergent\n ERCP.\n .\n Patient originally came to and went urgently to ERCP, where was\n quickly noted to be exanguinating from duodenum, though bleeding was\n too brisk to localize further as several units of blood were reported\n to be seen in stomach as well as in the small bowel. ERCP was aborted\n and trauma line was plaed by anesthesia in ERCP suite prior to patient\n being transferred back to for stabilization. Massive transfusion\n protocol was activated and paitent was transfused 5 units PRBC and 2\n units FFP prior to transfer to the MICU for\n stabilization prior to IR attempted angio and embolization.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Levofloxacin\n Rash;\n Quinolones\n Diarrhea;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 06:53 PM\n Azithromycin - 02:33 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n 1) Carbamazepine 200 mg PO QID\n 2) Simvastatin 10 mg PO DAILY\n 3) Zonisamide 100 mg PO DAILY\n 4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea\n 5) Furosemide 20 mg PO DAILY\n 6) Tamsulosin 0.4 mg PO HS\n 7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation \n 8) Metformin 500 mg PO BID\n 9) Sertraline 50 mg Tablet PO DAILY\n 10) Hydromorphone 2 mg PO Q4H:PRN pain\n 11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)\n 12) Pantoprazole 40 mg PO Q12H\n 13) Glyburide 2.5 mg PO DAILY\n 14) Gabapentin 600 mg PO QID\n Past medical history:\n Family history:\n Social History:\n 1) Multiple sclerosis with left hemiparesis/neurogenic bladder\n 2) CAD s/p 2 vessel CABG , PCI LCX \n 3) Chronic systolic heart failure (EF 45-50% with mild hypokinesis of\n the basal to mid inferior and inferolateral segments)\n 4) Atrial fibrillation (complicated by RVR at prior admissions, not on\n anticoagulation)\n 5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ()\n 6) Diabetes mellitus type II\n 7) COPD, on 2L home 02 at night and while ambulatory in summer, no\n current pulmonologist\n 8) Recurrent pseudomonal urinary tract infections\n 9) Recurrent aspiration pneumonia ( and )\n 10) Chronic left ankle fracture c/b non-healing malleolar ulcer\n 11) MRSA colonization\n 12) Hypertension\n 13) Trigeminal neuralgia\n 14) Benign prostatic hypertrophy\n 15) GERD\n Non-contributory\n Occupation: retired electronics tester.\n Drugs: denies\n Tobacco: roughly 120 pack-year history (3 PPD x 40 y)\n Alcohol: denies\n Other: Lives with wife and daughter in , NH\n Review of systems:\n Flowsheet Data as of 03:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.8\nC (96.4\n HR: 109 (97 - 119) bpm\n BP: 87/52(64) {87/52(64) - 121/71(84)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 581 mL\n 2,407 mL\n PO:\n TF:\n IVF:\n 313 mL\n 925 mL\n Blood products:\n 267 mL\n 1,482 mL\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 341 mL\n 2,387 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/56/289/30/4\n Ve: 9 L/min\n PaO2 / FiO2: 482\n Physical Examination\n VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB\n GEN: NAD\n HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient on\n non-rebreather\n NECK: Supple, no \n PULM: CTAB\n CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB\n ABD: obese, BS+, soft, non-tender, non-distended\n EXT: 1+ BLE edema to level of knees\n SKIN: No rashes\n NEURO: Oriented to self, month, year, location. Can not name specific\n day of week. CN II-XII grossly intact. BLE weakness.\n PSYCH: Restricted affect appropriate for clinical situation\n Labs / Radiology\n 230 K/uL\n 11.2 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 26 mg/dL\n 30 mEq/L\n 106 mEq/L\n 3.7 mEq/L\n 141 mEq/L\n 32.1 %\n 10.3 K/uL\n [image002.jpg]\n \n 2:33 A12/19/ 06:18 PM\n \n 10:20 P12/19/ 07:29 PM\n \n 1:20 P12/19/ 08:56 PM\n \n 11:50 P12/19/ 09:38 PM\n \n 1:20 A12/19/ 09:47 PM\n \n 7:20 P12/19/ 10:37 PM\n 1//11/006\n 1:23 P12/20/ 01:08 AM\n \n 1:20 P12/20/ 01:20 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n 10.2\n 10.3\n Hct\n 26.7\n 30\n 28.2\n 29.8\n 32.1\n Plt\n 189\n 250\n 230\n Cr\n 0.6\n 0.8\n TropT\n 0.04\n TC02\n 35\n 30\n 31\n 33\n Glucose\n 176\n 123\n Other labs: PT / PTT / INR:15.3/25.8/1.3, CK / CKMB /\n Troponin-T:21/2/0.04, ALT / AST:36/54, Alk Phos / T Bili:289/9.1,\n Fibrinogen:370 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:145\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from .\n .\n #. Upper GI bleed:\n Massive bleeding seen during ERCP. Likely bleeding source is duodenal\n papilla at site of prior sphincterotomy.\n - Appreciate GI, ERCP, surgery, IR recs\n - Maintain two large IVs and trauma line\n - Massive transfusion protocol active\n - Has anti-E antibodies, so will have to transfuse until the anti-E is\n consumed by hemolysis\n - Will continue to trend CBC, coags, and T and S\n - IR was able to identify bleeding from a branch of the gastroduodenal\n artery but unable to embolize it. Will hopefully go urgently to surgery\n control of his bleeding artery\n .\n #. Cholangitis:\n Patient has had mulitple pseudomonas UTIs in the past and all are\n sensitive to Zosyn. Given that, is reasonable to treat with Zosyn to\n cover his GI flora likely causing his current cholangitis.\n - Trend liver studies\n - ERCP when stable to assure bile duct patency and consider stenting\n - Antibiotic treatment with Zosyn\n .\n #. Hypoxia:\n Patient noted in ED to have hypoxia to 70s on room air and was\n subsequently placed on a non-rebreather. Patient's ABG on NRB was\n 7.46/48/77, indicating a significant A-a gradient.\n - Likely should remain intubated following procedure tonight\n - Post-intubation monitoring of PaO2\n - Antibiotic coverage with Vancomycin/Zosyn/Azithromycin empirically\n pending blood and sputum cultures\n .\n #. Systolic heart failure:\n Recent EF shows hypokinetic LV inferior wall, though EF of 45 to 50%.\n - Hold carvedilol while patient is in window of GI bleed\n .\n #. Atrial fibrillation:\n Patient reported as having atrial fibrillation with RVR during\n hospitalization in and plan at discharge was for cardiology\n follow-up to address anticoagulation; however, it appears that patient\n has not visited a cardiologist following discharge in 9/. At\n presentation to the ICU, HR in the 110s to 120s with stable BP.\n - Assess heart rate response to blood products and fluids\n - Control heart rate rise acutely with IV metoprolol if needed\n - Outpatient follow-up to determine better regimen for rate control and\n to consider patient's candidacy for anticoagulation\n .\n FEN: NPO for now\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen assessment once out of window of GI bleed\n .\n ACCESS: PIV's, trauma line\n .\n CODE STATUS: FULL, per discussion with patient\n .\n EMERGENCY CONTACT: Wife, , or \n .\n DISPOSITION: ICU for stabilization\n ADDEMDUM: Based on surgical risk and discussion with wife and surgery\n team, patient will not go to the OR. I spoke with his wife, , and\n she agreed to DNR. I made her explicitly aware that he will almost\n certainly die of his bleeding. She understood this. We will continue to\n transfuse 1uinit of pRBC per hour for now with 2 units of FFP, and 1u\n PLT. If this does not work after several more hours, we will discuss\n CMO with Mrs. .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:08 PM\n 20 Gauge - 06:08 PM\n Arterial Line - 06:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507240, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male adm to ICU with GI bleed and proceeded to\n ERCP where a bleeding source was visualized but required possible .\n Or embolization. Pt adm to MICU-6 emergently for further care.\n Arrived via ambulance and immediately taken to IR suite for possible\n intervention. Pt hemodynamically unstable requiring transfusions of\n total of 5 units pRBC\ns/ 2 units FFP prior to transfer to MICU-6.\n While in IR pt received 3 more units pRBC\ns and 1 bag of platelets. I\n received pt on IV neosynephrine at 0.7 mcgs/kg/min and IV propofol gtt\n at 33 mcgs/kg/min\n" }, { "category": "Physician ", "chartdate": "2126-12-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507233, "text": "TITLE:\n Chief Complaint: abdominal pain, marroon colored stools\n HPI:\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from . Of note,\n patient had a recent admission to from to for\n elective ERCP during which he had removal of CBD stones as well as a\n biliary stent placed. That hospital course was complicated by atrial\n fibrillation with RVR. He then presented on to for additional ERCP to have his previously placed biliary\n stent removed. At time of that procedure, ERCP team\n reported some blood from around the stent at the ampulla, which they\n cauterized to gain hemostasis. Patient was discharged from \n and reports that he was not feeling like he ws back to his baseline at\n any point in . This morning at 0600, he awoke with severe\n mid-abdominal pain and then had urgency to have bowel movement, which\n was described as \"mahagony-colored\". He then proceeded to Holy \n hospital, where he received one unit of blood and ~1 L IVF. Due to poor\n respiratory status, he received furosemide. He was then urgently\n transferred to for suspected upper GI bleed related to his\n history of multiple ERCPs.\n .\n Of note, patient has had upper respiratory sypmtoms for the last 3 to 4\n weeks and presented to his primary care physician several days prior to\n coming in for his acute complaint at this admission. He was prescribed\n an antibiotic of which he does not recall the name. Regardless, he\n never filled the prescription. He notes his breathing is a bit labored\n and though denies acute complaints, later admits that he has had\n increased cough and sputum production in last week.\n .\n Vitals upon presentation to the ED were: T 98, HR 120, BP 100/74, RR\n 16, O2Sat 100% on NRB. Once arriving at , ED obtained NG lavage,\n which failed to clear of blood and noted large amounts of melena.\n Additionally, U/A which showed moderate bacteria and positive nitrite,\n but was without WBCs. Urine culture and blood cultures are pending.\n Patient was given pantoprazole IV as only medical intervention. Patient\n was maintained on a non-rebreather throughout his stay in the ED and\n sats were 100%. He was noted to be in atrial fibrillation with RVR and\n HR was in the 110s to 120s throughout his ED stay with no intervention\n performed. GI, hepatology, and ERCP were consulted. GI attending in ED\n felt that source of bleed was likely to be sphincterotomy site as\n patient had an ERCP in , which was complicated by ulcerative\n bleed around stent. Surgery deferred managment decisions to GI and ERCP\n team. Patient was then transferred to the prior to signout of the\n patient to the admitting medicine ICU team due to need for emergent\n ERCP.\n .\n Patient originally came to and went urgently to ERCP, where was\n quickly noted to be exanguinating from duodenum, though bleeding was\n too brisk to localize further as several units of blood were reported\n to be seen in stomach as well as in the small bowel. ERCP was aborted\n and trauma line was plaed by anesthesia in ERCP suite prior to patient\n being transferred back to for stabilization. Massive transfusion\n protocol was activated and paitent was transfused 5 units PRBC and 2\n units FFP prior to transfer to the MICU for\n stabilization prior to IR attempted angio and embolization.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Levofloxacin\n Rash;\n Quinolones\n Diarrhea;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 06:53 PM\n Azithromycin - 02:33 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n 1) Carbamazepine 200 mg PO QID\n 2) Simvastatin 10 mg PO DAILY\n 3) Zonisamide 100 mg PO DAILY\n 4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea\n 5) Furosemide 20 mg PO DAILY\n 6) Tamsulosin 0.4 mg PO HS\n 7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation \n 8) Metformin 500 mg PO BID\n 9) Sertraline 50 mg Tablet PO DAILY\n 10) Hydromorphone 2 mg PO Q4H:PRN pain\n 11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)\n 12) Pantoprazole 40 mg PO Q12H\n 13) Glyburide 2.5 mg PO DAILY\n 14) Gabapentin 600 mg PO QID\n Past medical history:\n Family history:\n Social History:\n 1) Multiple sclerosis with left hemiparesis/neurogenic bladder\n 2) CAD s/p 2 vessel CABG , PCI LCX \n 3) Chronic systolic heart failure (EF 45-50% with mild hypokinesis of\n the basal to mid inferior and inferolateral segments)\n 4) Atrial fibrillation (complicated by RVR at prior admissions, not on\n anticoagulation)\n 5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ()\n 6) Diabetes mellitus type II\n 7) COPD, on 2L home 02 at night and while ambulatory in summer, no\n current pulmonologist\n 8) Recurrent pseudomonal urinary tract infections\n 9) Recurrent aspiration pneumonia ( and )\n 10) Chronic left ankle fracture c/b non-healing malleolar ulcer\n 11) MRSA colonization\n 12) Hypertension\n 13) Trigeminal neuralgia\n 14) Benign prostatic hypertrophy\n 15) GERD\n Non-contributory\n Occupation: retired electronics tester.\n Drugs: denies\n Tobacco: roughly 120 pack-year history (3 PPD x 40 y)\n Alcohol: denies\n Other: Lives with wife and daughter in , NH\n Review of systems:\n Flowsheet Data as of 03:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.8\nC (96.4\n HR: 109 (97 - 119) bpm\n BP: 87/52(64) {87/52(64) - 121/71(84)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 581 mL\n 2,407 mL\n PO:\n TF:\n IVF:\n 313 mL\n 925 mL\n Blood products:\n 267 mL\n 1,482 mL\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 341 mL\n 2,387 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/56/289/30/4\n Ve: 9 L/min\n PaO2 / FiO2: 482\n Physical Examination\n VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB\n GEN: NAD\n HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient on\n non-rebreather\n NECK: Supple, no \n PULM: CTAB\n CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB\n ABD: obese, BS+, soft, non-tender, non-distended\n EXT: 1+ BLE edema to level of knees\n SKIN: No rashes\n NEURO: Oriented to self, month, year, location. Can not name specific\n day of week. CN II-XII grossly intact. BLE weakness.\n PSYCH: Restricted affect appropriate for clinical situation\n Labs / Radiology\n 230 K/uL\n 11.2 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 26 mg/dL\n 30 mEq/L\n 106 mEq/L\n 3.7 mEq/L\n 141 mEq/L\n 32.1 %\n 10.3 K/uL\n [image002.jpg]\n \n 2:33 A12/19/ 06:18 PM\n \n 10:20 P12/19/ 07:29 PM\n \n 1:20 P12/19/ 08:56 PM\n \n 11:50 P12/19/ 09:38 PM\n \n 1:20 A12/19/ 09:47 PM\n \n 7:20 P12/19/ 10:37 PM\n 1//11/006\n 1:23 P12/20/ 01:08 AM\n \n 1:20 P12/20/ 01:20 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n 10.2\n 10.3\n Hct\n 26.7\n 30\n 28.2\n 29.8\n 32.1\n Plt\n 189\n 250\n 230\n Cr\n 0.6\n 0.8\n TropT\n 0.04\n TC02\n 35\n 30\n 31\n 33\n Glucose\n 176\n 123\n Other labs: PT / PTT / INR:15.3/25.8/1.3, CK / CKMB /\n Troponin-T:21/2/0.04, ALT / AST:36/54, Alk Phos / T Bili:289/9.1,\n Fibrinogen:370 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:145\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from .\n .\n #. Upper GI bleed:\n Massive bleeding seen during ERCP. Likely bleeding source is duodenal\n papilla at site of prior sphincterotomy.\n - Appreciate GI, ERCP, surgery, IR recs\n - Maintain two large IVs and trauma line\n - Massive transfusion protocol active\n - Has anti-E antibodies, so will have to transfuse until the anti-E is\n consumed by hemolysis\n - Will continue to trend CBC, coags, and T and S\n - IR was able to identify bleeding from a branch of the gastroduodenal\n artery but unable to embolize it. Will hopefully go urgently to surgery\n control of his bleeding artery\n .\n #. Cholangitis:\n Patient has had mulitple pseudomonas UTIs in the past and all are\n sensitive to Zosyn. Given that, is reasonable to treat with Zosyn to\n cover his GI flora likely causing his current cholangitis.\n - Trend liver studies\n - ERCP when stable to assure bile duct patency and consider stenting\n - Antibiotic treatment with Zosyn\n .\n #. Hypoxia:\n Patient noted in ED to have hypoxia to 70s on room air and was\n subsequently placed on a non-rebreather. Patient's ABG on NRB was\n 7.46/48/77, indicating a significant A-a gradient.\n - Likely should remain intubated following procedure tonight\n - Post-intubation monitoring of PaO2\n - Antibiotic coverage with Vancomycin/Zosyn/Azithromycin empirically\n pending blood and sputum cultures\n .\n #. Systolic heart failure:\n Recent EF shows hypokinetic LV inferior wall, though EF of 45 to 50%.\n - Hold carvedilol while patient is in window of GI bleed\n .\n #. Atrial fibrillation:\n Patient reported as having atrial fibrillation with RVR during\n hospitalization in and plan at discharge was for cardiology\n follow-up to address anticoagulation; however, it appears that patient\n has not visited a cardiologist following discharge in 9/. At\n presentation to the ICU, HR in the 110s to 120s with stable BP.\n - Assess heart rate response to blood products and fluids\n - Control heart rate rise acutely with IV metoprolol if needed\n - Outpatient follow-up to determine better regimen for rate control and\n to consider patient's candidacy for anticoagulation\n .\n FEN: NPO for now\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen assessment once out of window of GI bleed\n .\n ACCESS: PIV's, trauma line\n .\n CODE STATUS: FULL, per discussion with patient\n .\n EMERGENCY CONTACT: Wife, , or \n .\n DISPOSITION: ICU for stabilization\n ADDEMDUM: Based on surgical risk and discussion with wife and surgery\n team, patient will not go to the OR. I spoke with his wife, , and\n she agreed to DNR. I made her explicitly aware that he will almost\n certainly die of his bleeding. She understood this. We will continue to\n transfuse 1uinit of pRBC per hour for now with 2 units of FFP, and 1u\n PLT. If this does not work after several more hours, we will discuss\n with Mrs. .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:08 PM\n 20 Gauge - 06:08 PM\n Arterial Line - 06:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Attending Addendum:\n Agree with the note above. Please see the event note for full details\n of discussion with the patient\ns wife re-.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:26 ------\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507236, "text": "TITLE: ICU event note:\n After discussions with the surgery consult attending: Dr. as\n described in his note, I spoke with the patients wife over the\n phone and explained to her that the patient continues to have massive\n exanguinating GI bleed in the second duodenum based on the EGD done\n last evening and that IR were able to identify the source of bleeding\n but unable to embolize it and that any surgical intervention at this\n time is associated with very high morbidity and mortality given his\n extensive comorbidities. Based on the above as well as the fact that\n the patient himself had discussed his wishes with his wife few days\n back to be DNR, I informed her that any medical therapy at this time\n including massive blood and blood products transfusion as well as\n vasopressor support will not be able to reverse the ongoing bleeding.\n She understands all what had been mentioned above and all her questions\n have been answered. She made the decision to proceed with CMO at this\n time. Therefore, orders have been entered to discontinue all treatments\n while starting a Morphing IV gtt and titrate to comfort.\n" }, { "category": "ECG", "chartdate": "2126-12-07 00:00:00.000", "description": "Report", "row_id": 243295, "text": "Atrial fibrillation with rapid ventricular response. Right bundle-branch\nblock. Prior inferior wall myocardial infarction. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112928, "text": " 2:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for signs of fluid overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with SOB and GIB, hx of CHF\n REASON FOR THIS EXAMINATION:\n eval for signs of fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with shortness of breath, GI bleed and history of\n CHF.\n\n COMPARISON: Chest radiograph .\n\n CHEST, AP UPRIGHT PORTABLE VIEW: Ill defined left basilar retrocardiac\n opacity is new from prior studies. There is no evidence of pulmonary edema.\n Cardiac silhoette is normal in size. Hilar contours are unchanged.\n Nasogastric tube has been placed. The tip extends beyond the inferior aspect\n of the study. The sternal closure wires are unchanged.\n\n IMPRESSION: Retrocardiac opacity may reflect atelectsis, infection or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1112955, "text": " 9:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line place\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with new trauma line\n REASON FOR THIS EXAMINATION:\n line place\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed seven hours earlier.\n\n Right IJ catheter tip is in the upper SVC. There is no pneumothorax. ET tube\n tip is in standard position, 6.4 cm above the carina. Cardiomediastinal\n silhouette is unchanged. There is worsening left lower lobe opacities,\n consistent with worsening atelectasis or worsening infection. There is no\n evidence of vascular congestion. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "MOD SEDATION, EACH ADDL 15 MIN.", "row_id": 1112957, "text": " 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ******************************* CPT Codes *****************************\n INITAL 2ND ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT \n -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT \n -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT \n -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT \n -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, FIRST 30 MIN. \n MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN \n MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN \n MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN \n MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN \n MOD SEDATION, EACH ADDL 15 MIN \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with massive duodenal bleed.\n REASON FOR THIS EXAMINATION:\n Can angio and embolization be performed for source control?\n ______________________________________________________________________________\n WET READ: AGLc SUN 1:44 AM\n angio showed active extravasation from GDA into 2nd portion of duodenum but\n unable to selectively cannulate GDA for embolization.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male presenting with melena, hypotension and hypoxia,\n found to have massive duodenal bleeding on ERCP. History of cholecystectomy,\n recent plastic biliary stent placement for biliary dilatation due to stones,\n with recent admission at outside hospital 1-2 weeks ago for upper GI bleeding,\n status post stent removal and cauterization at prior sphincterotomy site.\n\n COMPARISON: ERCP images are available from . Images from CT abdomen\n performed at Caritas on are also reviewed on\n PACS.\n\n PROCEDURES:\n 1. Celiac arteriogram.\n 2. Selective common hepatic arteriogram.\n 3. SMA arteriogram.\n\n OPERATORS: Dr. , radiology resident, and Dr. , the\n attending radiologist, who was present and participated throughout the\n procedure.\n\n MEDICATIONS: Moderate sedation was provided by administering divided doses of\n 100 mcg of fentanyl throughout the total intraservice time of 2 hours 45\n minutes, during which the patient's hemodynamic parameters were continuously\n monitored. The patient was also intubated, on propofol. 1% lidocaine was\n also administered for local anesthesia.\n\n (Over)\n\n 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS/PROCEDURE: After discussion of the nature, benefits, risks, and\n alternatives to the proposed procedure, informed consent was given by the\n patient's wife over the phone, which was witnessed by Dr. . The\n patient was then brought to the angiography suite and placed supine on the\n imaging table. The right groin was prepped and draped in the usual sterile\n fashion. Pre-procedural timeout confirmed the patient's identity using three\n patient identifiers, as well as the procedure to be performed.\n\n Using usual sterile technique, 1% lidocaine for local anesthesia, and\n palpatory and fluoroscopic guidance, the right common femoral artery was\n accessed using a 19-gauge needle. An 0.035 wire was then advanced\n through the needle into the abdominal aorta under fluoroscopic guidance. The\n needle was exchanged over the wire for a 5 French vascular sheath, which was\n then connected to a continuous saline sidearm flush. A 5 French C2 Cobra\n catheter was then advanced over the wire into the abdominal aorta. The\n wire was removed. The C2 catheter was then used to access the\n superior mesenteric artery. Arteriogram performed with power injector of the\n SMA in frontal and LAO projections showed no active bleeding.\n\n The C2 Cobra catheter was then dislodged from the SMA, and used to select the\n celiac trunk. Arteriogram of the celiac trunk showed no definite active\n extravasation. Subsequently, a Renegade microcatheter with 0.018 transcend\n wire was advanced through the C2 catheter to selectively cannulate the common\n hepatic artery. Arteriography through the microcatheter showed no active\n extravasation. The microcatheter was removed. Arteriography performed\n through the C2 catheter at the common hepatic artery showed opacification of\n the gastroduodenal artery (GDA), with active extravasation of contrast seen\n from this artery into the second portion of the duodenum.\n\n Based on both clinical and radiologic findings, decision was made to attempt\n cannulization and embolization of the gastroduodenal artery. However, due to\n the tortuous course of the celiac trunk and the angle at the origin of the\n GDA, multiple attempts (Transcend/Fathom wires) to cannulate the GDA were\n unsuccessful. Decision was then made to terminate the procedure and the\n surgical team notified. The wires, catheter, and sheath were then removed and\n hemostasis achieved by manual compression for 20 minutes. A sterile dressing\n was applied. The patient was noted to have continued melena during the\n procedure and was transfused with multiple blood products. Otherwise the\n patient tolerated the procedure without immediate complication.\n\n IMPRESSION:\n 1. Selective common hepatic arteriogram demonstrating active contrast\n extravasation from the gastroduodenal artery (GDA) into the second portion of\n the duodenum. Multiple attempts to gain selective access into the GDA were\n unsuccessful, therefore the procedure was terminated and the surgical team\n (Over)\n\n 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n notified immediately, including surgical attending Dr. .\n 2. SMA arteriogram demonstrating no active extravasation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1113118, "text": " 11:14 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP film form - scout only\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with GI bleeding\n REASON FOR THIS EXAMINATION:\n ERCP film form - scout only\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with GI bleeding.\n\n STUDY: Two fluoroscopic images from endoscopy.\n\n FINDINGS: An endogastric tube is noted coursing towards the stomach. Midline\n sternotomy wires are also noted. No endoscope is seen. Per the endoscopy\n report, there was massive GI bleeding. For more details, please see the\n endoscopy note in the online medical record.\n\n\n" } ]
63,646	180,860	Patient electively presented and underwent a left occipital craniotomy and resection of mass on . Surgery was without complication and he tolerated it well. He was extubated and transferred to the ICU. Post op Head CT on revealed expected post-operative changes with no evidence of hemorrhage. Patient's diet was advanced and foley removed. He was started on subcutaneous heparin for DVT prophylaxis. Mr. was subsequently transferred to the floor in stable condition. Head MRI on demonstrated post-operative changes with pneumocephalus of left frontal lobe, mild enhancement in upper surgical bed which could represent residual tumor, and post-op cytotoxic edema vs. infarct. Patient will follow up in brain tumor clinic on for re-evaluation, particularly given possible residual tumor post-operatively. He was discharged with prescriptions for keppra 1000mg , dexamethasone taper (4mg TID x1 day -> 4mg BIDx1 day -> 4mg daily until brain tumor clinic follow up), oxycodone, tylenol, and colace. Home ASA was discontinued for now given no absolute need for med (stents etc) and risk of bleeding. ============================ TRANSITION OF CARE: 1. Please consider restarting home ASA 81mg at next follow-up if appropriate Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Dexamethasone 4 mg PO DAILY 2. Doxazosin 2 mg PO HS 3. Lorazepam 0.5 mg PO HS 4. Paroxetine 20 mg PO DAILY 5. Simvastatin 10 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Aspirin 81 mg PO DAILY 8. Cetirizine NF 10 mg Oral qday 9. codeine-guaifenesin NF 10-100 mg/5 mL Oral unknown Discharge Medications: 1. Dexamethasone 4 mg PO BID Duration: 1 Days Please follow up at Brain Clinic to determine future steroid dosing. RX dexamethasone 2 mg 2 Tablet(s) by mouth tapered dose Disp #40 Tablet Refills:0 2. Dexamethasone 4 mg PO daily Duration: 9 Days Start: After 4 mg tapered dose. Please follow up at Brain Clinic to determine future steroid dosing. 3. Doxazosin 2 mg PO HS 4. Simvastatin 10 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. LeVETiracetam 1000 mg PO BID RX Keppra 1,000 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 Tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:0 8. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 Capsule(s) by mouth twice a day Disp #60 Tablet Refills:0 9. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain RX acetaminophen 325 mg Tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 10. Cetirizine NF* 10 mg Oral qday 11. codeine-guaifenesin NF 10-100 mg/5 mL Oral unknown 12. Lorazepam 0.5 mg PO HS 13. Paroxetine 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: left occipital mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Craniotomy for Tumor Excision Dr. ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????You have nylon sutures you may wash your hair and get your incision wet day 7 after surgery. You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ??????If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. We made the following changes to your medications: 1. STOPPED aspirin (increases risk of bleeding - please discuss whether to restart this at your brain tumor clinic follow up) 2. INCREASED dexamethasone to 4mg three times daily for today (), then two times daily tomorrow (), then back to once daily ( until brain tumor clinic follow up) 3. STARTED levetericetam (Keppra) 1000mg twice daily (to prevent seizures) 3. STARTED oxycodone 5mg every 6 hours as needed for pain 4. STARTED acetaminophen (tylenol) 325-650mg every 6 hours as needed for pain 5. STARTED docusate (colace) 100mg twice daily as needed for constipation Followup Instructions: ??????You have an appointment in the Brain Clinic on @ 9:30AM. The Brain Clinic is located on the of , in the Building, . Their phone number is . Please call if you need to change your appointment, or require additional directions.	FINDINGS: The patient is status post left parieto-occipital craniotomy. FINDINGS: The patient is status post left parieto-occipital craniotomy. A small amount of vasogenic edema in the left occipital lobe is similar to MRI . Small extra-axial hematoma is noted adjacent to the surgical bed. Area of pneumocephalus layering along the left frontal lobe appears similar to the CT of . Pneumocephalus layering along the left frontal lobe similar to the prior examination. COMPARISON: MRI and . There is mild enhancement along the anterior aspect of the surgical bed, which may suggest residual tumor, attention on followup imaging is recommended. Slow diffusion along the periphery of the surgical bed may suggest post-op cytotoxic edema versus infarct. FINDINGS: A 2.1-cm transverse x 1.6 cm AP x 1.7 cm CC enhancing lesion within the left occipital lobe with broad-based dural attachment appears most consistent with meningioma (3:11 and 100A:75). IMPRESSION: Expected post-surgical changes after resection of left occipital lesion. Slow diffusion is noted along the periphery of the surgical bed, which may represent post-op cytotoxic edema versus infarct (series 9, image 14). Following the administration of IV contrast, axial T1 images were obtained. A small amount of hyperdense blood is seen in the surgical bed with small pneumocephalus in the left frontal lobe and left occipital lobe. IMPRESSION: 2.1 x 1.6 x 1.7-cm lesion with broad-based dural enhancing lesion with broad-based dural tail within the left occipital lobe appears most consistent with meningioma. Mild enhancement in the upper surgical bed may represent residual tumor. Evaluate for post-operative change and residual lesion. TECHNIQUE: MRI of the brain was obtained with and without the administration of IV contrast. TECHNIQUE: Non-contrast MDCT axial images were acquired through the head. COMPARISON: Outside hospital MRI of the head . Post-surgical changes after resection of left occipital lesion with blood products noted within the surgical bed as well as adjacent extra-axial hematoma and mild adjacent soft tissue hematoma. TECHNIQUE: MRI of the brain was obtained with the administration of IV contrast. COMPARISON: MRI of the brain with contrast . Blood products and hematoma is noted within the adjacent scalp. T1- and T2-hyperintense material within the surgical bed shows blooming on susceptibility images consistent with blood products within the surgical bed. (Over) 8:38 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change and residual lesion Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA Contrast: GADAVIST Amt: 7 FINAL REPORT (Cont) Sagittal T1, axial T1, axial FLAIR, axial T2 and axial susceptibility weighted images were obtained without the administration of IV contrast. Dense atherosclerotic calcifications are seen in the intracranial vertebral arteries. Bilateral mastoid air cells and visualized paranasal sinuses are clear. 8:38 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change and residual lesion Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA Contrast: GADAVIST Amt: 7 MEDICAL CONDITION: 59 year old man with left occipital lesion s/p resection REASON FOR THIS EXAMINATION: evalaute for post-op change and residual lesion No contraindications for IV contrast FINAL REPORT INDICATION: 59-year-old man with left occipital lesion status post resection. Attention to these areas on followup imaging is recommended. The ventricles and sulci appear normal in size and configuration. Ventricles and sulci are normal in size and symmetric in configuration. -white matter differentiation elsewhere is preserved. Evaluate for postoperative change. The visualized paranasal sinuses and mastoid air cells are clear. Diffusion-weighted and ADC maps were generated and reviewed. Basal cisterns are patent. Please obtain between 1430 and 1530 No contraindications for IV contrast FINAL REPORT CLINICAL HISTORY: 59-year-old man with left occipital lesion status post resection. 5:14 AM MR HEAD W/ CONTRAST Clip # Reason: pre-surgical mapping Contrast: GADAVIST Amt: 7 MEDICAL CONDITION: 59 year old man with left occipital tumor REASON FOR THIS EXAMINATION: pre-surgical mapping No contraindications for IV contrast FINAL REPORT INDICATION: 59-year-old man with left occipital tumor for pre-surgical mapping. Please obtain between 14 Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA MEDICAL CONDITION: 59 year old man with left occipital lesion s/p resection REASON FOR THIS EXAMINATION: evalaute for post-operative change. IMPRESSION: 1. 3:05 PM CT HEAD W/O CONTRAST Clip # Reason: evalaute for post-operative change.	3	[ { "category": "Radiology", "chartdate": "2177-05-29 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1246003, "text": " 5:14 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital tumor\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with left occipital tumor for pre-surgical\n mapping.\n\n COMPARISON: Outside hospital MRI of the head .\n\n TECHNIQUE: MRI of the brain was obtained with the administration of IV\n contrast.\n\n FINDINGS: A 2.1-cm transverse x 1.6 cm AP x 1.7 cm CC enhancing lesion within\n the left occipital lobe with broad-based dural attachment appears most\n consistent with meningioma (3:11 and 100A:75). No other enhancing foci are\n identified. The ventricles and sulci appear normal in size and configuration.\n There is no evidence of acute major vascular territory infarction. There are\n no foci of acute hemorrhage.\n\n Bilateral mastoid air cells and visualized paranasal sinuses are clear.\n\n IMPRESSION: 2.1 x 1.6 x 1.7-cm lesion with broad-based dural enhancing lesion\n with broad-based dural tail within the left occipital lobe appears most\n consistent with meningioma.\n\n" }, { "category": "Radiology", "chartdate": "2177-05-30 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1246172, "text": " 8:38 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change and residual lesion\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital lesion s/p resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change and residual lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with left occipital lesion status post resection.\n Evaluate for post-operative change and residual lesion.\n\n COMPARISON: MRI of the brain with contrast .\n\n TECHNIQUE: MRI of the brain was obtained with and without the administration\n of IV contrast. Sagittal T1, axial T1, axial FLAIR, axial T2 and axial\n susceptibility weighted images were obtained without the administration of IV\n contrast. Following the administration of IV contrast, axial T1 images were\n obtained. Diffusion-weighted and ADC maps were generated and reviewed.\n\n FINDINGS: The patient is status post left parieto-occipital craniotomy.\n Small extra-axial hematoma is noted adjacent to the surgical bed. Blood\n products and hematoma is noted within the adjacent scalp. T1- and\n T2-hyperintense material within the surgical bed shows blooming on\n susceptibility images consistent with blood products within the surgical bed.\n Area of pneumocephalus layering along the left frontal lobe appears similar to\n the CT of .\n\n There is mild enhancement along the anterior aspect of the surgical bed, which\n may suggest residual tumor, attention on followup imaging is recommended.\n Slow diffusion is noted along the periphery of the surgical bed, which may\n represent post-op cytotoxic edema versus infarct (series 9, image 14).\n\n IMPRESSION:\n\n 1. Post-surgical changes after resection of left occipital lesion with blood\n products noted within the surgical bed as well as adjacent extra-axial\n hematoma and mild adjacent soft tissue hematoma. Pneumocephalus layering\n along the left frontal lobe similar to the prior examination.\n\n 2. Mild enhancement in the upper surgical bed may represent residual tumor.\n\n 3. Slow diffusion along the periphery of the surgical bed may suggest post-op\n cytotoxic edema versus infarct. Attention to these areas on followup imaging\n is recommended.\n (Over)\n\n 8:38 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change and residual lesion\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2177-05-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1246079, "text": " 3:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalaute for post-operative change. Please obtain between 14\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital lesion s/p resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-operative change. Please obtain between 1430 and 1530\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 59-year-old man with left occipital lesion status post\n resection. Evaluate for postoperative change.\n\n COMPARISON: MRI and .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired through the head.\n\n FINDINGS: The patient is status post left parieto-occipital craniotomy. A\n small amount of hyperdense blood is seen in the surgical bed with small\n pneumocephalus in the left frontal lobe and left occipital lobe. There is no\n large hemorrhage or major vascular territorial infarct. A small amount of\n vasogenic edema in the left occipital lobe is similar to MRI .\n -white matter differentiation elsewhere is preserved. Ventricles and sulci\n are normal in size and symmetric in configuration. Basal cisterns are patent.\n There is no shift of normally midline structures. The visualized paranasal\n sinuses and mastoid air cells are clear. Dense atherosclerotic calcifications\n are seen in the intracranial vertebral arteries.\n\n IMPRESSION: Expected post-surgical changes after resection of left occipital\n lesion.\n\n" } ]
31,829	174,216	74M admitted with left side facial swelling. . 1. Facial swelling/angioedema: Patient admitted to ICU for monitoring. Ace inhibitor held-suspected offending . No shellfish etc. (Patient had similar episode in past with shellfish) Treated with benadryl, famotidine. Patient received tow doses of decadron as well. Patient had rpaid improvement in his swelling and angioedema. Decadron discontinued given recent right TKR and concern for septic joint. C1 and C4 complement levels sent. ENT consulted-no evidence of airway compromise. Discharged on 5 days of famotidine/benadryl. Allergy f/u with Dr. scheduled for patient. . 2 Acute renal failure - baseline 1.1, admit 1.3, likely dehydration. Resolved with IVF's. . 3) Right TKR: 2 weeks post replacement. Followed by ortho throughout. Staples removed. Ortho did not feel knee was infected. PT evaluated patient. Lovenox x 10 more days then apsirin as per ortho. F/u with Dr. scheduled. 4)HTN - continued home amlodipine. Ace inhibitor discontinued. Amlodipine titrated to 10mg from 5mg --bp generally well controlled 120's to 130's on amlodipine alone. 5) hyperlipidemia - continued statin. . 6)DM - HISS while inpt, restarted metformin upon discharge. . #PPx - lovenox 40 sc q24 given knee replacement. - bowel regimen not necessary given recent loose bm's in setting of colace. . . #COMM: wife , , sign language interpreter pager .	#DISPO - pending clinical improvement . #DISPO - pending clinical improvement . - f/u C1, C4 - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. Agree with pulse steroids x 3doses, benadryl, zantac. Agree with pulse steroids x 3doses, benadryl, zantac. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. - ENT consult to evaluate airway given ?dysphagia. - ENT consult to evaluate airway given ?dysphagia. - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. #FEN - liquids for now, pending ENT evaluation, then ok to advance. #FEN - liquids for now, pending ENT evaluation, then ok to advance. d/c lisinopril. d/c lisinopril. Tx with solumedrol, filodipine, benadry. Tx with solumedrol, filodipine, benadry. #HTN - continue home amlodipine. #HTN - continue home amlodipine. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # ARF - baseline 1.1, now 1.3, likely dehydration. # ARF - baseline 1.1, now 1.3, likely dehydration. - hydrate with 1L IVF today, encourage PO hydration (pt thirsty) - repeat chem7 in AM. - hydrate with 1L IVF today, encourage PO hydration (pt thirsty) - repeat chem7 in AM. Ortho saw patient, plan to remove staples soon. Lisinopril d/c'd. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 11:30 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: - follow knee exam- appreciate ortho rec will hold off on empiric steroids for now given risk of infection #HTN - continue home amlodipine. - consider allergy consult if not improving. - consider allergy consult if not improving. Action: HO in to assess Response: Per ortho, reluctant to give steroids (post knee)..however with ?increase swelling. # hyperlipid - continue statin. # hyperlipid - continue statin. # hyperlipid - continue statin. Andioedema likley from ACE. - continue home ferrous sulfate. - continue home ferrous sulfate. - continue home ferrous sulfate. #DM - - switch to HISS while inpt, restart metformin upon discharge. #DM - - switch to HISS while inpt, restart metformin upon discharge. #DM - - switch to HISS while inpt, restart metformin upon discharge. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. glaucoma s/p R TKR revision , ( MVA) deafness meningitis no h/o angioedema.	19	[ { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 319299, "text": "Chief Complaint: Facial swelling\n 24 Hour Events:\n - steroids d/c'd per ortho, however, developed increased swelling and\n pain with swallowing so restarted\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: minimal pain with swallowing, improved swelling of\n lips\n Gastrointestinal: Diarrhea, day beofre yesterday\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 87 (65 - 93) bpm\n BP: 158/73(90) {139/56(77) - 160/77(97)} mmHg\n RR: 24 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 74 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 74 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -626 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, lips swollen but improved\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: Systolic), II/VI SEM\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, deaf, reads lips\n Labs / Radiology\n 690 K/uL\n 9.5 g/dL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74M admitted with left side facial swelling.\n .\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation.\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - add on serum tryptase (if positive, suggests allergic component).\n - consisder adding on c1, c4 complement levels, though would be send\n outs, however this is is second episode of this type of event.\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids x 24hrs (decadron 10mg q8hr x3 dose)then would switch to\n po steroids for rapid taper (or d/c altogether).\n - ENT consult to evaluate airway given ?dysphagia.\n - consider allergy consult if not improving.\n .\n .\n # ARF - baseline 1.1, now 1.3, likely dehydration.\n - hydrate with 1L IVF today, encourage PO hydration (pt thirsty)\n - repeat chem7 in AM.\n .\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaic stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type event, will hydrate and\n follow in AM.\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n .\n #HTN - continue home amlodipine.\n - add BB or HCTZ if additional control needed.\n .\n # hyperlipid - continue statin.\n .\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge.\n .\n #FEN\n - liquids for now, pending ENT evaluation, then ok to advance.\n - encourage po hydration, no need for IVF.\n .\n #PPx\n - lovenox 40 sc q24 given knee replacement.\n - bowel regimen not necessary given recent loose bm's in setting of\n colace.\n .\n #CODE: FULL\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319302, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319303, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent &\n per ortho pt should not receive steroids.\n" }, { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 319306, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n events noted, received additional dose of decadron yesterday for voice\n change. no stridor at any time.\n subjectively improved lip swelling and voice this am.\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.5\nC (97.7\n HR: 73 (65 - 93) bpm\n BP: 143/62(82) {139/56(77) - 160/77(97)} mmHg\n RR: 17 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 578 mL\n PO:\n 480 mL\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 98 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), no stridor\n Extremities: Right: 1+, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 690 K/uL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible, less likely LMWH. No new foods.\n 1. Andioedema\n likley from ACE. no signs of stridor. Lisinopril d/c'd.\n better with two doses of steroids, benadryl, zantac. Stable.\n 2. S/p right knee surgery - warm to touch, thrombocytosis improved, no\n signs of infection. Ortho saw patient, plan to remove staples soon.\n 3. DM - watch glc with SS and continue metformin\n 4. HTN\n will initiate HCTZ\n Stable to be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 319309, "text": "Chief Complaint: Facial swelling\n 24 Hour Events:\n - steroids d/c'd per ortho, however, developed increased swelling and\n pain with swallowing so given one time dose 4mg decadron IV\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: minimal pain with swallowing, improved swelling of\n lips\n Gastrointestinal: Diarrhea, day beofre yesterday\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 87 (65 - 93) bpm\n BP: 158/73(90) {139/56(77) - 160/77(97)} mmHg\n RR: 24 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 74 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 74 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -626 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, lips swollen but improved\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: Systolic), II/VI SEM\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, deaf, reads lips\n Labs / Radiology\n 690 K/uL\n 9.5 g/dL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74M admitted with left side facial swelling.\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation. Most\n likely culprit ACEI, have d/c\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - f/u C1, C4\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids d/c\nd per ortho for risk of infection, can dose prn for\n symptoms of increased swelling or respiratory compromise\n - ENT consult appreciated\n - consider allergy consult if not improving, should probably arrange\n outpt allergy f/u\n # ARF - baseline 1.1, 1.3 on admission, likely dehydration. Now below\n baseline with fluids.\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaiac stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - overnight drop in HCT likely dilutional\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type eventv recent surgery,\n hydrated and significantly improved this am\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam- appreciate ortho rec\n will hold off on empiric\n steroids for now given risk of infection\n #HTN - continue home amlodipine.\n - will double dose of amlodipine in absence of ACE I\n - can add BB or HCTZ if additional control needed.\n # hyperlipid - continue statin.\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge. .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319316, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 319221, "text": "Chief Complaint: left lower lip, cheek swelling\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 74 yr old male, left lower lip and cheek swelling\n On ACE for 5 yrs. No known new exposure.\n have had similar symptoms a few years ago attributed to shrimp.\n Per wife, lip became more swollen. In ED, sat 100% on RA. Tx with\n solumedrol, filodipine, benadry. Swelling progressed to right lip. No\n stridor at any time. Transferred for close monitoring.\n Patient admitted from: ER\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. DM\n 2. HTN\n 3. deafness d/t meningitis as child\n 4. Anemia\n 5. Prostate ca s/p radiacal prostatectomy\n 6. glaucoma\n 7 hyperlipidemia\n 8. TKR, revision (osteo of right knee d/t MVA 95)\n MEDS PTA\n simvastatin, Fe, amlodipine, lisinopril, lovenox q24h since knee ,\n metformin, tylenol, oxycodone (not taking)\n No angioedema\n Occupation: retired, worked at polaroid\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Nausea, Diarrhea, loose stools yesterday\n attributed to colace and dairy\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 02:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Marked edema of lower lip and left upper lip, edema\n of left cheek, no tongue swelling\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), No stridor\n Extremities: Right: Absent, Left: Absent, right knee warm to touch, no\n erythema, no fluctuance, no drainage\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, deaf, phonates, communicates in sign\n language\n Labs / Radiology\n 825\n 33.2\n 109\n 1.3\n 22\n 4.5\n 7.3\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2\n Fluid analysis / Other labs: Plat were 400 during last admission.\n Wbc Diff: eos 2.6\n Creat baseline 1.1\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible. No new foods.\n 1. Andioedema - no signs of stridor. d/c lisinopril. Agree with pulse\n steroids x 3doses, benadryl, zantac.\n 2. S/p right knee surgery - warm to touch, thrombocytosis but no other\n signs of infection. Will touch base with ortho.\n 3. DM - watch glc with SS and continue metformin\n 4. Code status - full code\n If needed, can be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 319222, "text": "Chief Complaint: left lower lip, cheek swelling\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 74 yr old male, left lower lip and cheek swelling\n On ACE for 5 yrs. No known new exposure.\n have had similar symptoms a few years ago attributed to shrimp.\n Per wife, lip became more swollen. In ED, sat 100% on RA. Tx with\n solumedrol, filodipine, benadry. Swelling progressed to right lip. No\n stridor at any time. Transferred for close monitoring.\n Patient admitted from: ER\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. DM\n 2. HTN\n 3. deafness d/t meningitis as child\n 4. Anemia\n 5. Prostate ca s/p radiacal prostatectomy\n 6. glaucoma\n 7 hyperlipidemia\n 8. TKR, revision (osteo of right knee d/t MVA 95)\n MEDS PTA\n simvastatin, Fe, amlodipine, lisinopril, lovenox q24h since knee ,\n metformin, tylenol, oxycodone (not taking)\n No angioedema\n Occupation: retired, worked at polaroid\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Nausea, Diarrhea, loose stools yesterday\n attributed to colace and dairy\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 02:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Marked edema of lower lip and left upper lip, edema\n of left cheek, no tongue swelling\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), No stridor\n Extremities: Right: Absent, Left: Absent, right knee warm to touch, no\n erythema, no fluctuance, no drainage\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, deaf, phonates, communicates in sign\n language\n Labs / Radiology\n 825\n 33.2\n 109\n 1.3\n 22\n 4.5\n 7.3\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2\n Fluid analysis / Other labs: Plat were 400 during last admission.\n Wbc Diff: eos 2.6\n Creat baseline 1.1\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible. No new foods.\n 1. Andioedema - no signs of stridor. d/c lisinopril. Agree with pulse\n steroids x 3doses, benadryl, zantac.\n 2. S/p right knee surgery - warm to touch, thrombocytosis but no other\n signs of infection. Will touch base with ortho.\n 3. DM - watch glc with SS and continue metformin\n 4. Code status - full code\n If needed, can be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 319223, "text": "Chief Complaint: facial swelling\n HPI:\n 74 M h/o DM2, HTN, deaf presents to ED after awakening at 6:45AM with\n left lower lip and cheek swelling. no cp/sob/difficulty swallowing at\n that time, no urticara, pruritis. no recent medications changes (on\n ace-i x 5y), trauma, insect bite, food changes, detergent changes.\n similar type episode in after eating shrimp, though not as\n severe, and resolved within 1-2hrs. per wife, swelling this am\n progressed over minutes, so brought pt to ED. last took lisinopril at\n 10AM .\n .\n Upon arrival to ED 98.5 71 15/55 18 100%RA, pt given solumedrol\n 125mg iv x 1, famotidine 20mg iv x1, benadryl 25mg iv x1 at 0850AM,\n however swelling continued to progress, involving right lower lip, left\n upper lip, and worsening of left cheek swelling. again no cp, sob,\n stridor, though now admits to some difficulty swallowing. Admitted to\n for closer monitoring.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend, Interpreter\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n simvastatin 40 mg po qdaily, ferrous sulfate 325mg po qdaily,\n amlodipine 5mg po qdaily, lisinopril 40mg po qdaily, lovenox 40mcg sc\n qdaily, metformin 500mg po bid.\n Past medical history:\n Family history:\n Social History:\n DM2\n HTN\n hyperlipidemia\n anemia\n prostate ca - dx , s/p radical prostatectomy, no chemo/xrt.\n glaucoma\n s/p R TKR revision , ( MVA)\n deafness meningitis\n no h/o angioedema.\n Occupation: retired polaroid factory worker\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Diarrhea\n Neurologic: Numbness / tingling\n Flowsheet Data as of 02:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, right knee wound c/d/i\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 74M admitted with left side facial swelling.\n .\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation.\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - add on serum tryptase (if positive, suggests allergic component).\n - consisder adding on c1, c4 complement levels, though would be send\n outs, however this is is second episode of this type of event.\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids x 24hrs (decadron 10mg q8hr x3 dose)then would switch to\n po steroids for rapid taper (or d/c altogether).\n - ENT consult to evaluate airway given ?dysphagia.\n - consider allergy consult if not improving.\n .\n .\n # ARF - baseline 1.1, now 1.3, likely dehydration.\n - hydrate with 1L IVF today, encourage PO hydration (pt thirsty)\n - repeat chem7 in AM.\n .\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaic stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type event, will hydrate and\n follow in AM.\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n .\n #HTN - continue home amlodipine.\n - add BB or HCTZ if additional control needed.\n .\n # hyperlipid - continue statin.\n .\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge.\n .\n #FEN\n - liquids for now, pending ENT evaluation, then ok to advance.\n - encourage po hydration, no need for IVF.\n .\n #PPx\n - lovenox 40 sc q24 given knee replacement.\n - bowel regimen not necessary given recent loose bm's in setting of\n colace.\n .\n #CODE: FULL\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319280, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with benedryl IV, neg stridor, denies SOB,\n maintaining sats on RA w/o difficulty\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho, ?call out with continued improvement\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R , staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches at home\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, denies knee pain\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319275, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with benedryl IV, neg stridor, denies SOB,\n maintaining sats on RA w/o difficulty\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho, ?call out with continued improvement\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R , staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches at home\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, denies knee pain\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319338, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN 406\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319260, "text": " Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with standing and prn benedryl IV\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R TKR, staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, response unknown\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319328, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN $06\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319329, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN 406\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319319, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to normal\n" }, { "category": "Nursing", "chartdate": "2200-04-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319253, "text": "74 y/o man with hx of diabetes, htn and deafness, admitted to ICU from\n EW with lip and cheek swelling. Pt woke up early this am with tingling\n and numbness of lips. Given steroids and benadryl in EW and sent to ICU\n for further observation. Pt is also 2 weeks post TRK, still left with\n sutures.\n Problem - Description In Comments\n Assessment:\n Pt admitted with swollen upper lip and puffy left cheek. Over course of\n afternoon, decreased, felt better per pt. By 1800 pt and wife feel\n upper lip is more swollen, by visual..is slightly bigger. No airway\n involvement..Pt is able to eat and drink. Requires no o2.\n Action:\n HO in to assess\n Response:\n Per ortho, reluctant to give steroids (post knee)..however with\n ?increase swelling.\n Plan:\n To get x1 dose of dexa methasone\nContinue to monitor lips and cheek\n swellingl\n Impaired Physical Mobility\n Assessment:\n 2 week post TRK..sutures in. Slight swelling of knee. Per pt and wife,\n knee is much better, Denies pain at this time\n Action:\n Ortho by and assessed pt\n Response:\n To keep sutures in at this time..\n Plan:\n Continue to follow\n .H/O meningitis, other\n Assessment:\n Pt is totally deaf..at age 8 had meningitis.\n Action:\n Use of sign language interpretors..schedule posted in room and on\n chart.\n Response:\n Pt less anxious\n Plan:\n As above..Also speak TO pt so he can see our lips. He is able to lip\n read..\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319317, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319318, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n" } ]
64,195	141,264	HOSPITAL COURSE: This is a 58 year old gentleman with a history of recurrent syncope and systolic heart failure (EF 35%) who presented to the ED for pre-syncope w/u and was observed to have a tonic clonic seizure with combative post-ictal state who was intubated for airway protection. . ACTIVE ISSUES: # Seizure: Pt had generalized tonic clonic seizure in ED, most likely withdrawal seizure in setting of EtOH abstinence x2 days and polysubstance abuse (UTox positive for cocaine). Resolved after 5 minutes without any benzodiazepimes. CT head without acute findings. No prior seizure history but has h/o several recent unwitnessed syncopal episodes in setting of EtOH cessation. Patient received one dose of ativan 4mg IV for agitation while still intubated in MICU; after extubation he did not require more ativan over next few hours. He was followed by neurology who initially recommended MRI, EEG and Keppra but retracted these recs once more clear that this was EtOH withdrawal seizure. Patient was continued on CIWA with ativan (can switch to Valium on floor given normal liver synthetic function and fatty liver but no obvious cirrhosis on RUQ ultrasound). He did not require any benzodiazepines on HD2 and he was discharged home. . # Syncope: H/o recurrent pre-syncopal/syncopal events in past year which have all occured in setting of etoh cessation. Some of the events have been witnessed but no evidence of tonic clonic activity during the past, no episodes of blacking out, no loss of bladder control, never had tongue bite or incontinence, or confusion post episode. He was seen in the outpt setting by Neurology who felt his sx were not c/w seizure and ordered a CT scan of his which was unremarkable. Recently had extensive w/u at hospital including TTE and of Hearts which revealed cardiomyopathy and no evidence of malignant arryhthmia. He is followed by both neurology and cardiology at who feel sx c/w likely vasovagal. A follow-up TTE with Valsalva maneuver was negative for a left ventricular outflow tract obstruction. . # EtOH/polysubstance abuse, elevated LFTs: Long h/o EtOH abuse, per wife cut down considerably in recent years w/ recent effort at abstience. Etoh level 0 on arrival, UTox positive for cocaine. Last drink felt to be 2 days ago. LFTs elevated in 2:1 ratio consistent with EtOH hepatitis. Liver synthetic function intact. RUQ ultrasound showed fatty liver, no nodularity. Patient received banana bag in ICU, to be followed by PO folate/MV and 3 days of thiamine 500mg IV BID (given altered mental status which could represent Wernicke's encephalopathy). He was discharged on HD with oral thiamine replacement. . # Coronary Artery Disease: Systolic Heart Failure: Most recent TTE demonstrates global sysolic dysfunction w/ apical hypokinesis and EF 35%. Etiology felt to be multivessel disease versus cardiomyopathy of etoh. Given positive cocaine on UTox, also should consider cocaine cardiomyopathy. In the MICU his home ASA, lisinopril, crestor and metoprolol were continued. He is scheduled for outpatient cards f/u with Dr. on but wife requested earlier f/u if possible given pt noncompliance with appts. Dr. has arranged for cardiac cath in the following 2 weeks. The cath lab will call Mr. with formalized schueduling. The patient was encouraged to follow-up with all his appointments to demonstrate improved compliance. At this time, he was not a candidate for PCI give concern that he would not be faithful to plavix and aspirin. . # Airway Protection: Intubated for airway protection in setting of post-ictal combativeness. In the MICU he received ativan for agitation due to EtOH withdrawal, and was then extubated to room air without further issues, good oxygen sats. . # Memory loss: family reports patient has had progressive memory loss over several years. They reportedly have to leave Post-It notes around the house to remind him to do things. His head CT showed ventricular enlargement worse than expected for his age. Could have Korsakoff psychosis EtOH abuse vs. other form of dementia. Receiving IV thiamine, will need outpatient workup. . # Hypertension: Longstanding hypertension. Wife reports baseline BPs in 180s/80s and previously over 200 systolic. Continued home lisinopril and amlodipine. . # Depression: Stable per wife. Continued home trazodone and sertraline. . TRANSITIONAL ISSUES: - pending labs: blood cx x 2 pending - follow-up: PCP and cardiology - code: full - contact: wife	Stable appearance in comparison to the prior study with no acute intracranial process identified. Sinus rhythm with non-diagnostic repolarization abnormalities. The aorta is of normal caliber but is only partially visualized. The lungs are otherwise without a focal consolidation, pleural effusion, or pneumothorax. The intrahepatic portion of the IVC is unremarkable. Mild left baislar atelectasis. Moderate cardiomegaly. Compared to the previous tracingthere is no significant change.TRACING #2 No biliary dilatation is seen and the common duct measures 0.2 cm. Mild age-inappropriate prominence of the sulci is stable. No acute fractures are identified. Again identified is age-inappropriate prominence of sulci and ventricles. Cardiomediastinal silhouette appears moderately enlarged. No evidence of acute intracranial injury. Compared to the previous tracing there is no diagnostic change.TRACING #3 No previoustracing available for comparison.TRACING #1 The gallbladder is normal. The spleen is unremarkable measuring 10.2 cm. Mild mucosal thickening is noted in the ethmoidal and right maxillary sinuses. No focal liver lesion is identified. FINDINGS: There is no evidence of acute hemorrhage, edema, large vessel territorial infarction, shift of normally midline structures. No hydronephrosis is seen. No ascites is seen in the abdomen. The pancreas is unremarkable, but is only minimally visualized due to overlying bowel gas. Lung volumes are low. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Sinus rhythm with first degree atrio-ventricular conduction delay andnon-diagnostic repolarization abnormalities. COMPARISON: CT head from . COMPARISON: None available. Sinus rhythm. The portal vein is patent with hepatopetal flow. IMPRESSION: 1. IMPRESSION: 1. COMPARISON: No previous exam for comparison. The ventricles and sulci again appear prominent for the patient's age, but stable. -white matter differentiation appears well preserved. FINDINGS: The liver is diffusely echogenic consistent with fatty infiltration. WET READ VERSION #1 FINAL REPORT INDICATION: New seizure. Retraction by 2.0 cm is recommended. 5:06 AM CHEST (PORTABLE AP) Clip # Reason: please eval for tube placement MEDICAL CONDITION: History: 59M now intubated REASON FOR THIS EXAMINATION: please eval for tube placement No contraindications for IV contrast FINAL REPORT INDICATION: Endotracheal tube placement. FINDINGS: Endotracheal tube is in the lower trachea near the carina. IMPRESSION: Echogenic liver consistent with fatty infiltration. 11:35 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: Cirrhosis? The right kidney measures 12.5 cm and the left kidney measures 12.4 cm. 5:09 AM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for intracranial process MEDICAL CONDITION: History: 59M with new onset seizures REASON FOR THIS EXAMINATION: please evaluate for intracranial process No contraindications for IV contrast WET READ: 5:58 AM 1. 2. 2. 2. Endotracheal tube appears in the lower trachea near the carina. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. An enteric tube traverses through the stomach. If clinical suspicion for an acute infarction is high, MR is the recommended study of choice. Multiplanar reformatted images were prepared and reviewed. If clinical suspicion for an acute infarction is high, MRI is the recommended study of choice. FINAL REPORT INDICATION: 59-year-old man with history of ETOH abuse, withdrawal seizure, possible cirrhosis.	6	[ { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244337, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M now intubated\n REASON FOR THIS EXAMINATION:\n please eval for tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement.\n\n COMPARISON: None available.\n\n FINDINGS: Endotracheal tube is in the lower trachea near the carina. An\n enteric tube traverses through the stomach. Lung volumes are low. Mild left\n baislar atelectasis. The lungs are otherwise without a focal consolidation,\n pleural effusion, or pneumothorax. Cardiomediastinal silhouette appears\n moderately enlarged.\n\n IMPRESSION:\n 1. Endotracheal tube appears in the lower trachea near the carina. Retraction\n by 2.0 cm is recommended.\n 2. Moderate cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1244338, "text": " 5:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M with new onset seizures\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:58 AM\n 1. No evidence of acute intracranial injury. If clinical suspicion for an\n acute infarction is high, MRI is the recommended study of choice.\n 2. Mild age-inappropriate prominence of the sulci is stable.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New seizure.\n\n COMPARISON: CT head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared and\n reviewed.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, large vessel\n territorial infarction, shift of normally midline structures. The ventricles\n and sulci again appear prominent for the patient's age, but stable.\n -white matter differentiation appears well preserved. No acute fractures\n are identified. Mild mucosal thickening is noted in the ethmoidal and right\n maxillary sinuses.\n\n IMPRESSION:\n 1. Stable appearance in comparison to the prior study with no acute\n intracranial process identified. If clinical suspicion for an acute\n infarction is high, MR is the recommended study of choice.\n 2. Again identified is age-inappropriate prominence of sulci and ventricles.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1244374, "text": " 11:35 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Cirrhosis?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o EtOH abuse, admitted for withdrawal seizure, question\n whether has cirrhosis\n REASON FOR THIS EXAMINATION:\n Cirrhosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with history of ETOH abuse, withdrawal seizure,\n possible cirrhosis.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The liver is diffusely echogenic consistent with fatty\n infiltration. No focal liver lesion is identified. No biliary dilatation is\n seen and the common duct measures 0.2 cm. The portal vein is patent with\n hepatopetal flow. The gallbladder is normal. The pancreas is unremarkable,\n but is only minimally visualized due to overlying bowel gas. The aorta is of\n normal caliber but is only partially visualized. The intrahepatic portion of\n the IVC is unremarkable. No hydronephrosis is seen. The right kidney\n measures 12.5 cm and the left kidney measures 12.4 cm. The spleen is\n unremarkable measuring 10.2 cm. No ascites is seen in the abdomen.\n\n IMPRESSION: Echogenic liver consistent with fatty infiltration. Other forms\n of liver disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232693, "text": "Sinus rhythm. Compared to the previous tracing there is no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232694, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay and\nnon-diagnostic repolarization abnormalities. Compared to the previous tracing\nthere is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232695, "text": "Sinus rhythm with non-diagnostic repolarization abnormalities. No previous\ntracing available for comparison.\nTRACING #1\n\n" } ]
89,992	185,262	85M with h/o CLL and many recent admissions to , recently for pneumonias (aspergillus and citrobacter) and recurrent UTIs (pseudomonas, VRE, E.coli), presenting from rehab facility with lethargy and fever, found to have pseudomonas bacteremia.	The rhythm is now sinus and lateralST-T wave changes not seen as prominantly.TRACING #1 Intraventricular conduction defect. Diffuse non-specificST segment abnormality consistent with left ventricular hypertrophy butnon-specific. Sinus rhythm with intraventricular conduction defect, likely due to leftanterior fascicular block. Left ventricular hypertrophy. Compared to the previoustracing atrial fibrillation is new. Poor R wave progression.Consider prior anteroseptal myocardial infarction. Non-specific lateral ST segment changes. Sinus tachycardia. Sinus rhythm. Atrial fibrillation with rapid ventricular response. Compared to the previoustracing of the rate has increased. Comparedto tracing #1 no diagnostic interim change.TRACING #2 Compared to the previous tracing of there has been amarked increase in sinus rate.	4	[ { "category": "ECG", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 298785, "text": "Sinus rhythm with intraventricular conduction defect, likely due to left\nanterior fascicular block. Non-specific lateral ST segment changes. Compared\nto tracing #1 no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 298786, "text": "Sinus rhythm. Intraventricular conduction defect. Poor R wave progression.\nConsider prior anteroseptal myocardial infarction. Compared to the previous\ntracing of the rate has increased. The rhythm is now sinus and lateral\nST-T wave changes not seen as prominantly.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 298787, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 298788, "text": "Sinus tachycardia. Left ventricular hypertrophy. Diffuse non-specific\nST segment abnormality consistent with left ventricular hypertrophy but\nnon-specific. Compared to the previous tracing of there has been a\nmarked increase in sinus rate. No other interval diagnostic change.\n\n" } ]
27,230	104,170	The patient tolerated the initial surgery (EBL 150cc) and was taken to the PACU. In the PACU, she became unresponsive and hypotensive. She was subsequently intubated without sedation and a code blue was called; a femoral a line and right subclavian triple lumen were placed (after failed attempt at left subclavian and right IJ complicated by arterial puncture). Per nursing there was a brief episode of ? PEA/Asystole, but once the MICU code team responded they noted a DP/femoral pulses. She was responsive and following commands (squeezed hand to command). There was attempted resuscitation in the PACU for one hour after which the patient was taken to the OR for exploration as her blood pressure remained labile despite tansfusion of 4 units. Of note, the patient was able to move all limbs during this time and the patient seemed to respond to her family prior to returning to the OR. In the OR, the patient was found to be bleeding from the the renal left renal artery into her RP. Her retroperitoneum was evacuated and the bleeding site was oversewn. Assistance was provided by Dr. of Transplant Surgery. The patient had strong pulses and stable vitals throughout the procedure. She was given 2gm cefazolin periop. In sum, the estimated blood loss was -2.5 L. She received 2.7L of PBRC (~ 18 U), many of which were not cross-matched ()-pt has autoantibodies: anti-, anti-JKa. She also received 8 and 3L of LR. Postoperatively she was transferred to the MICU for further management including central monitoring, delayed extubation, and transient requirement for neosynephrine. In the the patient was noted to have a left pneumothorax and required Gen to place a chest tube on POD #0. During the several days in the ICU, pt required fluid management with hydration and lasix, respiratory support with intubation until POD2 and O2 supplementation until leaving the ICU. Once transfered to Urology, the patient required a PT consult difficulty ambulating and a nutrition consult decreased po intake. Upon discharge, pt afebrile with vital signs stable. Pt going to rehab center for PT. Pt tolerating po feeds and requires supplements that she normally takes as an outpatient. Pt pain controlled with po pain meds.	for interval change FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. FINDINGS: There has been interval placement of a left chest tube with almost complete resolution of the previously noted significant left-sided pneumothorax. Cardiac: Hr intially 110-120's ST rare PVC, then with sleep pt hr down to 90's BP stable 110-130/70's GU: foley in place and draining well. Chest tube in situ on left side with almost complete resolution of previously noted left pneumothorax. SBP to 170's HR 120's.Propofol gtt d/c'd. A right subclavian central venous line is in situ. They were updated on pt's condition and POC by this RN.A/P:Coont PS o/n Eval in AM for extubation.Crit stable. Mouth care done Q4 hrs.Crit 29.6.Abd dsg D&I. FINDINGS: The left-sided chest tube has been removed. There is a new left-sided central venous catheter with the distal tip in the mid SVC slightly perpendicular to the SVC wall. An ET tube is in situ, tip of which is situated 4.5 cm proximal to the carina. There is a left-sided central venous catheter with the distal tip in the mid SVC. An ET tube is in situ,, the tip of which is 4.5 cm proximal to the carina. Post extubation vitals were HR 119, BP 172/89, RR 34 and non-labored, SpO2 100% on 0.5 FiO2 via OFM. Epidural catheter capped. Frequent alb/atr nebs given. Right subclavian central venous line. The right subclavian central venous line is identified with tip in the expected region of the right atrium. S/B & followed by Pain service.SBP & HR very variable level of sedation, stimulation. Lungs at start of the shift were very bronchiol ,dim LLL, coarse in upper lobes. Please evaluate endotracheal tube. Right subclavian central venous line with tip in the expected region of the right atrium. The tip of the chest tube appears to be rather medially placed. There is persistent elevation of the left hemidiaphragm. Nasogastric tube in situ. Tmax 99.6.CV: HR 81-1teen's. INDICATION: Acute blood loss, status post left nephrectomy with left pneumothorax. Being repleted with K.Resp: See carevue for ETT data. RESP CARE: Pt recieved alb/atr by MDI or neb Q3-4, Tol fair. Old blood under tegederm dsg. INDICATION: Acute blood loss status post nephrectomy with left pneumothorax. BP 145-180/80-95, 40mg lasix given, -1300.Resp: extuabted @ 1300, on humidified mask O2 sat 95-100%, RR 20-30. expiratory wheezes resolved with inhalers. While the patient is rotated there does appear to be rightward mediastinal shift and there is downward depression of the left hemidiaphragm very concerning features for tension. MICU Nursing Progress Note Respiratory: RR 22-30's BS crackles to diminished at the bases. INDICATION: Acute blood loss, status post left-sided nephrectomy with left-sided pneumothorax. A right subclavian central venous line is in situ, the tip of which is in the right atrium. Continues on q4hour HCT, which have been stable.Resp: LS's rhoncherous in upper airways, diminished at bases. +PP b/l. Short bursts of SVT to 170's noted x2, resolves on own. Recieving neb treatments q2-4hrs. CVP HAS BEEN .PT. Receiving albutrol, atrovert, Qvar. Resp Care,Pt. BP up to 180's..restarted on verapimil. HAS BEEN SUCTIONED FOR SCANT AMT'S OF CLEAR/TAN SECRETIONS. B/P HAS BEEN 99-214/58-120. ABG on PS 7, PEEP 5 83/50/7.38/31/2. DSG D&I. Hypoactive BS. ONCE PT. RSBI 118 this am. BS with scattered insp. NGT to LIS. fld volume status. RISBI. Remains vented on PS 10, PEEP 5. Maint IVF started. WAS STABLIZED B/P RANGED 110-140'S/58-80'S. After line placement changed to A/C. HAS NGT TO LEFT NARE. Rec'd Haldol .5mg IV x2 with mod effect. THIS PUTS PT. of RSBI attempts w/ 7 of PS (due to #7.0 ETT) and ? follw CVP trend. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. I&O's. IS TOLERATING THIS WELL. Elevated BP's with systolic to 170's. Respiratory therapy following.Chest tube in place..left ant. Eval readiness for extubation. Received PRBC's 13U & FFP 8U. HAS BEEN NSR/ST 90-110 WITH OCCASIONAL PVC'S NOTED UPON ARRIVAL FROM O.R. ABG. Returned to OR. DRAINAGE FROM CHEST TUBE REMAINS SEROUS SANG. Developed audible wheezes. REMAINS NPO AT THIS TIME, EXCEPT FOR MEDS. Suctioned for sm thk/thin tan secretions. Denies incisional pain.Crits 27.7 -> 30 -> 27.2 In AM maintaining UO approx 30-35 cc hr. Sinus tachycardiaRightward axis - is are nonspecific and may be within normal limitsSince previous tracing of , sinus tachycardia present and axis appearsmore rightward Once pt adequately sedated & settled CVP shortly after 13-14. ARRIVED TO UNIT FROM O.R. Cont. Has left chest tube in..pt lists to the right..splinting..per xray..lower lung volumes on right. This afteroon pt noted to have occas to frequent ABPC's. Short P-R interval. Cont A/C O/n. Positive air leak, crepitus. Sinus rhythm. Asses response to lasix. benefit, since Pt unable to use IS. 10mg Diltiazem IV x3 with good effect. CONTINUES TO MAE'S WITH IMPROVING STRENGTH.PT. VT 300's, RR high 20's. Last ABG showed resp acidosis with good oxygenation (on SBT). Last ABG showed a mixed resp acid/meta alk. On previcid.SBP 100-170's, HR 90's-130's depending on level of sedation, anxiety. Changed to IPS this am, awake. Placed to water seal this am..repeat CXR ok. ?DC in am..Draining serousanquincous liquid. wheezes. Not tolerating face tent well, trying NC at this time.GI: BS noted during 0400 assessment. Repleted with Mg sulfate x1, 40mEq KCl. IPS as tol. Respiratory CarePt remains intubated (#7.0 ETT 20@lip) and on vent support. Respiratory CarePt remains intubated (#7.0 ETT 20 @lip) and on vent support. RECEIVED 20MEQ OF KCL, AND 4GM OF MAG. Improved cough effort. Decision made to hold off on extubation, sedate pt & replace CVL. Abd soft, nt, mildly distended. MDI's given with good effect. MICU NPN 1900-0700Events: Pt initially tachycardic, rec'd total of 2L NS IV boluses with good effect on HR and u/o.Neuro: Pt remains sedated to on 100mcg fentanyl and 3mg versed.	29	[ { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967530, "text": " 3:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: coded - check intubation\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n\n REASON FOR THIS EXAMINATION:\n coded - check intubation\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 75-year-old woman with cardiac arrest, check intubation.\n\n FINDINGS: Comparison is made to the prior radiograph from .\n\n The tip of the endotracheal tube is 3 cm from the carina. There is a right-\n sided central venous catheter with distal tip at the proximal right atrium.\n There is no focal opacities. There are low lung volumes. There is a large\n amount of gas seen within the stomach.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967548, "text": " 8:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please reassess ETT/CVC position\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with bleeding\n\n REASON FOR THIS EXAMINATION:\n please reassess ETT/CVC position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 75-year-old female with acute blood loss status post left\n nephrectomy. Please evaluate endotracheal tube.\n\n COMPARISON: six hours previous.\n\n FINDINGS: There has been interval development of a large left-sided\n pneumothorax with complete collapse of the left upper lobe and near complete\n collapse of the left lower lobe. While the patient is rotated there does\n appear to be rightward mediastinal shift and there is downward depression of\n the left hemidiaphragm very concerning features for tension.\n\n The right subclavian central venous line is identified with tip in the\n expected region of the right atrium. Endotracheal tube is well positioned.\n The nasogastric tube is difficult to visualize as it courses towards the\n diaphragm but the tip appears to terminate in the region of the\n gastroesophageal junction.\n\n IMPRESSION:\n\n 1. Large left pneumothorax with complete collapse of the left upper lobe and\n near complete collapse of the left lower lobe. There are also findings\n consistent with a tension component.\n\n 2. Right subclavian central venous line with tip in the expected region of\n the right atrium. For optimal positioning the tip may be withdrawn\n approximately 3 cm.\n\n 3. Endotracheal tube is well positioned.\n\n 4. Nasogastric tube should be advanced approximately 5 cm for optimal\n positioning.\n\n Findings were immediately relayed to Dr. at the time of\n dictation.\n (Over)\n\n 8:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please reassess ETT/CVC position\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 967553, "text": " 11:51 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p chest tube replacement\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p chest tube replacement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n INDICATION: Acute blood loss status post nephrectomy with left pneumothorax.\n\n COMPARISON: Comparison was made with the previous chest x-ray from the same\n day from one and a half hours previously.\n\n There is a chest tube in the left upper hemithorax with subcutaneous emphysema\n noted superficial to the chest wall on the left side. The tip of the chest\n tube appears to be rather medially placed. An ET tube is in situ,, the tip of\n which is 4.5 cm proximal to the carina. A right subclavian central venous\n line is in situ. There has been good resolution of the previously noted\n pneumothorax. No focal lung lesion identified. Allowing for portable semi-\n erect rotated film, the heart size appears within normal limits.\n\n IMPRESSION:\n\n 1. Chest tube in situ on left side with almost complete resolution of\n previously noted left pneumothorax.\n\n 2. ET tube in good position.\n\n 3. Right subclavian central venous line in good position.\n\n 4. NG tube in situ.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967551, "text": " 10:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p left chest tube\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p left chest tube\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n INDICATION: Acute blood loss, status post left nephrectomy with left\n pneumothorax.\n\n COMPARISON: Comparison was made with the previous chest x-ray from the same\n day from at one hour previously.\n\n FINDINGS: There has been interval placement of a left chest tube with almost\n complete resolution of the previously noted significant left-sided\n pneumothorax. Note is made of some surgical emphysema on the left side status\n post chest tube placement. A right subclavian central venous line is in situ,\n the tip of which is in the right atrium. An NG tube is in situ in the\n stomach. Some surgical clips are seen in the left paraspinal area. An ET\n tube is in situ, tip of which is situated 4.5 cm proximal to the carina.\n\n IMPRESSION:\n 1. Almost complete resolution of significant left pneumothorax when compared\n with the previous chest x-ray in patient status post chest tube placement on\n the left.\n 2. ET tube in good position.\n 3. Right subclavian central venous line.\n 4. Nasogastric tube in situ.\n\n" }, { "category": "Radiology", "chartdate": "2164-07-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 967710, "text": " 12:34 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check line placement\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax from initial line placement; now s/p new line placement\n\n REASON FOR THIS EXAMINATION:\n please check line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 75-year-old woman with acute blood loss status post left nephrectomy\n with left pneumothorax. Please check line placement.\n\n FINDINGS: Comparison is made to the previous study performed six hours\n earlier.\n\n There is a left-sided chest tube. No pneumothoraces are seen. There is a\n large amount of subcutaneous emphysema in the left side. The tip of the\n endotracheal tube is again low lying, 2 cm above the carina and could be\n pulled back 2-3 cm for more optimal placement. There is a nasogastric tube\n whose side port is at the gastroesophageal junction and could be advanced\n slightly for more optimal placement. There is a new left-sided central venous\n catheter with the distal tip in the mid SVC slightly perpendicular to the SVC\n wall. There is persistent elevation of the left hemidiaphragm. No focal\n consolidation is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-18 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 968150, "text": " 2:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p CT removal\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with\n left pneumothorax, CT now to water seal.\n REASON FOR THIS EXAMINATION:\n s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, \n\n HISTORY: Status post chest tube removal.\n\n FINDINGS: The left-sided chest tube has been removed. No definite\n pneumothoraces are identified on either side. There is a left-sided central\n venous catheter with the distal tip in the mid SVC. Soft tissue emphysema is\n seen on the left side. There is a right-sided pleural effusion which is\n stable. There are lung volumes with crowding of the pulmonary vascular\n markings at the lung bases.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-17 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 968020, "text": " 2:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: FOR 2PM PLEASE. Eval. for interval change\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with\n left pneumothorax, CT now to water seal.\n REASON FOR THIS EXAMINATION:\n FOR 2PM PLEASE. Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Acute blood loss, status post left-sided nephrectomy with\n left-sided pneumothorax. Now chest tube in place on water seal. Evaluate for\n interval change. AP single view of the chest obtained with patient in _____\n supine position leaning towards the right is analyzed in direct comparison\n with a preceding similar study obtained nine hours earlier during the same\n date.\n\n The previously identified tiny left-sided apical pneumothorax cannot be seen\n anymore. The position of the chest tube is unaltered and the degree of\n left-sided subcutaneous chest wall emphysema has mildly decreased. No new\n pulmonary abnormalities are present.\n\n IMPRESSION: Disappearance of left-sided tiny pneumothorax on portable view.\n Unchanged chest tube position.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618327, "text": " 4 ICU NPN 0700-1900\nRemains on PS 10, PEEP 5, 50%. RR 15-23 minute. VT's ~450. ABG 108/51/7.43/35/7. Suctioned for small amts thick to thin tan secretions. L CT dsg became wet with serrosang fld at approx 1000. ICU resident aware. No increase in drainage rest of shift. Mouth care done Q4 hrs.\nCrit 29.6.\nAbd dsg D&I. Abd firm, distended with hypoactive BS\nPt initially very anxious,thrashing about in bed. Attempting to write. SBP to 170's HR 120's.Propofol gtt d/c'd. Cont on fent gtt. Presently on 100 mcgs hr. Versed gtt started. Now at 3mg hr. Additional fent 30-50 mcg boluses and versed 0.5-1mg boluses given with good effect. Epidural catheter capped. Old blood under tegederm dsg. S/B & followed by Pain service.\nSBP & HR very variable level of sedation, stimulation. Brief episode (few sedonds) of SVT to 200. BP stable. HR down to 90's low 100's without intervention. Second event to 150 which also broke on own with stable BP.\nUO down 25-30 cc's for several hrs this afternoon. Currently receving 250 cc fld bolus.\nNG asp- 50 ml coffee grounds. Of note pt had dry blood from around outside nares and when mouth care done. resident aware\nDtrs & as wel as several other family members in to visit. They were updated on pt's condition and POC by this RN.\nA/P:\nCoont PS o/n Eval in AM for extubation.\nCrit stable. Cont serial crits Q4.\nFent & versed gtts with additional boluses PRN.\nPain service will access epidural catheter if pain management becomes an issue once fent & versed gtt stopped.\n? if coffee grounds 2/2 blood tracking down back of throat from traumatic NGT placement. Assess for bleeding\nSupport to pt & family\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618333, "text": "NPN 1900-0700\nFull code multiple drug allergies Urology surgical pt\n\nNeuro: Pt slept off and on. Sedation off @ 0545. Pt had been very lightly sedated, easily arousable, mouthing words. Moves UE's on bed, able to lift and hold LE's b/l. Gag impaired, cough intact. Tmax 99.6.\n\nCV: HR 81-1teen's. Occasional-frequent premature atrial beats. PVC's occurred with increasing frequency early in shift, EKG to document. Ectopy greatly decreased overnight. AM labs: K=3.0, HCT=25.4 down from 26.9. Being repleted with K.\n\nResp: See carevue for ETT data. Put on pressure support @ 0600 10/5peep after RSBI of 84. Looks ready to wean. LS mostly clear, diminished in LLL. Chest tube intact, only drained 25cc overnoc; +air leak, +crepitus (team aware).\n\nGI: Mildly obese abd soft/distended with hypoactive sounds, no BM this shift. AM glucose 96. OGT patent,remains on LIS draining small amts brown contents with total output 100cc in canister.\n\nGU: Patent foley draining 30-100+ cc clear yellow urine. Rec'd Lasix 20mg IV x1 this shift as u/o dropped off. Urology in to see patient now, being kept informed of all MICU interventions.\n\nWound: Abd incision from nephrectomy has dressing CDI; Chest tube on L lateral chest @~5th intercostal with dressing CDI. Some pain at this site.\n\nLines: PIV in L hand, L SC TLC patent and dressing changed this am.\n\nSocial: daughter, telephoned earlier, spoke w/ this RN and Dr. . Will be in this am\n\nPlan: Monitor and support hemodynamics, replete w/K now\n Plan to extubate.\n Monitor/manage pain\n Monitor urine output, bowel activity\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618334, "text": "Resp Care: Pt continues intubated #7 oett secured @ 20 @ lip and on ventilatory support with a/c overnoc miantaining metabolic alkalosis with good oxygenation; BS rare wheeze, scattered crackles, sxn thick clear/white secretions, rx with mdi albuterol/atrovent/beclomethasone, rsbi 84,changed to 10/5 in an attempt to wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618335, "text": "Respiratory Care\nPt was extubated today at 1310. Post extubation vitals were HR 119, BP 172/89, RR 34 and non-labored, SpO2 100% on 0.5 FiO2 via OFM. Lung sounds were clear t/o (pt given Albuterol pre extubation) and no stridor was noted. Pt has a mild cough and a raspy soft voice. Care plan is to continue OFM w/cool-mist and to continue to wean as tol. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618336, "text": "CV: ST with occasional runs of SVT 160-170s. BP 145-180/80-95, 40mg lasix given, -1300.\nResp: extuabted @ 1300, on humidified mask O2 sat 95-100%, RR 20-30. expiratory wheezes resolved with inhalers. LLL diminished, chest tube.\nNeuro: alert, ativan and morphine given regularly for complaints of anxiety and L side pain. follows commands, confused and anxious.\nGI/GU: foley putting out large amount of clear light yellow urine. no stool. L nares NGT tube to LIS, mod amount green/brown output.\nSkin: intact with multiple bruising. LUQ incision, stapled and open to air. L chest tube, dressing CDI.\nLines: L SC TL CVC, L hand PIV.\n\nFollowed by surgical urology.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618337, "text": "Respiratory Care: Pt became very wheezy and had episode of desaturation this shift. Frequent alb/atr nebs given. Placed on 60% hi flow aerosol mask. Weak cough. Will continue to follow with nebs at this time.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-18 00:00:00.000", "description": "Report", "row_id": 1618341, "text": "MICU Nursing Progress Note\n Respiratory: RR 22-30's BS crackles to diminished at the bases. right worse than left.CT to water seal on the left. draining serousangious fluid. output 140cc over 12hour period. incentive spirometry done with pt, poor complaince, only able to generate 200cc and mental status impeding improving that value. nemb treatments with mild CPT done q3-4 hour. congestive cough,O2 sat cont to be 96-98%.\n Neuro: pt very restless at the start of the night, unable to get comfortable in bed, trying to climb out of bed, pt able to tell you where she is but quickly will try to climb out of bed to go to the couch.. MAE, did recieve serax 10mg then morphine sulfate 0.5mg IV and able to fall asleep for 2hours, needs frequent repositioning to make her comfortable.\n Cardiac: Hr intially 110-120's ST rare PVC, then with sleep pt hr down to 90's BP stable 110-130/70's\n GU: foley in place and draining well. u/o 80-100cc/hr\n Skin: incision in the left chest wall, dry and intact,staples in place, +creptius posterior chest, edema noted over hip extending down to mid thiegh level,slighly pink, Dr. aware.\n Plan; cont to monitor BS, frequent nemb tx, plan is to D/C chest tube this morning. provide safety measures,all side rails up..reorient pt to her surrounding.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-18 00:00:00.000", "description": "Report", "row_id": 1618342, "text": "RESP CARE: Pt recieved alb/atr by MDI or neb Q3-4, Tol fair. 02 sats 97-99%.Insists she prefers the MDI over the neb Rxs. Lungs at start of the shift were very bronchiol ,dim LLL, coarse in upper lobes. Pt refused to cough stating \"it makes my asthma worse\" Gentle CPT to , pt constantly moving in the bed, insisting on leaning on R side. Pt also revieved Qvar x1 at 2200. Tol well. Will continue to follow as needed.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618323, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO ASA, ATENOLOL, BACTRIM, SULFA, SERVENT, AND ACE INHIBITORS.\n\nPT. AT PRESENT IS SEDATED ON FENTANYL GTT 25MCG/HR AND PROPOFOL GTT AT 10MCG/KG/MIN. PT. IS LIGHT ON THESE MEDICATIONS AND IS EASILY AROUSABLE. PT. NODS HEAD APPROPRIATELY TO QUESTIONS THROUGHOUT THIS SHIFT. PT. CONTINUES TO DENY ANY PAIN, OR DISCOMFORT. PT'S TEMP SPIKED TO 100.4, BUT PRESENTLY 99.8 ORALLY. PT'S PUPILS EXHIBIT A SURGICAL PUPIL ON THE RIGHT WHICH REMAINS UNREACTIVE, WHILE LEFT PUPIL IS 3MM AND BRISK. PT. REMAINS IN BILAT WRIST RESRAINTS FOR SAFETY, WITH PROTOCOL FOLLOWED AND PT. CONTINUES TO MAE'S WITH IMPROVING STRENGTH.\n\nPT. HAS BEEN NSR/ST 90-110 WITH OCCASIONAL PVC'S NOTED UPON ARRIVAL FROM O.R. BUT NO ECTOPTY NOTED OVER PAST 10HRS. RIGHT FEMORAL ALINE REMAINS INTACT, SECURED, AND FUNCTIONING WELL. THESE PRESSURES CORRELATE WITH CUFF PRESSURES. B/P HAS BEEN 99-214/58-120. MOST OF THIS SHIFT WHEN PT. WAS STABLIZED B/P RANGED 110-140'S/58-80'S. NO PRESSORS GIVEN DURING THIS SHIFT. SBP 214 DROPPED SIGNIFICANTLY ONCE PLACED ON PROPOFOL. CVP HAS BEEN .\nPT. RECEIVED 20MEQ OF KCL, AND 4GM OF MAG. PT. HCT HAS BEEN STABLE AT 29.5 WITH GOAL TO MAINTAIN HCT >28. NO BLOOD PRODUCTS WERE REQUIRED DURING THIS SHIFT. PT. RECEIVED 8UNITS OF PRBC'S AND 8UNITS OF FFP DURING INTRAOP, AND PACU STAY. FEW OF THESE UNITS WHERE NOT CROSS MATCH DUE TO PT. CODING. THIS PUTS PT. AT INCREASE RISK FOR HEMOLYSIS, AND PT. WILL PROBABLEY REMAIN INTUBATED FOR ANOTHER 24HRS, DUE TO INCREASE RISK OF FLASH PULMONARY EDEMA. AM LABS ARE PENDING AND LABS ARE TO BE CHECKED Q4HRS, NEST DUE AT 0900.\n\nPT. IS INTUBATED WITH A 7.0 AT 22CM LIP LINE. PT. HAS BEEN SUCCESSFULLY WEANED FROM AC TO PRESSURE SUPPORT SETTINGS OF AT 50% THIS AM AT 0530, PT. IS TOLERATING THIS WELL. PT. HAS BEEN SUCTIONED FOR SCANT AMT'S OF CLEAR/TAN SECRETIONS. O2 SATS REMAIN 100% WITH RESP RATE 14-24. ONCE PT. ARRIVED TO UNIT FROM O.R. PORTABLE CHEST XRAY PERFORMED, AND EXHIBITED MODERATE TO SEVERE LEFT PNEUMOTHORAX. CHEST TUBE PLACE AND THEN REPLACED FOR CORRECTED POSITIONING BY SURGERY. PT. TOLERATED THIS PROCEDURE WELL. #28 CHEST TUBE REMAINS INTACT, SECURED, WITH 20CM WALL SUCTION APPLIED. SMALL AIR LEAK NOTED WITH TEAM AWARE, AND VERY SMALL AREA OF CREPITIOUS NOTED AT INSERTION SITE. DRAINAGE FROM CHEST TUBE REMAINS SEROUS SANG. APPROX. 90-100CC SINCE INSERTION AT 2300.\n\nPT. REMAINS NPO AT THIS TIME, EXCEPT FOR MEDS. PT. HAS NGT TO LEFT NARE. ABD. IS LARGE ROUND AND FIRM . BOWEL SOUNDS ARE VERY HYPOACTIVE, BUT PRESENT X4 QUADRANTS. BLOOD SUGARS ARE ORDERED QID AND HAVE BEEN 120'S. FOLEY CATHETER REMAINS INPLACE, WITH URINE REMAINING CLEAR YELLOW, AND RANGING 38-160CC/HR. PT. HAS TRENDING DOWN OVER PAST TWO HRS FROM . TEAM IS AWARE.\n\nABD. TO LEFT FLANK EXHIBITS LARGE STERILE DRESSING WHICH REMAINS DRY AND INTACT. ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL.\n\nPT. REMAINS A FULL CODE. PT'S THREE DAUGHTER AND BROTHER WILL BE IN TODAY. THEY WIL\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618324, "text": "(Continued)\nL BE TAKING TURNS THROUGHTOUT THE DAY. PLAN IS TO KEEP PT. INTUBATED FOR ANOTHER 24HRS DUR TO INCREASE RISK OF FLASH PULMONARY EDEMA SECONDARY TO RECEIVING UNCROSSED BLOOD PRODUCTS DURING CODE SITUATION IN PACU YESTERDAY. PT. WILL NEED TO BE MONITORED FOR SIGNS OF HEMOLYSIS FOR UP TO 7DAYS. OTHERWISE PLAN ID FOR Q4HR BLOOD DRAWS AND REPLETION OF ELECTROLYTES, OR BLOOD PRODUCTS WHEN REQUIRED.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618325, "text": "Resp Care,\nPt. admitted from OR intubated #7ET taped at 20 lip. Ventilated on A/C overnoc, Fio2 weaned down to 50%. Changed to IPS this am, awake. VT 300's, RR high 20's. RSBI 118 this am. Cont. IPS as tol.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618326, "text": "Respiratory Care\nPt remains intubated (#7.0 ETT 20 @lip) and on vent support. No vent changes were made t/o shift. Lung sounds were clear with periods of exp wheezes that responded to MDI's. Suctioned for sm thk/thin tan secretions. MDI's given with good results. Last ABG showed a mixed resp acid/meta alk. Care plan is to continue to wean as tol, ? of RSBI attempts w/ 7 of PS (due to #7.0 ETT) and ? of extubation in the next few days. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618328, "text": "MICU NPN 1900-0700\nEvents: Pt initially tachycardic, rec'd total of 2L NS IV boluses with good effect on HR and u/o.\n\nNeuro: Pt remains sedated to on 100mcg fentanyl and 3mg versed. Attempted to wean versed to 2mg/hour but pt was becoming more anxious, so rate returned to 3mg/hour. Pt has been sleeping, easily arousable, nodding head appropriately to yes/no questions, and is cooperative with care. Denies incisional pain, but does have throat discomfort related to ETT.\n\nCV: HR 110's-120's prior to IV bolus, down to 90's after 1500cc, NSR. Short bursts of SVT to 170's noted x2, resolves on own. Continues with low grade fevers 100-100.9. Continues on q4hour HCT, which have been stable.\n\nResp: LS's rhoncherous in upper airways, diminished at bases. Remains vented on PS 10, PEEP 5. RR 10's-20's, non-labored. O2 sat 95-98% on 50% FiO2. Suctioned initially for small amount thick tan secretions. Secretions are now minimal and clear. CT to left ant CW to 20cm suction with serosang drainage. +crepitus to left chest, small airleak noted.\n\nGI: Abd softly distended with +bs's. NGT in place, clamped without further coffee ground drainage noted.\n\nGU: Foley draining 20-45cc/hour clear amber urine. Low u/o responsive to fluid boluses.\n\nSkin: Left transverse abd incision with staples, no drainage noted, DSD changed. Left CT dressing changed, no further drainage noted from site. No breakdown noted to backside, turned and repositioned. Bilat wrist restraints in place.\n\nID: Pt is on cefazolin while CT is in place.\n\nSocial: Spoke with pt's daughter last eve and updated her on pt's current status.\n\nPlan: Cont to monitor VS's, I&O, labs, and resp status. Possible extubation this am if continues to do well.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618329, "text": "Resp Care: Pt cont intubated and on ventilatory support with psv, no vent changes overnoc maintaining spo2 95-98%; bs with episodic exp wheeze, rx with mdi albuterol/atrovent/beclomethasone, sxn thick clear secretions, rsbi 65, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618330, "text": "Nursing addendum 0630\nPt noted to have brown drainage from mouth and ETT. NGT hooked to suction and same drainage noted from stomach, drained for 100cc. Suctioned ETT for small amounts of gastric content.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618331, "text": "Respiratory Care\nPt remains intubated (#7.0 ETT 20@lip) and on vent support. Vent changes were a SBT at start of shift later placed back onto PSV. After line placement changed to A/C. Pt received a recruitment x1 for sats in the low 90's and PEEP increased to 10 (sats now 98-100%). Lung sounds were course exp wheezes that responded to MDI's. Suctioned for small amounts of thk yellow secretions. MDI's given with good effect. Last ABG showed resp acidosis with good oxygenation (on SBT). Care plan is to continue to wean as tol, return to PSV when tol and to follow ABG's (no A-line). Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618332, "text": " 4 ICU NPN 0700-1900\n75 YO S/P L nephrectomy for renal mass complicated by episode of unresponsiveness & hypotension to 70's in PACU. ? brief episode of astole /PEA. Returned to OR. Bleeding was noted from renal artery which was corrected. Received PRBC's 13U & FFP 8U. Transferred to 4 postop for further management.\n\nThis morning RISBI 65, Fent & versed gtts d/c'd for SBT. AS pt became more awake she became more hypertensive & tachycardic. Developed audible wheezes. ABG on PS 7, PEEP 5 83/50/7.38/31/2. RR mid to high 20's, VT low to mid 300's. Decision made to hold off on extubation, sedate pt & replace CVL. Placed back on PS 10, PEEP 5, 50%. Sats at that X began dropping to low of 88%. Given recruitment breath & placed on A/C 450 X 16 X 50%, PEEP 10 with improvement in O2 sats. Sats now running 98-99%. BS with scattered insp. wheezes. Receiving albutrol, atrovert, Qvar. L chest tube to wall suction drained 150 cc's serosang fld this sgift. Positive air leak, crepitus. DSG D&I. CT sergery following\n\nL Nephrectomy DSG D&I. Denies incisional pain.Crits 27.7 -> 30 -> 27.2\n\n In AM maintaining UO approx 30-35 cc hr. Maint IVF started. CVL placed to monitor CVP's which was 19 on initial when pt hypertensive, tachycardic & agitated. Once pt adequately sedated & settled CVP shortly after 13-14. Urology MD aware of change in CVP value. The rest of the shift CVP ranging 13-15. UO dropping to 15-23 cc' hr. Lasix 20 mg IV X1 given at 1800.\n\nEpidural catheter removed by Pain service (anesthesia) in AM. Neuro checks done q2 hrs. FC, moving all extremities, positive sensation to extremities. On fentanly gtt 100 mcg hr, versed 2mg hr with additional versed 0.5mg & fentanyl 20-30 mcg boluses with good effect.\n Abd slightly less distended than previous 24hrs. NGT with mod amts coffee grounds 70-100 cc's. NGT to LIS. Hypoactive BS. No stool this admit. On previcid.\n\nSBP 100-170's, HR 90's-130's depending on level of sedation, anxiety. This afteroon pt noted to have occas to frequent ABPC's. No VEA or SVT noted.\n\nMany family members in to visit briefly with pt. Question answered. Dtr, HCP - stated Dr. (surgeon) phoned & updated her on pt's condition & POC.\n\nA/P: Developed exp wheezes with SBI & subsequent drop in sats in setting of marginal UO & ? fld volume status. ? wheezes cardiac VS pulmonary. Cont A/C O/n. In AM (0500). RISBI. ABG. wake up. Eval readiness for extubation. follw CVP trend. Asses response to lasix. I&O's.\n*** Per CT surgery Do not turn pt on L side while pt has CT in placed risk of kinking\n\nAssess pain & need for additional medications once gtts d/'d.\nNeuro checks Q2 hrs S/P removal of epidural catheter. PAIN service to follow.\n\nPage Urology for any interventions.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618338, "text": "NPN 1900-0700\nNeuro: Pt increasingly agitated overnoc, unfamiliar with surroundings. Rec'd Haldol .5mg IV x2 with mod effect. Frequent reorientation/repositioning. Denied pain but grimace with movement, given morphine 1mg x 2 w/moderate effect. Afebrile\n\nCV: ST with no ectopy noted this shift. Elevated BP's with systolic to 170's. 10mg Diltiazem IV x3 with good effect. +PP b/l. Chest tube intact draining small amts serosanginous fluid, dressing CDI. HCT stable @ 27-28 over past 48hrs. Began IVF at 300cc/hr x1 liter. Repleted with Mg sulfate x1, 40mEq KCl. K now 4.1\n\nResp: pt experienced acute asthma attack @, wheezing auscultated in all lobes, stridorous, highly anxious. Rec'd neb tx x2 immediately with very good effect and reg neb tx's now ordered. Pt now has scattered rales throughout, no sputum production. Improved cough effort. Not tolerating face tent well, trying NC at this time.\n\nGI: BS noted during 0400 assessment. Abd soft, nt, mildly distended. Pt has notmoved bowels since ICU admission.\n\nGU: Foley patent draining clear yellow urine @ ~100cc/hr.\n\nSkin: ecchymotic L anterior forearm, L thigh. Abd staples CDI\n\nLines: Patent PIV in L hand. TLC all ports flushing, only red port drawing.\n\nPlan: Monitor and support hemodynamic status\n Q4h nebs, monitor lung status\n Encourage turn/c/db\n CT may be d/c'd today\n Monitor u/o\n Reorient prn, anti-anxiety medications\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618339, "text": "Respiratory care: Pt seen for neb q2 hrs today. Pt c/o dyspnea, SpO2 95-98% on 6L NC, ? anxiety. At 1600 pt refused neb tx and requested MDI instead, ? benefit, since Pt unable to use IS. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618340, "text": " 4 ICU nursing progress note:\n Respiratory: Placed on 4-6l nc..with sats 94-98%..rr 30's Has wet sounding cough. Non productive. Feels she is having asthma attack. Recieving neb treatments q2-4hrs. No wheezes heard..but pt feels she is wheezing. Respiratory therapy following.\nChest tube in place..left ant. Placed to water seal this am..repeat CXR ok. ?DC in am..Draining serousanquincous liquid.\n Cardiac: Continues to be tachycardic to 120's..attempted iv dilt this am without change. Given 20 lasix this afternoon..good diuresis..??needs more this evening. BP up to 180's..restarted on verapimil.\n GI: Per urology can take only sips of water. Faint BS..no stool..\nAbdomen soft,distended. DSD\n GU: Good u/o with lasix.\n Neuro: Pt agitated most of day..calling out..stating she cant breath, shes lonely, worst place shes ever been. At times refusing to take her inhalers and respiratory tx. OOB to chair..30min and up to 70min. Tolerated well. Assist of 2. Pt states she takes serax at home..and admits to a \"few\" during the day. ??possibiltiy of benzo withdrawl\" Serax ordered and given this afternoon.\n S/P L nephrectomy: post op day #4. C/O lower back ache..given morphine with minimal releif. Has left chest tube in..pt lists to the right..splinting..per xray..lower lung volumes on right.\n Social: Daughter in..updated..HO spoke with her also.\n" }, { "category": "ECG", "chartdate": "2164-07-13 00:00:00.000", "description": "Report", "row_id": 259670, "text": "Sinus tachycardia\nRightward axis - is are nonspecific and may be within normal limits\nSince previous tracing of , sinus tachycardia present and axis appears\nmore rightward\n\n" }, { "category": "ECG", "chartdate": "2164-07-19 00:00:00.000", "description": "Report", "row_id": 259669, "text": "Sinus rhythm. Short P-R interval. Poor R wave progression. Compared to\ntracing of poor R wave progression is new and could be positional and\ntachycardia has resolved.\n\n" } ]
41,067	194,692	23yo F with no significant PMH admitted for BRBPR of unclear etiology, likely lower GI bleed.	FINDINGS: CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized heart and pericardium are unremarkable. CTA: The intra-abdominal vasculature is unremarkable. No acute hemorrhage identified. FINDINGS: CHEST: The partially visualized heart and pericardium are again unremarkable. TECHNIQUE: MDCT axial imaging was obtained through the abdomen without the administration of intravenous contrast material. There is no intra- or extra-hepatic biliary dilatation. The gallbladder is unremarkable. The liver is otherwise again unremarkable. (Over) 1:43 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: eval for site of bleed Admitting Diagnosis: LOWER GI BLEED FINAL REPORT (Cont) IMPRESSION: No acute hemorrhage or source of bleeding identified. There is no pericardial effusion or pleural effusion. No ectopic tracer uptake is present in the right lower quadrant or elsewhere. No acute hemorrhage or active bleeding detected. The bladder, rectum, and sigmoid colon are unremarkable. There is no pericardial effusion. CT PELVIS: The bladder, rectum, and sigmoid colon are unremarkable. ABDOMEN AND PELVIS: The small hypodensity within the left lobe of the liver is again seen, unchanged, and too small to accurately characterize. No source of bleeding is identified within the bowel. There is no biliary dilatation. There is no free air or lymphadenopathy. OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. The visualized stomach, small and large bowel are unremarkable. There is no hydronephrosis. source of bleeding No contraindications for IV contrast WET READ: EHAb WED 7:28 PM 1. There is no free fluid, free air, or lymphadenopathy within the pelvis. There is no free fluid, free air, or lymphadenopathy within the abdomen. There is no source of bleeding identified within the loops of bowel. CTA: The intra-abdominal vasculature is normal. There is normal hepatic arterial anatomy. There is normal hepatic arterial anatomy. The stomach, small and large bowel are unremarkable. IMPRESSION: No evidence of Meckel's diverticulum. There are stable bilateral ovarian cysts, likely physiologic. No fractures or evidence of degenerative change. Flow images demonstrate no abnormal distribution of tracer. The gallbladder, pancreas, spleen, and adrenal glands are unremarkable. There is no evidence of contrast extravasation. There is no evidence of contrast extravasation. IMPRESSION: No evidence of GI bleed during the time of study. Delayed images show normal excretion of tracer in the stomach and bilateral renal uptake. Bilateral ovarian cysts, likely physiologic. The kidneys enhance and excrete contrast symmetrically without any focal lesions. Bilateral ovarian cysts, likely physiologic but incompletely evaluated on this study. The liver otherwise enhances homogenously without any focal lesions. COMPARISON: CT on . COMPARISONS: None. A small hypodensity within the left lobe of the liver (image 4B:180) is too small to characterize. Tiny hypodensity in the left lobe of the liver too small to characterize (4b:180). Cyst in the region of the cervix may represent Nabothian cyst, but incompletely evaluated on this study. The pancreas, spleen, kidneys, adrenals are normal. Dynamic blood pool images over 90 minutes show no evidence of bleeding. There is a small amount of free fluid within the pelvis, which is new since the previous examination, and likely physiologic. The dose length product was 1169.7 mGy-cm. The portal vein is patent. Blood flow images show normal flow of tracer through the vessels and organs. Coronal and sagittal reformats were provided. source of bleeding Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 150 FINAL REPORT (Cont) 2.2 x 1.9 cm on the left (4:290) which are most likely physiologic. The portal veins are patent. Small hypodensity in the left lobe, too small to characterize. There are bilateral ovarian cysts measuring 2.3 x 1.8 cm on the right (4:285) and (Over) 6:06 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ? Coronal, sagittal, and maximum intensity projection imaging was obtained. The total DLP for the exam was 172.75 mGy/cm. , M.D. , M.D. , M.D. , M.D. IMPRESSION: 1. Approved: MON 3:02 PM RADLINE ; A radiology consult service. Approved: FRI 3:29 PM RADLINE ; A radiology consult service. The lung bases are clear. The lung bases are clear. MECKEL'S SCAN Clip # Reason: 22 Y/O W/ LARGE VOLUME GI BLEED X 1 DAY, COLONOSCOPY AND EGD NEGATIVE. 6:06 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ?	4	[ { "category": "Radiology", "chartdate": "2143-01-09 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1217826, "text": " 6:06 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ? source of bleeding\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with large volume GI bleed, needing RBCs, symptomatic,\n negative EGD and colonoscopy\n REASON FOR THIS EXAMINATION:\n ? source of bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb WED 7:28 PM\n 1. No acute hemorrhage or active bleeding detected. 2. Bilateral ovarian\n cysts, likely physiologic but incompletely evaluated on this study. 3. Cyst in\n the region of the cervix may represent Nabothian cyst, but incompletely\n evaluated on this study. 4. Tiny hypodensity in the left lobe of the liver too\n small to characterize (4b:180).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old woman with large volume GI bleed, needing\n transfusion, symptomatic, negative EGD and colonoscopy, question source of\n bleeding.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial imaging was obtained through the abdomen without the\n administration of intravenous contrast material. Subsequently, MDCT axial\n imaging was obtained through the abdomen and pelvis following the mesenteric\n CTA protocol. Coronal, sagittal, and maximum intensity projection imaging was\n obtained. The total DLP for the exam was 172.75 mGy/cm.\n\n FINDINGS:\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized heart and pericardium\n are unremarkable. There is no pericardial effusion. The lung bases are\n clear. A small hypodensity within the left lobe of the liver (image 4B:180)\n is too small to characterize. The liver otherwise enhances homogenously\n without any focal lesions. The portal vein is patent. There is no intra- or\n extra-hepatic biliary dilatation. The gallbladder, pancreas, spleen, and\n adrenal glands are unremarkable. The kidneys enhance and excrete contrast\n symmetrically without any focal lesions. There is no hydronephrosis. The\n visualized stomach, small and large bowel are unremarkable. There is no\n source of bleeding identified within the loops of bowel. There is no free\n fluid, free air, or lymphadenopathy within the abdomen.\n\n CTA: The intra-abdominal vasculature is unremarkable. The major branches\n including the celiac, SMA, and are patent. There is normal hepatic\n arterial anatomy. There is no evidence of contrast extravasation.\n\n CT PELVIS: The bladder, rectum, and sigmoid colon are unremarkable. There\n are bilateral ovarian cysts measuring 2.3 x 1.8 cm on the right (4:285) and\n (Over)\n\n 6:06 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ? source of bleeding\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2.2 x 1.9 cm on the left (4:290) which are most likely physiologic. There is\n no free fluid, free air, or lymphadenopathy within the pelvis.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. No acute hemorrhage identified.\n 2. Bilateral ovarian cysts, likely physiologic.\n 3. Small hypodensity in the left lobe, too small to characterize.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-01-09 00:00:00.000", "description": "MECKEL'S SCAN", "row_id": 1217828, "text": "MECKEL'S SCAN Clip # \n Reason: 22 Y/O W/ LARGE VOLUME GI BLEED X 1 DAY, COLONOSCOPY AND EGD NEGATIVE. ? AREA OF ECTOPIC GASTRIC MUCOSA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 10.5 mCi Tc-m Pertechnetate ();\n HISTORY: 22 yo with large volume GI bleed with blood at TI on otherwise normal\n colonoscopy.\n\n COMPARISON: Mesenteric CTA\n\n INTERPRETATION: Following the intravenous administration of Tc-m pertechnetate\n flow and 30 minute static images were obtained in the anterior and posterior\n projections. Flow images demonstrate no abnormal distribution of tracer.\n\n Delayed images show normal excretion of tracer in the stomach and bilateral\n renal uptake. Tracer flows out of the stomach and is seen looping through\n duodenum and proximal ileum on dynamic imaging.\n\n No ectopic tracer uptake is present in the right lower quadrant or elsewhere.\n\n IMPRESSION: No evidence of Meckel's diverticulum. Findings were discussed via\n phone with Dr via phone shortly after exam completion.\n\n\n\n\n , M.D.\n , M.D. Approved: FRI 3:29 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2143-01-11 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 1218113, "text": "GI BLEEDING STUDY Clip # \n Reason: BRBPR AND BLOOD IN COLON EVAL FOR GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 15.7 mCi Tc-m RBC ();\n HISTORY: Bright red blood per rectum and blood in the colon.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for minutes\n were obtained.\n\n Blood flow images show normal flow of tracer through the vessels and organs.\n\n Dynamic blood pool images over 90 minutes show no evidence of bleeding.\n\n IMPRESSION: No evidence of GI bleed during the time of study.\n\n\n , M.D.\n , M.D. Approved: MON 3:02 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2143-01-12 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1218250, "text": " 1:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for site of bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with BRBPR, likley lower GI bleed\n REASON FOR THIS EXAMINATION:\n eval for site of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAM OF THE ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: 23-year-old female with bright red blood per rectum, likely\n lower GI bleed. Evaluate for site of bleeding.\n\n COMPARISON: CT on .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis in a\n soft tissue algorithm before and after the administration of intravenous\n contrast material in the CTA protocol. Coronal and sagittal reformats were\n provided. The dose length product was 1169.7 mGy-cm.\n\n FINDINGS:\n\n CHEST: The partially visualized heart and pericardium are again unremarkable.\n There is no pericardial effusion or pleural effusion. The lung bases are\n clear.\n\n ABDOMEN AND PELVIS: The small hypodensity within the left lobe of the liver is\n again seen, unchanged, and too small to accurately characterize. The liver is\n otherwise again unremarkable. The portal veins are patent. There is no\n biliary dilatation. The gallbladder is unremarkable. The pancreas, spleen,\n kidneys, adrenals are normal.\n\n The stomach, small and large bowel are unremarkable. No source of bleeding is\n identified within the bowel.\n\n The bladder, rectum, and sigmoid colon are unremarkable. There are stable\n bilateral ovarian cysts, likely physiologic.\n\n There is a small amount of free fluid within the pelvis, which is new since\n the previous examination, and likely physiologic. There is no free air or\n lymphadenopathy.\n\n CTA: The intra-abdominal vasculature is normal. All the major branches\n including the celiac, SMA and are patent. There is normal hepatic\n arterial anatomy. There is no evidence of contrast extravasation.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. No\n fractures or evidence of degenerative change.\n\n (Over)\n\n 1:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for site of bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n No acute hemorrhage or source of bleeding identified.\n\n" } ]
12,183	145,571	MICU COURSE: On arrival to the MICU, the patient was found intubated and sedated. He was initially continued on broad spectrum antibiotics (cefepime, levofloxacin, vancomycin), vanc d/c'd on , cefepime d/c'd on as sputum culture came back pneumococcus sensitive to levofloxacin. DFA fr flu was negative. He was weaned off of a dopamine drip by . He received a steroid pulse and began a taper on . He was extubated on without complication. He had acute renal failure which resolved with fluids. Patient was transferred to the floor on in stable condition. . . . # PNA/COPD/Respiratory failure: Likely related to underlying poor pulmonary status (COPD) and pneumonia. Patient had a similar episode last year per his daughter when diagnosed with Strep pneumoniae. Sputum culture +S. pneumo. DFA for flu negative. S/p extubation , satting at 90% 3L. Patient was continued on Levofloxacin for which a 14 course will be completed. He will also remain on neb treatments and his home prednisone. All of his home medications were re-added back to his regimen prior to discharge. he idd have one episode of hypoxia that was thought to be due to mucus plugging and resolved quickly. . # Acute renal failure: Likely was volume depleted versus ATN in setting of sepsis. Resolved with aggessive fluid hydration. His urine output remained adequate while on the floor . # h/o NSTEMI: Patient was continued on statin, aspirin . . After discussion with the patient, the patient's daughter and the attending, all were in agreement that he was a suitable candidate for discharge. Medications on Admission: advair diskus 100/50 lasix 20 mg daily lipitor 10 mg daily lorazepam 0.5 mg prn prednisone 10 mg daily spiriva daily oxygen via NC 1 L/min Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 5 days. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation (2 times a day). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q2H PRN (). 16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB. Discharge Disposition: Expired Facility: & Rehab Center - Discharge Diagnosis: Primary Diagnosis: Streptococcus pneumonia pneumonia . Secondary Diagnoses: * H/o multilobar Strep pneumo pneumonia in requiring intubation at * HTN * hypercholesterolemia * Non-STEMI () * TIA/aphasia * s/p L CEA * COPD - PFTs FVC 2.95 (76%), FEV1 1.57 (62%), FEV1/FVC 53 (82%) * BPH s/p TURP * balanitis s/p circumcision * remote nephrolithiasis * former tobacco use (80 pack/year Hx) Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were initially admitted to the intensive care unit after requiring mechanical ventilation for what was found to be a serious pneumonia. You were extubated successfully and continue on antibiotics, for which you will continue for a total of 14 days. You also had an episode of hypoxiz while on the floor which was likely due to a mucus plug. . 1. Please take all medication as prescribed. 2. Please make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Dr. will contact you regarding a follow-up appointment.	A right central line ends in the upper SVC. A right subclavian PICC line terminates in the proximal one-third of the SVC. Bagged with ^ bp/hr. FINDINGS: In the interim, the upper mediastinal vessels including the azygos vein are less engorged on today's examination. Today's examination shows subtle interstitial markings that could be suggestive of slight interstitial edema. ID: Conts on antibx but is currently afebrile. Endotracheal tube and right subclavian CVL are in unchanged position. Bibasilar opacities have now resolved. Slight enlargement of the cardiac silhouette persists. O2 sats to be 88-92. lungs are clear/diminished. Otherwise, stable radiographic appearance of the chest with left lower lobe atelectasis. The "reverse-P" shaped opacity, projected over the lateral aspect of the right hemithorax, is no longer seen. While dtr driving him to noted him to be more cyanotic and pulseless> . Stable radiographic findings including interstitial opacities in both lungs, stable mild cardiomegaly, status post extubation. IMPRESSION: Endotracheal tube in satisfactory position as above. FINDINGS: This single bedside AP examination labeled "supine at 1710 H" is available for interpretation on . Sinus rhythmFirst degree A-V delayInferior infarct - age undetermined may be oldLow limb lead QRS voltagesDelayed R wave progression with late precordial QRS transition - is nonspecificST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -clinical correlation is suggestedSince previous tracing of , precordial lead T waves slight lessprominent Lungs with diminished aeration in bases otherwise clear. Sinus rhythmFirst degree AV delayInferior infarct, age indeterminate - may be oldLow limb lead QRS voltagesDelayed R wave progression with late precordial QRS transition - is nonspecificST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -clinical correlation is suggestedSince previous tracing of , no significant change CHEST AP: Cardiac, mediastinal, and hilar contours are unchanged. CV: Hr 60's 1st degree AVB, also noted AV disassociation with accelerated ventricular rhythm, team aware. CVP D/C. IMPRESSION: Interval placement of nasogastric tube with the proximal side hole near the GE junction. Lasix given x1 dose with good diauresis. The cardiac silhouette size is maintained slightly prominent. The proximal side hole is near the GE junction. Coccyx intact.A: rhythm disturbance ? FRONTAL CHEST RADIOGRAPH: The right-sided subclavian central venous line has been removed. Stable mild cardiomegaly. IMPRESSION: ET tube and right subclavian central venous catheter in satisfactory position, with persistent low lung volumes but no very short- interval change. weak peripheral pulses, A-line is very positional but matches cuff BP. cont to advise pt to cough up sx. Intubated and transferred here. Alb/atr mdi given as ordered.Strong cough reflex. NGT via R nare intact. The cardiac silhouette is within normal limits for size. Has multiple eccymotic areas and few skin tears. Lasix 40mg IV given with good diuresis.GI/GU: pt has NG tube, no residual. Minimal left basilar atelectasis is also evident. The lung volumes remain somewhat low with left more than right basilar atelectasis. pt cont on cefepime and levoflaxacin. pt sputum culture came back with strep. Pt bronchospastic with any movement and suctionning. Resp Care,Pt. drip up to 3mg back down to 2mg.CV: Nsr with occassional pvcs and pacs. see flow sheet for vent setting and ABGS,GI abd destended BS present. bronchospastic with turns and activity. Progress Note 0700-1900Pt admitted to MICU for PNA, pt has end stage COPD. PNA, vanco was D/C. ADM 83 yo reportly end stage COPD. started tf with little residual. Afternoon labs pndg.GI: Abd soft/obese with + BS. pt will at times drop SBP with suctioning.Cardio: NSR, HR 70-80, SBP 90-110. weak peripheral pulses, dopamine being weaned, goal CVP greater than 10, CVP is 8, goal map greater than 60.GI/GU: no bowel movement, pt is NPO, tube feeding consult is in, hypoactive bowel sounds, foley with good urine output. TF of Nutren Renal cont 2 goal 45ml/hr with scant residuals. no gtt needed at this time.SKIN: skin tears, bruising bil arms.ID: On levaqin, cefepime. Breath sounds still fairly tight, getting albuterol and atrovent inhalers. Hr and sbp improved post entubation. initally cvp 17 on arrival.Lungs: coarse throughout thick yellow to green sputum. Last ABG with adequate ventilation/oxygenation. pp intact Tmax 99.3 wbc elevating. RR 23-30. pt still haveing lots of inline secretions, whitie/yellow thick. sputum spect. positional, arm board onRESTRAINTS: dc'd. sputum sent for C+S. NKMA.Events: pt neg for Flu droplet prec. CVP 6-7. good peripheral pulses.A-line is very positional, having difficulty getting a good wave form.GI/GU: Tube feeds at goal of 35ml/hr no residuals noted, small smear brown bowel movement, foley 30-60 ml/hr. cvp 7-10. urine out minimal 30 cc hr. pt dopamine is being weaned, pt recieved 2 liters of NS bolus.Neuro: pt intubated, on versed at 2mg, pt is able to open eyes to voice, can follow commands, will mouth needs.Resp: AC 40%/500/26/10, goal O2 sat 88-92%. Respiratory CarePt remains on ventilator, Lung Sounds- Cl but diminished bilaterally. Resp CarePt remains intubated and currently vented on PSV 8/8 tol well with Vt around 500-600ml and MV 6-9L. placed on 2mg versed drip. ABG 7.33/54/106. given fluid for Low SBP then started on dopamine. D/C, also D/C tamiflu. Lung snds coarse->clear with freq suctionning of mod-copious amts thick white secretions. Sputum spec. Bronchodilators given with good effect noted. and pt turned.planmonitor sbp titrate dopamine as indicated.give fluid based on CVP , SBP and urine output. Clear dsg on RLA with scant amt serosang drainage.Social: Dgtr in to visit, updated by nurse.Plan: Cont to wean from vent as tol. pulm. toilet , vent and abgs as indicated Noted redness and skin breakdownon lt upper extrimity.Positioned and back care given as needed.Afebrile,on Levofloxacin/Cefipime.No contact from family at this shift.plan;? received order for prn fentanyl. palp DP/PT SBP 90-120's . awaiting coags.RESP: returned to AC ventation for hypovent with increase rr to 35 and diaphorectic and tachy. Pt transfered to . Extubate at AM.Haemodynamic monitoringUpdate with family.	26	[ { "category": "Radiology", "chartdate": "2197-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005115, "text": " 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD. CAD, s/p resp arrest and PNA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and chest CT scan examination.\n\n HISTORY: 83-year-old man with COPD, coronary artery disease status post\n respiratory arrest and pneumonia, evaluate for interval change.\n\n FINDINGS: In the interim, the upper mediastinal vessels including the azygos\n vein are less engorged on today's examination. The pulmonary opacification\n seen in both lungs predominantly at the lung bases has decreased with better\n identification of the pulmonary vessels. Scarcity of the vessels in the upper\n lobes reflects underlying emphysematous lung changes. The pulmonary arteries\n are prominent in keeping with patient's pulmonary arterial hypertension. The\n heart is not enlarged. There is no pleural effusion.\n\n The endotracheal tube is approximately 4.2 cm above the carina. A right\n central line ends in the upper SVC. A feeding tube tip is out of view on this\n examination.\n\n IMPRESSION:\n 1. Gradual decrease of the volume overload. 2. Emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-16 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1004911, "text": " 5:01 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 1659 HOURS.\n\n HISTORY: Followup.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The patient has been intubated with the distal tip of the\n endotracheal tube approximately 5.4 cm from the carina. There is widening of\n the mediastinum, likely due to underlying body habitus and aortic tortuosity.\n However, in the setting of trauma, mediastinal vascular injury cannot be\n entirely excluded. The cardiac silhouette is within normal limits for size.\n No definite consolidation is noted, however, subtle increased density is seen\n along the lateral aspects of the right lung, likely due to overlying soft\n tissue. In the more superior aspect, there is an abnormal density resembling a\n reverse \"P\" which may be extrinsic to the patient. Minimal left basilar\n atelectasis is also evident. No definite effusion or pneumothorax is seen.\n\n IMPRESSION: Endotracheal tube in satisfactory position as above.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006060, "text": " 2:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with resolving pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with resolving pneumonia.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The right-sided subclavian central venous line has\n been removed. Slight enlargement of the cardiac silhouette persists. The\n main pulmonary arteries are prominent, which may reflect underlying pulmonary\n arterial hypertension. Bibasilar opacities have now resolved. There is no\n new focal consolidation.\n\n IMPRESSION:\n\n 1. Stable mild cardiomegaly.\n\n 2. No focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004912, "text": " 5:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED :\n\n HISTORY: Intubation.\n\n FINDINGS: This single bedside AP examination labeled \"supine at 1710 H\" is\n available for interpretation on . It is compared with a bedside study\n performed only eight minutes earlier and retrospectively compared with a\n series of studies through today. The tip of the ET tube lies 3.2 cm proximal\n to the carina and a newly-placed right subclavian central venous catheter\n reaches the distal SVC, with no supine evidence of pneumothorax. The lung\n volumes remain somewhat low with left more than right basilar atelectasis. The\n \"reverse-P\" shaped opacity, projected over the lateral aspect of the right\n hemithorax, is no longer seen. The cardiomediastinal contour is unchanged,\n with extensive atherosclerotic change involving the thoracic aorta, but no\n pulmonary vascular congestion, supine pleural effusion, or other evidence of\n CHF.\n\n IMPRESSION: ET tube and right subclavian central venous catheter in\n satisfactory position, with persistent low lung volumes but no very short-\n interval change.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005267, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with pneumococcal pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 83-year-old man with pneumococcal pneumonia, evaluate for interval\n change.\n\n FINDINGS: The endotracheal tube tip is 5.5 cm above the carinal bifurcation.\n A right subclavian PICC line terminates in the proximal one-third of the SVC.\n\n The lungs are emphysematous. The pulmonary arteries are prominent in keeping\n with patient's pulmonary arterial hypertension. The heart size is borderline.\n There is no pleural effusion.\n\n IMPRESSION:\n 1. Emphysema.\n 2. Negative examination for any acute or chronic acute cardiopulmonary\n process.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004936, "text": " 12:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tubes/lines, infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD, prior MI, intubated with likely pneumonia.\n REASON FOR THIS EXAMINATION:\n eval tubes/lines, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with COPD, prior MI, intubated with likely\n pneumonia.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are unchanged. The aorta\n is calcified and tortuous. Pulmonary vasculature is unremarkable. There is\n left lower lobe atelectasis. No pleural effusion is identified, although the\n left costophrenic angle is not included on the exam. Endotracheal tube and\n right subclavian CVL are in unchanged position. There has been interval\n placement of a nasogastric tube with the tip in the stomach. The proximal\n side hole is near the GE junction.\n\n IMPRESSION: Interval placement of nasogastric tube with the proximal side\n hole near the GE junction. Otherwise, stable radiographic appearance of the\n chest with left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005577, "text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD, PNA s/p extubation\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and .\n\n HISTORY: 83-year-old man with COPD, pneumonia, status post extubation,\n evaluate for interval change.\n\n FINDINGS: The patient has been extubated showing persistent interstitial\n opacities seen in both lungs. The cardiac silhouette size is maintained\n slightly prominent. No newly occurred parenchymal opacities suggestive of\n pneumonia. No pleural effusion or pneumothorax are noted.\n\n IMPRESSION:\n 1. Stable radiographic findings including interstitial opacities in both\n lungs, stable mild cardiomegaly, status post extubation.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005416, "text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with respiratory failure; PNA\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices are in unchanged position. Today's examination shows subtle\n interstitial markings that could be suggestive of slight interstitial edema.\n The size of the cardiac silhouette is minimally increased. No newly occurred\n parenchymal opacities suggestive of pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 155271, "text": "Sinus rhythm\nFirst degree AV delay\nInferior infarct, age indeterminate - may be old\nLow limb lead QRS voltages\nDelayed R wave progression with late precordial QRS transition - is nonspecific\nST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -\nclinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-04-16 00:00:00.000", "description": "Report", "row_id": 155272, "text": "Sinus rhythm\nFirst degree A-V delay\nInferior infarct - age undetermined may be old\nLow limb lead QRS voltages\nDelayed R wave progression with late precordial QRS transition - is nonspecific\nST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -\nclinical correlation is suggested\nSince previous tracing of , precordial lead T waves slight less\nprominent\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422313, "text": "resp care\nPt remained on psv8/peep8 and 40% with sats 96%. Vt ranged from 400-1000cc and rr 8-20.BS coarse bil. Suct for copious amts of creammy thick sput. Alb/atr mdi given as ordered.Strong cough reflex. RSBI done =42.ABG revealed a resp acidosis.Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422314, "text": "MICU Progress Note 0700-1900\npt is 83 yr old adm. for PNA, pt has end stage COPD, Full code, NKMA\n\nEvents: pt was extubated in AM, tolerating it well. Pt still has NG tube and is NPO at this time. pt is able to cough up and sx lots of secretions. CVP D/C. Lasix given x1 dose with good diauresis. pt sat in chair for 1 hr today.\n\nNeuro: pt is alert x3, able to verbalize needs, follows commands, no pain.\n\nResp: pt on 35% FiO2 face tent. O2 sats to be 88-92. lungs are clear/diminished. pt is coughing up a lot of sx that he is able to sx out white/thick sx. pt does ask for mouth swabs.\n\nCardio: HR 50-70, 1st degree AV block, team knows about HR dropping into the 50's. In AM pt SBP was 170-180's 10mg of hydralizine given with good response, since extubation pt SBP 120-140's. weak peripheral pulses, A-line is very positional but matches cuff BP. Lasix 40mg IV given with good diuresis.\n\nGI/GU: pt has NG tube, no residual. NPO at this time. good bowel sounds. pt getting Q 4 hr fluid boluses for high sodium, sodium is decreasing. No bowel movement this shift. D5W at 125/hr.\n\nSocial: pt daughter is (HCP) numbers on the board, she also works at and has been in and out today and is updated with pt status.\n\nPlan: cont. antibiotics, monitor labs replete electrolyes as needed. cont to advise pt to cough up sx. monitor O2 sats. ? advancing diet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-21 00:00:00.000", "description": "Report", "row_id": 1422315, "text": "MICU NPN\n83 yo with pmhx of COPD (on home o2), NSTEMI and HTN. Was not doing well at home. While dtr driving him to noted him to be more cyanotic and pulseless> . Bagged with ^ bp/hr. Intubated and transferred here. DX with pna.\n ID: Conts on antibx but is currently afebrile.\n CV: Hr 60's 1st degree AVB, also noted AV disassociation with accelerated ventricular rhythm, team aware. Also has occ blocked pac's. BP 130-150's.\n Resp: O2 at 35% face tent with sats rnaging 90-96%, decrease sats to 86-88% on room air. Lungs with diminished aeration in bases otherwise clear. At beginning of shift productive cough of thick white sputum.\n GI/GU: Abd soft with (+) bowel sounds. No bm. NGT via R nare intact. Was given water but appeared to cough a few seconds after drinking. His NA is 141 today, no further free water boluses given. Foley drng clear yellow urine was -700cc yesterday and approx 300 for today. Is (+) approx 4500cc for LOS.\n MS: Alert and oriented. Able to follow all commands. Initially unsure of year, but otherwise intact.\n Skin: Weeping from R arm noted. Has multiple eccymotic areas and few skin tears. Coccyx intact.\nA: rhythm disturbance\n ? swallowing difficulty\nP: cont to follow rhythm closely, avoid nodal blockers, ? EP study\n cont to monitor closely swallowing ? swallowing study\n enc oob\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422309, "text": "Resp Care\nRemains intubated and ventilated overnight on a/c. Rate decreased from 26 to 22 but pt still taking one or two breaths above. Breath sounds still fairly tight, getting albuterol and atrovent inhalers. Suctioned for thick tan/yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422310, "text": "Nursing Progress Note 0700-1900\nReview of systems:\n\nNeuro: Pt remains very lightly sedated on Versed qtt @ 2mg/hr. Opens eyes to voice and responds approp with head nods and mouthing words. Follows commands consistantly and assists turning STS in bed. OOB to chair via 1200-1700, tolerated well. Consistantly denies pain.\n\nResp: pt on vent settings AC 40%/500 X 22/+10, with pt overbreathing rate ~ 2X/min. O2sat 95-97%. ABG 7.33/54/106. At 1600 vent changed to PS 8/+8/40%, RR low 20's. O2 sat unchanged and ABG 7.35/52/100. Lung snds coarse->clear with freq suctionning of mod-copious amts thick white secretions. Pt bronchospastic with any movement and suctionning. Very strong cough.\n\nCV: HR 65-76 1st degree AV block with escape beats->SR. BP 128/54-164/69. FWB increased to 150ml Q4hrs for am Na 149. Afternoon labs pndg.\n\nGI: Abd soft/obese with + BS. TF of Nutren Renal cont 2 goal 45ml/hr with scant residuals. Pt had med soft brown stool X 1.\n\nGU: Urine yellow/clear, draining via foley @ 40-90ml/hr. 24hr fluid balance +576ml @ 1700, LOS balance +5.6liters.\n\nSkin: Skin tears and bruising on both arms unchanged. Clear dsg on RLA with scant amt serosang drainage.\n\nSocial: Dgtr in to visit, updated by nurse.\n\nPlan: Cont to wean from vent as tol. NPO after MN for ? extubation tomorrow. Monitor Na level. Eggcrate pad to chair. Cont emotional support to pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422311, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 8/8 tol well with Vt around 500-600ml and MV 6-9L. BS course sxing for large to copious amts of secretions. Pt does have a good strong cough. Bronchodilators given with good effect noted. ETT rotated and retaped at 23cm at the lip. Last ABG with adequate ventilation/oxygenation. Will cont with vent support and reassess for further weaning with possible extubation tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422312, "text": "83 y/o male admitted with PNA,has PMH of COPD,intubated OSH since pt was unresponsive on the way to ,remains full code.NKDA.\n\nSedated with Versed 2 mg/hr pt alert and able to follow commands,coperative with care,moves all extrimities.\n\nLS are coarse/dim at bases,on CPAP 40/8/8 suctioned sevaral times for copiuos amts of thick yellow colored secretion.No vent changes overnight has good cough reflex.\n\nHR 60-80's occasional PVC's,ABP high to 170's when awake.For access one multilumen CVL,A-Line remains patent.Positive pedal pulses.+peripheral edema.D5W 100 ml/hr onflow for 1000ml-for NA 149,Getting Q4hr water bolus too.\n\nAbdomen obese positive bowel sounds,TF stopped since MN for possibe extubation,had bowel movement last night.\n\nFoley catheter draining adequte output.\n\nSkin has redness at sacrum,remains intact except both upper extrimities. Noted redness and skin breakdownon lt upper extrimity.Positioned and back care given as needed.\n\nAfebrile,on Levofloxacin/Cefipime.\n\nNo contact from family at this shift.\n\nplan;\n? Extubate at AM.\nHaemodynamic monitoring\nUpdate with family.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422306, "text": "Respiratory Care\nPatient remains intubated, on mechanical ventilation, breath sounds bilaterally diminished, suctioned intermittently for small to moderate amounts of thick yellow to white secretions, treated with Albuterol and atrovent inhalers, no ABGs drawn nor vent changes made, patient is alert, responsive, will continue to be followed.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422307, "text": "Progress Note 0700-1900\nPt admitted to MICU for PNA, pt has end stage COPD. Full code. NKMA.\n\nEvents: pt neg for Flu droplet prec. D/C, also D/C tamiflu. insulin sliding scale started. pt sputum culture came back with strep. PNA, vanco was D/C. pt cont on cefepime and levoflaxacin. Pt also started on prednisone taper dose. pt up to the chair for 1.5 hrs.\n\nNeuro: pt alert, versed at 3mg/hr. pt can follow commands, mouths needs, denies pain.\n\nResp: no changes to vent settings: AC 40%/500/26/10. RR 23-30. pt still haveing lots of inline secretions, whitie/yellow thick. also pt needs good oral care. pt has been asking for oral swobs for dry mouth and have been using vasoline for lips. lung sounds are clear/course.\n\nCardio: 1st degree AV block, HR 70-80, SBP 110-120. no additional boluses given during this shift. CVP 6-7. good peripheral pulses.\nA-line is very positional, having difficulty getting a good wave form.\n\nGI/GU: Tube feeds at goal of 35ml/hr no residuals noted, small smear brown bowel movement, foley 30-60 ml/hr. + bowel sounds.\n\nSocial: daughter is HCP, she works at visited pt twice today. pt ring was sent home with her today.\n\nPlan: cont antibiotics, try to wean from vent, cont good suctioning and oral care. cont monitoring urine output and CVP. Update family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422308, "text": "1900-0700 NPN\nNEURO: pt spont opens eyes, confused as to place, knows name, knows yr. mae, currently on versed 2 mgm hr decreased from 3 mgm overnight.\nPERL, follows commands\n\nCV: 1st degree avb with reg. dropped beats not wenkebach, not wandering atrial. denies chest pain. serial enzymes on admit neg. cms intact. Tmax 99.8 oral, urine out average 40cc hr this night. cvp 2-4\n\nRESP: diminished lower right lobe, BUL clear, left clear, no wheeze, AC 40%, TV 500cc rate decreased to 23 from 26 peep 10. suctioned for copious amts thick light yellow secretions, copious oral secretions. bronchospastic with turns and activity. good cough effort.\n\nGU/GI: foley with average out 40 cc. clear, abd rounded BT active. given senna. large soft brwn hem neg stool incont.\n\nENDO: bs elevated to 200's, sliding scale in place. pt on steroids and tube feeds nutren pulm at goal rate 45 cc hr with min. to no residuals\n\nPAIN: c/o pain general and ETT related. received order for prn fentanyl. gave 2 doses 50 mcq through night prn. no gtt needed at this time.\n\nSKIN: skin tears, bruising bil arms.\n\nID: On levaqin, cefepime. pending sputum cultures\n\nSOCIAL: family to visit. pt. appears well supported by family.\n\nPLAN: cont. pulm toilet, antibiotics, daily trials, wean from vent when appropriate, mobilize, replete elect. as needed. monitor card rhythm closely to see if further elongation or pr or other block developes.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422302, "text": "MICU Progress Note: 0700-1900\nPt is 83 yr old in for PNA and end stage COPD, pt is full code, NKMA.\n\nEvents: pt 2 decreased from 50% to 40%, goal O2 sat is 88-92%. pt dopamine is being weaned, pt recieved 2 liters of NS bolus.\n\nNeuro: pt intubated, on versed at 2mg, pt is able to open eyes to voice, can follow commands, will mouth needs.\n\nResp: AC 40%/500/26/10, goal O2 sat 88-92%. lungs are course, and pt has tons of copious yellow secretions both in-line and in mouth. pt will at times drop SBP with suctioning.\n\nCardio: NSR, HR 70-80, SBP 90-110. weak peripheral pulses, dopamine being weaned, goal CVP greater than 10, CVP is 8, goal map greater than 60.\n\nGI/GU: no bowel movement, pt is NPO, tube feeding consult is in, hypoactive bowel sounds, foley with good urine output. total of 2 liters of fluid boluses given.\n\nPlan: cont antibiotics, cont to wean dopamine off, may need to give additional fluid boluses, monitor blood pressure. lots of suctioning for thick secreations.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422303, "text": "Respiratory Care\nPt remains on ventilator, Lung Sounds- Cl but diminished bilaterally. FiO2 was lowered to 40%, where the target oxygen saturations are to be in the range of 88-92%. MDIs given at the appropriate times. Whiel ETT was being retaped, Copious amounts of secretions were suctioned out of both the tube and the mouth. Pt remains , con't to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422304, "text": "1900-0700 NPN\nNEURO: intact, mae, perl, follows commands. Increase versed to 4mgm hr for agitation and increase rr, decreased to 3 mgm hr this am and doing well.\n\nCV: pr .24 1st degree avb with occ. PVC. sys 127-140 off dopamine gtt. cvp 7-10. urine out minimal 30 cc hr. pp intact Tmax 99.3 wbc elevating. awaiting coags.\n\nRESP: returned to AC ventation for hypovent with increase rr to 35 and diaphorectic and tachy. suctioned for copious amt yellow secretions, mod oral clear secretions. lung sounds coarse and diminished bibasilar. sputum spect. sent.\n\nGU/GI: foley with 30 cc hr output average, abd with active BT. started tf with little residual. bun falling slightly creat stable. phos low.\n\nENDO: bs 150-200 . tube feedings advancing toward goal. pt pn steroids\n\nPAIN: denies\n\nSKIN: small skin tear left forearm drsd for prevent of further shearing.\n\nACCESS: mulitlumen right all ports avail., 1 , . line within 20 mmhg of cuff bp. positional, arm board on\n\nRESTRAINTS: dc'd. pt able to understand and not pull on tubes. follow commands.\n\nID: on levafloxin and cefapime and vanco, cultures pending\n\nSOCIAL: no visit or calls this night\n\nPLAN: pulm toilet, cont. antibiotics, cvp goal , replete electolytes prn, mobilize asap\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422305, "text": "Resp Care\nRemains intubated and ventilated on a/c with no remarkable changes overnight. Breath sounds with tight sounding expir wheezes. Suctioned for small to moderate amounts of thick tan sputum. Awaiting results of nasal aspirate for flu later today.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422300, "text": "Resp Care,\nPt. admitted from ED intubated #8ET taped at 23@lip. Placed on A/C, peep at 10 cm due to auto-peep. Suctioned copious amount very thick yellow sputum. Sputum spec. sent. MDI's as ordered. ABG acceptable, maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422301, "text": "ADM 83 yo reportly end stage COPD. on home O2. pt with hx URI for several days report by daughter who is a RN that he was cyanotic am. While daughter was transporting Pt to pt became unresponsive. Daughter took Pt to hospital. pt was reported pulselesss and unresponsive. pt at osh. copious amt of thick green sputum suctioned . antibiotics given. Hr and sbp improved post entubation. Pt transfered to . given fluid for Low SBP then started on dopamine. on arrival to floor pt had recieved 4L fluid, uo was 1000cc; Dopamine was at5mcg/kg.\n\nNuero: pt restless fighting vent . placed on 2mg versed drip. noted to MAE on bed. not opening eyes. drip up to 3mg back down to 2mg.\nCV: Nsr with occassional pvcs and pacs. palp DP/PT SBP 90-120's . sbp dropped when suctioned. dopamine initially 5mcg/kg down to 3mcg most of shift currently 2mcg. NS bolus 500cc given for CVP of 6 . initally cvp 17 on arrival.\nLungs: coarse throughout thick yellow to green sputum. sputum sent for C+S. see flow sheet for vent setting and ABGS,\nGI abd destended BS present. NG LWS initially coffee ground cleared with 50cc flush bilious drainage about 150cc.\nGu foley to gravity on arrival pt had scab on penis and pus draining around foley area cleaned and gauze applied.\nskin : very dry . purple spot and fragile skin noted on arms. rt leg with some scratches, coccyx red no breaks in skin lotion applied. and pt turned.\nplan\nmonitor sbp titrate dopamine as indicated.\ngive fluid based on CVP , SBP and urine output.\n pulm. toilet , vent and abgs as indicated\n" } ]
29,773	149,695	Patient admitted on with abdominal pain. CT scan confirmed appendicitis. On patient went to the operating room for a laparoscopic appendectomy without complications. He tolerated the procedure well. He was progressing well postoperatively until when he was noted to be in a rapid afib. He was given two additional doses of beta blocker with resulting hypotension. Patient was transferred to the intensive care unit. He was monitored and enzymes checked times 3. They were all negative. Cardiology was consulted. Cardiology recommends beta blocker, full dose asa, 1/2 dose of valsartan. Patient is now in normal sinus rhythm. completed, Showing little change from previous.	The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm.Conclusions:The left atrium is normal in size. There is no pericardialeffusion.IMPRESSION: Normal global and regional biventricular systolic function. IMPRESSION: No acute cardiopulmonary process - stable. Mildmitral annular calcification. Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. Sinus rhythmBorderline first degree A-V delayLeft atrial abnormalityEarly precordial QRS transition - is nonspecificSince previous tracing of the same date, atrial fibrillation absent VOIDING ADEQUATE AMOUNTS. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Normal aortic valve leaflets (3). The estimatedpulmonary artery systolic pressure is normal. Spontaneously voiding adequate amounts cyu. ABDOMEN SOFTLY DISTENDED, LAP SITES WITH STERI-STRIPS INTACT WITH NO REDNESS OR DRAINAGE. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Stable radiograph. Abd soft/approp tender to palpation. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. IMPRESSION: No acute pulmonary process. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.Height: (in) 69Weight (lb): 260BSA (m2): 2.31 m2BP (mm Hg): 120/55HR (bpm): 75Status: InpatientDate/Time: at 11:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). BP stable. FINAL REPORT CT ABDOMEN AND PELVIS WITH CONTRAST. Sinus rhythm with borderline P-R interval prolongation. The small bowel loops are normal in caliber and without focal wall thickening. The cardiac silhouette is within normal limits for size. +pp/csm. Compared to theprevious tracing of there is no significant change. Abdomenal lap sites intact. LE edema noted. Atrial fibrillation with rapid ventricular responseEarly precordial QRS transition - is nonspecificSince previous tracing of , atrial fibrillation now present The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. APPY/DIVERTIC. APPY/DIVERTIC. HISTORY: Bibasilar rales with intermittent shortness of breath. IV contrast was administered. denies n/v. 10mg IV Lasix x1 with + effect. +bs. Coronal and sagittal reformats were performed. Tolerating clears without incident. FINDINGS: Accounting for the more lordotic projection, there is no significant interval change with no evidence of new infiltrate, effusion, or worsening of fluid status. Nodiastolic dysfunction, pulmonary hypertension or significant valvular diseaseseen.Compared with the report of the prior study (images unavailable for review) of, the degree of LVH and aortic dilatation may be slightly reduced onthe current study. There is no mitral valve prolapse. No AS. No effusion or pneumothorax is noted. Coarse calcifications within the prostate are noted. ADAT. The rectum, sigmoid colon and bladder are unremarkable. AFEBRILE. Reporting minimal abdomenal pain with repositioning and palpation, but declining pain medications. There is a tortuous aorta with atheromatous disease. There is no intrahepatic or extrahepatic biliary dilatation. Nsg.progress notes;See flow sheet for specific:PAtient is alert and oriented, very pleasant and co op with care, able to get OOB by himself,denies pain, NSR, HR:60-80, with rare PVC'S,pottasium 20mmol replaced today morning for K 3.9, SBP 120-135, cardiac echo done at bed side, cardiology referred and seeen by them no new recomendation,denies CP or discomfort.afebriele, on anbx.ON RA, LS clear, O2 sat 95-97%, no cough. FINDINGS: The lung bases are clear. BREATHING UNLABORED @ REST, SP02 91-95% WITHOUT SUPPLEMENTAL O2. (Over) 7:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. COMPARISON: None. There is no pericardial or pleural effusion identified. Calm and cooperative with nursing care. There is no mesenteric or retroperitoneal lymphadenopathy. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). NURSING NOTEASSESSMENT: PATIENT ORIENTED AND APPROPRIATE. 7:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. There is no pelvic or inguinal lymphadenopathy. Pulmonary hygiene. Field of view: 45 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) Able to independently reposition self in bed.Plan: Monitor cardiac status closely. LSCTA - diminished at bases - using IS with good technique - O2 sats >95% on RA. Degenerative changes of the spine are noted. IMPRESSION: Fluid filled and dilated appendix measuring up to 1.3 cm with adjacent fat stranding consistent with uncomplicated appendicitis. HEART RATE MOSTLY 60'S NORMAL SINUS, SBP 130-140'S. TAKING LIQUIDS OVERNIGHT.PLAN: TRANSFER TO FLOOR IN AM. PHYSICAL THERAPY CONSULT. ? ? ? ? TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were obtained. COMPARISON: at 17:58. COMPARISON: Multiple priors, the most recent dated . The gallbladder is distended and contains multiple gallstones. COMPLAINING OF ABDOMINAL PAIN @ BEGINNING OF THE SHIFT, RELIEVED BY PERCOCET. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. There is no evidence of adjacent fluid collection or free air. Nursing NotePlease see carevue for detailsPt A&O x3. The liver, spleen, pancreas, adrenal glands and kidneys are unremarkable. There is no free fluid or free air. Bridging osteophytes are noted throughout the thoracic spine with degenerative changes also noted in the right acromioclavicular joint. PROVIDE SUPPORT. FINDINGS: The lungs are well expanded and clear. Field of view: 45 Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 71 year old man with epigastric pain this am and RLQ tenderness on exam REASON FOR THIS EXAMINATION: ?APPY, diverticulitis No contraindications for IV contrast WET READ: 8:27 PM Appendicitis.	10	[ { "category": "Echo", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 65242, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 69\nWeight (lb): 260\nBSA (m2): 2.31 m2\nBP (mm Hg): 120/55\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\ndiastolic dysfunction, pulmonary hypertension or significant valvular disease\nseen.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the degree of LVH and aortic dilatation may be slightly reduced on\nthe current study.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1015754, "text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: AFIB on floor\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p lap appy for rupt appendicitis\n REASON FOR THIS EXAMINATION:\n AFIB on floor\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 04:09\n\n INDICATION: New onset of atrial fibrillation.\n\n COMPARISON: at 17:58.\n\n FINDINGS:\n\n Accounting for the more lordotic projection, there is no significant interval\n change with no evidence of new infiltrate, effusion, or worsening of fluid\n status.\n\n IMPRESSION: No acute cardiopulmonary process - stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 1647237, "text": "Nursing Note\nPlease see carevue for details\n\nPt A&O x3. Calm and cooperative with nursing care. Pt in Afib with frequent PVCs and PACs at start of shift - over course of shift pt converted to NSR with occasional PVCs. 10mg IV Lasix x1 with + effect. BP stable. +pp/csm. LE edema noted. LSCTA - diminished at bases - using IS with good technique - O2 sats >95% on RA. Abd soft/approp tender to palpation. +bs. denies n/v. Tolerating clears without incident. Spontaneously voiding adequate amounts cyu. Abdomenal lap sites intact. Reporting minimal abdomenal pain with repositioning and palpation, but declining pain medications. Standing at bedside to urinate with steady gait. Able to independently reposition self in bed.\n\nPlan: Monitor cardiac status closely. Pulmonary hygiene. ADAT. ? transfer to floor/home in am.\n" }, { "category": "Nursing/other", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 1647238, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED AND APPROPRIATE. COMPLAINING OF ABDOMINAL PAIN @ BEGINNING OF THE SHIFT, RELIEVED BY PERCOCET. PATIENT SLEEPING ON/OFF OVERNIGHT. HEART RATE MOSTLY 60'S NORMAL SINUS, SBP 130-140'S. AFEBRILE. BREATHING UNLABORED @ REST, SP02 91-95% WITHOUT SUPPLEMENTAL O2. ABDOMEN SOFTLY DISTENDED, LAP SITES WITH STERI-STRIPS INTACT WITH NO REDNESS OR DRAINAGE. VOIDING ADEQUATE AMOUNTS. TAKING LIQUIDS OVERNIGHT.\nPLAN:\n TRANSFER TO FLOOR IN AM. ? PHYSICAL THERAPY CONSULT. PROVIDE SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 1647239, "text": "Nsg.progress notes;\nSee flow sheet for specific:\n\nPAtient is alert and oriented, very pleasant and co op with care, able to get OOB by himself,denies pain, NSR, HR:60-80, with rare PVC'S,pottasium 20mmol replaced today morning for K 3.9, SBP 120-135, cardiac echo done at bed side, cardiology referred and seeen by them no new recomendation,denies CP or discomfort.afebriele, on anbx.ON RA, LS clear, O2 sat 95-97%, no cough. Abd soft, +BS, BM x 2, using commode at bed side.voiding adq yellow clear urine in the urinal, Bld sug checked q6h , treated with Regular insulin per sliding scale,seen by Dr. this am, can discharge to home after echo and cardiology consult, all discharge paper work done by NP suregry, waiting for wife to come to take him home.\n\nPlan: monitor, discharge to home.\n" }, { "category": "Radiology", "chartdate": "2155-06-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1015478, "text": " 5:56 PM\n CHEST (PA & LAT) Clip # \n Reason: ?Effusion, pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with b/l basalar rales, intermittant sob\n REASON FOR THIS EXAMINATION:\n ?Effusion, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST AT 1758 HOURS.\n\n HISTORY: Bibasilar rales with intermittent shortness of breath.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The lungs are well expanded and clear. There is a tortuous aorta\n with atheromatous disease. The cardiac silhouette is within normal limits for\n size. No effusion or pneumothorax is noted. Bridging osteophytes are noted\n throughout the thoracic spine with degenerative changes also noted in the\n right acromioclavicular joint.\n\n IMPRESSION: No acute pulmonary process. Stable radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-06-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1015494, "text": " 7:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. ? APPY/DIVERTIC.\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with epigastric pain this am and RLQ tenderness on exam\n REASON FOR THIS EXAMINATION:\n ?APPY, diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:27 PM\n Appendicitis.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH CONTRAST.\n\n COMPARISON: None.\n\n HISTORY: 71-year-old male with epigastric pain this morning and right lower\n quadrant tenderness.\n\n TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed.\n\n FINDINGS: The lung bases are clear. There is no pericardial or pleural\n effusion identified. The liver, spleen, pancreas, adrenal glands and kidneys\n are unremarkable. The gallbladder is distended and contains multiple\n gallstones. There is no intrahepatic or extrahepatic biliary dilatation.\n There is no mesenteric or retroperitoneal lymphadenopathy. The small bowel\n loops are normal in caliber and without focal wall thickening. There is no\n free fluid or free air.\n\n CT OF THE PELVIS: The appendix is fluid filled and dilated up to 1.3 cm with\n associated fat stranding. There is no evidence of adjacent fluid collection\n or free air. There is no pelvic or inguinal lymphadenopathy. The rectum,\n sigmoid colon and bladder are unremarkable. Coarse calcifications within the\n prostate are noted.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n Degenerative changes of the spine are noted.\n\n IMPRESSION: Fluid filled and dilated appendix measuring up to 1.3 cm with\n adjacent fat stranding consistent with uncomplicated appendicitis.\n\n These findings were posted to the ED dashboard.\n\n\n\n (Over)\n\n 7:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. ? APPY/DIVERTIC.\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 130074, "text": "Sinus rhythm\nBorderline first degree A-V delay\nLeft atrial abnormality\nEarly precordial QRS transition - is nonspecific\nSince previous tracing of the same date, atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 130075, "text": "Atrial fibrillation with rapid ventricular response\nEarly precordial QRS transition - is nonspecific\nSince previous tracing of , atrial fibrillation now present\n\n" }, { "category": "ECG", "chartdate": "2155-06-05 00:00:00.000", "description": "Report", "row_id": 130076, "text": "Sinus rhythm with borderline P-R interval prolongation. Compared to the\nprevious tracing of there is no significant change.\n\n" } ]
57,985	140,497	76 yo male with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia Pan-Sensitive Enterococcus who was admitted from rehab for fevers and lethargy. . 1. Fevers: Patient was changed from Ampicillin/CTX to Vanc and Aztreonam secondary to drug rash. Infectious disease was consulted. Neurosurgery was consulted, and MRI of L spine was negative for epidural abscess. MRI showed ongoing discitis and osteo. Per ID recommendation, discitis/osteomyelitis is presumed to be Enterococcus at this time and patient is to complete 6 week course of Daptomycin for Enterococcus bactermia and osteomyelitis. Echo was negative for valvular vegetations concerning for endocarditis. Main concern is for recurrence of epidural abscess. CXR done on arrival to ICU showed increasing RLL infiltrate concerning for PNA vs Aspiration Pneumonitis. Patient was initially treated with Vancomycin and Aztreonam for a 2 week course given recent history of enterococcal bacteremia. C diff was negative. Blood cultures, UA and urine cultures were negative. CT torso was performed on which was only remarkable for pneumonia, not underlying abscess. -Pati ID recommended Daptomycin for an additional 2 weeks for enterococcal bacteremia/osteomyelitis (last day being ). -Please check weekly CKs, CBC, LFTs, BUN, Cr while on Daptomycin -Patient has follow up in Infectious disease clinic on with Dr. . . 2. Hypoxemic respiratory failure: During admission, patient decompensated from a respiratory standpoint becoming tachycardic with increased work of breathing. Right lower lobe opacification seemed to have worsened. The patient was emergently intubated on after aspirating his medications. He was continued on Vancomycin and Aztreonam for a 2 week course. Clindamycin was added for 8 days to cover for anaerobes that may have been associated with an aspiration event. However patient developed a maculopapular rash on . On Vanc and Aztreonam were stopped, and patient was started on Daptomycin (as above). Patient was successfully extubated on . . 3. Altered Mental status: Likely secondary to fevers and likely infection. CT Head done in ED showed no signs of acute hemorrhage or infarction. Patient was given Morphine 4mg IV x 3 in ED which may have contributed to AMS. Sedating meds were held. Mental status improved without other interventions. 4. Hypotension: Patient was briefly on neosynephrine for hypotension likely associated with pneumonia and afib with RVR. Patient was weaned off of vasopressors for several days prior to being discharged. 5. Acute renal failure: Patient had muddy brown casts in urine, consistent with ATN. Likely secondary to hypotension. Cr 2.3 on admission, peaked at 3.2. Trending down to 1.8 on discharge. 6. Atrial fibrillation: Patient was loaded with Amiodarone for 2 weeks. 7. Hypertension: Patient was persistently hypertensive. He was started on Hydralazine 30mg po q6h, Metoprolol 37.5mg po tid, and Amlodipine 10mg po daily. 8. Right atrial appendage thrombus: Patient was on coumadin as an outpatient. This was held as an inpatient because his INR was supratherapeutic. No thrombus seen on repeat ECHO, last ECHO also reviewed by cardiology, no thrombus seen. Thus anticoagulation was stopped. 9. Aspiration events: Patient was evaluated by speech and swallow and continued to aspirate. He was kept NPO, and was fed via NG tube with tube feeds. 10. Hypernatremia: Na 150 on discharge. Patient was given free water IV and in tube feeds. Also given 500cc of D5w today. Please follow up electrolytes and adjust free water appropriately. If increasing then may need diuresis and patient is total body fluid overloaded.	Pt appearing in distress post-intubation, Fentanyl gtt and versed gtt initiated. Plan for Echo today to R/O abscess. -- follow PT/INR - restart coumadin . Action: Received vancomycin, aztreonam, clindamycin. # FEN: IVFs / replete lytes prn / NPO for now # PPX: PPI, anticoagulated, bowel regimen # ACCESS: PIV # CODE: Full Code # DISPO: ICU ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 02:05 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. Pt with episodes of rapid afib and hypotension leading to IV amiodarone with bridge to PO amiodarone (converted to sinus rythym), and brief period of pressor requirement (neosynephrine). Response: Stable Plan: Sepsis, Severe (with organ dysfunction) Assessment: T-max 99.6 WBC Action: Response: Plan: Likely to demand ischemia in the setting of hypotenstion, renal failure and afib with RVR. Likely to demand ischemia in the setting of hypotenstion, renal failure and afib with RVR. - Cont vanc / aztreonam / clinda (check vanc level) - F/U cultures - F/U glucan / galactomannan - F/U ID and NSG recs # Anemia: Hct from 24 to 22 today. - Cont vanc / aztreonam / clinda (check vanc level) - F/U cultures - F/U glucan / galactomannan - F/U ID and NSG recs # Anemia: Hct from 24 to 22 today. Respiratory failure, acute (not ARDS/) Assessment: Started shift w/ pt on A/C. #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. Respiratory failure, acute (not ARDS/) Assessment: Started shift w/ pt on A/C. Yesterday, he developed afib and shock,- on amiodarone/neo infusion. Switch to flagyl with concerns regarding C Diff - Appreciate ID input # Anemia: Hct stable. Pt with episodes of rapid afib and hypotension leading to IV amiodarone with bridge to PO amiodarone (converted to sinus rythym), and brief period of pressor requirement (neosynephrine). #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to PaO2 > 65 #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. Plan for Echo today to R/O abscess. From rehab: - C. Diff neg, stool cx negative , , - Blood cultures NGTD. From rehab: - C. Diff neg, stool cx negative , , - Blood cultures NGTD. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. # HTN: Likely to weaning sedation - Continue to uptitrate hydralazine # Emesis: NPO. Hypertension, benign Assessment: Sbp in 180s in the begning of shift Action: Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and Lopressor Response: Sbp in the 140s. Hypertension, benign Assessment: Sbp in 180s in the begning of shift Action: Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and Lopressor Response: Sbp in the 140s. HPI: 24 Hour Events: PICC placed yest, RUE US yest with superficial cephalic v clot. Plan: Monitor temps, continue IV antibxs, check results of q day BCs. # HTN: Likely to weaning sedation - Continue to uptitrate hydralazine # Emesis: NPO. Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Afebrile today. Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats 93-97%. - rate control, restarted ASA, statin, restart home beta-blocker and uptitirate as tolerated # AMS: Initially had AMS likely fevers and infection. - rate control, restarted ASA, statin, restart home beta-blocker and uptitirate as tolerated # AMS: Initially had AMS likely fevers and infection. Will cont to monitor - f/u rheum recs - f/u nsgy recs # Hypertension: .On po hydral. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. Will cont to monitor - f/u rheum recs - f/u nsgy recs # Hypertension: .On po hydral. Action: Pt given standing PO hydral and Strted on amlodepine and mtoprolol Response: Normotensive most of the shift. - Consider pain consult in a few days when mental status fully cleared #Afib RVR: Initially on amio gtt, now transitioned to PO. - Consider pain consult in a few days when mental status fully cleared #Afib RVR: Initially on amio gtt, now transitioned to PO. Action: Pt turned gently, Lidocaine patch per order, restarted on his PO/NG neurontin. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. Right-sided central venous line ends low in the SVC. Since the previous tracing of sinus tachycardiais now present. IMPRESSION: There is a small posterior paraspinal fluid collection surrounding postoperative changes at L5-S1. There is soft tissue with heterogeneous enhencement posterior to the sacrum (9:12) , differential diagnosis is phlegmon, granulation tissue, or venous congestion. Unchanged extent and density of the pre-existing right lung opacities. Unchanged extent of the pre-existing small left-sided pleural effusion. Unchanged suspicion of mild left pleural effusion. COMPARISON: Non-contrast head CT, . Unchanged size of the cardiac silhouette, unchanged retrocardiac atelectasis. There is minimal right upper lobe bronchiectasis. UPRIGHT AP PORTABLE VIEW OF THE CHEST: Right PICC tip terminates in the mid SVC. Interstitial edema has almost resolved. There is persistent left retrocardiac opacity. A right IJ catheter terminates in the upper SVC. Diffuse hyperintensities are identified involving the musculature posteriorly. The previously noted fluid at the superior margin of the laminectomy has decreased. Bilateral subcutaneous edema is noted. A small fluid (Over) 12:03 AM MR L SPINE W/O CONTRAST Clip # Reason: cord compression?	310	[ { "category": "Nutrition", "chartdate": "2146-10-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706125, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 27\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 115%\n 10/09) 71.67 kg\n 112 %\n Diagnosis: fever\n PMHx:\n - Epidural abscess\n - Possible septic emboli versus infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Food allergies and intolerances: none noted\n Pertinent medications: fentanyl drip, versed drip, Lasix, ABX, Colace\n held, Pantoprazole, Coumadin, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:33 AM\n BUN\n 33 mg/dL\n 03:33 AM\n Creatinine\n 2.6 mg/dL\n 03:33 AM\n Sodium\n 139 mEq/L\n 03:33 AM\n Potassium\n 3.7 mEq/L\n 03:33 AM\n Chloride\n 108 mEq/L\n 03:33 AM\n TCO2\n 22 mEq/L\n 03:33 AM\n PO2 (arterial)\n 68 mm Hg\n 11:38 AM\n PCO2 (arterial)\n 41 mm Hg\n 11:38 AM\n pH (arterial)\n 7.36 units\n 11:38 AM\n pH (urine)\n 5.0 units\n 09:14 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:38 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:33 AM\n Phosphorus\n 3.5 mg/dL\n 03:33 AM\n Ionized Calcium\n 1.05 mmol/L\n 02:32 AM\n Magnesium\n 1.8 mg/dL\n 03:33 AM\n ALT\n 19 IU/L\n 03:33 AM\n Alkaline Phosphate\n 119 IU/L\n 03:33 AM\n AST\n 26 IU/L\n 03:33 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:33 AM\n WBC\n 6.1 K/uL\n 03:33 AM\n Hgb\n 7.6 g/dL\n 03:33 AM\n Hematocrit\n 23.4 %\n 03:33 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft/distended, (+) bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: -2256 (25-28 cal/kg)\n Protein: 80-105 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n76 YO male admitted from rehab with drug rash, altered mental status, fever and\ntachypnea. Concern for sepsis. MRI head/spine showed L5-S1 discitis/osteomylit\nis. Also likely RLL PNA. Deferred s+s evaluation . Noted last s+s evaluat\nion , SLP recommended soft solids and thin liquids. Emergently intubated 1\n after witnessed aspiration after patient had taken pills. Consulted for tub\ne feed recommendations. Patient with OGT. Agree with tube feed for nutrition s\nupport. Per rehab note, patient on no added salt diet with Healthshakes TID and\n 10 oz Prostat (protein supplement) twice a day.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Begin Fibersource HN @\n 20ml/hr, advance as tolerated to goal of 70ml/hr = calories and\n 89g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n" }, { "category": "Nutrition", "chartdate": "2146-10-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706126, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 27\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 115%\n 10/09) 71.67 kg\n 112 %\n Diagnosis: fever\n PMHx:\n - Epidural abscess\n - Possible septic emboli versus infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Food allergies and intolerances: none noted\n Pertinent medications: fentanyl drip, versed drip, Lasix, ABX, Colace\n held, Pantoprazole, Coumadin, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:33 AM\n BUN\n 33 mg/dL\n 03:33 AM\n Creatinine\n 2.6 mg/dL\n 03:33 AM\n Sodium\n 139 mEq/L\n 03:33 AM\n Potassium\n 3.7 mEq/L\n 03:33 AM\n Chloride\n 108 mEq/L\n 03:33 AM\n TCO2\n 22 mEq/L\n 03:33 AM\n PO2 (arterial)\n 68 mm Hg\n 11:38 AM\n PCO2 (arterial)\n 41 mm Hg\n 11:38 AM\n pH (arterial)\n 7.36 units\n 11:38 AM\n pH (urine)\n 5.0 units\n 09:14 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:38 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:33 AM\n Phosphorus\n 3.5 mg/dL\n 03:33 AM\n Ionized Calcium\n 1.05 mmol/L\n 02:32 AM\n Magnesium\n 1.8 mg/dL\n 03:33 AM\n ALT\n 19 IU/L\n 03:33 AM\n Alkaline Phosphate\n 119 IU/L\n 03:33 AM\n AST\n 26 IU/L\n 03:33 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:33 AM\n WBC\n 6.1 K/uL\n 03:33 AM\n Hgb\n 7.6 g/dL\n 03:33 AM\n Hematocrit\n 23.4 %\n 03:33 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft/distended, (+) bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: -2256 (25-28 cal/kg)\n Protein: 80-105 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n76 YO male admitted from rehab with drug rash, altered mental status, fever and\ntachypnea. (+) fever likely due to right-sided pneumonia. Also osteomyelitis a\nnd discitis (per MRI head/spine) may be contributing. Deferred s+s evaluation 1\n. Noted last s+s evaluation , SLP recommended soft solids and thin liqu\nids. Emergently intubated after witnessed aspiration following patient \ning juice after pills. Consulted for tube feed recommendations. Patient with O\nGT. Agree with tube feed for nutrition support. Per rehab note, patient on no\nadded salt diet with Healthshakes TID and 10 oz Prostat (protein supplement) twi\nce a day. BS well controlled. Renal following, no need for HD at this time.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Begin Fibersource HN @\n 20ml/hr, advance as tolerated to goal of 70ml/hr = calories and\n 89g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n BS management\n Will follow, page if questions \n" }, { "category": "Respiratory ", "chartdate": "2146-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706043, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Active exhalations, High flow demand; Comments:\n SEttle on PCV to match high flow demand.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: REq heavy sedation.\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Frequent alarms (High min. ventilation)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated;\n Comments: No RSBi for High PEEP & Fio2.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705882, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 101.4 ax/ HR 90s-160\ns with bursts of raf. NBP ranging 1-teens\n to 130s/50-60s. Pt with 2 episode of rapid afib to 170s, ist episode\n self limiting. Dr. . aware. generalized pitting edema +4. PP\n dopplerable. Lungs diminished bilaterally. CXR with worsening RLL\n infiltrate, Rec\nd on 4L nc. Pt had mri of head and spine done without\n incident. Incission at back from recent surgery for Epidural abscess\n on - approximated, open to air. Sm. Abrasion at perineal\n area. UOP at 40-60 ml/hr. Contact precautions for MRSA. Repeat Bld\n cx\ns done this am. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n MRI brain, and MRI L-spine done, receive GAT contrast dye for exam.\n Phone consent done in mri suite. - Pt and family aware of risks r/t\n kidneys, On vanco and aztreonam for coverage. Pt received lopressor 5mg\n ivp for 2^nd episode of raf with fair response. Cxr done and showed\n worsenin of rll infiltrate. Pt very wheezy and wob increased with resp\n rate as high as the 40\ns. nt sx\nd , med with morphine for pain. O2\n increased to high flow neb with 4 liter nc.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. o2 sat\ns in\n the mid 90s.\n Plan:\n Pt now cont taking off o2, need to check pt freq otherwise o2 sat\n down in the low 80\ns. keep right side down. Pulm toileting as\n tolerated. Morphine for pain.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. LE. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch removed. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n AM\n" }, { "category": "Respiratory ", "chartdate": "2146-10-20 00:00:00.000", "description": "Generic Note", "row_id": 705884, "text": "TITLE:\n Resp Care\n Pt. had increased resp distress with tight-audible expir wheezes. Given\n albuterol/atrovent nebs with some improvement. Desaturated down to 88on\n nasal prongs and changed to 95% hi flow neb. He appears more\n comfortable now, still with some tight sounding wheezes and maintaining\n sats in 95-97% range. NT suctioned x 1 for small amount of thick tan\n sputum. Will continue with albuterol/atrovent nebs q6, suction as\n needed.\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 705670, "text": "Chief Complaint:\n HPI:\n This is a 76 yom with history of Asthma, Gouth, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .\n Currently, Patient denies any pain or shortness of breath.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Daptomycin 300mg IV Daily\n Senna 2 tabs PO qHS\n Colace 100mg PO BID\n MVI daily\n Lidocaine 5% patch to low back\n Gabapentin 100mg PO BID\n Metoprolol 100mg PO BID\n Amlodipine 10mg daily\n Oxycodone 10mg PO QID\n Oxycontin 10mg PO BID\n Prostat?\n Prevacid 30mg daily\n Coumadin?\n Past medical history:\n Family history:\n Social History:\n Asthma\n Cataracts\n Gout\n Benign prostate hypertrophy\n (Prostate biopsy , TURP , cystoscopy/transrectal US\n )\n Chronic kidney disease (baseline 1.5-2.0)\n Epidural Abscess s/p L5-S1 Laminectomy\n Aortic Endocarditis\n Bactermia Enterococcus\n Non-contributory\n Born in . Lives with his wife, has 3 children and many\n grandchildren. Retired but frequently helps out at family restaurant.\n Denies any IVDU or alcohol use. Quit smoking 25 years ago.\n Review of systems:\n Flowsheet Data as of 04:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 106 (106 - 121) bpm\n BP: 107/48(64) {107/48(64) - 148/78(95)} mmHg\n RR: 13 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,037 mL\n PO:\n TF:\n IVF:\n 37 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,707 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76.//-2\n Physical Examination\n Vitals - T: 99.8 BP: 141/78 HR: 121 RR: 21 02 sat: 95%\n GENERAL: Elderly male in mild respiratory distress\n HEENT: ACAT,\n CARDIAC: +S1/S2, no M/R/G, +tachycardia\n LUNG: +Expiratory ronchi, no wheezes or crackles\n ABDOMEN: +BS, NT/ND\n EXT: +2 pitting anasarca, dopplerable pedal pulses\n NEURO: AAO x 1 to person, date and year is , does not recall\n place. Opens eyes on commands but not conversant, answers questions\n preferentially, moving all extremities.\n DERM: mild macular blanching rash of torso\n Labs / Radiology\n 286\n 112\n 2.3\n 27\n 23\n 102 mEq/L\n 4.3 mEq/L\n 137 mEq/L\n 25.5\n 13\n [image002.jpg]\n \n 2:33 A11/4/ 01:00 AM\n \n 10:20 P11/4/ 02:32 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n Other labs: CK / CKMB / Troponin-T:213/3/0.07, Lactic Acid:1.6 mmol/L\n ABG: pH 7.38, pCo2 37, pO2 76\n MICROBIOLOGY:\n UA: WBC, mod bacteria, many yeast\n At :\n C.diff toxin : negative\n Fecal Leukocytes : negative\n Blood cultures : NGTD\n LABS ():\n : WBC 10.5, HCT 23.7, PLT 216\n Na 138, K 3.8, Cl 104, Bicarb 24, BUN 16, Creat 2, Ca 7.7, Mg 1.9\n STUDIES:\n CXR :\n IMPRESSION: Retrocardiac opacity which is non-specific and may\n represent atelectasis, but an area of infection is not excluded.\n .\n CT Head :\n Suboptimal due to motion in the scanner.\n No acute hemmorhage. Evolving deep white matter infarcts, as seen on\n recent MR. If concern for acute ischemia MRI is more sensitive.\n Assessment and Plan\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ASSESSMENT & PLAN:\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n .\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n .\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705779, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 100.4. HR 90s-110s SR with no ectopy noted. NBP ranging 1-teens\n to 130s/50-60s. Pt with 1 episode of rapid afib to 170s, self\n limiting, EKG obtained, Dr. . aware. generalized pitting\n edema +4. PP dopplerable. Lungs clear to diminished bilaterally. CXR\n with RLL infiltrate, ? pna. Rec\nd on 4L nc. PICC removed and tip sent\n for culture on arrival. CT head negative. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Bld cx + for gram positive cocci in clusters.\n Pt with history of aortic vegetation seen on TEE last admission.\n Action:\n MRI brain, and MRI L-spine ordered, pt must receive GAT contrast dye\n for exam. Per history, pt has rec\nd HD post-MRI. Renal consult, their\n rec\ns are for pt to get a temporary HD line, then dialysis after\n rec\ning contrast dye. Pt and family aware of risks r/t kidneys, plan\n is for MRI with contrast, and no HD after (of note, pt with INR 2.2).\n Neurosurgery following. Bedside Echo this afternoon, awaiting\n results. On vanco and aztreonam for coverage.\n Response:\n Tcurrent 97.8. Afebrile this shift. Awaiting time for MRI. Pt\n family to sign a waiver form for contrast dye.\n Plan:\n Plan for MRI head & Spine. Follow fever curve. Closely monitor Heart\n rate & resp status. Cont monitoring Mental status closely. Wean off O2\n as tolerated. F/u with lab results./all culture data. F/U with ID for\n coverage.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, only c/o pain 1x despite grimacing with any\n manipulation of LE. Pupils are unequal .Rt >left & rt pupil\n non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch applied to back. Reoriented as needed.\n Family at bedside. Diet advanced to regular, only taking in 10% with\n assistance fm family. Frequent neuro checks.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706054, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705661, "text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with recent admission for epidural abscess with enterococcal\n bacteremia with aortic valve vegitation seen and sent out on Amp/CTX.\n At rehab patient with change to Daptomycin due to rash and now admitted\n to for recurrent fevers in that setting.\n Here--patient with altered mental status but found to have fever to 102\n and tachypnea.\n Vanco/Aztreonam started for broadened antibiotic coverage after\n discussion with ID and neurosurgery consultation.\n MRI desired and not able to be completed in the setting of patient\n non-compliance and LP deferred without MRI evaluation based upon\n neurosurgery input.\n MSO4 given for pain in ED (12mg total) and sent to ICU for further\n care.\n Upon arrival here patient able to be weaned to 4 liters NC for support\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Asthma\n Gout\n BPH\n Chronic Renal Failure\n Non-contributory\n Occupation: None\n Drugs: None\n Tobacco: None--quit 25 years ago\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:45 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (109 - 121) bpm\n BP: 112/50(65) {112/50(65) - 148/78(95)} mmHg\n RR: 13 (13 - 21) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,019 mL\n PO:\n TF:\n IVF:\n 19 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,689 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.38/37/76.//-2\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, Rash: improved areas of blanching with previous\n drug reaction\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, not appropriate, surgical pupil noted\n Labs / Radiology\n 286\n 25.5\n 108 mg/dL\n 2.3\n 27\n 106 mEq/L\n 3.8 mEq/L\n 132 mEq/L\n 13\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n Other labs: CK / CKMB / Troponin-T:213/3/0.07, Lactic Acid:1.6 mmol/L\n Fluid analysis / Other labs: 7.38/37/76\n U/A-moderate bacteria, WBC \n Imaging: CXR--Patient with right lower lobe opacity seen and\n persistence of left sided retrocardiac opacity.\n CT Head-no lesions or hemorrhage seen\n ECG: ST, normal intervals seen\n Assessment and Plan\n 76 yo male with recent epidural abscess and now with recurrence of\n significant fever in the setting of ongoing antibiotics with recent\n change to daptomycin. He has possible pulmonary source for sepsis but\n of more significant concern is possible evolution of endocarditis and\n epidural abscess is of concern.\n 1)SEPSIS WITHOUT ORGAN DYSFUNCTION-Possible sources as above\n -Will continue with Vanco/Aztreonam\n -Sputum culture when obtained\n -Will follow up with MRI for possible recurrence of epidural abscess\n when patient able to tolerate\n -Neurosurgery following\n -Will have to consider repeat ECHO to evaluate for persistent\n vegitation but reasonable to consider ID consultation\n -IVF as needed and will look to see trend down in heart rate as volume\n replaced\n -Consider CTX for CNS penetration if Aztreonam not adequate\n -Cultures pending\n ICU Care\n Nutrition: NPO pending improvement in mental status\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705773, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Received patient from ED on NRM. Patient is lethargic, opens eyes to\n verbal stimuli & follows simple commands. He denies pain but patient\n grimaces whenever touched him for movement / turning. From the\n grimace scale it is obvious that he has intense pain at the bilat\n lower extremities. Pupils are unequal .Rt >left & rt pupil\n non-reactiove ( S/P cataract sx) . Significant generalized pitting\n edema +4. Pedal pulses dopplerable. Moves extremities on the bed.\n Received 3 L IVF at Ed for Sinus tachy episode ( HR at 130\ns). Upon\n arrival to ICU he has been Sinus tachy mostly., satting at high 90\n nasal cannula. Febrile : T max : 102.2 ( Oral) . Lungs rhonchous &\n insp/exp wheezing bilat. Drug Rash present all over the body from\n Ceft & ampi at rehab, switched to Daptomycin as recommended by ID.\n Monitor shows Sinus tachy with no ectopics. HR went upto 150\ns for a\n brief period with movement/turning. Foleys cath in place , placed at\n ED today Patient has had PICC at rt AC , Non-functioning. Received 3 L\n NS at ED. Received Morphine sulfate 4 mg X3 at ED. Received Vancomycin\n 1 gm & Aztreonam 1 gm IV & 650 mg Tylenol Supp at ED. CT head done for\n ? mental status changes. Incission at back from recent surgery for\n Epidural abscess on /09l close approximated, opens to\n air.Abrasion at perineal area. UOP at 10-30 ml/hr. Contact precautions\n for VRE Pos.\n Action:\n CXR done upon arrival to MICU 07, Atrovent nebs given. IV nurse pulled\n out PICC line & tip sent for culture. Blood culture & Urine culture\n send. Tylenol Sup given. Weaned O2 to 4 L from NRM. Ct head done.\n Neurosurgery consulted. ABG done upon arrival. Pain meds held off at\n this time for ? mental status. restart pain meds once mental\n status improves. .\n Response:\n CXR showing RLL infiltration. Ct head Negative. Na : 132, HCT :\n 25.8, WBC : 12.9. Trop : 0.07 & CK : 213. Last ABG : 7.38/37/76. T :\n 98.4 after Tylenol sups.\n Plan:\n Plan for MRI head & Spine. Plan for Echo today to R/O abscess.\n Follow fever curve. Closely monitor Heart rate & resp status. Cont\n monitoring Mental status closely. Need good pain control regimen.\n Wean off O2 as tolerated. need Nasotracheal suctioning if\n needed. F/u with lab results. F/U with ID for coverage.\n" }, { "category": "General", "chartdate": "2146-10-20 00:00:00.000", "description": "ICU Event Note", "row_id": 705993, "text": "TITLE: ICU Event Note\n Clinician: Attending\n Around 5pm, the pt was witnessed by the nurse , after which\n he abruptly became tachypneic and tachycardic with dropping sats on\n 95-100% NRB- intubated for acute respiratory failure due to\n PNA/aspiration. Remained persistently hypoxic after intubation with\n oxygen sats 82-87% with bagging followed by AC ventilation (PEEP 10,\n FiO2 1.0). However, there was significant improvt once re-positioned\n for left side down.\n with PNA/aspiration would normally consider ARDSnet Tidal volumes-\n however his CXR this morning and positional influence on oxygenation\n suggests unilateral process. As PEEP may be worsening respiratory\n status, would favor decreasing. Post-intubation film pending.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705983, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At 1800, attempted to give pt PO Tylenol, pt with witnessed aspiration\n on juice following Tylenol. Pt coughing, desating to 84%, HR up to\n 140s ST.\n Action:\n Anesthesia paged stat, pt emergently intubated uneventfully.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706059, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706060, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706063, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - restart coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706064, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - continue coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706065, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po, heart rate in the 150\ns, wbc down to 6.1 this am.\n u/o initially very good from Lasix given in prior shift.\n Action:\n Pt given Tylenol, and cooling blanket placed on top of pt.\n Response:\n Temp came down only to 102.8 after a few hours with cooling blanket on\n top of pt. pt given a cool bath, more Tylenol and cooling blanket\n placed underneath pt. temp has come down quickly to 99.5 orally. Pt\n remains tachycardic with hr in the low 100\n Plan:\n Follow temp, remove cooling blanket as soon as able.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705989, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n Addendum:\n **Respiratory failure, acute (not ARDS/)\n Assessment:\n Given 40mg ivp Lasix at 1700. At 1800, attempted to give pt PO\n Tylenol, pt with witnessed aspiration on juice following Tylenol. Pt\n coughing, desating to 84%, HR up to 140s ST.\n Action:\n Anesthesia paged stat, pt emergently intubated uneventfully. Pt\n appearing in distress post-intubation, Fentanyl gtt and versed gtt\n initiated. CXR taken post-intubation. Sxned for copious pink-tinged\n frothy sputum. ABG 7.41/30/48 prior to intubation\n Response:\n Pt currently sating 98% on AC 100% 500/14/10 PEEP, pt dysynchronous\n with vent, titrating sedation to comfort. Currently on 75 mcg/hr\n Fentanyl gtt, 2mg/hr versed gtt. UO 380cc to Lasix.\n Plan:\n Pulm. Toilet, ? more Lasix. f/u with post-intubation ABG.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706369, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706562, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG. Possible\n Bronchoscopy of R lung.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706563, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG. Possible\n Bronchoscopy of R lung.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706552, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue ventilating as ordered; wean settings as\n tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706547, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n He is tolerating APRV better with improved ventilation and oxygenation.\n Secretions are minimal. He continues to have good UO for now despite\n elevated creatinine. We will attempt slowly diurese if BP and HR\n allow. Broad antibiotics to continue for now until culture data back.\n He may need therapeutic bronchoscopy if there is evidence for mucous\n plugging as pneumonia begins to resolve. His wife has been updated\n regarding his progress.\n Patient is critically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 15:51 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706653, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706610, "text": "Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given ,\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706618, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706619, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706774, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 40cc/hr. Goal 80cc/hr.\n Action:\n Checked residuals q4h, advanced TF as tolerated.\n Response:\n still no stool, + bowel sounds, increasing LFT\ns, TF at 70cc/hr.\n Plan:\n cont with bowel meds, cont. to advance TF as tolerated.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr.\n Plan:\n Next PTT @ 0600AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706450, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and BO back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good. No changes needed in sedation meds\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%, Pt still very rigid and grimacing with any\n touching or moving especially when moving left leg\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down. Cont\n sedation/pain meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n Alteration in Nutrition\n Assessment:\n Pts ABD still distended and hypoactive bowel sounds, no stool as yet,\n no NGT asp noted\n Action:\n Senecot and colace given\n Response:\n No rsp as yet\n Plan:\n Nutrition consult for TF\n Social; family in to visit and updated by NSG\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706751, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706755, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Cont abx, vanco trough prior to giving tonight\ns dose, monitor temp,\n f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 40mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H.\n Increased fentanyl gtt to 100mcg for better pain control.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 40mg\n IV lasix, LS remain clear RUL and diminished in all other fields. CXR\n from AM shows improvement MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO\n Action:\n Started heparin gtt @ 1300units/hr after 3000unit bolus.\n Response:\n HR regular with stable BP. Hep gtt running @ 1300units/hr.\n Plan:\n Next PTT @ 2200pm.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706831, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. Currently off pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred two nights ago and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current\n ECHO,last ECHO also reviewed and per Dr. , no thrombus seen\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706833, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706835, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. Currently off pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred two nights ago and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current\n ECHO,last ECHO also reviewed and per Dr. , no thrombus seen\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706997, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Since admissions patient\ns course has been c/b high oxygen\n requirements, with witnessed asp. Event leading to intubation. Febrile\n daily, with neg. cultures to date. Pt with episodes of rapid afib and\n hypotension leading to IV amiodarone with bridge to PO amiodarone\n (converted to sinus rythym), and brief period of pressor requirement\n (neosynephrine). Pt remains intubated, sedated, and off pressors.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Tmax 100.7.\n Action:\n Pt cont on IVAB, lasix started , Vanco held tonight again for level\n 23.3, c.diff cx sent, would reorder Tylenol if temp over 101 persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50%. ETT advanced on day shift.\n Action:\n No vent changes made o/n. Sxned for copious pink tinged thin\n secretions. Rec\nd standing dose lasix.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4\n generalized edema. UO > 180 cc/hr fm diureses.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn. Wean vent. As tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Prior Echo with ? of clot in right\n atrium. Repeat Echo and review of prior echo revealing no clot.\n Heparin gtt dc\nd yesterday 11/10 days.\n Action:\n On SQ hep TID, Pboots, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >170s with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707176, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707189, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CT torso - multifocal PNA, bilateral effusions, biliary sludge,\n diverticulosis\n - C. diff negative\n - Tm 100.9\n - Possible aspiration this am after CXR when OG tube came out while TF\n were running - now with increased secretions and rhoncorous breath\n sounds\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.4\nC (99.4\n HR: 79 (71 - 88) bpm\n BP: 128/44(69) {110/38(60) - 150/56(84)} mmHg\n RR: 12 (10 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 3,202 mL\n 919 mL\n PO:\n TF:\n 1,011 mL\n 432 mL\n IVF:\n 1,201 mL\n 427 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,330 mL\n Urine:\n 3,720 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -518 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 636 (465 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 8.3 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.4 g/dL\n 268 K/uL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Imaging: CT torso - multifocal PNA, bilateral effusions, biliary\n sludge, diverticulosis\n Microbiology: C. diff negative.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - Recheck CXR given possible aspiration this am\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam / clinda\n - F/U cultures, fever curve\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 25 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707092, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen. Electrolyte repletion.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP.\n Action:\n Attempted to place pt on 50%- however, due to patients worsening\n chest xray- PEEP was increased to 10. Now is on CPAP/PS, 50%.\n Obtained Chest and abdominal CT today. ET pulled out by 2cm.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707172, "text": "Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours:\n \\\\\\\\\\\\\\\\ support:\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg on this patient. RSBI deferred due\n to high PEEP requirements.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706817, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: Pt demonstrates periods of vent dysynchrony, but able to tol\n APRV well.\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707152, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP. CXR worsening.\n Abd/Chest CT, awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707164, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707165, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707086, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1400\n uneventful\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear and diminished, suctioned intermittently for small to\n moderate amounts of thick blood-tinged to tan secretions, PEEP\n increased from 5 to 10, traveled to CT around 1400 for chest and\n abdominal CT, uneventful trip, SPO2 remained upper 90s, no distress\n occurred, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707235, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 8 of 14) /Aztreonam (day 8 of 14)/ Clinda (day 7 of 10)\n -keep PEEP at 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with lasix drip for goal negative 2L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso did not reveal obvious source of infxn\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707237, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Plan to transfuse 1U PRBC\ns. Pt is a difficult cross match- awaiting\n blood from blood bank. Resident aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Initiated Lasix gtt after administering\n 60 mg IVP bolus.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706147, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706286, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt has remained nicely in SR rate in70\n Action:\n Pt cont on Amiodarone drip, now at .5mg until 5pm this evening\n Response:\n SR cont , BP inching up\n Plan:\n Will cont with load and? starting po vs IV dosing\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated , no changes made, Good O2 sats , min secretions,\n Remains sedated but not comfortable\n Action:\n Freq SX, cont in IVAB , Not placed with RT side lung down(desats),\n Cont onfentanyland versed drips\n Response:\n New aspiration PNA, more comfortable in APRV mode, Still very\n uncomfortable with any turning or moving\n Plan:\n Aggressive pulm toilet,\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP was slowly increasing once in SR but then when he was given\n PRBC, BP increased nicely\n Action:\n Given 1unit of blood and even Lasix to push those kidneys (no u/o after\n the IVF bolus) CVP up to 16\n Response:\n Min u/o rsp but by 5am, pt able to be weaned off NEO( also coincided\n with CXR so ? pain response)\n Plan:\n Check hct, keep BP up to perfuse kidneys, note lytes and follow renal\n function\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706294, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n APRV\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706296, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n APRV\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation. C diff negative. Urine legionella Ag\n negative.\n -- cont Vanco/Aztreonam/Clinda\n --f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- change foley\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 4.3 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706140, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706141, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707071, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Guiac negative\n - PS decreased from to \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.2\n HR: 87 (81 - 106) bpm\n BP: 136/49(74) {120/41(64) - 195/59(99)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 14)mmHg\n Total In:\n 2,565 mL\n 1,009 mL\n PO:\n TF:\n 1,424 mL\n 449 mL\n IVF:\n 900 mL\n 501 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,600 mL\n Urine:\n 3,815 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,250 mL\n -591 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (160 - 741) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.38/41/86/25/0\n Ve: 5.6 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Crackles : R,\n Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.6 g/dL\n 247 K/uL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: Glucan negative.\n Imaging: CXR- Worsening R-sided infiltrate/effusion.\n Microbiology: C. diff negative. sputum culture + MRSA,\n yeast\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Bronchodilators\n - Pull back ET tube 2 cm\n No attempt to wean on PSV until secretions/ fevers and clinical wheeze\n improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Would consider effusion/empymea\n given CXR appearance. Drug fever would be dx of exclusion.\n - CT scan to evaluate for possible R sided effusion\n if effusion\n ,would have concern for empyema as source of fevers\n - Will scan abd/pelvis while at CT scanner\n - Cont vanc / aztreonam / clinda\n - F/U cultures\n - F/U galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >21\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706113, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Intbuated, sedated, using some abdominal muscles to breathe\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles on R side, on anterior exam\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation. C diff negative. Urine legionella Ag\n negative.\n -- cont Vanco/Aztreonam/Clinda\n --f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- change foley\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 4.3 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706096, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation,\n possible aspiration event in setting of worsening R-sided infiltrate on\n CXR\n - Placed on PCV for comfort\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706097, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706099, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2146-10-21 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 706100, "text": "TITLE:\n DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on \n from rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have\n pan-sensitive enteroccus fecalis AV endocarditis, bacteremia,\n spinal epidural abscess s/p L5 & S1 laminectomy and abscess\n decompression on , as well as neurologic microabscesses. He\n was readmitted with rash, persistent fevers. Portable CXR with\n possible retrocardiac infiltrate so started empirically on\n antibiotics for possible pneumonia. Then repeat CXR with RLL\n opacity. We were consulted to evaluate oral and pharyngeal\n swallow function to determine if aspiration/dysphagia could be\n contributing to current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the\n previous admission. Was initially recommended for soft solids\n and nectar thick liquids on with aspiration of thin liquids.\n Etiology of dysphagia was suggested to be either related to\n medications or neuro issues. On , re-evaluated and cleared\n for diet upgrade to soft solids and thin liquids, as dysphagia\n was resolving. Records from Hospital state pt on house\n diet with supplements TID. Consult was received on , however, it\n was deferred on RN request.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n Returned today for swallowing evaluation. Upon arrival to unit, pt was\n intubated with ET tube and OG tube. Please reconsult when pt is stable\n post extubation.\n __________________________________\n , B.A., SLP/s\n Pager #\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n" }, { "category": "Rehab Services", "chartdate": "2146-10-21 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 706103, "text": "TITLE:\n DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on \n from rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have\n pan-sensitive enteroccus fecalis AV endocarditis, bacteremia,\n spinal epidural abscess s/p L5 & S1 laminectomy and abscess\n decompression on , as well as neurologic microabscesses. He\n was readmitted with rash, persistent fevers. Portable CXR with\n possible retrocardiac infiltrate so started empirically on\n antibiotics for possible pneumonia. Then repeat CXR with RLL\n opacity. We were consulted to evaluate oral and pharyngeal\n swallow function to determine if aspiration/dysphagia could be\n contributing to current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the\n previous admission. Was initially recommended for soft solids\n and nectar thick liquids on with aspiration of thin liquids.\n Etiology of dysphagia was suggested to be either related to\n medications or neuro issues. On , re-evaluated and cleared\n for diet upgrade to soft solids and thin liquids, as dysphagia\n was resolving. Records from Hospital state pt on house\n diet with supplements TID. Consult was received on , however, it\n was deferred on RN request.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n Returned today for swallowing evaluation. Upon arrival to unit, pt was\n intubated with ET tube and OG tube. Please reconsult when pt is stable\n post extubation.\n __________________________________\n , B.A., SLP/s\n Pager #\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: Whitmill, SLP\n on: 10:32 AM ------\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706364, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95%\n Plan:\n Wean vent as tol. Follow seriel ABG\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Amiodarone infusion conversion to Amiodarone PO.\n Response:\n Stable\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706311, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient with worsening\n Right Lung Pneumonia which seems to involve the entire lung field on\n CXR. Patient on , cont to wean as tolerated. On\n Vanc/Aztreonam/Clina, with minimal improvement. Will speak with ID\n regarding Abx coverage\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. Patient was started on amiodarone and now converted\n to NSR.\n - monitor on tele\n - cont Amio, transition to PO\n - wean Neo as tolerated\n .\n # Hypotension: Likely Pneumonia as well as Afib yesterday. BP\n improved with return to NSR. Still requiring low dose Neo today.\n - 1L IVF bolus with goal of weaning Neo off.\n - abx as above\n # Troponin leak: Patient with troponin leak after episode of afib\n yesterday. CK elevated slightly but MB flat. Likely to \n ischemia in the setting of hypotenstion, renal failure and afib with\n RVR. Troponin continues to rise this morning\n - recheck Cardiac Enzymes this afternoon\n - if continues to rise, consider cards consult\n # Fevers: Presented for continued fevers, which have now resolved.\n Improvement suggests that antibiotic coverage is working but Right lung\n worsening is concerning. Will cont the course for now and speak with\n ID as above\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 5.9 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706631, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706632, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to involve the entire lung field on CXR; it seems to have slightly\n improved since yesterday on CXR. Patient on , cont to wean as\n tolerated. On Vanc/Aztreonam/Clinda, but persistently febrile.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706713, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.8\n - Neurosurgery came by - nothing to add at this time.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, PPI, Gabapentin, Lido TD, Vanco, Versed, Clinda, Aztreonam,\n Fentanyl gtt, Atrovent, Amio, Aspirin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.1\nC (100.5\n HR: 89 (77 - 94) bpm\n BP: 150/50(79) {104/46(64) - 153/57(81)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 601 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 431 mL\n Blood products:\n Total out:\n 1,925 mL\n 675 mL\n Urine:\n 1,925 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 10\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94./21/-2\n Ve: 10.8 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: R, L\n base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 257 K/uL\n 123 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 107 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n 3.1\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n 123\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR\n Improved R sided infiltrate.\n Microbiology: Sputum + MRSA; No other new cultures.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n #HypoTN: Afib. Now resolved and off neo. Continue to follow. This\n is likely etiology of renal failure too.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706891, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n still no stool, + bowel sounds, TF\ns @ goal.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr, repeat PTT\n at 0400 > 150, heparin gtt held, will resume at 0500.\n Plan:\n Will resume heparin gtt at 0500, at a rate of 700units/hr, plan to\n recheck PTT at 1200 PM.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706894, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 1-2 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:40 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706448, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and BO back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706380, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706382, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Follow cultures and ID recommendations.\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone 6g Afib load. After amio gtt completed (24hr) start\n amio 400mg PO tid\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n Goal MAP>60\n Fluid Bolus for low u/o\n Real following refer to recommendations.\n resume TF pending U/S results.\n Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706383, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Follow cultures and ID recommendations.\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone 6g Afib load. After amio gtt completed (24hr) start\n amio 400mg PO tid\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n Goal MAP>60\n Fluid Bolus for low u/o\n Real following refer to recommendations.\n resume TF pending U/S results.\n Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706471, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and Bp back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good. No changes needed in sedation meds\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%, Pt still very rigid and grimacing with any\n touching or moving especially when moving left leg\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down. Cont\n sedation/pain meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n Alteration in Nutrition\n Assessment:\n Pts ABD still distended and hypoactive bowel sounds, no stool as yet,\n no NGT asp noted\n Action:\n Senecot and colace given\n Response:\n No rsp as yet\n Plan:\n Nutrition consult for TF\n Social; family in to visit and updated by NSG\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706633, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n CXR may be beginning to improve. Pt scheduled for TEE today. Remains\n ventilated on , ABG WNL on those settings. See flow sheet\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706880, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Weaned down to AC around 8am\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Gen: Intubated, Sedated\n Lungs Rhochi bilaterally on anterior exam\n CV: RRR. No murmurs\n Abdomen: Distended. NT. +BS. Soft. No rebound or guarding\n Extremities: WWP. 2+ LE edema bilaterally\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n Blood culture pending\n Sputum: S. aureus\n Sputum: S. aureus\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS this morning. On Vanc (day 6\n of 14) /Aztreonam (day 6 of 14)/ Clinda (day 5 of 10)\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -advance ET tube this morning\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Resolved. Likely Pneumonia. Currently off\n pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- cont Vanco (day 6 of 14) /Aztreonam (day 6 of 14) /Clinda (day 5 of\n 10)\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/d heparin gtt\n .\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -d/c heparin gtt\n -active T&S\n -check HCT\n -guaiac stools\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706268, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706473, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Oxygenation has remained good t/o night, last ABG WNL on APRV 20/3\n pressures. 3/.6 sec\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706571, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706882, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 1-2 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:30 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706210, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Rec\nd on PCV 60% 18/12 PEEP. Lung sounds very rhonchorus, sx\ning very\n small amt\ns of thin tan secretions. Rec\nd pt sedated on fent 125mcg/hr\n /versed 1 mg/hr, but initially was very dysynchronous with the vent.\n Action:\n Titrating fentanyl and versed gtt to comfort. Pt appearing more\n comfortable on higher sedation ( 200mcg/hr fentanyl gtt, and 3 mg/hr\n versed gtt) but became hypotensive and gtt paused, then restarted at 50\n mcg/hr fentanyl gtt and 1 mg/hr versed gtt. Multiple vent chg\ns made\n according to abg\ns/sats that had been drawn. Attempted to wean peep\n to 10, pt desating to 87%, so peep increased to 12. ABG obtained.\n Response:\n Pt appearing to be comfortable on current sedation, no longer\n dysynchronous with vent. Sating 98%. Last ABG 7.35/40/61.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as needed.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n statin. SBP currently 95.\n Plan:\n ? cards. Consult. Cont. amio gtt per protocol.\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on 3mcg/kg/min neo gtt. SBP 95. CVP 13. UO poor\n (15-30cc/hr)\n Plan:\n Dr. . aware of low uo, plan is to cont. to monitor. Cont. to\n wean neo as tolerated.\n ------ Protected Section ------\n HR converted to SR 60s-70s. Able to wean neo gtt slightly, currently\n on 2.5 mcg/kg/min. Amio gtt infusing per protocol. UO o for past\n three hours, 1 unit PRBCs ordered. Awaiting product fm blood bank,\n currently rec\ning a 250cc NS bolus. Family in to see patient, updated\n by this RN and MD about pt\ns tenuous status/current POC. Support\n offered.\n ------ Protected Section Addendum Entered By: , RN\n on: 22:32 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706794, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 40cc/hr. Goal 80cc/hr.\n Action:\n Checked residuals q4h, advanced TF as tolerated.\n Response:\n still no stool, + bowel sounds, increasing LFT\ns, TF at 80cc/hr.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr, repeat PTT\n at 0400 > 150, heparin gtt held, will resume at 0500.\n Plan:\n Will resume heparin gtt at 0500, at a rate of 700units/hr, plan to\n recheck PTT at 1200 PM.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706080, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Intbuated, sedated, using some abdominal muscles to breathe\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles on R side, on anterior exam\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- f/u urine legionella Ag\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - continue coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706688, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.8\n - Neurosurgery came by - nothing to add at this time.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, PPI, Gabapentin, Lido TD, Vanco, Versed, Clinda, Aztreonam,\n Fentanyl gtt, Atrovent, Amio, Aspirin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.1\nC (100.5\n HR: 89 (77 - 94) bpm\n BP: 150/50(79) {104/46(64) - 153/57(81)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 601 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 431 mL\n Blood products:\n Total out:\n 1,925 mL\n 675 mL\n Urine:\n 1,925 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 10\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94./21/-2\n Ve: 10.8 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: R, L\n base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 257 K/uL\n 123 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 107 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n 3.1\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n 123\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR\n Improved R sided infiltrate.\n Microbiology: Sputum + MRSA; No other new cultures.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n #HypoTN: Afib. Now resolved and off neo. Continue to follow.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706870, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n - Advance ET tube 3 cm\n #HypoTN: Afib. Now resolved and off neo. Continue to follow. This\n is likely etiology of renal failure too.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706872, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 3 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - TEE today\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:30 minutes\n" }, { "category": "Nutrition", "chartdate": "2146-10-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706875, "text": "Objective\n Pertinent medications: Fentanyl drip, Versed drip, Heparin drip, Normal\n saline @ 10ml/hr, Colace, ABX, Lasix, Pantoprazole\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 03:41 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 51 mg/dL\n 03:41 AM\n Creatinine\n 3.2 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.0 mEq/L\n 03:41 AM\n Chloride\n 107 mEq/L\n 03:41 AM\n TCO2\n 22 mEq/L\n 03:41 AM\n PO2 (arterial)\n 94. mm Hg\n 05:41 AM\n PCO2 (arterial)\n 40 mm Hg\n 05:41 AM\n pH (arterial)\n 7.36 units\n 05:41 AM\n pH (urine)\n 5.0 units\n 08:35 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 05:41 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:41 AM\n Phosphorus\n 4.1 mg/dL\n 03:41 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.0 mg/dL\n 03:41 AM\n ALT\n 122 IU/L\n 03:41 AM\n Alkaline Phosphate\n 217 IU/L\n 03:41 AM\n AST\n 107 IU/L\n 03:41 AM\n Total Bilirubin\n 0.9 mg/dL\n 03:41 AM\n WBC\n 7.6 K/uL\n 03:41 AM\n Hgb\n 7.5 g/dL\n 03:41 AM\n Hematocrit\n 22.8 %\n 03:41 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Fibersource HN @ 70ml/hr\n GI: soft, (+) bowel sounds\n Assessment of Nutritional Status\n Estimation of current intake: Excessive\n Specifics:\n Patient admitted with aspiration PNA with dense, large R-sided\n infiltrate. Remains intubated/sedated, pressor off. Tube feed running\n at 80ml/hr, goal changed to 70ml/hr after discussion with MD . \n RN, patient tolerating tube feed, but team would like more concentrated\n tube feed formula to minimize fluid. Also, goal for patient to have bm\n today. Agree with plan, can change to 2 calorie per ml formula to\n decrease free water to 700ml (currently getting 1.5 L).\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Change to Nutren 2.0 with goal\n of 42ml/hr = calories and 81g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n BS management\n Bowel regimen PRN\n Will follow, page if questions \n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707049, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Guiac negative\n - PS decreased from to \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.2\n HR: 87 (81 - 106) bpm\n BP: 136/49(74) {120/41(64) - 195/59(99)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 14)mmHg\n Total In:\n 2,565 mL\n 1,009 mL\n PO:\n TF:\n 1,424 mL\n 449 mL\n IVF:\n 900 mL\n 501 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,600 mL\n Urine:\n 3,815 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,250 mL\n -591 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (160 - 741) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.38/41/86/25/0\n Ve: 5.6 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Crackles : R,\n Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.6 g/dL\n 247 K/uL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: Glucan negative.\n Imaging: CXR- Worsening R-sided infiltrate/effusion.\n Microbiology: C. diff negative. sputum culture + MRSA,\n yeast\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Bronchodilators\n - Pull back ET tube 2 cm\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Would consider effusion/empymea\n given CXR appearance. Drug fever would be dx of exclusion.\n - CT scan to evaluate for possible R sided effusion\n if effusion\n ,would have concern for empyema as source of fevers\n - Will scan abd/pelvis while at CT scanner\n - Cont vanc / aztreonam / clinda\n - F/U cultures\n - F/U galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >21\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 22 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707060, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/Dl\n Beta glucan negative\n Galactomannam\n All bcx negative or pending\n MRSA in sputum from \n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706355, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706523, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts\n ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to involve the entire lung field on CXR; it seems to have slightly\n improved since yesterday on CXR. Patient on , cont to wean as\n tolerated. On Vanc/Aztreonam/Clinda, but persistently febrile.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706190, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Rec\nd on PCV 60% 18/12 PEEP. Lung sounds very rhonchorus, sx\ning very\n small amt\ns of thin tan secretions. Rec\nd pt sedated on fent 125mcg/hr\n /versed 1 mg/hr, but initially was very dysynchronous with the vent.\n Action:\n Titrating fentanyl and versed gtt to comfort. Pt appearing more\n comfortable on higher sedation ( 200mcg/hr fentanyl gtt, and 3 mg/hr\n versed gtt) but became hypotensive and gtt paused, then restarted at 50\n mcg/hr fentanyl gtt and 1 mg/hr versed gtt. Multiple vent chg\ns made\n according to abg\ns/sats that had been drawn. Attempted to wean peep\n to 10, pt desating to 87%, so peep increased to 12. ABG obtained.\n Response:\n Pt appearing to be comfortable on current sedation, no longer\n dysynchronous with vent. Sating 98%. Last ABG 7.35/40/61.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as needed.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n statin. SBP currently 95.\n Plan:\n ? cards. Consult. Cont. amio gtt per protocol.\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on 3mcg/kg/min neo gtt. SBP 95. CVP 13. UO poor\n (15-30cc/hr)\n Plan:\n Dr. . aware of low uo, plan is to cont. to monitor. Cont. to\n wean neo as tolerated.\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706527, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #PNA: Continued fever. CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] send sputum cx\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n #Fevers:\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] send lipase\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706529, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706531, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706604, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706346, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV TV> 500 RR 20-24\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706347, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%.\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706939, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n Now stooling; /loose, guiac negative, sent for c.diff sample, +\n bowel sounds, TF\ns @ goal, residuals down.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, lasix started , Vanco to be held tonight again for\n level 23.3, c.diff cx sent, would reorder Tylenol if temp over 101\n persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt on A/C.\n Action:\n Changed to psup , 50%, advanced ETT 3cm, CXR confirmed placement.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4 generalized\n edema.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 700\n units/hr.\n Action:\n Dc\nd hep gtt and started SQ hep TID, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >200 with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707018, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: __________\n : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707019, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: __________\n : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS this morning. On Vanc (day 6\n of 14) /Aztreonam (day 6 of 14)/ Clinda (day 5 of 10)\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -advance ET tube this morning\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Resolved. Likely Pneumonia. Currently off\n pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- cont Vanco (day 6 of 14) /Aztreonam (day 6 of 14) /Clinda (day 5 of\n 10)\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/d heparin gtt\n .\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -d/c heparin gtt\n -active T&S\n -check HCT\n -guaiac stools\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706179, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po, heart rate in the 150\ns, wbc down to 6.1 this am.\n u/o initially very good from Lasix given in prior shift.\n Action:\n Pt given Tylenol, and cooling blanket placed on top of pt.\n Response:\n Temp came down only to 102.8 after a few hours with cooling blanket on\n top of pt. pt given a cool bath, more Tylenol and cooling blanket\n placed underneath pt. temp has come down quickly to 99.5 orally. Pt\n remains tachycardic with hr in the low 100\n Plan:\n Follow temp, remove cooling blanket as soon as able.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n pla\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706339, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706342, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706345, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV TV> 500 RR 20-24\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706493, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts! ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706494, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts! ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient with worsening\n Right Lung Pneumonia which seems to involve the entire lung field on\n CXR. Patient on , cont to wean as tolerated. On\n Vanc/Aztreonam/Clina, with minimal improvement. Will speak with ID\n regarding Abx coverage\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. Patient was started on amiodarone and now converted\n to NSR.\n - monitor on tele\n - cont Amio, transition to PO\n - wean Neo as tolerated\n .\n # Hypotension: Likely Pneumonia as well as Afib yesterday. BP\n improved with return to NSR. Still requiring low dose Neo today.\n - 1L IVF bolus with goal of weaning Neo off.\n - abx as above\n # Troponin leak: Patient with troponin leak after episode of afib\n yesterday. CK elevated slightly but MB flat. Likely to \n ischemia in the setting of hypotenstion, renal failure and afib with\n RVR. Troponin continues to rise this morning\n - recheck Cardiac Enzymes this afternoon\n - if continues to rise, consider cards consult\n # Fevers: Presented for continued fevers, which have now resolved.\n Improvement suggests that antibiotic coverage is working but Right lung\n worsening is concerning. Will cont the course for now and speak with\n ID as above\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 5.9 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706496, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 457 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 357 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706738, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Cont abx, vanco trough prior to giving tonight\ns dose, monitor temp,\n f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 40mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H.\n Increased fentanyl gtt to 100mcg for better pain control.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 40mg\n IV lasix, LS remain clear RUL and diminished in all other fields. CXR\n from AM shows improvement MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO\n Action:\n Started heparin gtt @ 1300units/hr after 3000unit bolus.\n Response:\n HR regular with stable BP. Hep gtt running @ 1300units/hr.\n Plan:\n Next PTT @ 2200pm.\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706983, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Since admissions patient\ns course has been c/b high oxygen\n requirements, with witnessed asp. Event leading to intubation. Febrile\n daily, with neg. cultures to date. Pt with episodes of rapid afib and\n hypotension leading to IV amiodarone with bridge to PO amiodarone\n (converted to sinus rythym), and brief period of pressor requirement\n (neosynephrine). Pt remains intubated, sedated, and off pressors.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Tmax 100.7.\n Action:\n Pt cont on IVAB, lasix started , Vanco held tonight again for level\n 23.3, c.diff cx sent, would reorder Tylenol if temp over 101 persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50%. ETT advanced on day shift.\n Action:\n No vent changes made o/n. Sxned for copious pink tinged thin\n secretions. Rec\nd standing dose lasix.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4\n generalized edema. UO > 180 cc/hr fm diureses.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn. Wean vent. As tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Prior Echo with ? of clot in right\n atrium. Repeat Echo and review of prior echo revealing no clot.\n Heparin gtt dc\nd yesterday 11/10 days.\n Action:\n On SQ hep TID, Pboots, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >170s with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707008, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg re4sults at this time. RSBI = 37 on\n 0-PEEP and 5 cm PSV.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707208, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CT torso - multifocal PNA, bilateral effusions, biliary sludge,\n diverticulosis\n - C. diff negative\n - Tm 100.9\n - Possible aspiration this am after CXR when OG tube came out while TF\n were running - now with increased secretions and rhoncorous breath\n sounds\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.4\nC (99.4\n HR: 79 (71 - 88) bpm\n BP: 128/44(69) {110/38(60) - 150/56(84)} mmHg\n RR: 12 (10 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 3,202 mL\n 919 mL\n PO:\n TF:\n 1,011 mL\n 432 mL\n IVF:\n 1,201 mL\n 427 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,330 mL\n Urine:\n 3,720 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -518 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 636 (465 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 8.3 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.4 g/dL\n 268 K/uL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Imaging: CT torso - multifocal PNA, bilateral effusions, biliary\n sludge, diverticulosis\n Microbiology: C. diff negative.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - Recheck CXR given possible aspiration this am\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam / clinda\n - F/U cultures, fever curve? Switch to flagyl with concerns regarding C\n Diff\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706185, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n pla\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2146-10-23 00:00:00.000", "description": "Generic Note", "row_id": 706502, "text": "Nutrition:\n Received consult for tube feeding recommendations. Consulted for tube\n feeding recommendations on see full nutrition assessment on \n for further details, tube feeding not started yet. Recommend goal of\n Fibersource HN @ 70 ml/hr to provide 2106 kcals and 89 g protein. Will\n follow. Page with questions\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706504, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 457 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 357 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV) likely PNA\n [] Cont APRV, wean FiO2 to PaO2 > 65\n #PNA (with persistent hypotension): Continued fever, CXR improved R\n dense opacity. Sputum c MRSA. Vanc level 19.\n [] vanc / aztreonam / clinda\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n [] f/u repeat blood cx and sputum sent this morning.\n [] send lipase\n #hct 26 (no increase after 1u pRBC yesterday)\n [] hct , goal hct > 25\n #CV/R: Afib RVR: amio gtt started 2d ago, rebolused with amio yesterday\n now back in NSR\n [] 6g Afib load. Amio 400mg PO tid x 1week\n #CV/I: Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat\n at 9. Most likely demand in setting of RVR / hypoTN.\n [] cont ASA, defer BB in setting of hypoTN/vasopressor\n #Acute transaminitis. Fri night increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n Now LFTs trended down to 215 / 481.\n --Defer RUQ U/S for now since unlikely to change management and LFTs\n improving.\n --statin has been d/c\n [] trend LFTs\n #Elevated INR 5.9\n 9.1 (coumadin started at 1mg 2 days ago).\n --vit K 5 given this AM, monitor\n #HypoTN: briefly on neo o/n, now back off. UOP 30mL/hr. CVP = 13. fluid\n response in past.\n [] check albumin (may need alb/lasix for diuresis if low)\n [] for total body volume up, attempt gentle diuresis net 0.5L out.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Elevated Cr: muddy brown casts in urine sed\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition: tube feed, off at MN for TEE\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706725, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707081, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen. Electrolyte repletion.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP.\n Action:\n Attempted to place pt on 50%- however, due to patients worsening\n chest xray- PEEP was increased to 10. Now is on CPAP/PS, 50%.\n Obtained Chest and abdominal CT today. ET pulled out by 2cm.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707200, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Initiated Lasix gtt after administering\n 60 mg IVP bolus.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706586, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706732, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear over the right upper lobe, diminished every where\n else, suctioned intermittently for small amounts of thick to thin tan\n secretions, treated with Albuterol and Atrovent inhalers, SPO2 remained\n upper 90s, no distress occurred, will continues to be followed.\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706981, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n Now stooling; /loose, guiac negative, sent for c.diff sample, +\n bowel sounds, TF\ns @ goal, residuals down.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, lasix started , Vanco to be held tonight again for\n level 23.3, c.diff cx sent, would reorder Tylenol if temp over 101\n persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt on A/C.\n Action:\n Changed to psup , 50%, advanced ETT 3cm, CXR confirmed placement.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4 generalized\n edema.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 700\n units/hr.\n Action:\n Dc\nd hep gtt and started SQ hep TID, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >200 with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707247, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilationPMHX: epidural abcess. Now\n with fever aortic endocarditis.suctioned for thick tan looking\n sputum,remains on PSV\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706392, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined the pt, and was physically present with the ICU team\n for the key portions of services provided. I agree with Dr. \n note,including assessment and plan. I would add: 76 yo male with gout,\n asthma, recent complicated hospitalization for enterococcal aortic\n valve endocarditis, epidural abscess, atrial thrombus on coumadin,\n admitted with recurrent fevers. In the ICU he developed worsening\n respiratory distress with witnessed aspiration resulting in\n intubation/mechanical ventilation. Yesterday, he developed afib and\n shock,- on amiodarone/neo infusion. Converted to NSR overnight.\n Plans:\n 1. Acute respiratory failure- has Aspiration/PNA with MRSA\n recovered from sputums ((+) cultures last hospitalization, then felt to\n be a contaminant)- on Vanco. Ventilator requirements have been\n difficult given process almost exlucisvely involves the right side.\n Previously dyssynchronous on AC, transiently on PC ventilation.\n Attempts to decrease PEEP (due to concern of overdistending normal\n lung) resulted in hypoxia, desaturations do respond to recruitment\n maneuvers. Now on APRV and tolerating reasonably. Keep left side down.\n 2. elevated transaminases: shock liver most likely in his\n scenario, will follow LFT\ns and consider abd US if it does not improve\n 3. Fevers: Blood culture previously reported as GPC returned\n NEGative as final result, LS MRI negative for progression and only\n positive culture S.aureus from sputum\nmostly pointing toward lung as\n primary source. Abx are Vanc/aztreonam to cover PNA/enterococcal\n endocaridtis- will touch base with ID re abx\n Pt is critically ill. Total time spent: 45 minutes.\n ------ Protected Section Addendum Entered By: , Fellow\n on: 19:00 ------\n" }, { "category": "Respiratory ", "chartdate": "2146-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706910, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear and diminished, suctioned intermittently for small\n to moderate amounts of thick tan to old blood-tinged secretions,\n treated with Atrovent inhaler, switched from APRV to AC, well tolerated\n then, weaned to PSV so far well tolerated, SPO2 remained upper 90s,\n will continues with Diuretics, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706170, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined this pt, and was present with the ICU team for the\n relevant portions of services provided. I agree with Dr. \ns note,\n and would add: 76 yo male with asthma, with recent complicated hospital\n course from Enterococcal aoV endocarditis, left atrial clot, epidural\n abscess, readmitted with fevers and respiratory distress from\n aspiration vs. PNA. Intubated yesterday for acutely worsening distress\n developing immediately after witnessed aspiration. This afternoon, he\n developed rapid afib with hypotension, now on neo and amio infusion.\n Microbiology still shows just the one +bd culture for GPC (since\n amended to NEGATIVE blood culture), no speciation back yet and\n surveillance cx\ns NGTD.\n CXR shows progressing of infiltrates- very impressive unilateral\n process.\n Imp: 76 yo male with fevers, acute respiratory failure from aspiration,\n afib, shock. With blood cultures so far negative and Lspine MRI\n negative for recurrent abscess, lung appears to be the only\n identifiable source so far.\n On abx for HAP, PC ventilation, amiodarone, neo infusion. Given\n strongly unilateral process, would position pt left side down to\n increase blood flow to more functional lung. Some concern in this\n context that PEEP could be over-distending his normal lung- did not\n tolerate attempt to drop earlier this afternoon, but several vent\n changes made and pt then in rapid afib. Will continue amio for rate\n control, neo infusion to maintain MAP>60.\n Pt is critically ill. Total time spent: 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:22 ------\n" }, { "category": "Respiratory ", "chartdate": "2146-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706176, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Frequent desaturation episodes\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706397, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined the pt, and was physically present with the ICU team\n for the key portions of services provided. I agree with Dr. \n note,including assessment and plan. I would add: 76 yo male with gout,\n asthma, recent complicated hospitalization for enterococcal aortic\n valve endocarditis, epidural abscess, atrial thrombus on coumadin,\n admitted with recurrent fevers. In the ICU he developed worsening\n respiratory distress with witnessed aspiration resulting in\n intubation/mechanical ventilation. Yesterday, he developed afib and\n shock,- on amiodarone/neo infusion. Converted to NSR overnight.\n Plans:\n 1. Acute respiratory failure- has Aspiration/PNA with MRSA\n recovered from sputums ((+) cultures last hospitalization, then felt to\n be a contaminant)- on Vanco. Ventilator requirements have been\n difficult given process almost exlucisvely involves the right side.\n Previously dyssynchronous on AC, transiently on PC ventilation.\n Attempts to decrease PEEP (due to concern of overdistending normal\n lung) resulted in hypoxia, desaturations do respond to recruitment\n maneuvers. Now on APRV and tolerating reasonably. Keep left side down.\n 2. elevated transaminases: shock liver most likely in his\n scenario, will follow LFT\ns and consider abd US if it does not improve\n 3. Fevers: Blood culture previously reported as GPC returned\n NEGative as final result, LS MRI negative for progression and only\n positive culture S.aureus from sputum\nmostly pointing toward lung as\n primary source. Abx are Vanc/aztreonam to cover PNA/enterococcal\n endocaridtis- will touch base with ID re abx\n Pt is critically ill. Total time spent: 45 minutes.\n ------ Protected Section Addendum Entered By: , Fellow\n on: 19:00 ------\n Please note that the above addendum was actually written by me but\n signed under the wrong account.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:51 ------\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705725, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain noted to touch, but denied it\n when asked.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Home meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Athma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n - Epidural abscess\n - Aortic veg\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in \n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): Person, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n # Asthma:\n -- Ipratropium nebs PRN\n # Gout: no acute issues\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705729, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain to touch. Picc line pulled and\n tip sent for culture.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Rehab meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Epidural abscess\n - Possible septic emboli vs infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Athma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in , English speaking\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to):\n Person/Place/Year, Movement: Wiggles b/l toes, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705695, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Received patient from ED on NRM. Patient is lethargic, opens eyes to\n verbal stimuli & follows simple commands. He denies pain but patient\n grimaces whenever touched him for movement / turning. From the\n grimace scale it is obvious that he has intense pain at the bilat\n lower extremities. Pupils are unequal .Rt >left & rt pupil\n non-reactiove ( S/P cataract sx) . Significant generalized pitting\n edema +4. Pedal pulses dopplerable. Moves extremities on the bed.\n Received 3 L IVF at Ed for Sinus tachy episode ( HR at 130\ns). Upon\n arrival to ICU he has been Sinus tachy mostly., satting at high 90\n nasal cannula. Febrile : T max : 102.2 ( Oral) . Lungs rhonchous &\n insp/exp wheezing bilat. Drug Rash present all over the body from\n Ceft & ampi at rehab, switched to Daptomycin as recommended by ID.\n Monitor shows Sinus tachy with no ectopics. HR went upto 150\ns for a\n brief period with movement/turning. Foleys cath in place , placed at\n ED today Patient has had PICC at rt AC , Non-functioning. Received 3 L\n NS at ED. Received Morphine sulfate 4 mg X3 at ED. Received Vancomycin\n 1 gm & Aztreonam 1 gm IV & 650 mg Tylenol Supp at ED. CT head done for\n ? mental status changes. Incission at back from recent surgery for\n Epidural abscess on /09l close approximated, opens to\n air.Abrasion at perineal area. UOP at 10-30 ml/hr. Contact precautions\n for VRE Pos.\n Action:\n CXR done upon arrival to MICU 07, Atrovent nebs given. IV nurse pulled\n out PICC line & tip sent for culture. Blood culture & Urine culture\n send. Tylenol Sup given. Weaned O2 to 4 L from NRM. Ct head done.\n Neurosurgery consulted. ABG done upon arrival. Pain meds held off at\n this time for ? mental status. restart pain meds once mental\n status improves. .\n Response:\n CXR showing RLL infiltration. Ct head Negative. Na : 132, HCT :\n 25.8, WBC : 12.9. Trop : 0.07 & CK : 213. Last ABG : 7.38/37/76. T :\n 98.4 after Tylenol sups.\n Plan:\n Plan for MRI head & Spine. Plan for Echo today to R/O abscess.\n Follow fever curve. Closely monitor Heart rate & resp status. Cont\n monitoring Mental status closely. Need good pain control regimen.\n Wean off O2 as tolerated. need Nasotracheal suctioning if needed.\n F/u with lab results. F/U with ID for coverage.\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705940, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing discitis and\n osteomyelitis of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition: NPO, SLP consult\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 44 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705955, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - restart coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Rehab Services", "chartdate": "2146-10-20 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 705956, "text": "TITLE: DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on from\n rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have pan-sensitive\n enteroccus fecalis AV endocarditis, bacteremia, spinal epidural abscess\n s/p L5 & S1 laminectomy and abscess decompression on , as well as\n neurologic microabscesses. He was readmitted with rash, persistent\n fevers. Portable CXR with possible retrocardiac infiltrate so started\n empirically on antibiotics for possible pneumonia. Then repeat CXR with\n RLL opacity. We were consulted to evaluate oral and pharyngeal swallow\n function to determine if aspiration/dysphagia could be contributing to\n current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the previous\n admission. Was initially recommended for soft solids and nectar thick\n liquids on with aspiration of thin liquids. Etiology of dysphagia\n was suggested to be either related to medications or neuro issues. On\n , re-evaluated and cleared for diet upgrade to soft solids and\n thin liquids, as dysphagia was resolving. Records from \n Hospital state pt on house diet with supplements TID.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n RN, pt's daughter fed him on without overt difficulties (on\n regular diet/thin liquids). On evening , pt had episode of desat\n to high 80s, required NRB. MD notes from AM suggest need to remain NPO\n pending possible intubation, though consult placed mid-day. Currently\n sating in mid-90s on 100% O2 via face mask. RN feels not appropriate\n for PO today. We will return tomorrow morning to attempt the\n evaluation, if stable. Pending our evaluation, encourage maintaining\n NPO except essential meds and ice chips for comfort, both with strict\n 1:1 supervision by RN for aspiration precautions.\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705957, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of head and spine\n showing ? L1 osteomylitis. Incission at back from recent surgery for\n Epidural abscess on - approximated, open to air. Sm. Abrasion\n at perineal area. UOP at 40-60 ml/hr. Contact precautions for MRSA.\n Repeat Bld cx\ns done this am. Pt with history of aortic vegetation\n seen on TEE last admission.\n Action:\n MRI brain, and MRI L-spine done, receive GAT contrast dye for exam.\n Phone consent done in mri suite. - Pt and family aware of risks r/t\n kidneys, On vanco and aztreonam for coverage. Pt received lopressor 5mg\n ivp for 2^nd episode of raf with fair response. Cxr done and showed\n worsenin of rll infiltrate. Pt very wheezy and wob increased with resp\n rate as high as the 40\ns. nt sx\nd , med with morphine for pain. O2\n increased to high flow neb with 4 liter nc.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. o2 sat\ns in\n the mid 90s.\n Plan:\n Pt now cont taking off o2, need to check pt freq otherwise o2 sat\n down in the low 80\ns. keep right side down. Pulm toileting as\n tolerated. Morphine for pain.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. LE. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch removed. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705958, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705901, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705902, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n .\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n .\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705920, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing osteo of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n #Acute respiratory distress: initially tachypneic and on NRB- improved\n after a nebulizer with oxygen weaned to 4 liters n.c. This likely\n represents PNA vs aspiration with underlying asthma\n - Wean oxygen as tolerated\n - nebulizers prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705923, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing discitis and\n osteomyelitis of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - Wean oxygen as tolerated\n - Nebulizers prn\n - Continue antibiotics\n ICU Care\n Nutrition: NPO, SLP consult\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Echo", "chartdate": "2146-10-24 00:00:00.000", "description": "Report", "row_id": 84461, "text": "PATIENT/TEST INFORMATION:\nIndication: Prior aortic vegetation. Recurrent enterococcus bacteremia. Rule out recurrent endocarditis.\nHeight: (in) 55\nWeight (lb): 140\nBSA (m2): 1.51 m2\nBP (mm Hg): 140/75\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:35\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of\nthe RA. Good RAA ejection velocity (>20cm/s). No thrombus in the RAA.\nLipomatous hypertrophy of the interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTA: Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Small vegetation on\naortic valve. Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nLeft pleural effusion.\n\nConclusions:\nNo spontaneous echo contrast or mass/thrombus is seen in the left atrium/left\natrial appendage. Mild spontaneous echo contrast is seen in the body of the\nright atrium. No thrombus or spontaneous echo contrast is seen in the body of\nthe right atrium or right atrial appendage (heavily trabeculated). Right\natrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect\nis seen by 2D or color Doppler. Overall left ventricular systolic function is\nnormal (LVEF>55%). There are complex (>4mm, non-mobile) atheroma in the\ndescending thoracic aorta and aortic arch. The aortic valve leaflets (3) are\nmildly thickened. A small vegetation (4mm) is seen in the LVOT side of the\naortic valve. There is no associated abscess. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is\nseen. There is a trivial/physiologic circumferential pericardial effusion.\n\nIMPRESSION: Mild-moderate aortic regurgitation with small vegetation. Mild\nmiltral regurgitation. No intra-atrial thrombi identified.\nCompared with the prior TEE study (images reviewed) of , severity of\naortic regurgitation is greater and the aortic valve vegetation is smaller.\nThe previously noted right atrial appendage thrombus appears to be\ntrabeculations in the RAA.\n\n\n" }, { "category": "Echo", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 84462, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 122/51\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 12:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. A vegetation or abscess cannot be adequately excluded. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is a small\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , mitral\nregurgitation is now more prominent.\nUnable to adequately compare presence/absence or size of aortic valve\nvegetation identified in the transesophageal echocardiogram. The\nsmall pericardial effusion appears similar.\n\n\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705770, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain to touch. Picc line pulled and\n tip sent for culture.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Rehab meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Epidural abscess\n - Possible septic emboli vs infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in , English speaking\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: normal turgor, warm, no rashes\n Neurologic: Responds to: verbal commands, Oriented (to):\n Person/Place/Year, Movement: Wiggles b/l toes, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n #Acute respiratory distress: initially tachypneic and on NRB- improved\n after a nebulizer with oxygen weaned to 4 liters n.c. This likely\n represents PNA vs aspiration with underlying asthma\n - Wean oxygen as tolerated\n - nebulizers prn\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707838, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n This pm started having muscle twitching of right\n shoulder. Awake at the time and able to nod to questions. Dr\n made aware. Will see if she can find a muscle relaxant that\n will not effect his level of awakeness.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile. Temp max 98.2.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400. resp around 9 with tv around 700cc. sats 98%.\n Abg 7.44/44/103/31/ . Rested on 5 and 5.\n Plan:\n ? extubate in am.\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Cont to sleep when not stimulation. When stimulated awakens and obeys\n commands. Nods to questions.\n Plan:\n Wean Fentanyl drip further tomorrow.\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc. Wife in later in\n day and updated on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707942, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707944, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Extubate today\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever. Now\n afebrile x 24 hours.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responsive today. Head CT unremarkable.\n - Off sedation\n - Will assess pain once extubated and consider pain consult\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO. Will need formal assessment for aspiration before\n starting any POs.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707946, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Will need formal speech and swallow consult prior to starting po\n Without ngt at present.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Rehab Services", "chartdate": "2146-11-02 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 707948, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: respiratory failure / 088.81\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 76 yo M with recent\n admission enterococcal aortic valve endocarditis, NSTEMI, ARF,\n and L5 epidural abscess s/p laminectomy. He is now admitted from rehab\n on with fevers and lethargy c/w aspiration pneumonia and was\n subsequently intubated for dense large R-sided infiltrate. Extubated\n .\n Past Medical / Surgical History: BPH, gout, CKD\n Medications: aspirin, heparin, tylenol, amiodarone, gabapentin,\n fentanyl, lactulose, hydralazine, daptomycin\n Radiology: CXR - Increasing opacification at the left base in the\n retrocardiac region is consistent with substantial left lower lung\n atelectasis\n Labs:\n 23.0\n 7.1\n 380\n 9.1\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest, ok for EOB activity\n Social / Occupational History: retired, lives with wife and family.\n more recently at rehab.\n Living Environment: multi-level home with flight of stairs to enter\n Prior Functional Status / Activity Level: Ind prior to initial\n admission, more recently at rehab however per daughter has not been\n mobilizing there.\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic but easily\n arousable, follows all simple commands, oriented to self and place,\n . Hypophonic, minimally verbal.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 90\n 162/50\n 97% on FT\n Activity\n 92\n 185/62\n 96% on FT\n Recovery\n 90\n 152/52\n 96% on FT\n Total distance walked:\n Minutes:\n Pulmonary Status: coarse upper BS R>L, strong congested cough, did not\n expectorate. Tolerated gentle percussion to B lung fields in sitting.\n On 40% FiO2 via face tent.\n Integumentary / Vascular: L radial a-line, RIJ multilumen, foley,\n rectal tube, R PIV, tele\n Sensory Integrity: B LE's intact to light touch, denies parasthesias\n Pain / Limiting Symptoms: denies pain however grimaces with LLE ROM and\n mobility, hypersensitive\n Posture: mild kyphosis\n Range of Motion\n Muscle Performance\n B LE's grossly WNL, B gastroc tightness\n moves BLE extremities against gravity, not tolerating resistance.\n B UE's grossly t/o\n Motor Function: rapid flexion reaction to ROM LLE.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: not assessed\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: able to maintain static sitting at edge of bed with min-mod A.\n Tolerated sitting at edge of bed for several minutes, limited by\n increased BP requiring return to supine.\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n 5.\n Impaired pulmonary hygiene\n 6.\n Increased pain\n Clinical impression / Prognosis: 76 yo M with respiratory failure p/w\n above impairments a/w ventilatory pump dysfunction. He is most limited\n by general weakness and deconditioning a/w prolonged icu\n hospitalization and bedrest, as well as Le hip and knee pain. He is\n significantly below his baseline level and would recommend rehab upon\n d/c. Prognosis remains guarded given his age and prolonged and\n complicated medical course, however would anticipate fair to good rehab\n potential given his prior level of function and his home support. PT\n to continue to follow and progress as able at acute level.\n Goals\n Time frame: 1 week\n 1.\n Mod A bed mobility, assess transfers\n 2.\n CG static/dynamic sitting, assess standing balance\n 3.\n Tolerate OOB >/= 2 hours/day\n 4.\n Tolerates daily strengthening\n 5.\n Able to clear secretions independently\n 6.\n Tolerates PT/OOB mobility despite pain\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, ambulation, balance, strengthening, chest PT,\n endurance, education, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707951, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707952, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds will be held tonight including neurotin and amiodarone.\n Dr aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Extubated at 1115. pos cuff leak prior to\n extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Weaned to 2l nc with sats in mid 90\ns. Could not get the grasp of how\n to use is. Encouraged to take deep breaths and cough which he does\n well. Coughing and raising thick yellow sputum.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708045, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708046, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics, on Dapto for treatment of Enterococcus.\n SBT went well this morning, not extubated and doing well on face tent.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS done yesterday negative for clot. Left knee not tender to\n palpation today, less concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/rising leukocytosis: Improved today, afebrile overnight,\n likely drug fever/rash, now improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708218, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n ( drug fever and rashes from other antibiotics)\n # Pain:\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708223, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708228, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708232, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n - Auto\ndiuresed overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: voice\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg] ALT 43, AST 32, Alk phos 165, LDH 262\n Sputum: S aureus\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - continue 2 week course of Dapto\nfinal day \n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: resolved.\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - Increase metoprolol to 37.5 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , d/c amiodarone today\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ, PICC line placement today\n # CODE: Full Code\n # DISPO: case management re: d/c to LTAC tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708348, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n ULTRASOUND - At 01:00 PM\n of right arm\n PICC LINE - START 02:53 PM\n RUE US: + for superficial cephalic vein clot\n PICC line placed\n Has a bed for rehab\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 85 (80 - 96) bpm\n BP: 130/58(75) {128/57(75) - 175/88(100)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 937 mL\n PO:\n TF:\n 836 mL\n 244 mL\n IVF:\n 455 mL\n 393 mL\n Blood products:\n Total out:\n 2,415 mL\n 370 mL\n Urine:\n 1,915 mL\n 370 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 765 K/uL\n 7.8 g/dL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presented from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - continue 2 week course of Dapto\nfinal day \n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: resolved.\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - Increase metoprolol to 37.5 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , d/c amiodarone today\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ, PICC line placement today\n # CODE: Full Code\n # DISPO: case management re: d/c to LTAC tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708355, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in 180\ns in the begning of shift\n Action:\n Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and\n Lopressor\n Response:\n Sbp in the 140\ns. Of not his cuff for bp is on his leg as he has a picc\n on the left arm and a clot is his right arm.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707386, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Suctioning yellow secreations via ett lung sound diminished in bases\n pt remains on a lasix drip at 2 mg /hr.\n Response:\n pending\n Plan:\n Wean vent\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n Cont on neurontin, Grimacing for any simple touch on him, Bolused w/\n Fentanyl and versed before doing any care on him. MRI done result\n pending.\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Follow MRI result and neuro team, ? pain consult.\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707390, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: )\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP\n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707543, "text": "Chief Complaint: AMS, aspiration\n HPI:\n I saw and examined the patient, and was physically present with Dr.\n for key portions of the services provided. I agree with the\n medicine resident note and would add / emphasize and add the following\n points:\n 24 Hour Events:\n Fever to 102, PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n - MRI per ID and NeuroSurg not concerning for new infectious process\n - Taper MRI\n - Versed gtt d/c\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Lidoderm patch, ASA, Lipitor. Fentanyl patch, Neurontin, Amiodarone\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), RRR\n Peripheral Vascular: (Right radial pulse: palpable), (Left radial\n pulse: palpable), (Right DP pulse: palpable), (Left DP pulse: palpable)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilaterally )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: No rash\n Ext: Bilat LE edema to mid shin, warm L knee, L ankle, no effusion\n Neurologic: Responds to: painful stimuli, moves extremities to stimuli;\n no spont movement\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Sputum\n MRSA\n Urine legionella Negative\n C Diff negative\n Blood Cx NGTD\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, mental status is main barrier\n currently to extubation.\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout,\n Rheum eval for ?tap ?gout\n if ID w/u is otherwise negative, would\n consider pred for gout flare.\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition: On TFs\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: PPI\n VAP: HOB at 30 degrees, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Pt is critically ill.\n Total time spent: 35 min\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707619, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707620, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -stop Lasix gtt as UOP decreased on 12mg/hr\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today and SBT\n - ET tube at 8cm yesterday will f/u today and advance ET as needed\n # L leg contracture: Given tenderness of Left knee on exam, likely \n gouty arthritis\n -patient given prednisone this morning but will hold off on more\n prednisone for now, will consult Rheum for definitive diagnosis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest today to look for intraabdominal source, pulmonary\n source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2146-10-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 707314, "text": "Objective\n Pertinent medications: Fentanyl drip, versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole\n Labs:\n Value\n Date\n Glucose\n 108 mg/dL\n 05:41 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 46 mg/dL\n 05:41 AM\n Creatinine\n 2.5 mg/dL\n 05:41 AM\n Sodium\n 141 mEq/L\n 05:41 AM\n Potassium\n 4.1 mEq/L\n 05:41 AM\n Chloride\n 106 mEq/L\n 05:41 AM\n TCO2\n 28 mEq/L\n 05:41 AM\n PO2 (arterial)\n 251 mm Hg\n 06:01 AM\n PCO2 (arterial)\n 43 mm Hg\n 06:01 AM\n pH (arterial)\n 7.44 units\n 06:01 AM\n pH (urine)\n 5.0 units\n 08:35 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 06:01 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.2 mg/dL\n 05:41 AM\n Phosphorus\n 3.7 mg/dL\n 05:41 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.0 mg/dL\n 05:41 AM\n ALT\n 58 IU/L\n 04:15 AM\n Alkaline Phosphate\n 203 IU/L\n 04:15 AM\n AST\n 36 IU/L\n 04:15 AM\n Total Bilirubin\n 0.6 mg/dL\n 04:15 AM\n WBC\n 12.9 K/uL\n 05:41 AM\n Hgb\n 8.0 g/dL\n 05:41 AM\n Hematocrit\n 25.2 %\n 05:41 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren 2.0 @ 42ml/hr\n GI: soft/distended, (+) bowel sounds; loose-liquid stool\n Assessment of Nutritional Status\n Specifics:\n Patient with aspiration PNA with dense, large R-sided infiltrate, now\n improving, (+) persistent fevers. Tube feed changed to very\n concentrated formula as team trying to diuresis patient.\n Currently, tube feed running at 40ml/hr. Liquid/loose bm after 3 days\n of polyethylene glycol. Possible extubation over the weekend. Noted\n lytes/ FSBG WNL.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Increase tube feed to goal of\n 42ml/hr = calories and 81g protein\n o Check residuals, hold tube feed if greater than 200ml\n Bowel regimen PRN\n Check chemistry 10 panel\n If extubated, recommend NPO until seen by SLP for bedside\n evaluation\n SLP deferred evaluation due to intubation\n Will follow, page if questions \n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707612, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Cont on fentanyl GTT still grimacing w/ activity but relatively less.,\n Fent weaned to 50mics/kg/min.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% CMV/10/5/5\n Action:\n No vent changes overnight. Suctioned for moderate amount blood tinged\n secretion\n Response:\n Pending\n Plan:\n Continue to attempt to wean sedation and ?\ning extubation in the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 40-60cc u/o.\n Action:\n monitiring\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708402, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC placed yest, RUE US yest with superficial cephalic v clot.\n History obtained from Medical records\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Lidocaine patch, ASA, Heparin SC, Lipitor, Neurontin, fentanyl patch,\n hydralazine, amlodipine, metoprolol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 78 (78 - 90) bpm\n BP: 142/71(89) {128/54(72) - 175/88(100)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 1,443 mL\n PO:\n TF:\n 836 mL\n 468 mL\n IVF:\n 455 mL\n 425 mL\n Blood products:\n Total out:\n 2,415 mL\n 630 mL\n Urine:\n 1,915 mL\n 630 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, 2+ UE edema bilaterally\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.8 g/dL\n 765 K/uL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Imaging: RUE US- superficial cephalic v clot.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA now\n improving and extubated .\n HAP/aspiration PNA + pulmonary edema- Extubated and resolved\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n - repeat echo without abscess or vegetations\n L5-S1 discitis/ osteomyelitis: stable from to MRI\n -will touch base re: f/u and tx for this as separate from endocarditis\n Hypernatremia: stabilized and not improved with increased free H2O\n flushes yest\n - cont enteric free H20, will give 500cc D5W today as well and monitor\n RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n Afib RVR: resolved\n - now off amio and in sinus\n - no anticoag at this time, will f/u with Cards as an outpt\n HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n Aspiration risk: Failed swallow study with tachypnea, desaturation and\n evidence of applesauce in pharynx.\n - Dobhoff placed and will cont tube feeds\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Comments: 250 q4 free H2O\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 45 minutes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707277, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains minimally vent supported on PSV/CPAP. No changes made\n overnight. Administering Albuterol and Atrovent MDI\ns as ordered.\n Legionella cx sent. See flowsheet for further pt data. Will follow,\n wean as tolerable.\n 06:15\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707280, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Clindamycin d/c\nd and stool for Cdiff sent. Results are pending at this\n time. Otherwise continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN\n Transfused 1U PRBC\ns last evening. Pt is a difficult cross match-\n blood from blood bank. Resident aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Lasix gtt infusing at 3mg/hr. Plan to\n run pt. -2 liters.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable. Pt. met goal of -2.5\n liters at midnight.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707290, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707374, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation \n RSBI 18\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 2330\n MRI L-spine without incident\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707499, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707456, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contracted. MRI of spine\n showed no changes from previous one, no abscess or cord compression\n noted. When not stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl and Versed with any activity. PO Neurontin\n increased to 300mg PO bid and increased Fentanyl patch from 100mcq to\n 200mcq.\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently..\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results. IV antibx\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707526, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707721, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500. NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708365, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in 180\ns in the begning of shift\n Action:\n Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and\n Lopressor\n Response:\n Sbp in the 140\ns. Of not his cuff for bp is on his leg as he has a picc\n on the left arm and a clot is his right arm.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n ------ Protected Section ------\n Screening for rehab, Follow up w/ case manager in am.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:47 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707369, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Suctioning this yellow secreations out or mouth and yellow secreation\n via ett lung sound diminished in bases pt remains on a lasix drip at 2\n mg /hr\n Response:\n pending\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707502, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -daily chest x-rays\n # L leg contracture: Concerning for central process vs. gouty\n arthiritis of knee given history of gout.\n -f/u MRI read\n -speak with neurosurgery regarding read\n -would not treat with gout medications right now given renal function.\n If above are negative, consider prednisone for gouty arthritis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -increase gabapentin to 300 po tid\n -increase Fentanyl patch to 200mcg/72 hours\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n -repeat C diff\n -consider CT abdomen to look for intraabdominal source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n - change to Amio 200 tid starting \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: continue to follow\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707503, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contracted. When not\n stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl with any activity. Versed GTT turned off @\n 0500\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently Lasix GTT 12mg /hr urine\n output 110-160ml/hr.\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102 PO 0400\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results. IV antibx\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707516, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 min\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708035, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc12.2 down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707600, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Cont on fentanyl GTT still grimacing w/ activity but relatively less.,\n Fent weaned to 50mics/kg/min.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% CMV/10/5/5\n Action:\n No vent changes overnight. Suctioned for moderate amount blood tinged\n secretion\n Response:\n Pending\n Plan:\n Continue to attempt to wean sedation and ?\ning extubation in the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 40-60cc u/o.\n Action:\n monitiring\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707603, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Comments: ETT advanced ~ 3 cm.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments: Low resp drine. Placed on MMV. Will atemp to place back on\n PSV.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~26.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707715, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli , obey simple commands at times. Was seen by pain mx\n yesterday . Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt\n stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head .\n Plan:\n Wean Fentanyl Gtt as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500. NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707588, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd on Lasix Gtt @ 12mg/hr with only 40-60cc u/o. BUN/Cre elevated to\n 49/2.5 from 46/2.2. K+4.5.\n Action:\n Lasix Gtt was d/c\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707705, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS now MMV apnea . CXR\n subsequently worsesend with reduced PEEP likely increased\n atelectasis. On Vanc (day 11 of 14) /Aztreonam (day 11 of 14)/ Clinda\n stopped on day 7 of 10\n -MMV\nPSV, wean sedation to decrease apnea\n -stop Vanc/Aztreonam for PNA per ID given course to date and rash\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today; c/s pain service for assistance\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Respiratory ", "chartdate": "2146-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707822, "text": "Demographics\n Day of mechanical ventilation: 13\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n ETT:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n :\n Comments: passed sbt. Good abg. Plan extubation tomorrow.\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707923, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707924, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Extubate today\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever. Now\n afebrile x 24 hours.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responsive today. Head CT unremarkable.\n - Off sedation\n - Will assess pain once extubated and consider pain consult\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO. Will need formal assessment for aspiration before\n starting any POs.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707928, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707929, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707931, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n GEN: Intubated, awake, responding to commands appropriately\n CVS: +S1/S2, no M/R/G, RRR\n LUNGS: CTAB in anterior lung fields\n ABD: +BS, soft, NT/ND\n EXT: +b/l upper extremity and lower extremity peripheral edema, +2\n pulses, no rashes, no TTP of left knee\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics, on Dapto for treatment of Enterococcus.\n SBT went well this morning, not extubated and doing well on face tent.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS done yesterday negative for clot. Left knee not tender to\n palpation today, less concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/rising leukocytosis: Improved today, afebrile overnight,\n likely drug fever/rash, now improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707343, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Pt been on since around 12 noon, suctioning this yellow secreations\n out or mouth and yellow secreation via ett lung sound diminished in\n bases pt remains on a lasix drip at 2 mg /hr\n Response:\n Abg on above settings 7.42/45/116\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707423, "text": "Chief Complaint: Aspiration, Atrial Fibrillation\n HPI:\n 24 Hour Events:\n -- Found to have contracted LLE contracture, concern for cord\n compression, obtained MRI after discussion with Neurosurgery\n -- Marked pain, P-boots d/c\nd, neurontin increased\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Other medications:\n ASA, Amiodarone, Hep sc, Lipitor, atrovent, neurontin, lidoderm patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: bounding), (Left radial\n pulse: bounding), (Right DP pulse: dopplerable), (Left DP pulse:\n Dopplerable)\n Respiratory / Chest: (Breath Sounds: Crackles and Diminished at bases:\n )\n Skin: Not assessed\n Ext: L knee flexed, slightly warm, anasarcic\n Neurologic: Grimaces in pain\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Urine Culture\n Pending\n C. Diff\n Negative x2\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: Protonix\n VAP: Chlorhexidine, Elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707347, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt changed to CPAP/PS today.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707350, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Pt been on since around 12 noon, suctioning this yellow secreations\n out or mouth and yellow secreation via ett lung sound diminished in\n bases pt remains on a lasix drip at 2 mg /hr\n Response:\n Abg on above settings 7.42/45/116\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n ------ Protected Section ------\n Consult came by neurosurg tonight because of contracture of left hip,\n will be put in for an mri tonight, for rule out cord compression.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:52 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707433, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contact. MRI of spine showed\n no changes from previous one, no abscess or cord compression noted.\n When not stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl and Versed with any activity. PO Neurontin\n increased to 300mg PO bid and increased Fentanyl patch from 100mcq to\n 200mcq.\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently..\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results.\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707358, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n RRR, no mr/r/g, lungs clear on anterior exam, 2+ pitting edema in lower\n ext., hyperesthesia over lower exts. Abd mildly TTP diffusely, no\n guarding or rebund, warm ext\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 9 of 14) /Aztreonam (day 9 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707811, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400. resp around 9 with tv around 700cc. sats 98%.\n Abg 7.44/44/103/31/ . Rested on 5 and 5.\n Plan:\n ? extubate in am.\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Cont to sleep when not stimulation. When stimulated awakens and obeys\n commands. Nods to questions.\n Plan:\n Wean Fentanyl drip further tomorrow.\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708032, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc12.2 down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707410, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remain on Aztreonam IV.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707413, "text": "Chief Complaint: Aspiration, Atrial Fibrillation\n HPI:\n 24 Hour Events:\n -- Found to have contracted LLE contracture, concern for cord\n compression, obtained MRI after discussion with Neurosurgery\n -- Marked pain, P-boots d/c\nd, neurontin increased\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Other medications:\n ASA, Amiodarone, Hep sc, Lipitor, atrovent, neurontin, lidoderm patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: bounding), (Left radial\n pulse: bounding), (Right DP pulse: dopplerable), (Left DP pulse:\n Dopplerable)\n Respiratory / Chest: (Breath Sounds: Crackles and Diminished at bases:\n )\n Skin: Not assessed\n Ext: L knee flexed, slightly warm, anasarcic\n Neurologic: Grimaces in pain\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Urine Culture\n Pending\n C. Diff\n Negative x2\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: Protonix\n VAP: Chlorhexidine, Elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent: 25\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707417, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Intubated, sedated. Grimaces with pain\n CV: RRR. No murmurs.\n Lungs: CTAB on anterior exam. No wheezes or crackles.\n Abdomen: Soft, NT, ND. No masses\n Extremities: L leg contracted. Pain with movement. L knee may be warm,\n though no effusion or erythema.\n R leg without contracture. 1+ DP and PT pulses bilaterally.\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg] UA +, UCx pending\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -daily chest x-rays\n # L leg contracture: Concerning for central process vs. gouty\n arthiritis of knee given history of gout.\n -f/u MRI read\n -speak with neurosurgery regarding read\n -would not treat with gout medications right now given renal function.\n If above are negative, consider prednisone for gouty arthritis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -increase gabapentin to 300 po tid\n -increase Fentanyl patch to 200mcg/72 hours\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n -repeat C diff\n -consider CT abdomen to look for intraabdominal source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n - change to Amio 200 tid starting \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: continue to follow\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707692, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.3 in this shift,am labs with wbc 17,pt had evolved new drug\n rash in the abdomen,thigh and left arm predominantly\n Action:\n d/ced vanco and aztrenem,changed to daptomycin ,received 1^st dose\n today,also given Tylenol 650mg x1 ,pt had undergone usg of the rt knee\n to r/out any effusion\n Response:\n Pt had undergone ct of abd pelvis,chest head yesterday,no souce of\n infection ct chest shows improving pnuemonia\n Plan:\n Monitor temps, continue IV antibx\ns, follow final cx and senitivities\n Chronic Pain\n Assessment:\n Pt extremely grimaces with pain,especially with left knee,left knee is\n contracted,even with slight slight pt grimaces,poorly tolerates\n turns,received the pt on fent patch 50mcg and fent patch 200mcg.\n Action:\n Pt had pain consult today,fent drip incrased to 75 but patch decreased\n to 100mcg/hr,contd gabapentin and Lidocaine patch\n Response:\n Pt was better until around 4pm,becomes more awake even though doesn\n follow commands,but become grimacing very bad and becomes more\n tachycardic and hypertensive,pain team wants to cut it down fent and\n lean forward for extubation\n Plan:\n Continue with Fentanyl gtt,will titrate up if needed,monitor bowel\n function with fent use\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on MMV 40%,10,,sats 96-100%,ronchorous breath\n sounds,\n Action:\n Vent settings changed to cpap/spsv 5/.5,sedation weaned\n slightly,suctioned as needed\n Response:\n Pt MS this am,arousable with stimulation,pt was getting\n apnic spells,pt was more asouable this afternoon,apparently it was\n noted pt was more hypertensive tachycardic around 5pm with increased\n secretions,suctioned for large amount of secretions ,and pt did vomit\n small amount of tube feed,pt didn\nt drop sats during this time,tube\n feed turned off and started NG to suction.mental status has been a\n limiting factor for extubation,abg was 7.41,44,116\n Plan:\n Will cont vent support,manage pain adequately,suction as needed,\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707804, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n - Rheum consult\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday. B/L LENIS negative per report.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707806, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Plan:\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707887, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n This pm started having muscle twitching of right\n shoulder. Awake at the time and able to nod to questions. Dr\n made aware. Will see if she can find a muscle relaxant that\n will not effect his level of awakeness.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600,\n Remains afebrile on IVAB\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707912, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday.\n Action:\n Cont on daptomycin.\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n mucha reaction from him.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708136, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708137, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Auto-diuresing, will dose lasix if not 1L neagtive at 8pm\n Picc line to be placed as needs dapto for VRE until \n ------ Protected Section Addendum Entered By: , MD\n on: 20:49 ------\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707401, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707403, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 9 of 14) /Aztreonam (day 9 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707479, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: remain on min PSV.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~84.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707563, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 27.2 ,\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707564, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 27.2 ,\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707565, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707566, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd on Lasix Gtt @ 12mg/hr with only 40-60cc u/o. BUN/Cre elevated to\n 49/2.5 from 46/2.2. K+4.5.\n Action:\n Lasix Gtt was d/c\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707689, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.3 in this shift,am labs with wbc 17,pt had evolved new drur\n rash in the abdomen,thigh and left arm predominantly\n Action:\n d/ced vanco and aztrenem,changed to daptomycin ,received 1^st dose\n today,also given Tylenol 650mg x1 ,pt had undergone usg of the rt knee\n to r/out any effusion\n Response:\n Pt had undergone ct of abd pelvis,chest head yesterday,no souce of\n infection ct chest shows improving pnuemonia\n Plan:\n Monitor temps, continue IV antibx\ns, follow final cx and senitivities\n Chronic Pain\n Assessment:\n Pt extremely grimace with pain,especially with left knee,left knee is\n contracted,even with slight slight pt grimaces,poorly tolerates\n turns,received the pt on fent patch 50mcg and fent pacth 200mcg.\n Action:\n Pt had pain consult today,fent drip incrased to 75 but patch decresed\n to 100mcg/hr\n Response:\n Pt was better until around 4pm,becomes more awake even thogh doesn\n follow commands,but become grimacing very bad and becomes more\n tachycardic and hypertensive,pain team wants to cut it the down fent\n and lean forward for extubation\n Plan:\n Continue with Fentanyl gtt,will titrate up if needed,monitor bowel\n function with fent use\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on MMV 40%,10,,sats 96-100%,ronchorous breath\n sounds,\n Action:\n Vent settings changed to cpap/spsv 5/.5,sedation weaned\n slightly,suctioned as needed\n Response:\n Pt MS this am,arousable with stimulation,pt was getting\n apnic spells,pt was more asouable this afternoon\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nutrition", "chartdate": "2146-11-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 707792, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 77.6 kg ( 08:00 AM)\n 27\n Pertinent medications: Fentanyl drip, Normal saline @ 10ml/hr,\n Pantoprazole, Heparin\n Labs:\n Value\n Date\n Glucose\n 125 mg/dL\n 04:40 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 57 mg/dL\n 04:40 AM\n Creatinine\n 2.3 mg/dL\n 04:40 AM\n Sodium\n 139 mEq/L\n 04:40 AM\n Potassium\n 4.4 mEq/L\n 04:40 AM\n Chloride\n 103 mEq/L\n 04:40 AM\n TCO2\n 28 mEq/L\n 04:40 AM\n PO2 (arterial)\n 222 mm Hg\n 05:05 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:05 AM\n pH (arterial)\n 7.46 units\n 05:05 AM\n pH (urine)\n 5.0 units\n 08:23 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 05:05 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.3 mg/dL\n 04:40 AM\n Phosphorus\n 3.2 mg/dL\n 04:40 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.1 mg/dL\n 04:40 AM\n ALT\n 44 IU/L\n 05:01 AM\n Alkaline Phosphate\n 183 IU/L\n 05:01 AM\n AST\n 40 IU/L\n 05:01 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:01 AM\n WBC\n 19.2 K/uL\n 04:40 AM\n Hgb\n 8.3 g/dL\n 04:40 AM\n Hematocrit\n 26.3 %\n 04:40 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: OFF (Nutren 2.0 @ 42ml/hr = calories and 81g protein)\n GI: soft, (+) bowel sounds; guiac negative loose stool\n Assessment of Nutritional Status\n Specifics:\n Patient presents with aspiration PNA with dense, large R-sided\n infiltrate, now improving. Remains intubated/sedated. Patient was\n tolerating tube feed at goal until episode of emesis pm. Tube\n feed on hold since with NGT to intermittent suction. Possible\n extubation today, if not then plan to discuss tracheostomy with\n family. (+) stooling after Lactulose last night.\n Medical Nutrition Therapy Plan - Recommend the Following\n If unable to extubate, recommend restart tube feeds\n o Check residuals, hold tube feeds if greater than 200ml\n o Monitor for N/V\n o Consider starting Reglan\n If extubated, recommend restart tube feeds for now\n o Consult SLP for swallowing evaluation before beginning po\n diet\n SLP was following before intubation\n o Patient may need tube feeds for full or supplemental\n nutrition support even if po diet started\n Check chemistry 10 panel daily\n Will follow, page if questions \n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707885, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707886, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Respiratory ", "chartdate": "2146-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707892, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707893, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation\n . VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708128, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing IV hydral per order, pt started on PO hydral, \n taken to check correlation. Pain treated.\n Response:\n Pt\ns ABP with no significant change after IV hydral, PO hydral with\n mild improvement. Pt\ns systolic 20 points lower than ABP.\n Pt denies pain when at rest.\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO.\n Action:\n Speech and swallow eval done at bedside with pt upright in chair, pt\n grossly failed and had post pyloric dobhoff placed in IR today.\n Response:\n Pt now receiving PO meds through the dobhoff.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, he did get up to the stretcher chair x3hours. A new\n Fentanyl patch was placed, Lidocaine patch per order, restarted on his\n PO/NG neurontin.\n Response:\n Although pt with deny pain when he is laying down he does still grimace\n with movement, however, nurses more familiar with the patient have\n stated his pain appears to be more under control than in previous\n shift.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC, LSCTA bilaterally.\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions and provide frequently mouth\n care.\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707408, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707562, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707639, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, mental status is main barrier\n currently to extubation.\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout,\n Rheum eval for ?tap ?gout\n if ID w/u is otherwise negative, would\n consider pred for gout flare.\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707783, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C. diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Wean sedation\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707784, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n - Rheum consult\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday. B/L LENIS negative per report.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707787, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin.\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands.\n Action:\n Weaning fentanyl drip.\n Response:\n Plan:\n Social- patient\ns daughter called and was updated by this nurse.\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707788, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n - rheum c/s concerned for septic joint and dvt\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation .\n VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition: tube feeds on hold in anticipation of SBT this pm\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP: routine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707874, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707875, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation\n . VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708003, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down to 14.2 Drug rash all over body slowly\n improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Extubated at 1115. pos cuff leak prior to\n extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Weaned to 2l nc with sats in mid 90\ns. Could not get the grasp of how\n to use is. Encouraged to take deep breaths and cough which he does\n well. Coughing and raising thick yellow sputum.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708005, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708006, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708190, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708191, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n - Auto -diuresisng\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707645, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - Pain consult\n - I/Os even\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Pain consult.\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707652, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - Pain consult\n - I/Os even\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Pain consult.\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2146-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707674, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ? extubation in the am.\n Reason for continuing current ventilatory support: Cannot protect\n airway\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707741, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\ns. WBC uo to 19.2 from\n 17.0\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Et # 7.5 , 26 cm at teeth. Bilat breathing sounds auscultated.\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, , 40% at 0515 am. Patient seems more awake at this time,\n following simple commands at times. . NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm. Last ABG ( AC/40%/X16/500) :\n 7.46/41/222/5/30\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-180\ns. Minimal response to PO hydralazine. MD made aware.\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n [image002.jpg]\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707761, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707763, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS now MMV apnea . CXR\n subsequently worsesend with reduced PEEP likely increased\n atelectasis. On Vanc (day 11 of 14) /Aztreonam (day 11 of 14)/ Clinda\n stopped on day 7 of 10\n -MMV\nPSV, wean sedation to decrease apnea\n -stop Vanc/Aztreonam for PNA per ID given course to date and rash\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today; c/s pain service for assistance\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708180, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive most of the shift.\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert and oriented 1 to 2, occasionally he is able to say that he\n is in the hospital. Has short term memory loss, Put legs through side\n rails and try to come out of bed, Denies pain.\n Action:\n Reoriented frequently, Bed alarm on,\n Response:\n Cont to be confused\n Plan:\n Monitoring and frequent reorientation\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708346, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n ULTRASOUND - At 01:00 PM\n of right arm\n PICC LINE - START 02:53 PM\n RUE US: + for superficial cephalic vein clot\n PICC line placed\n Has a bed for rehab\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 85 (80 - 96) bpm\n BP: 130/58(75) {128/57(75) - 175/88(100)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 937 mL\n PO:\n TF:\n 836 mL\n 244 mL\n IVF:\n 455 mL\n 393 mL\n Blood products:\n Total out:\n 2,415 mL\n 370 mL\n Urine:\n 1,915 mL\n 370 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 765 K/uL\n 7.8 g/dL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707728, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, at 0515 am. Patient seems more awake at this time, following\n simple commands at times. . NG tube connected to LIS. Tube feeding has\n been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707729, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Et # 7.5 , 26 cm at teeth. Bilat breathing sounds auscultated.\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, at 0515 am. Patient seems more awake at this time, following\n simple commands at times. . NG tube connected to LIS. Tube feeding has\n been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-180\ns. Minimal response to PO hydralazine. MD made aware.\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Respiratory ", "chartdate": "2146-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707732, "text": "Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707746, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708178, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive,\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708283, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in the 160\ns this am.\n Action:\n Cont on hydralazine and amlodipine. Lopressor increased to 37.5mg tid\n today from 25mg.\n Response:\n Sbp in the 140\ns. after picc line repositioned his sbp up to170\ns. he\n was due for his hydralazine which he just received. Of not his cuff for\n bp is on his leg as he has a picc on the left arm and a clot is his\n right.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n son and daughter in at different times today. Updated on poc.\n Plan is for ? rehab tomorrow. He has a bed most likely at .\n Case management will check on sat to see if he is ready and bed is\n available.\n" }, { "category": "General", "chartdate": "2146-10-31 00:00:00.000", "description": "Generic Note", "row_id": 707631, "text": "TITLE:\n Rehab Services Physical Therapy: Events noted. Will f/u once sedation\n weaned to initiate PT eval. X32507\n" }, { "category": "Rehab Services", "chartdate": "2146-11-03 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 708087, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for referring this 76 yo man re-admitted on \nfrom rehab. Pt originally admitted approximately one month ago\n()with fevers and back pain, found to have\npan-sensitive enterococcus fecalis AV endocarditis, bacteremia,\nspinal epidural abscess s/p L5 and S1 laminectomy and abscess\ndecompression on , as well as neurologic microabscesses. He\nwas readmitted with rash, persistent fevers. Portable CXR with\npossible retrocardiac infiltrate so started empirically on\nantibiotics for possible pneumonia. Then repeat CXR with RLL\nopacity. We were consulted to evaluate oral and pharyngeal\nswallow function to determine if aspiration/dysphagia could be\ncontributing to current fever and opacity on CXR.\nPt is known to our department by four evaluations during the\nprevious admission. Was initially recommended for soft solids\nand nectar thick liquids on with aspiration of thin liquids.\nEtiology of dysphagia was suggested to be either related to\nmedications or neuro issues. On , re-evaluated and cleared\nfor diet upgrade to soft solids and thin liquids, as dysphagia\nwas resolving. Records from Hospital state pt on house\ndiet with supplements TID.\nWe attempted to see him this admission on but evaluation was\ndeferred possible intubation which occurred later on .\nChart documents witnessed aspiration with pills with worsened\nright sided infiltrate on CXR. Pt with MRSA in sputum. TEE showed\nsm vegetation and no clots. Pt had difficulty weaning from the\nvent but was extubated . Of note, pt had question of\naspiration of tube feeds with aspiration event, and tube feeds\nwere held the 2 days prior to extubation. Pt continues to be NPO\nand RN has held meds.\nPAST MEDICAL HISTORY:\n1. Osteoporosis\n2. Gout\n3. Cataracts\nPAST SURGICAL HISTORY:\ns/p cataract repair\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair in the MICU.\nCognition, language, speech, voice:\nPt was awake, but uncomfortable with reduced interaction. His\nvoice was initially aphonic, improved with ice chips and oral\nswabs. Pt was oriented and followed basic one step commands.\nTeeth: full set in average condition\nSecretions: dry oral mucosa with mild coating of dried secretions\n- wet cough before POs that was intermittently productive\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nPalatal elevation was symmetrical. Gag present with Yankauer\nsuctioning.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp), nectar thick\nliquids (tsp) and tsp of puree. Oral transit was timely and\nwithout oral cavity residue, but laryngeal elevation was mild to\nmoderately reduced to palpation.He had overt coughing after ice\nchips and water with desat to 95% and increase in RR to low 30s.\nPt had delayed cough after nectar liquids and reported puree was\nstuck in his throat. He was suctioned with return of apple sauce\nfrom the pharynx. He took swallows for all bites and sips. He\nhad increased SOB as the exam continued.\nSUMMARY / IMPRESSION:\nMr. is having mild difficulty tolerating secretions and had\novert signs of aspiration and pharyngeal residue with all boluses\ngiven. He had multiple episodes of desaturation and increase in\nRR and had observable SOB as the exam continued. He is not safe\nfor anything PO at this time, including meds which were not\ngiven. He will likely need to have the Dobbhoff replaced for\nalternate means of nutrition, hydration and medication.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 1.\nRECOMMENDATIONS:\n1. Suggest pt remain NPO, including ice chips and meds.\n2. Consider humidified shovel mask to assist with keeping oral\nmucosa moist.\n3. Pt will likely need to have Dobbhoff replaced.\n4. Q4 oral care.\n5. We will f/u early next week to repeat the evaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 9:30-9:45\nTotal time: 50 minutes\n [BUTTON Input] (not implemented)_____\n 01:10 PM\n" }, { "category": "Nutrition", "chartdate": "2146-11-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 708091, "text": "Subjective\n Patient off floor getting feeding tube placed\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 76.7 kg ( 07:00 AM)\n 27\n Pertinent medications: normal saline @ 10ml/hr, Pantoprazole, Heparin\n Labs:\n Value\n Date\n Glucose\n 92 mg/dL\n 03:36 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 49 mg/dL\n 03:36 AM\n Creatinine\n 2.0 mg/dL\n 03:36 AM\n Sodium\n 145 mEq/L\n 03:36 AM\n Potassium\n 4.0 mEq/L\n 03:36 AM\n Chloride\n 109 mEq/L\n 03:36 AM\n TCO2\n 25 mEq/L\n 03:36 AM\n PO2 (arterial)\n 98. mm Hg\n 12:10 PM\n PCO2 (arterial)\n 44 mm Hg\n 12:10 PM\n pH (arterial)\n 7.43 units\n 12:10 PM\n pH (urine)\n 5.0 units\n 08:23 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 12:10 PM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:36 AM\n Phosphorus\n 4.0 mg/dL\n 03:36 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.3 mg/dL\n 03:36 AM\n ALT\n 52 IU/L\n 03:36 AM\n Alkaline Phosphate\n 182 IU/L\n 03:36 AM\n AST\n 41 IU/L\n 03:36 AM\n Total Bilirubin\n 0.5 mg/dL\n 03:36 AM\n WBC\n 12.2 K/uL\n 03:36 AM\n Hgb\n 7.9 g/dL\n 03:36 AM\n Hematocrit\n 24.6 %\n 03:36 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: OFF - Nutren 2.0 @ 42ml/hr\n GI: soft, (+) bowel sounds; liquid stool\n Assessment of Nutritional Status\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n Patient with HAP/aspiration PNA + pulmonary edema. Extubated .\n Has been NPO and without enteral nutrition since after emesis.\n Seen by SLP today, who recommended NPO as patient having difficulty\n with secretions. MD, patient getting PPFT now. Patient also\n getting double lumen PICC with one port available for TPN if patient\n does not tolerate enteral nutrition. Agree with enteral nutrition for\n nutrition support while NPO. TPN may not decrease aspiration risk as\n patient can aspirate on own secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: NPO\n o After feeding tube placed and checked, resume tube feed\n o Nutren 2.0 @ 20ml/hr, advanced as tolerated to goal of\n 42ml/hr = calories and 81g protein\n Multivitamin / Mineral supplement: in tube feed\n No residual checks with PPFT, monitor abdominal exam; N/V\n Monitor hydration, Na; may need to change tube feed formula\n Check chemistry 10 panel daily\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708278, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray needs to be done to confirm placement.\n Hypertension, benign\n Assessment:\n Sbp in the 160\ns this am.\n Action:\n Cont on hydralazine and amlodipine. Lopressor increased to 37.5mg tid\n today from 25mg.\n Response:\n Sbp in the 140\ns. after picc line repositioned his sbp up to170\ns. he\n was due for his hydralazine which he just received. Of not his cuff for\n bp is on his leg as he has a picc on the left arm and a clot is his\n right.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707329, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708069, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated yesterday\n - Failed SLP eval\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Hydralazine - 09:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 100 (80 - 102) bpm\n BP: 163/54(89) {123/39(64) - 169/59(98)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 208 mL\n PO:\n TF:\n IVF:\n 435 mL\n 208 mL\n Blood products:\n Total out:\n 2,115 mL\n 945 mL\n Urine:\n 2,065 mL\n 945 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -737 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 720 K/uL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Diuresis\n # Persistent fevers: Now afebrile - presumed drug fever.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation. Will discuss\n how to list drug allergies given numerous reactions to abx\n # Pain: Knee concerning for gout. Low suspicion for septic joints. No\n fluid on knee U/S.\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placement today\n - NPO\n - Will get double lumen picc for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition: Dobhoff as above.\n Glycemic Control:\n Lines: Order PICC today (double lumen)\n Arterial Line - 09:11 PM\n d/c today\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor after Dobhoff\n Total time spent: 25 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708079, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated yesterday\n - Failed SLP eval\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Hydralazine - 09:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 100 (80 - 102) bpm\n BP: 163/54(89) {123/39(64) - 169/59(98)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 208 mL\n PO:\n TF:\n IVF:\n 435 mL\n 208 mL\n Blood products:\n Total out:\n 2,115 mL\n 945 mL\n Urine:\n 2,065 mL\n 945 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -737 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 720 K/uL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Diuresis\n # Persistent fevers: Now afebrile - presumed drug fever.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation. Will discuss\n how to list drug allergies given numerous reactions to abx\n # Pain: Knee concerning for gout. Low suspicion for septic joints. No\n fluid on knee U/S.\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placement today\n - NPO\n - Will get double lumen picc for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition: Dobhoff as above.\n Glycemic Control:\n Lines: Order PICC today (double lumen)\n Arterial Line - 09:11 PM\n d/c today\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor after Dobhoff if stable\n Total time spent: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708155, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive,\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708424, "text": "Discharge to rehab: pt was d/ced to at at\n 1600 hrs today,all d/c meds and x ray report faxed to rehab,vs were at\n the time of transfer were 99.2,80,157/70,98% 2l nc,the Rt IJ CVl was\n removed prior to d/c.,Dtr was called and informed about the d/c\n plan.pt was up in the chair .all dc paper works sent with the pt,all\n meds due at 1600 hrs were also given .pt updated about the plan.\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708259, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Case Management ", "chartdate": "2146-11-04 00:00:00.000", "description": "Discharge Plan", "row_id": 708262, "text": "Case Management Discharge Planning Note\n The patient is 76M a (h/o asthma, gout and recent complicated hospital\n course including epidural abscess requiring surgery, enterococcus\n bacteremia, aortic endocarditis, septic emboli to brain, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving and\n extubated . Per the MICU team, he should be ready for LTACH\n transfer on Saturday, .\n This Nurse case manager spoke with the patient\ns daughter \n ( regarding post-acute care options. expressed some\n concern about the patient going to in where he has\n been in the past, and asked for a referral to . This NCM\n did make that referral and was informed that has no male\n beds available and none expected through the weekend. This NCM also\n informed and she indicated that she will talk to her mother and\n get back to case management on whether the family will agree to\n . did call back to say that she and her family agree to\n the patient\ns transfer to \n The patient does have a bed on Saturday at . The weekend case\n manager will call central intake at ( on Saturday\n to set up a time for transfer and will f/u with the MICU team to\n facilitate the discharge.\n Please page anytime for case management assistance.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Page: \n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707291, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 8 of 14) /Aztreonam (day 8 of 14)/ Clinda (day 7 of 10)\n -keep PEEP at 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with lasix drip for goal negative 2L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso did not reveal obvious source of infxn\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707302, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. C .diff a posibility given increased diarrhea and clinda\n use. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - F/U cultures, sputum legionella culture, fever curve\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707303, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow \n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707319, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP\n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707530, "text": "Chief Complaint: AMS, aspiration\n HPI:\n 24 Hour Events:\n Fever to 102, PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n - MRI per ID and NSG not concerning for new infectious process\n - Taper MRI\n - Versed gtt d/c\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Lidoderm patch, ASA, Lipitor. Fentanyl patch, Neurontin, Amiodarone\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), RRR\n Peripheral Vascular: (Right radial pulse: palpable), (Left radial\n pulse: palpable), (Right DP pulse: palpable), (Left DP pulse: palpable)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilaterally )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: No rash\n Ext: Bilat LE edema to mid shin, warm L knee, L ankle, no effusion\n Neurologic: Responds to: painful stimuli, moves extremities to stimuli\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Sputum\n MRSA\n Urine legionella Negative\n C Diff negative\n Blood Cx NGTD\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, consider extubation in next \n hrs pending MS\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout, will try Prednisone 20mg\n daily\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition: On TFs\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: PPI\n VAP: HOB at 30 degrees, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 min\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707538, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n GEN: Intubated, sedated, +grimacing when palpating left knee\n CVS: +S1/S2, no M/R/G, RRR\n LUNGS: CTAB anterior lung fields\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of bilateral LE\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -stop Lasix gtt as UOP decreased on 12mg/hr\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today and SBT\n - ET tube at 8cm yesterday will f/u today and advance ET as needed\n # L leg contracture: Given tenderness of Left knee on exam, likely \n gouty arthritis\n -patient given prednisone this morning but will hold off on more\n prednisone for now, will consult Rheum for definitive diagnosis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest today to look for intraabdominal source, pulmonary\n source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "ECG", "chartdate": "2146-10-21 00:00:00.000", "description": "Report", "row_id": 227665, "text": "Atrial fibrillation with rapid ventricular response. Non-specific\nintraventricular conduction delay. Poor R wave progression. Non-specific\ninferolateral T wave flattening. Low QRS voltage in the limb leads. Compared to\nthe previous tracing of the seven beat run of wide complex tachycardia\nis absent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 227666, "text": "Atrial fibrillation with rapid ventricular response. After a pause, an early\nbeat is followed by seven beats of wide complex tachycardia -aberration versus\nventricular tachycardia. Since the previous tracing of atrial\nfibrillation is new and wide complex tachycardia is new. Clinical correlation\nis suggested.\n\n" }, { "category": "ECG", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 227667, "text": "Sinus tachycardia. Low limb lead QRS voltage. Delayed R wave progression.\nST-T wave abnormalities. Findings are non-specific and unstable baseline makes\nassessment difficult. Since the previous tracing of sinus tachycardia\nis now present. Delayed R wave progression is more prominent and further\nST-T wave changes are seen.\n\n" }, { "category": "ECG", "chartdate": "2146-10-28 00:00:00.000", "description": "Report", "row_id": 227661, "text": "Sinus rhythm. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2146-10-23 00:00:00.000", "description": "Report", "row_id": 227662, "text": "Sinus rhythm. Baseline artifact. Poor R wave progression. Possible septal\nmyocardial infarction of indeterminate age. Non-specific inferolateral T wave\nflattening. Low QRS voltages in limb leads. Compared to the previous tracing\nof the wide complex tachycardia, left bundle-branch block and\nST segment depression are now absent.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2146-10-22 00:00:00.000", "description": "Report", "row_id": 227663, "text": "Wide complex tachycardia, probably supraventricular. Left bundle-branch block\npattern. Lateral ST segment depression with possible retrograde P waves.\nCompared to tracing #2 earlier the same day wide complex tachycardia, left\nbundle-branch block and ST segment depression are all new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2146-10-22 00:00:00.000", "description": "Report", "row_id": 227664, "text": "Sinus rhythm. Short P-R interval without other signs of pre-excitation.\nNon-specific inferolateral T wave flattening. Low QRS voltage in the limb\nleads. Compared to tracing #1 on rapid atrial fibrillation is absent.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2146-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106658, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with HAP, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased. This could be a consequence of mechanical ventilation. Diffuse\n but mainly perihilar extensive opacity in the right lung has minimally\n decreased in size. Unchanged is the retrocardiac atelectasis. The size of\n the cardiac silhouette is unchanged. The appearance of the left lung\n parenchyma is constant.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1106460, "text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for right CVL placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RLL PNA, now hypotensive with afib, intubated, newly\n placed central line\n REASON FOR THIS EXAMINATION:\n eval for right CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: Evaluate right central venous line placement.\n\n FINDINGS: The new right CVL line tip is in the upper SVC in satisfactory\n position with no evidence of a pneumothorax.\n\n Increased diffuse consolidation throughout the right lung with mild\n superimposed pulmonary edema is noted with mild cardiomegaly. Left lower lobe\n atelectasis is unchanged.\n\n The NG tube passes into the stomach and out of view. ET tube is satisfactory\n at the thoracic inlet and 47 mm above the carina.\n\n IMPRESSION:\n\n Increased right-sided diffuse infectious consolidation and mild pulmonary\n edema. Satisfactory placement of right central venous line.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1105950, "text": " 12:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed? septic emboli?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with AMS, fevers, h/o endocarditis\n REASON FOR THIS EXAMINATION:\n bleed? septic emboli?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 1:53 AM\n Suboptimal due to motion in the scanner.\n No acute hemmorhage. Evolving deep white matter infarcts, as seen on recent\n MR.\n If concern for acute ischemia MRI is more sensitive.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with altered mental status, fevers and history of\n endocarditis. Evaluate for bleed or septic emboli.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: Compared to MR and NECT head .\n\n FINDINGS: This is a suboptimal evaluation, particularly of the posterior\n fossa, due to excessive patient motion-artifact (despite four attempts).\n\n There is no evidence of acute hemorrhage, large acute vascular territorial\n infarction, mass or cerebral edema. There are scattered subcortical\n paraventricular hypodensities likely reflecting chronic microvascular ischemic\n changes. There is a hypodense focus within the right centrum semiovale\n (2:24-25), new from the prior CT, likely representing the evolving small\n subcortical white matter infarct, as seen on recent MR/DWI. There is no shift\n of midline structures. There is no evidence of hydrocephalus. There is\n mucosal thickening in the right maxillary sinus. No fracture is seen.\n\n IMPRESSION: No acute hemorrhage. Evolving small infarct in the subcortical\n white matter of the right centrum semiovale, as seen on the recent MR.\n If concern for furtheracute ischemia, MRI is more sensitive.\n\n Findings posted to the ED dashboard.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105954, "text": " 2:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with sepsis, now s/p 4L IVF with oxygen desaturation\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with sepsis. Hypoxia following fluid resuscitation.\n\n IMPRESSION: AP chest compared to at 7:36 p.m.:\n\n New opacification in both lower lobes, much greater on the right, could be\n considered pneumonia until proved otherwise. Small bilateral pleural\n effusions and mild perihilar haze on the left suggests a component of cardiac\n decompensation. Heart size is normal and mediastinal vasculature is not\n particularly engorged. Right-sided central venous line ends low in the SVC.\n No pneumothorax. Findings were discussed by telephone with Dr. at\n the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107125, "text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure.\n\n Comparison is made with prior study performed a day earlier.\n\n Extensive opacities in the right lung have increased in the base this could be\n due to increased atelectasis and increased in the pleural effusion and\n unchanged in position of the patient. A small left pleural effusion with\n adjacent atelectasis is stable. ET tube, NG tube and right IJ catheter remain\n in place. Right perihilar consolidation is unchanged. Mild interstitial\n edema is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 1106116, "text": " 8:03 PM\n MR W & W/O CONTRAST Clip # \n Reason: eval for epidural abscess. Please use contrast\n Admitting Diagnosis: FEVER\n Contrast: PROHANCE Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with history of epidural abscess s/p L5-S1 laminectomy who\n returns with fevers/lethary, concern for recurrent epidural abscess\n REASON FOR THIS EXAMINATION:\n eval for epidural abscess. Please use contrast\n CONTRAINDICATIONS for IV CONTRAST:\n Chronic Renal Failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: IPf 3:16 AM\n Post-surgical changes seen in the lower lumbar spine. There is soft tissue\n with heterogeneous enhencement posterior to the sacrum (9:12) , differential\n diagnosis is phlegmon, granulation tissue, or venous congestion. No definite\n fluid collection seen. There is increased signal in STIR at the disk at L5-S1\n and endplates at this level, concerning for ongoing discitis-osteomyelitis.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Lumbar spine MRI with and without contrast.\n\n HISTORY: 76-year-old male who presents with a history of epidural abscess,\n status post L5-S1 laminectomy who returns with fevers and lethargy and\n clinical concern for recurrent abscess.\n\n COMPARISON: Multiple prior lumbar spine MRIs and .\n\n TECHNIQUE: Sagittal pre- and post-gadolinium T1, T2 FSE, STIR, axial pre- and\n post-gadolinium T1- and T2-weighted sequences of the lumbar spine were\n obtained. Note, the clinical team received a nephrology consultation allowed\n for dialysis given the patient's EGFR of 28.\n\n FINDINGS: The patient is status post L5-S1 laminectomy. There is extensive\n enhancement within the posterior paraspinal soft tissues with an ovoid 4.0 x\n 0.6 cm fluid collection superficial to the laminectomy at L5 which\n demonstrates peripheral enhancement. No significant extension into the\n epidural space. There is circumferential epidural enhancement which is\n predominantly present at and below the L5-S1 intervertebral disc space. This\n surrounds the bilateral S1 roots.\n\n There is a linear intrathecal enhancement which is likely venous without\n additional abnormal intrathecal enhancement.\n\n Irregularity, increased T2 signal and enhancement surrounding the L5-S1 disc\n space is diminished when compared to the prior study, particularly the\n anterior paraspinal fluid collection and enhancement. No progressive endplate\n irregularity is identified to suggest progressive discitis.\n\n (Over)\n\n 8:03 PM\n MR W & W/O CONTRAST Clip # \n Reason: eval for epidural abscess. Please use contrast\n Admitting Diagnosis: FEVER\n Contrast: PROHANCE Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The appearance of the remainder of the spine, including T2 hyperintense signal\n within the intervertebral discs at multiple levels is unchanged. No new\n epidural or bone marrow signal abnormality is present.\n\n IMPRESSION: There is a small posterior paraspinal fluid collection\n surrounding postoperative changes at L5-S1. Represent infected material or\n simply reflect postoperative change, and this does not continue into the\n epidural space. There is circumferential thick epidural enhancement\n surrounding the caudal thecal sac which likely reflects phlegmonous change\n with no new compressive lesions. There is nonprogressive\n discitis/osteomyelitis at L5-S1 with no new areas of involvement.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1108570, "text": ", MED MICU-7 12:52 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RUE swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n Thrombus in the right cephalic vein, which is a superficial vein. No right\n upper\n extremity deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1108331, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with R-sided PNA, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Followup pneumonia.\n\n Comparison is made with prior study performed a day earlier.\n\n Lower lobe consolidation/pneumonia is unchanged. Left lower lobe retrocardiac\n opacity is a combination of pleural effusion and atelectasis. Of note a right\n lateral CP angle was not included on the film, there appears to be a small\n pleural effusion on the right. Right IJ catheter tip is in the mid SVC.\n Cardiac size is normal.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-03 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1108440, "text": " 2:38 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric dobhoff\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recurrent aspiration PNA\n REASON FOR THIS EXAMINATION:\n please place post-pyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with recurrent aspiration pneumonia. Please\n place post-pyloric Dobbhoff tube.\n\n TECHNIQUE: Fluoroscopy guided post-pyloric Dobbhoff tube (nasointestinal\n tube) placement.\n\n PROCEDURE/FINDINGS:\n After local anesthesia of the right nostril and the nasopharynx with lidocaine\n gel and spray, a Dobbhoff tube was advanced through the right nostril into the\n esophagus. Tube was advanced beyond the GE junction and location of the in\n the stomach was confirmed under fluoroscopy. Subsequently, the tube was\n advanced beyond the pylorus into the descending duodenum. Subsequently,\n post-pyloric placement of the tube was confirmed by contrast. The tip of the\n tube projects over the proximal transverse portion of the duodenum.\n\n IMPRESSION:\n Successful placement of a post-pyloric nasointestinal tube.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1108592, "text": " 3:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 47 cm Picc placed in left brachial vein, need Picc tip place\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc placed in left brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: New PICC line.\n\n FINDINGS: The new left-sided PICC line tip is in the distal brachiocephalic\n vein, right central venous line is unchanged. An NG tube passes into the\n stomach and out of view. A small left pleural effusion is stable,\n consolidation in the right lower lobe is unchanged. Heart size is top normal.\n\n IMPRESSION:\n New left PICC line tip is in the brachiocephalic vein, IV nurse informed.\n Bilateral pleural effusions with unchanged right lower lobe consolidation,\n most likely pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1108569, "text": " 12:52 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RUE swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf FRI 2:21 PM\n Thrombus in the right cephalic vein, which is a superficial vein. No right\n upper\n extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER EXTREMITY VENOUS SON\n\n INDICATION: 76-year-old man with right upper extremity edema.\n\n COMPARISON: Not available at the .\n\n FINDINGS: Grayscale and color Doppler images of the right internal jugular,\n subclavian, axillary, brachial, basilic, and cephalic veins were obtained.\n There is lack of color flow, non-compressibility and lack of pulse Doppler\n waveforms in the right cephalic vein, consistent with thrombus. The remainder\n of the venous structures demonstrate normal color flow and compressibility and\n pulse Doppler waveforms.\n\n IMPRESSION: Thrombosed right cephalic vein, which is a superficial vein. No\n deep venous thrombosis in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1108613, "text": " 5:40 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 51cm SL L PICC exchanged - 47cm PICC at bracheocephalic\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 51cm SL L PICC exchanged - 47cm PICC at bracheocephalic\n ______________________________________________________________________________\n WET READ: IPf FRI 6:38 PM\n PICC line at mid SVC. Othervise no significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess left PICC.\n\n Comparison is made to prior study performed three hours earlier.\n\n PICC tip is in the mid-to-lower SVC. Otherwise no interval change from prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107612, "text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 76-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The tip of the endotracheal tube is 8 cm above the carina and has migrated\n more proximally since the previous study. The feeding tube is unchanged and\n distal tip is below the field of view of the study. There is a unchanged\n right IJ central venous catheter with the distal lead tip in proximal SVC.\n\n There is a unchanged left retrocardiac opacity.\n\n Remains some mild interstitial edema. There is faint areas of consolidation\n within the right lower lobe, stable.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106766, "text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices are in unchanged position. The pre-existing right-sided parenchymal\n opacity, predominantly in perihilar distribution, has further decreased in\n extent. Unchanged size of the cardiac silhouette, on today's radiograph,\n there is new blunting of the left costophrenic sinus, potentially caused by a\n small pleural effusion. No other changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107301, "text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung pna, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a slight decrease\n in severity of the pre-existing right parenchymal opacities. The right lung\n base is slightly improved in transparency as compared to the previous\n examination. The left lung base is also slightly more transparent, suggesting\n improved ventilation. Unchanged extent of the pre-existing small left-sided\n pleural effusion. The size of the cardiac silhouette is unchanged. The\n nasogastric tube has been removed in the interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106546, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: , 3:45 p.m.\n\n FINDINGS: The monitoring and support devices are in unchanged position.\n Unchanged size of the cardiac silhouette, unchanged retrocardiac atelectasis.\n The extensive right-sided parenchymal opacity is better delineated than on the\n previous examination, the right costophrenic sinus is no longer blunted.\n Unchanged aspect of the left lung, no evidence of newly appeared left lung\n opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105919, "text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia? CHF?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with fever, pain, early SIRS picture\n REASON FOR THIS EXAMINATION:\n pneumonia? CHF?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, pain, early SIRS picture.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP PORTABLE VIEW OF THE CHEST: Right PICC tip terminates in the mid\n SVC. The cardiac, mediastinal and hilar contours are unremarkable and\n unchanged without evidence of cardiomegaly. Aortic knob calcifications are\n again noted. The pulmonary vascularity is normal. Retrocardiac opacity is\n non-specific, and may represent an area of atelectasis but infection is not\n excluded. No large pleural effusion or pneumothorax is visualized. Mild\n degenerative changes are noted in the thoracic spine.\n\n IMPRESSION: Retrocardiac opacity which is non-specific and may represent\n atelectasis, but an area of infection is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1107761, "text": " 12:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SUN 1:49 PM\n No hemorrhage, edema, or significant change since days prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with altered mental status. Evaluate for interval\n change.\n\n COMPARISON: Non-contrast head CT, .\n\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\n vertex without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass effect,\n shift of midline structures, or evidence of major vascular territory\n infarction. Bilateral punctate basal ganglia calcifications are again seen. A\n focal hypodensity in the right centrum semiovale (2:23) is somewhat more\n prominent than the prior study, but apparently represents sequela of apparent\n prior infarction (MRI, ), with no current evidence of ischemia,\n allowing for limitations of non-contrast CT. There is no hemorrhage. The\n periventricular white matter demonstrates diffuse hypodensity consistent with\n chronic small vessel ischemic change (as on the MR). The left maxillary sinus\n demonstrates air-fluid level and a mucus- retention cyst (2:4). There is mild\n ethmoid mucosal thickening (2:8). The globes and remainder of soft tissues\n appear unremarkable.\n\n IMPRESSION: No hemorrhage, edema, or significant change since the NECT of 11\n days before; MRI with DWI would be more sensitive for an acute ischemic\n event.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1107762, "text": ", MED MICU-7 12:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No hemorrhage, edema, or significant change since days prior\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107763, "text": " 12:29 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with fevers\n REASON FOR THIS EXAMINATION:\n eval for infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp SUN 4:48 PM\n Findings c/w multifocal pna persist decreased, perisistent mod b/l simple\n effusions, vic contrast Vs sludge in GB, nrml appendix, diverticulosis w/o\n diverticulitis, L inguinal bowel containing hernia wo/obstruction, sigmoidal\n wall thickness underdistension, bladder appararent wall thickening prob\n underdistension ( w./UA) GWlms\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of endocarditis and pneumonia with fevers.\n\n TECHNIQUE: MDCT of the chest, abdomen, and pelvis was performed following\n administration of oral contrast only.\n\n Comparison exam is dated .\n\n CHEST: Again noted are moderate bilateral pleural effusions, stable from the\n prior exam. There are prominent mediastinal lymph nodes, which may be\n reactive. An endotracheal tube in satisfactory position. A right-sided\n central venous line terminates in the superior vena cava. A nasogastric tube\n is identified, and oral contrast is seen within the esophagus. There are\n aortic and coronary artery calcifications.\n\n Lung windows demonstrate patchy multifocal areas of consolidation consistent\n with infection, which are decreased from the prior exam. No new areas of\n consolidation are identified. The central airways are patent. There is\n minimal right upper lobe bronchiectasis.\n\n ABDOMEN: Layering density is noted within the gallbladder, consistent with\n sludge. The gallbladder is otherwise grossly unremarkable. Allowing for lack\n of IV contrast, the liver, spleen, right kidney, adrenal glands, and pancreas\n are grossly normal. Again noted is a hypodensity projecting from the\n posterior left renal mid pole, likely a cyst. There are no pathologically\n enlarged lymph nodes. A nasogastric tube terminates in the distal stomach.\n\n There is diverticulosis, without evidence of acute inflammation. The small\n bowel loops are non-dilated. There is no free fluid or focal fluid\n collection. Diffuse mild-to-moderate anasarca is noted. There are moderate\n atherosclerotic calcifications of the aorta and iliac arteries.\n\n PELVIS: There is moderate sigmoid diverticulosis, without evidence of acute\n inflammation. Again noted is a left inguinal hernia, which now contains a\n (Over)\n\n 12:29 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portion of sigmoid colon. There is no evidence of bowel obstruction. There\n is no free fluid, and there are no pathologically enlarged lymph nodes. The\n bladder contains a Foley catheter and gas.\n\n Bone windows demonstrate degenerative changes of the spine and lumbar\n laminectomy.\n\n IMPRESSION:\n\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n\n 2. Stable moderate bilateral pleural effusions.\n\n 3. No source of infection identified within the abdomen or pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107827, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure.\n\n Portable AP chest radiograph was compared to obtained at\n 04:51 a.m.\n\n The ET tube tip is 3.5 cm above the carina. The NG tube tip passes below the\n diaphragm, most likely terminating at the stomach. The right internal jugular\n line tip is at the level of mid SVC. The cardiomediastinal silhouette is\n unchanged. There is slight improvement in the left retrocardiac aeration.\n The patient continues to be in mild volume overload with most likely present\n bilateral pleural effusion. No overt pneumothorax is noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1107346, "text": " 10:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recurrent aspiration event\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recurrent aspiration. Evaluation for interval change.\n\n COMPARISON: , 4:21 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged extent and density of the pre-existing right lung\n opacities. Unchanged suspicion of mild left pleural effusion. In the\n interval, a nasogastric tube has been placed. The tip of the tube is not\n included in the image, the side port is located 3 cm below the\n gastroesophageal junction. No evidence of complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107205, "text": " 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung Pneumonia, continues with fevers\n REASON FOR THIS EXAMINATION:\n eval for effusion, PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh WED 4:59 PM\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with right lung pneumonia and continued fever.\n\n STUDY: CT of the torso without contrast; MDCT images were generated through\n the chest, abdomen, and pelvis without intravenous contrast and with oral\n contrast. Coronal and sagittal reformatted images were also generated.\n\n COMPARISON: .\n\n FINDINGS:\n\n CHEST: The thyroid is normal appearing without evidence of masses. The\n patient is intubated with the endotracheal tube approximately 2.5 cm above the\n carina. Moderate-sized bilateral pleural effusions are noted and the patchy\n densities are seen in the right upper and right lower lung lobes as well as in\n the left upper lung lobe. Air bronchograms are seen through these opacities.\n This appearance is consistent with multifocal pneumonia. Calcified\n atherosclerotic disease is seen along the aortic arch and descending aorta. A\n central line tip is seen in the lower SVC. A very small pericardial effusion\n is seen (2; 45).\n\n ABDOMEN: The liver shows no evidence of focal lesions or biliary dilatation.\n The spleen is normal in size and appearance. Gallbladder shows high-density\n blurring consistent with biliary sludge. The pancreas is normal appearing\n without evidence of masses, cysts, or calcifications. The adrenal glands are\n normal appearing bilaterally without evidence of masses. In the left kidney,\n there is a well-circumscribed area of low density that measures 33 x 25 mm and\n likely represents a simple cyst. The large and small intestines show no signs\n of obstruction, wall thickening, or masses. Diverticulosis without evidence\n for diverticulitis is seen in the sigmoid colon. On this limited non-contrast\n study, the aorta, IVC, portal vein and their major branches all appear patent.\n No lymphadenopathy is seen. No free air or fluid is noted in the abdomen.\n Diffuse anasarca is noted within the abdominal wall.\n\n PELVIS: Foley catheter is noted within the bladder. The prostate and rectum\n (Over)\n\n 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appear normal. No lymphadenopathy is seen. No free air or fluid is noted in\n the pelvis. In the left inguinal canal, there is a fat- and fluid-filled\n hernia that does not appear to contain a loop of bowel.\n\n BONES: Mild levoscoliosis is noted in the lumbar spine with moderate\n degenerative changes noted at nearly all levels of the thoracolumbar spine.\n Vacuum phenomenon seen at the L4-L5 intervertebral disc with a likely\n Schmorl's node at the inferior endplate of L4. No focal lytic or sclerotic\n lesions are seen.\n\n IMPRESSION:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-31 00:00:00.000", "description": "US EXTREMITY NONVASCULAR", "row_id": 1107879, "text": " 11:27 AM\n US EXTREMITY NONVASCULAR Clip # \n Reason: LT KNEE PAIN. EVL FOR EFFUSION\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with history of gout, intubated for PNA, now with pain in left\n knee. please eval left knee for effusion\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 76-year-old man with pain in the left knee. Evaluate for\n effusion.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Transverse and sagittal images of the joint space at the left knee\n were obtained. No joint effusion could be identified on this exam. Note is\n made of some soft tissue edema in the subcutaneous tissues.\n\n IMPRESSION: No fluid collection identified in the left knee space although\n some soft tissue edema is seen in the subcutaneous tissues.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107206, "text": ", MED MICU-7 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung Pneumonia, continues with fevers\n REASON FOR THIS EXAMINATION:\n eval for effusion, PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106312, "text": " 5:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET tube placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for ET tube placement\n ______________________________________________________________________________\n WET READ: 6:46 PM\n ETT 6.8cm above carina. New extensive RUL opacification from 00:34 hrs ,\n progressive left retrocardiac opacity. Persistent central, perihilar\n bilateral opacities, right much greater than left, Kerley B lines suggestive\n of pulmonary edema. Layering left effusion. Cardiac silhouette similar to\n most recent study.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 18:18\n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Endotracheal tube assessment.\n\n FINDINGS: Endotracheal tube terminates approximately 6.5 cm above the carina.\n Cardiac silhouette is upper limits of normal in size. Pulmonary vascularity\n is engorged and indistinct, and bilateral septal lines are present.\n Additionally, there is a worsening right-sided central alveolar process, which\n has now extended superiorly to also involve the right upper lobe.\n Additionally, there is worsening dense left retrocardiac opacification as well\n as an increasing small left pleural effusion and persistent small right\n effusion.\n\n IMPRESSION:\n 1. Endotracheal tube terminates 6.5 cm above carina.\n 2. Worsening multifocal pneumonia superimposed upon interstitial pulmonary\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1106610, "text": " 2:53 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFTS ACUTE PROCESS\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man intubated, aspiration PNA, LFT elevation likely secondary to\n shock liver, but please eval liver w/ dopplers\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 4:51 PM\n PFI:\n\n 1. Main portal venous flow hepatopetal.\n\n 2. No intra or extrahepatic bile duct dilatation with a CBD measuring 5 mm.\n\n 3. Hepatic veins patent.\n\n 4. No ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, aspiration pneumonia, LFT elevation likely secondary\n to shock liver but please evaluate the liver.\n\n COMPARISON: .\n\n PORTABLE SON STUDY OF THE LIVER: Grayscale and color son\n images were obtained. The liver appears homogeneous in echotexture. There is\n no ascites. There is no intra- or extra-hepatic bile duct dilatation with the\n CBD measuring to 5 mm. Main portal venous flow is patent with wall-to-wall\n hepatopedal flow. The gallbladder appears normal with no evidence of\n cholelithiasis. The hepatic veins are patent and normal in terms of direction\n and flow demonstrating wall-to-wall flow. There is a small right pleural\n effusion.\n\n IMPRESSION:\n 1. Patent portal vein and hepatic venous system.\n 2. No cholelithiasis.\n 3. No ascites.\n 4. Small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1106611, "text": ", C. MED MICU-7 2:53 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFTS ACUTE PROCESS\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man intubated, aspiration PNA, LFT elevation likely secondary to\n shock liver, but please eval liver w/ dopplers\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Main portal venous flow hepatopetal.\n\n 2. No intra or extrahepatic bile duct dilatation with a CBD measuring 5 mm.\n\n 3. Hepatic veins patent.\n\n 4. No ascites.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107982, "text": " 3:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with multilobar PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multilobar pneumonia.\n\n FINDINGS: In comparison with study of , allowing for some obliquity of\n the patient, there is no change in the appearance of the monitoring and\n support devices. Increasing opacification at the left base in the\n retrocardiac region is consistent with substantial left lower lung\n atelectasis. Poor definition of the hemidiaphragms persists, consistent with\n layering effusions. Prominence of interstitial markings is consistent with\n some volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106357, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with study , there is worsening opacification\n with air bronchograms that now involve almost the entire right lung. The\n pulmonary vascular congestion is slowly improving. Opacification at the left\n base is consistent with some atelectasis or consolidation with pleural fluid.\n\n Endotracheal tube tip lies approximately 6.5 cm above the carina and\n nasogastric tube extends well into the stomach.\n\n IMPRESSION: Worsening right lung pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1107998, "text": " 7:37 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: LE EDEMA, PLEASE ASSESS FOR DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LE edema, left sided contracture and intractable LE pain\n REASON FOR THIS EXAMINATION:\n please assess for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 11:39 AM\n PFI: No lower extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VEIN SON\n\n INDICATION: A 76-year-old man with lower extremity edema, left-sided\n contracture and intractable lower extremity pain.\n\n COMPARISON: Left lower extremity son dated .\n\n FINDINGS: Grayscale and color Doppler images of the left and right common\n femoral, superficial femoral and popliteal veins were obtained. These\n demonstrate normal flow, compressibility and augmentation.\n\n Bilateral subcutaneous edema is noted.\n\n IMPRESSION: No evidence of deep venous thrombosis in the lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1107999, "text": ", MED MICU-7 7:37 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: LE EDEMA, PLEASE ASSESS FOR DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LE edema, left sided contracture and intractable LE pain\n REASON FOR THIS EXAMINATION:\n please assess for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No lower extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107715, "text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 76-year-old man with respiratory failure.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is persistent left retrocardiac opacity. There is again seen some\n prominence of pulmonary interstitial markings consistent with fluid overload.\n Lines and tubes are unchanged. There is a left-sided pleural effusion which is\n slightly increased.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1107593, "text": " 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL ADDENDUM\n This is a correction regarding the communication between Dr. and Dr.\n described in the impression . Dr. did not directly speak to Dr. \n but left a message for him.\n\n\n 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with l-spine abcesses s/p laminectomy. Intubated for PNA. Now\n with contracture of left leg. Pt's Cr=2.2. Family has waived HD for gado--NSGY\n wants contrast.\n REASON FOR THIS EXAMINATION:\n cord compression? porgression of fluid collections? abcess?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 11:05 AM\n PFI:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the lumbar spine.\n\n CLINICAL INFORMATION: Patient with lumbar spine abscess status post\n laminectomy and intubation with high creatinine, for further evaluation.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were acquired. Diffusion sagittal images were also obtained.\n Given patient's renal failure and prior discussion with the referring\n physician, . , gadolinium enhancement was not performed. Comparison was\n made with the previous MRI examination of .\n\n FINDINGS: From T11-12 to L4-5, no change in appearance of the lumbar spine\n seen with degenerative change and disc bulging as described previously with\n signal changes within the discs. At L5-S1 level, increased signal is\n identified within the disc, predominantly on the left side. Mild thickening\n of the epidural soft tissues is seen immediately posterior to the L5-S1 disc.\n This finding is essentially unchanged compared to the prior study. No\n intraspinal fluid collection is identified. No paraspinal fluid collection is\n seen, although evaluation is slightly limited without contrast administration.\n\n Extensive soft tissue changes are seen posteriorly within the soft tissues,\n particularly at the level of laminectomy at L5-S1 level. The previously noted\n fluid at the superior margin of the laminectomy has decreased. A small fluid\n (Over)\n\n 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collection is now seen measuring 2 cm adjacent to the right facet joint at\n L4-5 level. This fluid collection demonstrates restricted diffusion on the\n diffusion-weighted images. There is no new fluid collection seen in the\n posterior soft tissues. Diffuse hyperintensities are identified involving the\n musculature posteriorly.\n\n The distal spinal cord shows normal signal intensities.\n\n IMPRESSION:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1107594, "text": ", MED MICU-7 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with l-spine abcesses s/p laminectomy. Intubated for PNA. Now\n with contracture of left leg. Pt's Cr=2.2. Family has waived HD for gado--NSGY\n wants contrast.\n REASON FOR THIS EXAMINATION:\n cord compression? porgression of fluid collections? abcess?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107044, "text": " 1:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Respiratory failure.\n\n FINDINGS: Since the chest radiograph earlier of the same date, the position\n of the ET tube is lower in the trachea and 2 cm above the carina. NG tube\n passes into the stomach and out of view.\n\n Right peri- and infrahilar consolidation is unchanged; however, there has been\n some improvement in the asymmetrical superimposed pulmonary edema, layering\n right pleural effusion is unchanged, and mild cardiomegaly stable with no\n pneumothorax.\n\n IMPRESSION:\n\n Interval improvement in superimposed pulmonary edema with stable right lung\n consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106136, "text": " 12:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inteerval change, flash pulm edema?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with acute resp distress\n REASON FOR THIS EXAMINATION:\n inteerval change, flash pulm edema?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Acute respiratory distress, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing bilateral\n opacities, much more evident on the right than on the left, show a clear\n tendency to concentrate in the central and perihilar areas of the lung. The\n dynamic of the changes as compared to the previous examination as well as the\n development of a subtle interstitial component (Kerley B lines) strongly\n suggests pulmonary edema.\n\n The size of the cardiac silhouette has minimally increased. The lowest part\n of the left and the complete right costophrenic sinus are not included in the\n image. The right-sided PICC line is not visible on today's examination.\n\n IMPRESSION: Increasing centralization of pre-existing pulmonary edema,\n development of a subtle interstitial component.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106956, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INTERVAL CHANGE\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with unilateral PNA.\n REASON FOR THIS EXAMINATION:\n INTERVAL CHANGE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Interval change in unilateral pneumonia.\n\n COMPARISON: Chest radiograph from and .\n\n SINGLE AP SEMI UPRIGHT BEDSIDE CHEST RADIOGRAPH: In comparison with the prior\n radiograph, there has been no significant change in the multifocal airspace\n opacities within the entire right lung, allowing for differences in technique\n and lung volumes. The left lung appears clear. The left costophrenic angle is\n not well visualized and a small left pleural effusion cannot be excluded.\n There is mild pulmonary vascular congestion better seen on the left lung, may\n suggest underlying volume overload.\n\n The endotracheal tube is in stable position with the tip 7 cm from the carina.\n A right IJ catheter terminates in the upper SVC.\n\n IMPRESSION: Findings suggestive of mild volume overload with no significant\n interval change in the right lung pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107453, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure.\n\n Comparison is made with prior study .\n\n Cardiomediastinal contours are normal. Almost complete collapse of the left\n lower lobe has improved. Small left and moderate right pleural effusions are\n unchanged. Right perihilar consolidation has slightly improved. Interstitial\n edema has almost resolved. ET tube tip is 5.7 cm above the carina. NG tube\n tip is out of view below the diaphragm. Right IJ catheter remains in place.\n There is no pneumothorax.\n\n" } ]
48,366	107,273	43F with no prior cardiac history presenting with vague esophageal symptoms and a slightly positive troponins.	In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. Nopathologic valvular abnormality seen. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Normal coronaries & LV. Normal coronaries & LV. Action: IV Nitro weaned off. Action: IV Nitro weaned off. Action: IV Nitro weaned off. Action: IV Nitro weaned off. EKG with chest burning/jaw numbness without acute ischemic changes noted. NECK: Supple with JVP not elevated CARDIAC: RR, normal S1, S2. Slight non-specific anterolateral ST segment elevation.Clinical correlation is suggested. Gastroesophageal reflux disease (GERD) Assessment: Pt denies any reflux. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. NSTEMI.Height: (in) 75Weight (lb): 198BSA (m2): 2.19 m2BP (mm Hg): 95/53HR (bpm): 72Status: InpatientDate/Time: at 10:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Given sensitivity of troponin, this most likely represents myocardial ischemia (ACS) though patient with CHF, LVH, kidney disease can have elevated troponins; this patient has none of these. Given sensitivity of troponin, this most likely represents myocardial ischemia (ACS) though patient with CHF, LVH, kidney disease can have elevated troponins; this patient has none of these. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. FINDINGS: The cardiomediastinal silhouette is within normal limits. Normal ascending aorta diameter. Plan: Continue pt on antiishemic regimen, antiplt, hold off B Blocker as HR is in low 60s currently. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Labs / Radiology [image002.jpg] Assessment and Plan # NSTEMI: Ruled-in by troponin; no ECG changes noted. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Given GI cocktail less lidocaine. Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Sclera anicteric. The aortic root is mildly dilated at thesinus level. Plavix and Lipitor dc Gastroesophageal reflux disease (GERD) Assessment: Pt returned from cath c/o reflux and slight nausea. Plavix and Lipitor dc Gastroesophageal reflux disease (GERD) Assessment: Pt returned from cath c/o reflux and slight nausea. be related to eosinophilic esophagitis. be related to eosinophilic esophagitis. - Continue PPI - Recheck in AM # DYSPHAGIA/GERD: - require outpatient EGD FEN: NPO for now given possibility of cath come morning. - Continue PPI - Recheck in AM # DYSPHAGIA/GERD: - require outpatient EGD FEN: NPO for now given possibility of cath come morning. Normalaortic arch diameter. Vague c/o R sided chest pain worse with inspiration. Vague c/o R sided chest pain worse with inspiration. Vague c/o R sided chest pain worse with inspiration. Plan: Pt sent for cardiac cath. Plan: Pt sent for cardiac cath. PTT 150. vague c/o R sided chest pain worse with inspiration. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt admitted to CCU for (+) troponin leak/Chest discomfort for r/I MI w/u. NPO for possible CV cath. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Occupation: Anesthiologist. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Response: Pt sleeping, weaning down TNG, remains on heparin 1300u. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath.	15	[ { "category": "Echo", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 86704, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. NSTEMI.\nHeight: (in) 75\nWeight (lb): 198\nBSA (m2): 2.19 m2\nBP (mm Hg): 95/53\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Normal regional and global biventricular systolic function. No\npathologic valvular abnormality seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050449, "text": " 12:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with chest pain, pos trop\n REASON FOR THIS EXAMINATION:\n eval for CHF, effusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Chest pain.\n\n COMPARISONS: None available.\n\n FINDINGS: The cardiomediastinal silhouette is within normal limits. The\n hilar structures appear normal. No effusion or pneumothorax is detected.\n Minimal blunting of the left costophrenic angle likely represents scarring or\n atelectasis. Pulmonary vascularity appears within normal limits. No focal\n consolidation is detected.\n\n IMPRESSION:\n\n 1. No radiographic evidence of pneumonia or acute CHF.\n\n 2. Minimal scarring or atelectasis in the left lung base.\n\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240861, "text": "Sinus rhythm. Slight non-specific anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to tracing #3 no significant\nchange.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240862, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to tracing #2 no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240863, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2108-10-31 00:00:00.000", "description": "Report", "row_id": 240864, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648894, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648898, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in\n symptoms.PT was transferred to CCU at 4am . He arrived with\n intermittent rt sided chest discomfort, worse with deep breath and/or\n change in position and mild nausea s/p the MS dose in ER , accompanied\n by wife. Decision made to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. vague\n c/o R sided chest pain worse with inspiration.\n Action:\n IV Nitro weaned off. IV heparin off at 10am.\n Response:\n Headache improved. Less nausea.\n Plan:\n Pt sent for cardiac cath.\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648899, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration.\n Action:\n IV Nitro weaned off. IV heparin off at 10am.\n Response:\n Headache improved. Less nausea.\n Plan:\n Pt sent for cardiac cath.\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt denies any reflux.\n Action:\n Cont on prilosex.\n Response:\n Plan:\n ? further GI workup.\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648861, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648865, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath. Please refer to CCU Resident note\n for involved recent HPI.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in\n symptoms.PT was transferred to CCU at 4am d/t no CV step down beds\n available. He arrived with intermittent rt sided chest discomfort,\n worse with deep breath and/or change in position and mild nausea s/p\n the MS dose in ER , accompanied by wife.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt admitted to CCU for (+) troponin leak/Chest discomfort for r/I MI\n w/u.\n Action:\n Pt on TNG/Heparin gtt as well as ASA/Plavix. NPO for possible CV cath.\n EKG with chest burning/jaw numbness without acute ischemic changes\n noted. Pt given prilosec dose early as well as GI slurry and fell\n sleep, pain free. Cycling CPK\ns. Possible ECHO today as well for\n further w/u diagnostics. Teaching/support for wife and pt.\n Response:\n Pt sleeping, weaning down TNG, remains on heparin 1300u. Aware of plan\n of care as is his wife. Appears comfortable currently.\n Plan:\n Continue pt on antiishemic regimen, antiplt, hold off B Blocker as HR\n is in low 60\ns currently. Continue to assess each episode of\n pain/continue to decrease pt anxiety/teaching/support. c/o to 3\n once bed available. Check labs 8am- cycle CPK\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt with hx GERD admitted for r/I MI, continues with GI symptoms.\n Action:\n Pt developing chest burning with jaw numbness- given prilosec/slurry .\n EKG done as well.\n Response:\n Pt becoming more comfortable and falling asleep. VS remain stable.\n Plan:\n Continue to w/u GERD/Gi as possible etiology of some of pt\ns symptoms.\n Continue to support, decrease anxiety.\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648940, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration. Cardiac echo shows nl LV\n function.\n Action:\n IV Nitro weaned off. IV heparin off at 10am. To cath lab.\n Response:\n Headache improved. Less nausea.\n Plan:\n To cardiac cath lab. Normal coronaries & LV. Plavix and Lipitor dc\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt returned from cath c/o reflux and slight nausea.\n Action:\n HOB ^\nd to 15 & reverse trendelenberg. Given dry crackers. Prilosec ^\n to \n Response:\n Pt presently sleeping.\n Plan:\n ? further GI workup. To follow up with PCP.\n" }, { "category": "Physician ", "chartdate": "2108-11-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 648846, "text": "TITLE:\n Chief Complaint: NSTEMI\n HPI:\n Dr. is a 43 year-old man with a history of GERD who presents with\n pleuritic pain and elevated troponin.\n Approximately 6 weeks prior to admission patient hurt his low back\n afters slipping; he began using high doses of NSAIDs (ibuprofen 800mg\n TID with toradol). On , he noted a \"warm\" feeling in his chest\n which lasted seconds; there may have been some associated nausea but no\n SOB or overt CP. From he was in during which time he\n experienced two further episodes, similar in nature.\n Approximately 1.5 weeks prior to admission, he began also feeling\n abdominal pain and occasional sensations that something was getting\n stuck in his throat. He spoke with his cardiologist who ordered an\n ETT. This was done on and returned normal (13 minutes with HR up\n to 160+). The following day he felt burning and reflux and induced\n vomiting to alleviate the symptoms. Two days later he spoke with a\n gastroenterologist and was told he may have eosinophilic esophagitis.\n Over the last couple days he has experienced right lower pleuritic\n chest pain. On the day of admission he was at work and ate stir fry.\n He began feeling as though \"food was lined up in the stomach\" though he\n was hungry. He then presented to the ED at his place of work.\n At the OSH ED he was found to have a troponin I of 0.51 and CK of 89;\n aspirin, plavix and heparin gtt were started and he was transferred for\n further evaluation.\n In the ED, VSS with HR in the 60s and blood pressure in 120s systolic.\n Given persistent chest pain, nitro gtt was started.\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n He denies recent fevers, chills or rigors. He denies exertional buttock\n or calf pain. He reports frequent \"gas\" and recent low back pain with\n radiation down the right leg, improved of late.\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.5 mcg/Kg/min\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS:\n (-) Diabetes\n (-) Dyslipidemia\n (-) Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None.\n -PCI: None.\n -PACING/ICD: None.\n 3. OTHER PAST MEDICAL HISTORY:\n - GERD\n - Exercise induced asthma\n - Psoriasis\n - s/p tonsillectomy, bilateral hernia repair\n - Colonoscopy at age 40; normal\n Brother and father with . No history of early CAD. Father is\n otherwise healthly at age 70. GF with leukemia; other GF with prostate\n v. colon cancer.\n Occupation: Anesthiologist.\n Drugs: None.\n Tobacco: None.\n Alcohol: Rare.\n Other:\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea\n Flowsheet Data as of 05:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 65 (63 - 72) bpm\n BP: 98/59(69) {98/50(64) - 108/65(75)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 34 mL\n PO:\n TF:\n IVF:\n 34 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 34 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, Rash: Prosiaris plaques on LE\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n # NSTEMI: Ruled-in by troponin; no ECG changes noted. Given\n sensitivity of troponin, this most likely represents myocardial\n ischemia (ACS) though patient with CHF, LVH, kidney disease can have\n elevated troponins; this patient has none of these. Elevations may\n also be seen in PE/myocarditis/pericarditis; these also appear unlikely\n in this patient. Without CK elevations, this may represent very early\n (2-3 hours) myocardial injury or late (days).\n - Trend CE\n - Continue with anti-platelets (aspirin/plavix)\n - Continue with heparin gtt\n - Continue with nitro gtt though unclear if benefitting\n - Try morphine PRN\n # PUMP: Euvolemic.\n # RHYTHM: NSR.\n # ANEMIA: Mild; will follow while on triples\n # EOSINOPHILIA: Mild with absoluate count of ~1000. Unclear\n etiology. be related to eosinophilic esophagitis.\n - Continue PPI\n - Recheck in AM\n # DYSPHAGIA/GERD:\n - require outpatient EGD\n FEN: NPO for now given possibility of cath come morning.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin\n -Pain managment with nitro gtt and morphine\n CODE: Presumed full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:18 AM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2108-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648851, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt. having right sided jaw discomfort and chest burning this am. Given\n GI cocktail less lidocaine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.5 mcg/Kg/min\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 65 (63 - 72) bpm\n BP: 98/59(69) {98/50(64) - 108/65(75)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 141 mL\n PO:\n 100 mL\n TF:\n IVF:\n 41 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 141 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n GENERAL: Lying in bed, mildly groggy after receiving morphine. In no\n distress.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP not elevated\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Cyst noted on lateral knee\n on the left.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n # NSTEMI: Ruled-in by troponin; no ECG changes noted. Given\n sensitivity of troponin, this most likely represents myocardial\n ischemia (ACS) though patient with CHF, LVH, kidney disease can have\n elevated troponins; this patient has none of these. Elevations may\n also be seen in PE/myocarditis/pericarditis; these also appear unlikely\n in this patient. Without CK elevations, this may represent very early\n (2-3 hours) myocardial injury or late (days).\n - Trend CE\n - Continue with anti-platelets (aspirin/plavix)\n - Continue with heparin gtt\n - Continue with nitro gtt though unclear if benefitting\n - Try morphine PRN\n # PUMP: Euvolemic.\n # RHYTHM: NSR.\n # ANEMIA: Mild; will follow while on triples\n # EOSINOPHILIA: Mild with absoluate count of ~1000. Unclear\n etiology. be related to eosinophilic esophagitis.\n - Continue PPI\n - Recheck in AM\n # DYSPHAGIA/GERD:\n - require outpatient EGD\n FEN: NPO for now given possibility of cath come morning.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin\n -Pain managment with nitro gtt and morphine\n CODE: Presumed full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:18 AM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648903, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration. Cardiac echo shows nl LV\n function.\n Action:\n IV Nitro weaned off. IV heparin off at 10am. To cath lab.\n Response:\n Headache improved. Less nausea.\n Plan:\n To cardiac cath lab. Normal coronaries & LV. Plavix and Lipitor dc\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt returned from cath c/o reflux and slight nausea.\n Action:\n HOB ^\nd to 15 & reverse trendelenberg. Given dry crackers.\n Response:\n Pt presently sleeping.\n Plan:\n ? further GI workup.\n" } ]
12,104	126,725	The patient was admitted on . She underwent preoperative placement of a pulmonary artery catheter to monitor pulmonary artery pressures. She was taken to the Operating Room on where she underwent an exploratory thoracotomy with multiple lymph node biopsies and biopsy of right diaphragmatic plaque. Intraoperatively it was found that the patient had extensive nodal involvement and it was determined that a lobectomy should not be undertaken and the patient was taken to the post anesthesia care unit. In the post anesthesia care unit she developed some respiratory difficulties and required reintubation and also required vaso active pressors and fluids to improve her low blood pressure and heart rate. Nitroglycerin was used for elevated pulmonary artery pressures. On postoperative day one the patient remained intubated and was noted to have a significant rise in creatinine at 2.7. Nephrology was consulted and determined that this was acute renal failure superimposed upon a history of chronic renal problem and advised gentle diuresis and avoidance of agents that induce renal vaso constriction. Neurology was also consulted for mental status changes. The patient had undergone an examination and was nonfocal and had no further recommendations or indications of acute neurological pathology appearing at that time. The patient was weaned to extubation on the course of postoperative day two and on postoperative day three was placed on CPAP. By postoperative day four the patient had weaned off all drips and had been extubated and was doing well and was therefore transferred to the floor. During her period on Far 2 she experienced some confusion as a result of her narcotics, which were subsequently stopped, but otherwise her course was unremarkable. She continued aggressive incentive spirometry and pulmonary toilet with ambulation and her respiratory examination improved and she was able to maintain good O2 sats on room air. On postoperative day six the patient was weaned down from her O2 and given the ability to ambulate and her respiratory condition she was discharged to home and asked to follow up with Dr. in three days at his clinic. She was also told to follow up with her primary care physician in one week. To note laboratories at the time of discharge showed a hematocrit of 29.9 with a BUN and creatinine of 46 and 1.6 respectively with a potassium of 4.1.	DENIES SHORTNESS OF BREATH.GI: NPO AFTER MID NOC. Neo gtt weaned off. Pt gently hyperventilated to normalize ABG. Sinus bradycardiaNormal ECG except for rateSince previous tracing of : supraventricular tachycardia has reverted tosinus rhythm Lungs clear, slightly diminished upper right.NEURO: Alert, oriented, follows commands, MAE equally.GU: Foley, adequate UOP.GI: Reglan given x 2 for nausea. Neo gtt to tx hypotension. SBP 130'S TO 168/ ,NITRO WEANED TO OFF . Volume given, atropine given with good effect, briefly. OG tube d/c'd with extubation. POST CXR DONE. Plan to cont vent support, labile hemodynamics. Hemodynamically NTG infusing. Sinus bradycardiaNormal ECG except for rateNo previous tracing for comparison BP immediatley recovers when converts back to NSB. Antiobiotic therapy changed.PAIN: Epidural catheter intact, site WNL. CT draining scant serosang fluid. SBP RANGED 78 TO 180'S AND REMAINS DEPENDENT ON NEO DRIP. Breathing became labored, Sa02 dropped, anesthesia called STAT. Resp Care Note, Pt weaning on cpap/psv ps 10cmh2o for vt's 3-400. will cont to wean as tol Resp Care Note, Pt reains on current vent settings T 100.2 weaning neo,Given bicarb for met acidosis. STARTED ON CLONIDINE TID. Started on nitro gtt for elevated PA pressures. Pt slowly stabilized and dopamine weaned off and Neo at 2mcg/kg/min. focus: status update.NEURO: ALERT AND ORIENTED X3 MAE ON COMMAND, PERL, NO APPARENT NEURO DEFICIT.CV: PA LINE PLACED AFTER FEW ATTEMPTS. Maintaing good PaO2, metabolic acidosis on first post-extubation gas. ONE AMP OF DEXTROSE AND REG INSULIN FOR ELEVATED K. C/ IMPROVEMENT.RESP: LUNG SOUNDS COARSE TO CLEAR. NEO BEING WEANED OFF AS TOLERATED. OGT PLACED AFTER PT STARTED ON PROPROFOL AND TO LWS DRAINING MINIMAL BILIOUS DRAINAGE.GU; PT WITH LOW URINE OP AND DR AND DR WITH NO ORDERS WRITTEN. MAE.CV: NSR no VEA.Palp DP. Dilaudid gtt, weaned to off to assess neuro status. Pt reintubated. PT DENIES NAUSEA. WAKE PT TO WEAN TO EXTUBATE IF REMAINS STABLE. CREATININE > 2.0 THIS AM.COMFORT; PT WITH EPIDURAL CATH IN BACK BUT NOT IN USE AT THIS TIME PER PAIN TEAM. ABG SHOWED ACIDEMIA, ONE AMP OF BICARB C/ IMPROVEMENT IN ABG, CT DRAINING SMALL TO MODERATE AMOUNTS OF S/S DRAINAGE. tolerating meds and water.GU: urine output adeaquet. RT PLEURAL CHEST TUBE WITH INTERMITTENT SM AIR LEAK DR AND DRAINING MINIMAL THIN SEROSANQ DRAINAGE.CARDIOVAS; HR AND BP VERY LABILE MOST OF THE . PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 63Weight (lb): 155BSA (m2): 1.74 m2BP (mm Hg): 164/49HR (bpm): 52Status: InpatientDate/Time: at 03:06Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. In the mean time hemdynamic instability continued, pt required dopamine and neo to maintain SBP. See adm history for PMH. PT IN AND OUT OF ACC. Since dopa gtt stopped, NSB consistently and BP much more stable. Dilauded infusion started for pain management, epidural on hold per pain service. Resp. Resp. CT Site D/I , no redness or break down.A pt is stable epidural is functioning.PAS and SBP are highP continue with lopressor and titrate up nitroglercerine for PAS < 60. note labs replete lytes as needed. NITRO GTT STARETD IN HOPES THAT PAS WOULD IMPROVE C/ LITTLE EFFECT. Regular supraventricular rhythmLead(s) unsuitable for analysis: V1ST junctional depression is nonspecificSince previous tracing of : supraventricular tachycardia is seen PAIN MANAGEMENT: EPIDURAL FENTANYL/BUPIVICAINE AT 12 CC ..PT DENIES PAIN. ID: Afebrile. PH WNL. C-XRAY, CARDIOLOGY CONSULT, AND CARDIAC ECHO DOWN FOR INSTABILITY AND INCREASED CK/MB AND TROPONIN. U/O qs, +BS. Bicarb given for most recent ABG.GI: Abd. Left ventricular systolic function ishyperdynamic (EF>75%).AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened.PERICARDIUM: There is a small pericardial effusion. PULSES PALPABLE.RESP: LUNG SOUNDS CLEAR. Shift NoteNeurologically pt intact, MAE to command. PT ON DILAUDID GTT AND TITRATED BETWEEN 0.75MG TO 1 MG/HR WITH GOOD EFFECT.PLAN; CONT TO MONITOR AND ASSESS MONITOR URINE OP AND POTASSIUM LEVEL POSS. Pt continued to be labile, ABG revealed profound Resp. CONT C/ LOW GRADE FEVER. OG TUBE IN PLACE--CLAMPPED.GU: FOLEY CATH PATENT DRAINING YELLOW CLEAR URINE SEE FLOW SHEET FOR SPECIFICS.PAIN: PT DENIES PAIN.ENDO: BS WNL. Intubated with 7.5 ETT and placed on vent with settings as per carevue. foley to gravity.Skin: thoracotomy Dsg D/I. Failed RSBI 166.7. TRACKS C/ EYES. Very little extra movement to painful stimuli.CV: At beginning of shift, alternating between junctional rhythm 40-50s and NSB rate 50s. Pt then became hemodynamically unstable, JR 30's, SBP 60's. gtt, but SBP increased 170's, nitro. MAE EQUAL STRENGTH BIL LOWER EXTREMITIES AND UPPER EXTREMITIES. Resp: Lungs cta, SAO2 100% ra. CONTINUE C/ CURRENT PLAN OF CARE Pt returned extubated but required intubation shortly after arrival back to unit for resp. Cont vent support. 2 Units PRBC given for low Hct.PULM: Metabolic acidosis during the day. Care NotePt to OR today for thoracotomy. good wave PA pressures high nitroglycerine started to decrease PAS. IVF D5W with sodium bicarbonate at 40.Lungs : coarse in upper lobes coarse to wheezing in bases. MAE and follows commands.CV: SB/NSR with no ectopy, SWAN dc'd, introducer to LSC, team wanted to d/c nitro. PT NOW SEDATED OVER ON PROPROFOL AT 30 MCG/KG/MIN DUE TO ANY MANIPULATION PT WOULD ATTEMPT TO SIT UP, GAGGING ON ETT, MAKING BP,HR, AND PA NUMBERS VERY LABILE.RESP; LUNGS SOUND VERY COARSE THRUOUT AND SUCTION FOR MOD AMTS THICK BLOODY SPUTUM. There is a small pericardial effusion. PT WITH MAINT. CI WNL. NITRO OFF PA PRESSURES UNCHANGED. PERRL. 7a-7pCV: NSR, rare PAC. Renal: HNV Heme: Bloodwork to be drawn when SG placed. SKin: Intact.A: Stable, awaiting SG insertion and lobectomy.P: As above. NEURO: A/O X 3. BLD CULTURES X2 DONE AND AT THIS TIME PT NEEDS URINE CULTURE AND SPUTUM CULTURE. Pt with met. MAINT FLUID STARTED, NS @60 ML/H.	20	[ { "category": "Echo", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 100211, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 155\nBSA (m2): 1.74 m2\nBP (mm Hg): 164/49\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 03:06\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%).\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Left ventricular systolic function is hyperdynamic\n(EF>75%). Right ventricular chamber size is normal with preserved free wall\nmotion. The aortic valve leaflets are mildly thickened. The mitral valve\nleaflets are mildly thickened. There is a small pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 274934, "text": "Sinus bradycardia\nNormal ECG except for rate\nSince previous tracing of : supraventricular tachycardia has reverted to\nsinus rhythm\n\n" }, { "category": "ECG", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 274935, "text": "Regular supraventricular rhythm\nLead(s) unsuitable for analysis: V1\nST junctional depression is nonspecific\nSince previous tracing of : supraventricular tachycardia is seen\n\n" }, { "category": "ECG", "chartdate": "2177-06-30 00:00:00.000", "description": "Report", "row_id": 274936, "text": "Sinus bradycardia\nNormal ECG except for rate\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421443, "text": "Shift Note\nNeurologically pt intact, MAE to command. Hemodynamically NTG infusing. U/O qs, +BS. Pt sent to OR with anesthesia.\n\nPatient admitted to the CSRU S/P R. thoracotomy. Pt arrived extubated with Sa02 99% on face mask, pt C/O severe pain, APS into see patient and adjust epidural. Pt's pain continued to escalate and pt became increasingly restless, thrashing in the bed and hypertensive, SBP >200mmHg, Team in room to assess patient, NTG and SNP started to reduce BP. Breathing became labored, Sa02 dropped, anesthesia called STAT. Pt reintubated. Pt then became hemodynamically unstable, JR 30's, SBP 60's. Volume given, atropine given with good effect, briefly. Pt continued to be labile, ABG revealed profound Resp. acidosis, PCO2 111. Pt gently hyperventilated to normalize ABG. In the mean time hemdynamic instability continued, pt required dopamine and neo to maintain SBP. Pt slowly stabilized and dopamine weaned off and Neo at 2mcg/kg/min. Dilauded infusion started for pain management, epidural on hold per pain service. Pt is sleeping comfortably in bed, arousable adn neurologically intact, denies pain. See flow sheet for details. Vitals documented q 5 minutes while unstable.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421444, "text": " CSRU 7P-7A SHIFT SUMMARY;\n\nNEURO; SEDATED ON DILAUDID FOR PAIN BUT EASILY ARROUSABLE BY VOICE DID FOLLOW COMMANDS AND MOVED ALL EXTREMITIES. PERRL. PT NOW SEDATED OVER ON PROPROFOL AT 30 MCG/KG/MIN DUE TO ANY MANIPULATION PT WOULD ATTEMPT TO SIT UP, GAGGING ON ETT, MAKING BP,HR, AND PA NUMBERS VERY LABILE.\n\nRESP; LUNGS SOUND VERY COARSE THRUOUT AND SUCTION FOR MOD AMTS THICK BLOODY SPUTUM. ABG'S WNL EXCEPT C02 33 THIS AM. PH WNL. 02 SAT'S 100% NO VENT CHANGED OVER AND PT REMAINS ON SIMV 50% 16 X 500 . RT PLEURAL CHEST TUBE WITH INTERMITTENT SM AIR LEAK DR AND DRAINING MINIMAL THIN SEROSANQ DRAINAGE.\n\nCARDIOVAS; HR AND BP VERY LABILE MOST OF THE . C-XRAY, CARDIOLOGY CONSULT, AND CARDIAC ECHO DOWN FOR INSTABILITY AND INCREASED CK/MB AND TROPONIN. PT IN AND OUT OF ACC. JUNCTIONAL RHYTHMS TO SB 40'S- 50'S TO SVT 130 AND THEN SR 60'S. THIS AM PT MOSTLY SB 40'S. SBP RANGED 78 TO 180'S AND REMAINS DEPENDENT ON NEO DRIP. PT GIVEN 250CC LR BOLUS AND A PARTIAL 250CC BOLUS FOR LOW BP'S AND LOW URINE WITH NO REMARKABLE EFFECT. DOPAMINE DRIP AT 5MCG/KG/MIN AND DOWN TO 3MCG/KG/MIN PER ORDERS. PAS AND PAD REMAIN 50-60'S /20'S. CI >2.00 ALL SHIFT. POTASSIUM CLIMBING UP TO 5.8 TX WITH 30 GMS KAYXYLATE/SORBITAL PER ORDERS DOWN OGT. TEMP SPIKE TO 102.7 DR AND PT TX WITH 1000MGS TYLENOL GIVEN PR. BLD CULTURES X2 DONE AND AT THIS TIME PT NEEDS URINE CULTURE AND SPUTUM CULTURE. PT WITH MAINT. IV OF LR AT 70CC HR BUT STOPPED PER ORDERS DURING THE .\n\nGI; BS ABSENT. PT WITHOUT OGT AND ATTEMPTED TO PLACE ONE BUT PT BECAME VERY AGGITATED AND DID NOT TOLERATE. OGT PLACED AFTER PT STARTED ON PROPROFOL AND TO LWS DRAINING MINIMAL BILIOUS DRAINAGE.\n\nGU; PT WITH LOW URINE OP AND DR AND DR WITH NO ORDERS WRITTEN. CREATININE > 2.0 THIS AM.\n\nCOMFORT; PT WITH EPIDURAL CATH IN BACK BUT NOT IN USE AT THIS TIME PER PAIN TEAM. SITE CDI. PT ON DILAUDID GTT AND TITRATED BETWEEN 0.75MG TO 1 MG/HR WITH GOOD EFFECT.\n\nPLAN; CONT TO MONITOR AND ASSESS MONITOR URINE OP AND POTASSIUM LEVEL POSS. WAKE PT TO WEAN TO EXTUBATE IF REMAINS STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421445, "text": "Respiratory Care:\nPatient remained on ventilatory support with no changes made throughout the night. ABG's show that the patient is receiving adequate oxygenation with a compensated metabolic acidemia.\n\nNo RSBI performed due to patient's cardiac instability.\n\nPlan is to eliminate sedation and allow patient to be weaned from ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421446, "text": "NEURO: , , weaned off propofol and dilaudid to assess neuro status, hands and feet move on own but not to command, gets restless and agitated at times, Has nodded head to questions a couple of times. Looks at speaker, but does not follow most of time. Very little extra movement to painful stimuli.\n\nCV: At beginning of shift, alternating between junctional rhythm 40-50s and NSB rate 50s. When junctional, becomes very hypotensive quickly. BP immediatley recovers when converts back to NSB. Neo gtt to tx hypotension. Dopamine gtt weaned off per Dr. is dopa may be counterproductive due to diastolic dysfunction. Since dopa gtt stopped, NSB consistently and BP much more stable. Started on nitro gtt for elevated PA pressures. CI WNL. Cardiology in to see patient.\n\nRESP: Lungs coarse throughout, CT with SS drainage, no air leak, suctioned small amounts of thick blood tinged secretions. Several vent changes made due to ABG results, see flowsheet for changes. Bicarb given for most recent ABG.\n\nGI: Abd. soft. OGT clamped. Absent BS\n\nGU: U/O 20-25cc/hr, 500 NS fluid bolus given, CR 2.7 this afternoon.\n\nID: Febrile. Urine and sputum cx sent, blood sent previous shift. Antiobiotic therapy changed.\n\nPAIN: Epidural catheter intact, site WNL. Dilaudid gtt, weaned to off to assess neuro status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421447, "text": "Resp. Care Note\npt remains intubated and vented on settings as per carevue. Please see flowsheet for changes made. Pt with met. acidosis on ABG's. Cont vent support.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421448, "text": "Pt beginning to answer questions by nodding head more consistently and seems to be gripping hands and moving feet to command instead of just at random.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-30 00:00:00.000", "description": "Report", "row_id": 1421440, "text": "CSRU Admission\nS/O: 73 yo woman admitted preop RU Lobectomy for SG evaluation. See adm history for PMH.\n Neuro: Alert and oriented.\n CV: SB 50s, 160/50.\n Resp: Lungs cta, SAO2 100% ra.\n Renal: HNV\n Heme: Bloodwork to be drawn when SG placed.\n ID: Afebrile.\n GI: Not much appetite.\n Endo: Awaiting bloodwork.\n SKin: Intact.\nA: Stable, awaiting SG insertion and lobectomy.\nP: As above. Preop teaching.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421441, "text": "focus: status update.\nNEURO: ALERT AND ORIENTED X3 MAE ON COMMAND, PERL, NO APPARENT NEURO DEFICIT.\n\nCV: PA LINE PLACED AFTER FEW ATTEMPTS. HIPERTENSIVE TO 160'S, PA PRESSURES SYSTOLIC 40'S TO 50'S. NITRO GTT STARETD IN HOPES THAT PAS WOULD IMPROVE C/ LITTLE EFFECT. MAINT FLUID STARTED, NS @60 ML/H. PT . PULSES PALPABLE.\n\nRESP: LUNG SOUNDS CLEAR. SATS 98 TO 100 AT RA. DENIES SHORTNESS OF BREATH.\n\nGI: NPO AFTER MID NOC. BOWEL SOUNDS PRESENT. ABD SOFT NON TENDER TO PALPATION.\n\nGU: VOIDS YELLOW CLEAR URINE.\n\nENDO: BS COVERED C/ REG INSULIN AS PER PROTOCOL.\n\nSOCIAL: FAMILY CALLED. FAMILY COMING IN TODAY IN AM.\n\nPLAN: PRE-OP TEACHING, OPTIMIZED LAVEL OF COMFORT PROVIDE EMOTIONAL SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421442, "text": "Resp. Care Note\nPt to OR today for thoracotomy. Pt returned extubated but required intubation shortly after arrival back to unit for resp. failure. Intubated with 7.5 ETT and placed on vent with settings as per carevue. Please refer to flowsheet for parameters and changes made. Plan to cont vent support, labile hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-05 00:00:00.000", "description": "Report", "row_id": 1421455, "text": "CV: HR 70'S TO 80'S SR OCCASIONAL PVC. SBP 130'S TO 168/ ,NITRO WEANED TO OFF . STARTED ON CLONIDINE TID. REQUIRED HYDRALAZINE 10 MG IV TIMES 2.\nRESP: EXPIRATORY WHEEZES BILATERAL ALBUTEROL TX BY RESP Q 6 PRN WITH SOME EFFECT BUT WHEEZING CONTINUES.O2 SATS 96-97 % ON 2 LNC. LASIX 20 MG IV TIME ONE WITH NO EFFECT. LASIX 40 MG IV WITH GOOD RESPONSE SEEE FLOW SHEET.CHEST TUBE D.C.'D. POST CXR DONE.\n\n PAIN MANAGEMENT: EPIDURAL FENTANYL/BUPIVICAINE AT 12 CC ..PT DENIES PAIN. MAE EQUAL STRENGTH BIL LOWER EXTREMITIES AND UPPER EXTREMITIES. PT CAN LIFT BOTH ARMS OFF BED AND HOLD. CAN BEND BOTH LEGS TO ASSIST WITH LIFTING UP IN BED.\nGU FOLEY DRAINING CLEAR YELLOW URINE. DIURESING WITH LASIX.\nGI; BOWEL SOUNDS PRESENT.\nMENTAL STATUS: PATIENT INITIALLY REFUSING TO TAKE MEDS.SHE LATER AGREED TO TAKE PILLS SHE WAS ALERT AND ORIENTD BUT STATED THAT SHE DIDNOT KNOW ME AND WAS CONCERNED ABOUT TAKING MEDS FROM SOMEONE SHE DID NOT RECOGNIZE.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-04 00:00:00.000", "description": "Report", "row_id": 1421453, "text": "D Neuro: Alert and oriented. MAE.\nCV: NSR no VEA.Palp DP. Swan in Lsc. good wave PA pressures high nitroglycerine started to decrease PAS. titrated up to 2mcg/kg PAs continued to be consistantly > 60 Nitroglercerine order,\n increased . currently at 3mcg with pas high 50\"s.CVP 10-12. IVF D5W with sodium bicarbonate at 40.\nLungs : coarse in upper lobes coarse to wheezing in bases. TCDP,CPT and IS done every 2 hour with effect pt able to cough up thich bloody sputum. on 5L NC pt does not tolerate a FT well finds it very uncomfortable.RT cheat tube to suction draining straw colored Fld to suction as ordered.\nPain: pt has a thoracic epidural in place insertion site is clear and dry. Epidural drip was changed at about 2200 .Fentanyl was added with bupivicaine. Initially drip at 5cc but pt having pain increased to 10cc with effect pt able to tolerate TCDP and CPT . At 5am pt started having increased pain at incision site repositioning did not help insertion site intact called pain service .Order 5cc bolus with a repeat if needed and to increase drip to 12cc.Pt is now resting comfortablly.\nGI: ABD slightly distended , BS present. No N/V/D. tolerating meds and water.\nGU: urine output adeaquet. foley to gravity.\nSkin: thoracotomy Dsg D/I. CT Site D/I , no redness or break down.\nA pt is stable epidural is functioning.PAS and SBP are high\nP continue with lopressor and titrate up nitroglercerine for PAS < 60. note labs replete lytes as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-04 00:00:00.000", "description": "Report", "row_id": 1421454, "text": "NEURO: A/O X 3. MAE and follows commands.\n\nCV: SB/NSR with no ectopy, SWAN dc'd, introducer to LSC, team wanted to d/c nitro. gtt, but SBP increased 170's, nitro. gtt titrated up to 5 mcg/kh/hr with additional hydralazine 10 mg X3 given, SBP decreased to 150's, afebrile, received 1 UPRBC\n\nRESP: CT to water seal with minimal drainage, lungs coarse with occasional expiratory wheeze, 02 @ 2l via NC, sat's 99%, thoracotomy dressing D/I, instructed on IS use, coughing up blood tinged sputum,\n\nGI: BS +, abd soft, tolerated house diet\n\nGU: foley patent and draining clear yellow urine, good UO\n\nPAIN: Thoracic epidural in place with fentanyl and marcaine, pain well controlled, site intact.\n\nPLAN: Monitor and control BP, wean off Nitro., encourage pulmonary toilet, possible d/c CT?\n\nACTIVITY: OOB to Chair and up with PT walking today.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421449, "text": "focus: status update.\nNEURO: PT ALERT MAE ON COMMAND--INCONSISTENTLY, BUT MORE FREQUENTLY. PERL. ABLE TO RESPOND TO YES/NO QUESTIONS. TRACKS C/ EYES. MOUTHS WORDS. NO SEDATION. NO APPARENT NEURO ISSUES. EPIDURAL IN PLACE NOT BEING USED.\n\nCV: NSR TO SINUS BRADY--NO JUNCTIONAL RHYTHM. NITRO OFF PA PRESSURES UNCHANGED. NEO BEING WEANED OFF AS TOLERATED. CI >2 SEE FLOW SHEET. CONT C/ LOW GRADE FEVER. ONE AMP OF DEXTROSE AND REG INSULIN FOR ELEVATED K. C/ IMPROVEMENT.\n\nRESP: LUNG SOUNDS COARSE TO CLEAR. ABG SHOWED ACIDEMIA, ONE AMP OF BICARB C/ IMPROVEMENT IN ABG, CT DRAINING SMALL TO MODERATE AMOUNTS OF S/S DRAINAGE. SX FOR LARGE AMOUNTS OF THICK BLOODY TINGED SPUTUM.\n\nGI: PT TOLERATING PO MEDS. NO BM NO FLATTUS. PT'S ABD SOFT OBESE. NON TENDER TO PALPATION. PT DENIES NAUSEA. OG TUBE IN PLACE--CLAMPPED.\n\nGU: FOLEY CATH PATENT DRAINING YELLOW CLEAR URINE SEE FLOW SHEET FOR SPECIFICS.\n\nPAIN: PT DENIES PAIN.\n\nENDO: BS WNL. NO INSULIN REQUIRED. 10 MG IV REG INSULIN GIVEN C/ DEXTROSE.\n\nSOCIAL: FAMILY CALLED FOR UPDATE ON PT.\n\nPLAN: WEAN OFF VENT TO EXTUBATION, WEAN OFF NEO, MONITOR K LEVELS, MONITOR HEMODYNAMICS. CONTINUE C/ CURRENT PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421450, "text": "Resp Care Note, Pt reains on current vent settings T 100.2 weaning neo,Given bicarb for met acidosis. ABG'S improving. Failed RSBI 166.7. Not ready for extubation\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421451, "text": "Resp Care Note, Pt weaning on cpap/psv ps 10cmh2o for vt's 3-400. will cont to wean as tol\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421452, "text": "7a-7p\nCV: NSR, rare PAC. Normal temp in a.m., starting to have low grade fever in afternoon. CI >2. PA pressures continue to be elevated. Neo gtt weaned off. 2 Units PRBC given for low Hct.\n\nPULM: Metabolic acidosis during the day. Kept on CPAP all day. Extubated at 1500. Maintaing good PaO2, metabolic acidosis on first post-extubation gas. Currently on 50% face tent, attempted NC but patient stated she felt she could breath easier with face tent although pulse ox was 96-97% on NC. Strong cough, raising thick yellow, blood tinged sputum. CT draining scant serosang fluid. Lungs clear, slightly diminished upper right.\n\nNEURO: Alert, oriented, follows commands, MAE equally.\n\nGU: Foley, adequate UOP.\n\nGI: Reglan given x 2 for nausea. OG tube d/c'd with extubation. Hypo bowel sounds.\n\nPAIN: Pain service tested epidural this morning and reordered epidural. After extubation and coughing, pain level has increased. Increased epidural rate, now at 10cc/hr which is max rate ordered by pain service.\n\nPLAN: Pulmonary toilet, monitor ABGs.\n" } ]
23,478	113,289	In summary, this is a 88 year old female with DM, HTN who presented with STEMI and was brought emergently to cath lab, was transferred to the CCU following procedure with IABP given hypotension. Hospital course was complicated by upper GI bleed, slow afib requiring cardiopulmonary resusitation. The pt was made DNR during the admission and passed on at 12:08 AM while in the CCU, cause of death noted to be cardiogenic shock following STEMI. . # CORONARIES: Patient presented with STEMI. During cath patient had successful thrombectomy of proximal LAD occlusion with 20% residual stenosis. However, developed acute occlusion of OM (due to an embolus) treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion but restoration of flow. Patient was unstable during procedure and consequently was intubated and IABP placed. No stent was placed during procedure. She was transferred to the CCU on IABM, integrillin, hepain. Attempts were made to wean the balloon pump but were unsuccessful due to hypotension. On day 3 of the hospitalization, family meeting was held and pt was made CMO, IABP weaned, pt started on morphine gtt. . # PUMP: ECHO performed on the showed EF of 30% to 35% with mild regional left ventricular systolic dysfunction and dilated right ventricle with moderate regional systolic dysfunction. New changes secondary to ACS. . # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on Verapamil for rate control. No anti-coagulation had been given in the past due to prior history of GI bleed. During this admission, she developed slow afib and the family was called and decided to make DNR after the first code, no escalation of care. . # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at GE junction. Patient's HCT and hemodynamics currently stable. Due to ballon pump patient was initially placed on heparin, started on IV PPI. Crits were followed. . # Diabetes: Insulin sliding scale . # Hypertension: Outpatient Lisinopril, Lasix and Verapamil were held due to hypotension after cath . # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 - 1.9. During this admission, pt developed with creatinine rising to 2.3, unclear etiology but concerning for pre-renal vs cholesterol emboli vs contrast-induced nephropathy (less likely due to timing of onset). . # Shock: on day 2 of the admission, pt developed mixed cardiogenic/septic shock, 2 blood cxs growing gram + cocci, was started on vanc/cefepime for broad coverage. . # Coagulopathy: Pt with declining platelets, hct, concerning for DIC, platelet distruction in the setting of IABP. . # Asthma: Patient intubated. . # Gout: Hold Allopurinol in acute setting. . # GERD: IV PPI given UGI bleed.	# Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. There is a trivial/physiologicpericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w LADdisease. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. Pt systemically vasodilated. Pt systemically vasodilated. Action: Blood sugars q 1 hr. High LDH, abnormally high PTT on low amts heparin --> sent DIC labs, periph smear. High LDH, abnormally high PTT on low amts heparin --> sent DIC labs, periph smear. # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . Pt taken emergent cath; initially showed thrombus with occlusion in proximal LAD; wiring of this lesion restored flow, export removed clot, however it appear to travel to LCx, this was exported; during the latter, pt began having recurrent CP, respiratory distress, and hypotension. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. Blood in the lower third of the esophagus and gastroesophageal junction Friability in the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to duodenal bulb ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression lead III, aVR. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: s/p stemi, s/p thrombectomy of prox lad occlusion, thrombectomy & ptca to occluded OM. Pt systemically vasodilated. cont with Bair Hugger to achieve normothermia. Hyperglycemia Assessment: Action: Response: Plan: Hematemesis (upper GI bleed, UGIB) Assessment: Action: Response: Plan: IVF as needed. Requiring ^ pressor support Response: Stbale bp w dopamine support. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. DISPO: CCU for now ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 12:04 PM Arterial Line - 12:28 PM IABP line - 12:28 PM Sheath - 12:29 PM PA Catheter - 01:46 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Shock, other Assessment: Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC Action: Cont on Dopamine, IV ABs: vanco and cepepime Response: Remains pressor dependent Plan: Will cont current level of care, will not add pressor, increase Dopa and given IVFs, blood as indicated. # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now . - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. Pt systemically vasodilated. Pt systemically vasodilated. Pt systemically vasodilated. Pt systemically vasodilated. Blood in the lower third of the esophagus and gastroesophageal junction Friability in the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to duodenal bulb ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression lead III, aVR. - IV PPI , sucralafate 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy.	66	[ { "category": "Echo", "chartdate": "2130-09-02 00:00:00.000", "description": "Report", "row_id": 97987, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 82/34\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 11:05\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIntra-aortic balloon pump was in position during the study.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. [Due to acoustic shadowing, the severity of MR may\nbe significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThere is moderate regional left ventricular systolic dysfunction with\nhypokinesis of the mid to distal septum, anterior wall and lateral wall. Right\nventricular chamber size is normal. with focal hypokinesis of the apical free\nwall. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. The\npulmonary artery systolic pressure could not be determined. There is a small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , overall LV\nfunction is slightly more depressed, particularly in the lateral wall. The\nother findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 97988, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 115/15\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIntraaortic balloon pump was at 1:1 during this study.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Mild regional LV systolic\ndysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Focal apical hypokinesis of RV\nfree wall.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is small and underfilled. There is\nmild regional left ventricular systolic dysfunction with septal akinesis. The\nremaining segments contract normally (LVEF = 45%). The right ventricular\ncavity is moderately dilated with focal akinesis of the apical one-half of the\nfree wall. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w LAD\ndisease. Dilated right ventricle with moderate regional systolic dysfunction,\nc/w CAD.\n\nCompared with the prior study (images reviewed) of , regional\nbiventricular systolic dysfunction is new.\n\n\n" }, { "category": "General", "chartdate": "2130-09-04 00:00:00.000", "description": "ICU Event Note", "row_id": 388557, "text": "Clinician: Resident\n Family meeting held with patient's children, grandchildren, , and\n Dr. regarding overall decline in clinical status. Patient\n had previously expressed to her family that she would not want\n prolonged mechanical/artifical support. After discussing poor prognosis\n and overall deteriorating condition, decision was made to focus on\n comfort care and withdraw support. Will hold all medications including\n dopamine and turn IABP to 1:8, start morphine for comfort.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2130-09-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388360, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ABG 7.35/34/154/19/5. RSBI=no resps\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved; Comments: presently still\n on balloon pump\n" }, { "category": "Respiratory ", "chartdate": "2130-09-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388443, "text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue on present settings. Pt arrested during noc,\n compABG 7.26/22/95ressions performed, some improvement in bp.\n 7.26/22/95\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388446, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hyperglycemia\n Assessment:\n Blood glucose trending down while on insulin gtt. Please see\n metavision for data.\n Action:\n Blood sugars q 1 hr. insulin gtt off as blood glucose down to 50.\n given 1 amp d50. cont blood sugars q1 hr,\n Response:\n Blood glucose now 132, insulin gtt off.\n Plan:\n Cont to follow blod glucose, restart insulin gtt if blood sugars high.\n Impaired Skin Integrity\n Assessment:\n Excoriation noted under both breasts. Site red, oozing small amt of\n sero/sang fluid.\n Action:\n Sites cleaned with foam cleanser and adaptic with duoderm gel applied.\n Response:\n Wound sites remain unchanged.\n Plan:\n Cont with good skin care, adaptic and duoderm gel to excoriation.\n Coagulopathy\n Assessment:\n Less bleeding noted from puncture sites. Heparin cont as ordered.\n Small amt of bloody drainage from ett and ogt. Small amt of bleeding\n from oral cavity.\n Action:\n Following ptt, 2400 ptt 36, heparin rate increased to 400 units/hr as\n per protocol.\n Response:\n Am ptt pending\n Plan:\n Follow ptt, inr and adjust heparin gtt accordingly\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n pt in rapid af, rate 150\ns, hypotensive with sbp 40\ns pt.\n becoming unresponsive- code blue initiated with chest compressions. 1\n amp epinephrine, ns fluid w/o. dopa cont at 12.5 mcg/kg/min. returned\n to sr with several run of accelerated af with hypotension. Family\n called and updated on serious situation. Decision made not to\n cardiovert and no further chest compressions. Pt. now DNR. Pt. now\n in SR with occ pvc, IABP 1:1\n Action:\n IABP 1:1, dopa gtt @ 12.5 mcg/kg/min, 1 unit prbc given for hct 22, 3l\n NS fluid bolus given overnight.\n Response:\n Maintaining MAP60-65, pad increased to 19-20 after receiving blood and\n fluid\n Plan:\n Cont to monitor hct, hemodynamics, PAD/CVP. ? wean IABP if tol.\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388451, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n SHOCK, OTHER\n COAGULOPATHY\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388452, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388454, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur, IABP heard obscuring some heart sounds.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l. Right femoral A line with pressure\n dressing in place. Left femoral IABP in place.\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388428, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on 1:1\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor.\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388429, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 ,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388430, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 , EKG\ns to assess for\n signs of impending CHB\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388431, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 , EKG\ns to assess for\n signs of impending CHB\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Coagulopathy\n Assessment:\n Received with heparin off due to PTT>150,decreased drip by 400 units/hr\n to 500, repeat PTT , bleeding profusely from IABP and , also\n bleeding from all finger sticks even through dressings. LFT\ns elevated\n Action:\n Kept heparin off for 4hrs, two hrs off heparin PTT 98.6, pressure\n dressing applied to IABP/PA site\n Response:\n No change in bleeding from sites.\n Plan:\n Heparin restarted after being off x 4hrs, now at 100 units/hr ,repeat\n PTT 6hrs from start. Check all sites for bleeding.\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388539, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388546, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Call family as patient not improving, discuss poor prognosis as\n patient not improving. Discuss withdrawal of care.\n - Will pull IABP, as patient not improving on balloon pump and\n platelets low, possibly balloon pump, also with possible\n bacteremia. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - Will continue to monitor Hct and Plts\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388338, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received from cath lab on integrillin, IABP and PA line.\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388339, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics,\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)/ cardiogenic shock\n Assessment:\n Received from cath lab on integrillin, IABP and PA line. Dopamine at\n 5mcg/kg/min, initial temp 92.9 po. No pulses on left side dopplerable\n on left. Ext all cold.\n Action:\n Good augmentation and unloading with IABP. MAPS 88-94 dopamine\n titrating to maintain MAPS >55, heparin started at 900 units/hr. Bair\n hugger placed.\n Response:\n Temp is slowly increasing still below 35. now there are no pulses on\n either foot. Adequate capillary refill. MAPS maintained above 55 on\n dopamine.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388340, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics,\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)/ cardiogenic shock\n Assessment:\n Received from cath lab on integrillin, IABP and PA line. Dopamine at\n 5mcg/kg/min, initial temp 92.9 po. No pulses on left side dopplerable\n on left. Ext all cold.\n Action:\n Good augmentation and unloading with IABP. MAPS 88-94 dopamine\n titrating to maintain MAPS >55, heparin started at 900 units/hr. Bair\n hugger placed.\n Response:\n Temp is slowly increasing still below 35. Now there are no pulses on\n either foot. Adequate capillary refill. MAPS maintained above 55 on\n dopamine. Most recent CO/CI 5.5/3.0 SVR 1000\n Plan:\n Cont with current med plan, IABP, PA line, titrate dopamine to maintain\n MAPS >55. cont with Bair Hugger to achieve normothermia.\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388426, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage.\n Action:\n Numerous EKG\ns throughout day per EP\n s request, on aspirin,\n plavix,lipitor.\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388529, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n SHOCK, OTHER\n COAGULOPATHY\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388530, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-01 00:00:00.000", "description": "Cardiology Fellow Admission Note Addendum", "row_id": 388330, "text": "TITLE: Cardiology Fellow Admission Note Addendum\n Pt examined, discussed with CCU team. For full details please refer to\n housestaff note.\n 88 yo F w/ DM, HTN in USOH until this am when suddenly had intense CP\n and diaphoresis. Initially found to be hypotensive with BP 83/43. EKG\n demonstrated SR at 75, ST elevations lead I, aVL, V1, V2; ST\n depressions III, aVR. Pt taken emergent cath; initially showed thrombus\n with occlusion in proximal LAD; wiring of this lesion restored flow,\n export removed clot, however it appear to travel to LCx, this was\n exported; during the latter, pt began having recurrent CP, respiratory\n distress, and hypotension. She was intubated and an IABP was placed. A\n small amount of residual thrombus remained in the LCx near the OM1. No\n stents were placed as no underlying plaque apparent. Started on\n integrilin and heparin. This afternoon developed UGIB\nEGD revealed\n hematomas in esophagus, small amount of blood in stomach with clots.\n PE\n VS T 34.8C, BP 100/28 on IABP, P 80, RR 19, 100% AC 500/20/5/100%\n Intubated, sedated\n No JVD apparent\n Coarse bs bilat\n RRR, mechanical IABP sounds\n Abd soft, ND\n LE no edema, warm\n Labs notable for CK 999, MB 50, Tn 0.72; Hct stable at 26\n ECG as described above, post-procedure improved ST elevations, slight\n residual in I, L, and present in V2-V4 with depression in II,\n III, F\n Echo today showed EF 45-50%, basal anterior HK, mild symm LVH, +MR,\n 1+TR\n Imp: Anterior STEMI, s/p thrombectomy + antiplt agents, with small\n residual LCx thrombus; GIB esophageal tears in setting of\n anticoagulation, hemodynamically stable\n Plan:\n 1. Continue integrilin and heparin\n 2. Keep active T+C, 4u; check hct now and q8h for now (but will\n see via OGT if GIB increases), if stable can decrease frequency of hct\n check\n 3. Wean IABP tonight, once d/c\nd will be able to d/c heparin\n 4. Wean pressors\n 5. Cont ASA, statin; begin plavix, BB, ACEI when able\n 6. Consider hypercoagulability workup given thrombus without\n underlying plaque, though would be unusual to present with first\n unprovoked thrombus at this point in life; would ensure up to date on\n general malignancy recommendations\n 7. Remainder of plan as per housestaff note.\n 8. Electronically signed by , MD 18:38\n 9.\n 10.\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388334, "text": "88 yo in usual state of health until this morning when she awoke with\n chest pain, family called life line assessed pt and brought to ED. In\n ED alert and oriented x3, chest pain, bloused with heparin and\n integrillin and drips started. In cath lab Hypotensive to 70/30\n dopamine started, RCA chronically occluded, LAD occluded thrombectomy\n and export cath flow\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388414, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: No vent changes.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388417, "text": "Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388418, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood.\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388343, "text": "TITLE: CCU Admission Note\n Chief Complaint: Chest pain\n HPI:\n 88 year old female with PMH significant for HTN, DM who was brought by\n EMS to ER for chest pain and diaphoresis. Per ED intake BP in\n field 68/p, ASA given. Patient's presenting vitals in ED were HR 92, BP\n 148/91, 100 NRB, however shortly after presentation patient became\n hypotensive with BP 50/30. EKG demonstrated ST elevations lead I, lead\n aVL, V1, V2; ST depression lead III, aVR. Patient was taken emergently\n to cardiac cath which demonstrated thrombus with occlusion in proximal\n LAD; wiring of this lesion restored flow, export removed clot, however\n it traveled to LCx. Patient then began having recurrent chest pain,\n respiratory distress, and hypotension. She was intubated and an IABP\n was placed. A small amount of residual thrombus remained in the LCx\n near the OM1. No stents were placed as no underlying plaque apparent.\n Patient was started on integrilin and heparin and transferred to the\n CCU for further care.\n .\n While in the CCU RN noticed blood in the oropharynx, while placing an\n OG patient regurgitated approximately 25 cc of bright red blood with\n clots. Upon placement of OG approximately 10 cc of bright red blood was\n suctioned. Patient was transfused 2 units pRBC, started on IV PPI and\n GI consulted. EGD demonstrated diffuse friable mucosa with clotted\n blood in the lower third of esophagus and GE junction. Blood clot felt\n to be partially tamponading the bleed. For full report please see\n reports below. GI recommended conservative care unless clinical picture\n changes overnight.\n .\n Unable to do review of systems as patient intubated.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Eptifibatide (Integrilin) - 1 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, + Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 1.)Coronary angiography of this codominant system showed single vessel\n coronary artery disease. The left main was without significant\n stenosis, and the LAD was also without stenosis, but the first diagonal\n had an ostial 50% lesion. The circumflex had no\n significant disease. The RCA was also without any significant\n stenoses.\n 2.) Resting hemodynamics showed normal right and left sided filling\n pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac output\n was normal at 5.5 with an SVR of 1207 and a PVR of 58.\n 3.) Left ventriculograpy revealed a normal ejection fraction of 62%\n with mild mitral regurgitation and no significant wall motion\n abnormalities.\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n - diverticulosis requiring 8 units transfusion with\n negative angiogram.\n - grade 1 internal hemorrhoids\n - sigmoid diverticulitis with an adjacent abscess \n - Afib: not on coumadin\n - Chronic diarrhea\n - Asthma\n - Gout\n - Recurrent urinary tract infections\n - gastroesphogeal reflux\n - Tremor: essential tremor, followed previously by Dr. \n - Chronic Renal Failure\n - Choledocholithiases/cholangitis (): found to have\n pseudomonas bacteremia, treated with ceftazidime and flagyl, and\n referred for cholecystectomy but patient refused\n - Neuropathic pain\n - Right hip fracture\n - bilateral knee replacements\n - right leg pins\n - cataract repair\n Unable to obtain as patient intubated.\n Unable to obtain as patient intubated.\n Review of systems: Unable to obtain\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 82 (80 - 94) bpm\n BP: 146/66(106) {91/31(60) - 154/66(106)} mmHg\n RR: 18 (16 - 25) insp/min\n SpO2: 100%\n Height: 64 Inch\n CVP: 6 (4 - 7)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 3,901 mL\n PO:\n TF:\n IVF:\n 3,526 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 345 mL\n Urine:\n 245 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,556 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.40/28/171/17/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 342\n Physical Examination\n VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1\n GENERAL: Opens eyes to name. Intubated.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET tube.\n NECK: No JVP appreciated.\n CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,\n gallops.\n LUNGS: Coarse breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Cold feet, pulses not palpable.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 165 K/uL\n 8.7 g/dL\n 365 mg/dL\n 2.0 mg/dL\n 62 mg/dL\n 17 mEq/L\n 106 mEq/L\n 4.8 mEq/L\n 137 mEq/L\n 34.2 %\n 11.2 K/uL\n [image002.jpg]\n \n 2:33 A9/25/ 09:53 AM\n \n 10:20 P9/25/ 10:00 AM\n \n 1:20 P9/25/ 10:18 AM\n \n 11:50 P9/25/ 11:10 AM\n \n 1:20 A9/25/ 03:05 PM\n \n 7:20 P9/25/ 03:14 PM\n 1//11/006\n 1:23 P9/25/ 05:34 PM\n \n 1:20 P9/25/ 09:45 PM\n \n 11:20 P9/25/ 10:07 PM\n \n 4:20 P\n WBC\n 6.9\n 11.2\n Hct\n 26\n 24.8\n 25\n 29\n 26.5\n 32\n 34.2\n Plt\n 169\n 165\n Cr\n 1.9\n 2.0\n TropT\n 0.72\n TC02\n 17\n 19\n 18\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:13.7/43.9/1.2, CK / CKMB /\n Troponin-T:999/50/0.72, Differential-Neuts:56.4 %, Lymph:40.6 %,\n Mono:1.7 %, Eos:1.1 %, Lactic Acid:2.5 mmol/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:4.0 mg/dL\n 2D-ECHOCARDIOGRAM : The left atrium is mildly dilated. There\n is mild symmetric left ventricular hypertrophy. The left ventricular\n cavity is small and underfilled. There is mild regional left\n ventricular systolic dysfunction with septal akinesis. The remaining\n segments contract normally (LVEF = 45%). The right ventricular cavity\n is moderately dilated with focal akinesis of the apical one-half of the\n free wall. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. Mild to moderate (+)\n mitral regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is mild pulmonary artery systolic hypertension. There\n is a trivial/physiologic pericardial effusion. IMPRESSION: Mild\n regional left ventricular systolic dysfunction, c/w LAD disease.\n Dilated right ventricle with moderate regional systolic dysfunction,\n c/w CAD.\n .\n CARDIAC CATH:\n 1. Selective coronary angiography in this right dominant system\n demonstrated two vessel disease. The LMCA was normal. The LAD had a\n 100% proximal thrombotic occlusion and a 50% stenosis in the\n mid-portion. The Cx had a 30% mid-vessel stenosis.\n 2. Resting hemodynamics revealed elevated right and left sided filling\n pressures with RVEDP of 19mm Hg and mean PCW of 28mm Hg. Cardiac index\n was preserved at 4.0L/min/m2. There was systemic hypotension with SBP\n of 96mm Hg and DBP of 41mm Hg.\n 3. Successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis.\n 4. Acute occlusion of OM (due to an embolus) treated with thrombectomy\n and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion\n but restoration of TIMI 3 flow.\n 5. Cardiogenic shock requiring placement of an IABP via the right\n femoral artery.\n EGD :\n Normal mucosa in the duodenum\n Normal mucosa in the stomach\n Blood in the stomach body and fundus\n Blood clot extended from GE junction was noticed in gastric cardia\n area.\n Blood in the lower third of the esophagus and gastroesophageal junction\n Friability in the lower third of the esophagus and gastroesophageal\n junction\n Otherwise normal EGD to duodenal bulb\n ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression\n lead III, aVR.\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n - Patient will require ACE-I and B-blocker as outpatient, however held\n today due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed.\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - Daily EKG\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n - IV PPI , carafate slurry 1 g QID\n - q4hr HCT\n - cross match 4 units\n - wean ballon pump overnight in order to stop heparin\n - if patient decompensates overnight contact GI, IR aware for possible\n embolization. Patient may require Sang- tube.\n .\n # Diabetes: Insulin sliding scale\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9.\n - renal dose all meds\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n : , \n .\n DISPO: CCU for now\n ICU Care\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n FEN: NPO\n .PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .CODE: Full Code - confirmed with \n .: , \n .DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388519, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388422, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388520, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: 7.23/32/117/13\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: pt is dnr, balloon pump continues\n Reason for continuing current ventilatory support: Hemodynimic\n instability\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388523, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic/septic\n Assessment:\n Con\nt on iabp @ 1:1 sbp 90-100 w assisted map\ns > 65. cvp 12-15. wbc\n 12.3. temp max 99.5. has GPC bld cult.\n Action:\n Con\nt on contact precautions hx mrsa. Receiving renal dose cefepime and\n vanco. Requiring ^ pressor support\n Response:\n Stbale bp w dopamine support.\n Plan:\n Am vanco level pending. Pt currently DNR. No new pressors, but may\n titrate dopamine to max if needed. support w fluid if needed.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n s/p stemi, s/p thrombectomy of prox lad occlusion, thrombectomy & ptca\n to occluded OM. Hr 75-110. multiple rhythm chgs from nsr- a-fib. (pt\n has hx a-fib on verapamil @ home for rate control) has short bursts of\n a-fib w rates 100-120, than back to 80-90. slight drop in bp\ns overnoc\n related to rate chgs. Ptt 44.5\n Action:\n ^ dopamine to 15mcg/kg/min, dopamine rate increased per ss to 550u/hr\n Response:\n Improving bp w map\ns > 60 con\nt from nsr to a-fib w varying rates.\n Plan:\n Con\nt to monitor am ptt pending.\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Received pt on 6 units reg insulin via gtt. BS 79.\n Action:\n Gtt decreased to 3 units BS from 63-125. insulin further decreased to\n 0.5-1u/hr md aware of bs\n Response:\n Currently bs 146 @ 1u/hr\n Plan:\n Con\nt q 1/hr bs may chg to ssi today pending am bs results\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Abd soft but distended. Bs +. No stool overnoc. While assessing\n placement of ogt, aspirated dk red blood from tube. Dr .\n Hct overnoc 28.7 no vomiting noted. Tol meds via ogt.\n Action:\n Ogt clamped.\n Response:\n Hct stable hemodynamically stable\n Plan:\n Follow hct. Con\nt carafate, raglan per GI. GI following if further\n bleed may scope again. Clott sent to BB this am.\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388619, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388620, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388621, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps 36-19 with\n IABP in place, IV Morphine at 5mg/hour with Pt. unresponsive, family at\n bedside, at approx. 0005, Pt. bradycardic to asystole within minutes\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death,\n CCU team in to assess and pronounce Pt\ns death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n Additional family in to spend time with Pt. Autopsy declined.\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388508, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388393, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n CXR\n IABP noted to be in proximal position near great vessels, PA\n catheter in good position, OG tube in gastric fundus\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388320, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388507, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388609, "text": "Family meeting with pt\ns 2 daughters, son, grandchildren, Dr. and\n Dr. ; . Decision made to make pt .\n At 1315 morphine gtt started at 5 mg/hr, all other medications\n including dopamine d/c, IABP turned down to 1:8.\n BP has bee 50-60/ 30-40\ns since, hr dropping to 50\ns sr,.\n Pt appears very comfortable on 5 mg morphine. Family at bedside.\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388615, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Unresponsive, sr to sb, sbp 60\ns-50\ns, iabp 1:8, right and left fem\n sites d+I, +pp. warm to touch . family with patient. Morphine gtt @\n 5mg.\n Action:\n Repositioned, morphine gtt continues at 5,\n Response:\n Remains unresponsive, sr 70\ns , sbp 50\n Plan:\n CMO, family present in room, questions answered , support given.\n" }, { "category": "General", "chartdate": "2130-09-05 00:00:00.000", "description": "ICU Event Note", "row_id": 388618, "text": "TITLE: Death Note\n Clinician: , MD\n Called to bedside by nursing staff for asystole at 12:00 AM on\n . Pt was made CMO this AM after extensive discussion with the\n family. Pt examined and found to be pulseless, without heart sounds or\n pupillary reflex. Family at bedside. Time of death 12:08 AM.\n Cause of death determined to be cardiogenic shock following myocardial\n infaction earlier this week. Family to discuss whether they would like\n autopsy when additional family members arrive. Admitting notified.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388489, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cefepime given today(renally\n dosed)\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA. Last CO/CI 7/3.8/svr 592 on IABP 1:2\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Hep gtt restarted @400\n units/hr. PTT due @2200. Cont to monitor, titrate Dopa to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Cont to follow hct, goal Hct 25, NPO, protonix , carafate\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic applied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388368, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Vomited x1 dark red blood with many clots. Ogt draining small amt of\n dark red blood with small clots. Received 2 units prbc, hct 34-30\n following transfusion.\n Action:\n Started on carafate slurry via ogt q 6 hrs. continues on protonix iv q\n 12 hrs. monitoring hct q3hrs.\n Response:\n No further vomiting,\n Plan:\n Continue to follow serial hct, cont carafate and protonix as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt on IABP 1:1 ratio, MAP >60. on dopamine 7 mcg/kg/min.\n right groin oozing with small hematoma, Doppler pulses on right PT\n only. Left groin with small hematoma, no bleeding noted. Weaned IABP\n to 1:2 with adequate bp control. Able to wean IABP to 1:4 for approx.\n 1 hr, however pt MAP down to 50. Placed back on 1:2. dopamine\n increased to 10 mcg/kg/min. Please refer to metavision for\n hemodynamics/PA #\ns. am cpk 6000.\n Action:\n Increased dopamine to 10 mcg/kg/min, weaned IABP to 1:2, attempted to\n wean to 1:4. integrilin d/c\nd. heparin off x1 hr.\n Response:\n MAP < 50 following IABP wean to 1:4.\n Plan:\n ? wean IABP to 1:4 as plan is to d/c balloon. Follow HCT, ck, trop\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388371, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388479, "text": "Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388482, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved LAD, large\n OM occluded probably from embolus, thrombectomy and PTCA improved flow\n w/ residual 60% thrombotic lesion, IABP and intubated due to severe\n hypotension & resp distress, echo mildly depressed EF, severe rt\n hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388483, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved LAD, large\n OM occluded probably from embolus, thrombectomy and PTCA improved flow\n w/ residual 60% thrombotic lesion, IABP and intubated due to severe\n hypotension & resp distress, echo mildly depressed EF, severe rt\n hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given atropine, regained pulse\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388484, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cefepime given today(renally\n dosed)\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA. Last CO/CI on IABP 1:2\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Cont to follow hct, goal Hct 25, NPO\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic applied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388388, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388477, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388586, "text": "Family meeting with pt\ns 2 daughters, son, grandchildren, Dr. and\n Dr. ; . Decision made to make pt .\n At 1315 morphine gtt started at 5 mg/hr, all other medications d/c,\n IABP turned down to 1:8.\n" }, { "category": "Respiratory ", "chartdate": "2130-09-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388587, "text": "Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours: Comfort measures only\n :\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388588, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarcic\n Head, Ears, Nose, Throat: ET tube in place\n Cardiovascular: irregular rate, no MRG\n Peripheral Vascular: 2+ radial pulses\n Respiratory / Chest: CTA bilaterally anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: 1+ bilateral LE edema\n Skin: Warm\n Neurologic: Opens eyes to voice, cannot follow commands.\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Poor prognosis discussed with family, pt made .\n - Will wean IABP. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, on Verapamil for rate\n control. No anti-coagulation due to prior history of GI bleed. ECG\n now showing left axis deviation and RBB block -> pt likely has left\n anterior fascicular block and RBB block, and is at high risk to develop\n complete heart block. Overnight, patient intermittently in A fib with\n fast then slow ventricular response. Tends to become hypotensive when\n rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts, however\n now stable in high 40s\n - Will continue to monitor Hct and Plts, expect improvement with d/c of\n IABP\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Holding outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Continue ASA 325 mg\n - Continue plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1.\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no signs of volume\n overload currently\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , sucralafate 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - follow crit, has been stable\n - 4 units cross-matched\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: continue insulin gtt\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now\n .\n #Acute on Chronic Renal Failure: Recent creatinine range as outpatient\n 1.3 - 1.9. Pt now with creatinine to 2.8. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position). Renal failure is likely contributing to acidotic state.\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor creatinine\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: IV pantoprazole\n VAP: elevate HOB\n Comments:\n Communication: Comments: Daughters , \n \n Code status: DNR/DNI, \n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy.\n Total time spent on patient care: 35 minutes. Greater than 50% time\n counseling / coordinating care.\n Additional comments:\n Due to overwhelming nature of patient's illness and near-impossibility\n of chance of reasonable recovery, along with her stated wishes\n (confirmed by family) to not have extreme end of life measures, we will\n withdraw the current intensive level of care and make the patient\n comfortable. Family meeting (including Dr. and Nurse )\n during which family agreed with this plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:48 ------\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388366, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Vomited x1 dark red blood with many clots. Ogt draining small amt of\n dark red blood with small clots. Received 2 units prbc, hct 34-30\n following transfusion.\n Action:\n Started on carafate slurry via ogt q 6 hrs. continues on protonix iv q\n 12 hrs. monitoring hct q3hrs.\n Response:\n No further vomiting,\n Plan:\n Continue to follow serial hct, cont carafate and protonix as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt on IABP 1:1 ratio, MAP >60. on dopamine 7 mcg/kg/min.\n right groin oozing with small hematoma, Doppler pulses on right PT\n only. Left groin with small hematoma, no bleeding noted. Weaned IABP\n to 1:2 with adequate bp control. Able to wean IABP to 1:4 for approx.\n 1 hr, however pt MAP down to 50. Placed back on 1:2. dopamine\n increased to 10 mcg/kg/min. Please refer to metavision for\n hemodynamics/PA #\ns. am cpk 6000.\n Action:\n Increased dopamine to 10 mcg/kg/min, weaned IABP to 1:2, attempted to\n wean to 1:4. integrilin d/c\nd. heparin off x1 hr.\n Response:\n MAP < 50 following IABP wean to 1:4.\n Plan:\n ? wean IABP to 1:4 as plan is to d/c balloon. Follow HCT, ck, trop\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388457, "text": "TITLE: CCU Admission Note\n Chief Complaint: Chest pain\n HPI:\n 88 year old female with PMH significant for HTN, DM who was brought by\n EMS to ER for chest pain and diaphoresis. Per ED intake BP in\n field 68/p, ASA given. Patient's presenting vitals in ED were HR 92, BP\n 148/91, 100 NRB, however shortly after presentation patient became\n hypotensive with BP 50/30. EKG demonstrated ST elevations lead I, lead\n aVL, V1, V2; ST depression lead III, aVR. Patient was taken emergently\n to cardiac cath which demonstrated thrombus with occlusion in proximal\n LAD; wiring of this lesion restored flow, export removed clot, however\n it traveled to LCx. Patient then began having recurrent chest pain,\n respiratory distress, and hypotension. She was intubated and an IABP\n was placed. A small amount of residual thrombus remained in the LCx\n near the OM1. No stents were placed as no underlying plaque apparent.\n Patient was started on integrilin and heparin and transferred to the\n CCU for further care.\n .\n While in the CCU RN noticed blood in the oropharynx, while placing an\n OG patient regurgitated approximately 25 cc of bright red blood with\n clots. Upon placement of OG approximately 10 cc of bright red blood was\n suctioned. Patient was transfused 2 units pRBC, started on IV PPI and\n GI consulted. EGD demonstrated diffuse friable mucosa with clotted\n blood in the lower third of esophagus and GE junction. Blood clot felt\n to be partially tamponading the bleed. For full report please see\n reports below. GI recommended conservative care unless clinical picture\n changes overnight.\n .\n Unable to do review of systems as patient intubated.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Eptifibatide (Integrilin) - 1 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, + Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 1.)Coronary angiography of this codominant system showed single vessel\n coronary artery disease. The left main was without significant\n stenosis, and the LAD was also without stenosis, but the first diagonal\n had an ostial 50% lesion. The circumflex had no\n significant disease. The RCA was also without any significant\n stenoses.\n 2.) Resting hemodynamics showed normal right and left sided filling\n pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac output\n was normal at 5.5 with an SVR of 1207 and a PVR of 58.\n 3.) Left ventriculograpy revealed a normal ejection fraction of 62%\n with mild mitral regurgitation and no significant wall motion\n abnormalities.\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n - diverticulosis requiring 8 units transfusion with\n negative angiogram.\n - grade 1 internal hemorrhoids\n - sigmoid diverticulitis with an adjacent abscess \n - Afib: not on coumadin\n - Chronic diarrhea\n - Asthma\n - Gout\n - Recurrent urinary tract infections\n - gastroesphogeal reflux\n - Tremor: essential tremor, followed previously by Dr. \n - Chronic Renal Failure\n - Choledocholithiases/cholangitis (): found to have\n pseudomonas bacteremia, treated with ceftazidime and flagyl, and\n referred for cholecystectomy but patient refused\n - Neuropathic pain\n - Right hip fracture\n - bilateral knee replacements\n - right leg pins\n - cataract repair\n Unable to obtain as patient intubated.\n Unable to obtain as patient intubated.\n Review of systems: Unable to obtain\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 82 (80 - 94) bpm\n BP: 146/66(106) {91/31(60) - 154/66(106)} mmHg\n RR: 18 (16 - 25) insp/min\n SpO2: 100%\n Height: 64 Inch\n CVP: 6 (4 - 7)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 3,901 mL\n PO:\n TF:\n IVF:\n 3,526 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 345 mL\n Urine:\n 245 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,556 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.40/28/171/17/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 342\n Physical Examination\n VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1\n GENERAL: Opens eyes to name. Intubated.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET tube.\n NECK: No JVP appreciated.\n CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,\n gallops.\n LUNGS: Coarse breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Cold feet, pulses not palpable.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 165 K/uL\n 8.7 g/dL\n 365 mg/dL\n 2.0 mg/dL\n 62 mg/dL\n 17 mEq/L\n 106 mEq/L\n 4.8 mEq/L\n 137 mEq/L\n 34.2 %\n 11.2 K/uL\n [image002.jpg]\n \n 2:33 A9/25/ 09:53 AM\n \n 10:20 P9/25/ 10:00 AM\n \n 1:20 P9/25/ 10:18 AM\n \n 11:50 P9/25/ 11:10 AM\n \n 1:20 A9/25/ 03:05 PM\n \n 7:20 P9/25/ 03:14 PM\n 1//11/006\n 1:23 P9/25/ 05:34 PM\n \n 1:20 P9/25/ 09:45 PM\n \n 11:20 P9/25/ 10:07 PM\n \n 4:20 P\n WBC\n 6.9\n 11.2\n Hct\n 26\n 24.8\n 25\n 29\n 26.5\n 32\n 34.2\n Plt\n 169\n 165\n Cr\n 1.9\n 2.0\n TropT\n 0.72\n TC02\n 17\n 19\n 18\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:13.7/43.9/1.2, CK / CKMB /\n Troponin-T:999/50/0.72, Differential-Neuts:56.4 %, Lymph:40.6 %,\n Mono:1.7 %, Eos:1.1 %, Lactic Acid:2.5 mmol/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:4.0 mg/dL\n 2D-ECHOCARDIOGRAM : The left atrium is mildly dilated. There\n is mild symmetric left ventricular hypertrophy. The left ventricular\n cavity is small and underfilled. There is mild regional left\n ventricular systolic dysfunction with septal akinesis. The remaining\n segments contract normally (LVEF = 45%). The right ventricular cavity\n is moderately dilated with focal akinesis of the apical one-half of the\n free wall. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. Mild to moderate (+)\n mitral regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is mild pulmonary artery systolic hypertension. There\n is a trivial/physiologic pericardial effusion. IMPRESSION: Mild\n regional left ventricular systolic dysfunction, c/w LAD disease.\n Dilated right ventricle with moderate regional systolic dysfunction,\n c/w CAD.\n .\n CARDIAC CATH:\n 1. Selective coronary angiography in this right dominant system\n demonstrated two vessel disease. The LMCA was normal. The LAD had a\n 100% proximal thrombotic occlusion and a 50% stenosis in the\n mid-portion. The Cx had a 30% mid-vessel stenosis.\n 2. Resting hemodynamics revealed elevated right and left sided filling\n pressures with RVEDP of 19mm Hg and mean PCW of 28mm Hg. Cardiac index\n was preserved at 4.0L/min/m2. There was systemic hypotension with SBP\n of 96mm Hg and DBP of 41mm Hg.\n 3. Successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis.\n 4. Acute occlusion of OM (due to an embolus) treated with thrombectomy\n and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion\n but restoration of TIMI 3 flow.\n 5. Cardiogenic shock requiring placement of an IABP via the right\n femoral artery.\n EGD :\n Normal mucosa in the duodenum\n Normal mucosa in the stomach\n Blood in the stomach body and fundus\n Blood clot extended from GE junction was noticed in gastric cardia\n area.\n Blood in the lower third of the esophagus and gastroesophageal junction\n Friability in the lower third of the esophagus and gastroesophageal\n junction\n Otherwise normal EGD to duodenal bulb\n ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression\n lead III, aVR.\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n - Patient will require ACE-I and B-blocker as outpatient, however held\n today due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed.\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - Daily EKG\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n - IV PPI , carafate slurry 1 g QID\n - q4hr HCT\n - cross match 4 units\n - wean ballon pump overnight in order to stop heparin\n - if patient decompensates overnight contact GI, IR aware for possible\n embolization. Patient may require Sang- tube.\n .\n # Diabetes: Insulin sliding scale\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9.\n - renal dose all meds\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n : , \n .\n DISPO: CCU for now\n ICU Care\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n FEN: NPO\n .PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .CODE: Full Code - confirmed with \n .: , \n .DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n Critically ill due to acute anterior MI, acute systolic and diastolic\n CHF, need for IABP, acute respiratory faiulre, acute renal failure.\n Date/time was 9/25/9 at 2300\n ------ Protected Section Addendum Entered By: , MD\n on: 08:17 ------\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388459, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n CXR\n IABP noted to be in proximal position near great vessels, PA\n catheter in good position, OG tube in gastric fundus\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). and (admission\n notes from yesterday)\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n Critically ill due to acute anterior MI, acute systolic and diastolic\n CHF, need for IABP, acute respiratory faiulre, acute renal failure.\n Date/time was 9/26/9 at 1300\n ------ Protected Section Addendum Entered By: , MD\n on: 08:20 ------\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388470, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur, IABP heard obscuring some heart sounds.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l. Right femoral A line with pressure\n dressing in place. Left femoral IABP in place.\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388574, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarcic\n Head, Ears, Nose, Throat: ET tube in place\n Cardiovascular: irregular rate, no MRG\n Peripheral Vascular: 2+ radial pulses\n Respiratory / Chest: CTA bilaterally anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: 1+ bilateral LE edema\n Skin: Warm\n Neurologic: Opens eyes to voice, cannot follow commands.\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Poor prognosis discussed with family, pt made CMO.\n - Will wean IABP. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, on Verapamil for rate\n control. No anti-coagulation due to prior history of GI bleed. ECG\n now showing left axis deviation and RBB block -> pt likely has left\n anterior fascicular block and RBB block, and is at high risk to develop\n complete heart block. Overnight, patient intermittently in A fib with\n fast then slow ventricular response. Tends to become hypotensive when\n rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts, however\n now stable in high 40s\n - Will continue to monitor Hct and Plts, expect improvement with d/c of\n IABP\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Holding outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Continue ASA 325 mg\n - Continue plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1.\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no signs of volume\n overload currently\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , sucralafate 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - follow crit, has been stable\n - 4 units cross-matched\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: continue insulin gtt\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now\n .\n #Acute on Chronic Renal Failure: Recent creatinine range as outpatient\n 1.3 - 1.9. Pt now with creatinine to 2.8. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position). Renal failure is likely contributing to acidotic state.\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor creatinine\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: IV pantoprazole\n VAP: elevate HOB\n Comments:\n Communication: Comments: Daughters , \n \n Code status: DNR/DNI, CMO\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388473, "text": "Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2130-09-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 388566, "text": "Patient screened per ICU policy. Noted plan to focus on comfort.\n Will sign off at this time, please consult if needed. *\n PM\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388571, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Call family as patient not improving, discuss poor prognosis as\n patient not improving. Discuss withdrawal of care.\n - Will pull IABP, as patient not improving on balloon pump and\n platelets low, possibly balloon pump, also with possible\n bacteremia. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - Will continue to monitor Hct and Plts\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "ECG", "chartdate": "2130-09-02 00:00:00.000", "description": "Report", "row_id": 266376, "text": "Possible ectopic atrial rhythm. Right bundle-branch block with left anterior\nfascicular block. Q waves in leads V1-V3. Small R wave in lead V4-V5. Consider\nanterior myocardial infarction of indeterminate age. Compared to tracing #2\nof right bundle-branch block and left anterior fascicular block are\nnew. There is a new Q wave in lead V2 and tiny R wave in V3-V4, all consistent\nwith an evolving myocardial infarction.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 266377, "text": "Sinus rhythm. Poor R wave progression with biphasic T waves in leads V2-V3.\nT flattening in lead I and inverted T wave in lead aVL. Possible myocardial\nischemia. Compared to tracing #1 of earlier the same day the ST segment\nelevation has resolved. The inferior ST segment depression has also resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2130-09-03 00:00:00.000", "description": "Report", "row_id": 266374, "text": "Sinus tachycardia. Poor R wave progression consistent with an anterior wall\nmyocardial infarction which, based on the prior recent tracings, is\nrecent/evolving. Non-specific inferolateral T wave flattening. Compared to\ntracing #4 earlier the same day the P-R interval is shorter and the\nventricular premature beat is absent.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2130-09-03 00:00:00.000", "description": "Report", "row_id": 266375, "text": "Sinus tachycardia with first degree A-V conduction delay and ventricular\npremature beat. Poor R wave progression. Low QRS voltage in the limb leads and\nthe precordial leads. Compared to tracing #3 of right bundle-branch\nblock and left anterior fascicular block are now absent. Ventricular premature\nbeat is new. There is loss of precordial R wave and sinus tachycardia is new.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 266378, "text": "Sinus tachycardia. ST segment elevation in leads I, aVL and V1-V4 suggesting a\nmyocardial infarction with Q waves in leads VI-V2 and loss of R wave in\nlead V3. Reciprocal ST segment depression in leads II, III and aVF.\nLow QRS voltage in the precordial leads. Compared to the previous tracing\nof ST segment elevation is new with Q wave in lead V2 and loss of R wave\nin V3 suggesting an acute/evolving myocardial infarction.\nTRACING #1\n\n" } ]
10,861	135,752	This 83 year old male was admitted with a history of colonic adenoma, status post right hemicolectomy and prostate cancer, status post radiation therapy, presented with new onset melena on . History is not fully clear but patient says melena began that day only. The patient had associated diaphoresis and lightheadedness. The patient's wife notes that he appeared pale and tired over the prior week. The patient denies headache, abdominal pain, cough, hematuria, shortness of breath, coughing or vomiting. The patient also denied any bright red blood per rectum. The patient went to the Emergency Department on where he was not found to be orthostatic on examination. Gastric lavage was performed and was negative for blood. The patient had another bowel movement that was dark and guaiac positive. The patient was admitted to Firm on . In the PM of after dinner, the patient's hematocrit dropped to 24.7% from 33.8%. The patient was then admitted to the Medical Intensive Care Unit where he received 2 units of packed red blood cells. Later the patient was admitted for esophagogastroduodenoscopy. Esophagogastroduodenoscopy on reported no tears, positive gastritis of the antrum, positive erosion of the stomach body, positive erosion of the duodenal bulb. The patient was then started on intravenous Protonix but the hematocrit dropped under 4%. The patient then received another 2 units of packed red blood cells and was observed. Hematocrit then remained stable over the next two days and the patient was then deemed stable for transfer to the floor. The patient's hematocrit post transfusion was 31.5%. The patient was transferred to the Medicine Service where he remained stable with his current hematocrit 32.7%. In preparation for discharge, the patient's intravenous Protonix was discontinued and he was started on 40 mg p.o. q.d. of oral Protonix. Also the patient's outpatient hypertensive medications were initiated first starting with Atenolol 25 mg p.o. q.d. with a plan to restart Losartan 50 mg p.o. q.d. prior to discharge. The patient will be encouraged to restart the Coumadin which he last took six months prior to admission, to restart that after his discharge as per his primary medical doctor.	HR UP TO 120'S WHEN ASSISTED TO EDGE OF BED TO VOID, HOWEVER BACK TO BASELINE WITH REST. PT ARRIVED TO MICU WITH ONE UNIT PRBC'S INFUSING. DR MADE AWARE.CV- HR 60-70'S AFIB. KEPT NPO FOR REPEAT EGD THIS AM TO FOLLOW UP ON ULCERS SINCE HCT DROPPED. DENIES SOB.CV- HR 60-70'S AFIB. CALCUIM LEVEL AT WAS 7.9 AND WAS REPLETED WITH 2GM IV.RESP- LUNG SOUNDS CLEAR. Sleeping/resting intermittently.CV- VSS- 98-1121/50-60, HR 80-90's afib w/ ^ 100 when standing/ @ commode.F/E- IV changed to D5.45NS @100/hr; u/o adequate/voiding. KEPT NPO FOR EGD IN AM SCHEDULED FOR 0730. MAINTENANCE IVF AT 150CC/HGI- ABD SOFT NT ND POSTIVE BS. BOLUS DOSE WAS GIVEN. No c/o dizziness, mild c/o of very slight lightheadedness when changing position to void or commode wh/ resolves <2 min. nsg addendum:pt was assisted to edge of bed to void. CALL-OUT WAS CANCELLED, RECEIVED BLOOD TRANSFUSION X2 AND REPEAT EGD TO BE DONE IN AM. MAE, PERLA.RESP- LS CLEAR SATS 98-100% RA.CV- HR 70-80'S AFIB, SBP 98-120'S. CONTINUES TO RECEIVE IVF AT 100C/H. TRANSFUSED WITH PRBC'S FOR LOW HCT, REPEAT TO BE DRAWN. WITH VAGUE COMPLAINTS EARLY IN NOC. NURSING NOTE:7P-7AEVENT: PT HAD BEEN CALLED OUT TO TRANSFER TO FLOORS HOWEVER CHECK OF HCT WAS 24.7 FROM 29.1. NO PERIPHERAL EDEMA NOTED.GI- ABD SOFT NT ND POSITIVE BS. CALL OUT TO FLOOR TODAY. 5am HCT 29.5, 12n=26.7. HCT CHECKED AT 11PM WAS 24.7 DOWN FROM 29.1. SBP 78-120. REPEAT EGD THIS MORNING. SATS HIGH 90'S.GI- ABD SOFT POSITIVE BS. NSG ADDENDUMPT WAS ASSISTED OOB TO COMMODE, WITH MINIAML ASSISTANCE. IV as above, protonix IV 8mg/hr cont. PT ASSISTED TO EDGE OF BED TO VOID IN URINAL Q2-4H. HCT CHECK AT 7PM AND MIDNOC STABLE AT 31. CONSENT OBTAINED FOR TLCL HOWEVER HELD OFF FOR THE MOMENT SINCE PERIPHERAL ACCESS MAINTAINED, BE PLACED IN AM PER TEAM. EGD IN AM. SBP 80'S-120. Atrial fibrillationModest inferior T wave changes are nonspecificSince previous tracing , no significant change REPEAT LABS TO BE DRAWN AT 0500. REPEAT LABS TO BE DRAWN AT 0500. Nursing Note 0700-1900See Nursing Transfer Note for shift note DR AWARE.DISPO- REMAINS IN MICU, FULL CODE. Pt informed that stress and overwork is a strong possibility in contributing to his present GI status.A/P-- Very stable yet HCT decreasing despite transfusion. Micu -B Nursing Progress NoteNeuro- Alert and oriented x3, appropriate, compliant. etiology of cont decreasing HCT., wife and daughter visiting this am and late this afternoon. +~1000 cc today including IV + blood products.GI- Remains NPO. PT ALERT AND ORIENTED X3. STARTED ON PROTONIX GTT AT 8MG/H. Transfused w/ 2uPRBC over 2-3 hr each.Post HCT to be drawn p end 2nd unit infuses ~1800. Atrial fibrillationInferior T wave changes are nonspecificRepolarization changes may be partly due to rhythmLeft axis deviationSince previous tracing, no significant change PT STATES HX OF AFIB HAS BEEN OFF COUMADIN APPROX 6 MONTHS. pm HCT to be done p 2u transfusion completed.Endoscopy this evening.Stongly encourage stress management w/ patient/family. NURSING NOTE: 7P-7A PT ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. URINAL AT BEDSIDEACCESS- THREE #18 GAUGE PIV'S INTACT. TRANSFUSED TWO UNITS PRBC'S. PT HAS NOT VOIDED SINCE ARRIVAL TO UNIT. REPEAT HCT TO BE DRAWN AT APPOX 6AM. CONTINUESON PROTONIX GTT AT 8MG/H. IVF NS AT 100CC/H ALSO STARTED LAST EVENING DUE TO NPO STATUS. VERY PLEASANT AND COOPERATIVE WITH CARE.FOLLOWS COMMANDS, PERLA, MAE.RESP- LUNG SOUNDS CLEAR SAT 96-100% RA. PT 500 CC FLUID BOLUS X1 FOR LOW BP WITH EFFECT. PT WAS TO THE MICU FOR FALLING HCT FROM 33 IN ED TO 25 A FEW HOURS LATER. NO C/O NAUSEA. SPOKE TO GI TEAM. DAUGHTER CALLED TO CHECK UP ON PATIENT.DISPO/ PT REMAINS IN MICU, FULL CODE. MEDS AT HOME INCLUDE NORVASC, ATENOLOL, COZAAR NKDAROS:NEURO- ALERT AND ORIENTED X3. NEEDS TO DANGLE AT BEDSIDE IN ORDER TO VOID. IF HCT STABLE ? NO PERIPHERAL EDEMA NOTED. GI TEAM SAW PATIENT LAST EVENING AND DEFERRED REPEAT EGD DUE TO NO NEW S/S BLEEDING, AND HCT STABLE. RR 12-20. CLEAR YELLOW URINE ADEQUATE AMONUTS.ACCESS- TWO #18 PIV. SECOND UNIT NOW INFUSING. PT AND MD SPOKE TO WIFE, UPDATED ON TRANSFER AND NEED FOR BLOOD AND AN EGD IN AM.DISPO- IN MICU, FULL CODE. ASSITED BACK TO BED WITHOUT INCIDENCE. ADEQUATE CLEAR YELLOW URINE OUTPUT.ACCESS- 2 #18 PIV'S PATENT, SITES WNL. HCT CHECKS Q6H, DUE AT 6AM. NO STOOL SINCE ARRIVAL. NGT LAVAGED ON FLOOR FOR BRB.PMH: PROSTATE CA S/P XRT, S/P R HEMICOLECTOMY FOR COLON LESION, AFIB, HTN, GOUT, COLON POLYPS. C/O DIZZINESS, WEAKNESS AND COOL SWEATS. DENIES N&V. Plan to re-endoscope this evening to visualize ? RR 16-20. PT VOIDS IN URINAL. CONTINUE TO MONITOR. POOR VENOUS ACCESS FOR BLOOD DRAWS OR FUTRUE IV'S IF NEEDED. voided 450cc clear yellow urine without difficulty DAUGHTER, WIFE AND BROTHER AT BEDSIDE LAST EVENING. NO COMPLAINTS VOICED. PATIENT AND FAMILY SPOKE TO GI TEAM, AND PT WILL BE RESCOPED TODAY IF HIS HCT FALLS AGAIN OR SHOWS ACTIVE BLEED. NURSING NOTE: TRANSFER TO MICUTHIS IS A 83 YEAR OLD MALE PATIENT ADMITTED TO 7 VIA THE ED LAST EVENING WITH C/O BLACK TARRY STOOLS AND WEAKNESS. 4 black tarry stools out/small to mod amt. NO OBVIOUS SIGNS OF BLEEDING OVER NOC. Conversing w/ family and business contacts by phone most of day. Pt has very active occupational lifestyle; runs own construction business. NO STOOL. NO STOOL . HE HAD A LARGE BLACK TARRY STOOL, GUIAC POSITIVE.	9	[ { "category": "ECG", "chartdate": "2143-07-06 00:00:00.000", "description": "Report", "row_id": 302291, "text": "Atrial fibrillation\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nLeft axis deviation\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2143-07-10 00:00:00.000", "description": "Report", "row_id": 302290, "text": "Atrial fibrillation\nModest inferior T wave changes are nonspecific\nSince previous tracing , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405330, "text": "NURSING NOTE: TRANSFER TO MICU\nTHIS IS A 83 YEAR OLD MALE PATIENT ADMITTED TO 7 VIA THE ED LAST EVENING WITH C/O BLACK TARRY STOOLS AND WEAKNESS. PT WAS TO THE MICU FOR FALLING HCT FROM 33 IN ED TO 25 A FEW HOURS LATER. NGT LAVAGED ON FLOOR FOR BRB.\n\nPMH: PROSTATE CA S/P XRT, S/P R HEMICOLECTOMY FOR COLON LESION, AFIB, HTN, GOUT, COLON POLYPS.\n MEDS AT HOME INCLUDE NORVASC, ATENOLOL, COZAAR NKDA\nROS:\nNEURO- ALERT AND ORIENTED X3. VERY PLEASANT AND COOPERATIVE WITH CARE.\nFOLLOWS COMMANDS, PERLA, MAE.\n\nRESP- LUNG SOUNDS CLEAR SAT 96-100% RA. RR 16-20. DENIES SOB.\n\nCV- HR 60-70'S AFIB. SBP 78-120. NO PERIPHERAL EDEMA NOTED. PT STATES HX OF AFIB HAS BEEN OFF COUMADIN APPROX 6 MONTHS. PT ARRIVED TO MICU WITH ONE UNIT PRBC'S INFUSING. SECOND UNIT NOW INFUSING. REPEAT HCT TO BE DRAWN AT APPOX 6AM. PT 500 CC FLUID BOLUS X1 FOR LOW BP WITH EFFECT. MAINTENANCE IVF AT 150CC/H\n\nGI- ABD SOFT NT ND POSTIVE BS. NO STOOL SINCE ARRIVAL. KEPT NPO FOR EGD IN AM SCHEDULED FOR 0730. DENIES N&V. STARTED ON PROTONIX GTT AT 8MG/H. BOLUS DOSE WAS GIVEN.\n\n PT HAS NOT VOIDED SINCE ARRIVAL TO UNIT. URINAL AT BEDSIDE\n\nACCESS- THREE #18 GAUGE PIV'S INTACT. CONSENT OBTAINED FOR TLCL HOWEVER HELD OFF FOR THE MOMENT SINCE PERIPHERAL ACCESS MAINTAINED, BE PLACED IN AM PER TEAM.\n\n PT AND MD SPOKE TO WIFE, UPDATED ON TRANSFER AND NEED FOR BLOOD AND AN EGD IN AM.\n\nDISPO- IN MICU, FULL CODE. TRANSFUSED WITH PRBC'S FOR LOW HCT, REPEAT TO BE DRAWN. EGD IN AM. CONTINUE TO MONITOR.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405331, "text": "nsg addendum:\npt was assisted to edge of bed to void. voided 450cc clear yellow urine without difficulty\n" }, { "category": "Nursing/other", "chartdate": "2143-07-09 00:00:00.000", "description": "Report", "row_id": 1405336, "text": "NURSING NOTE: 7P-7A\n PT ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. NO COMPLAINTS VOICED. MAE, PERLA.\n\nRESP- LS CLEAR SATS 98-100% RA.\n\nCV- HR 70-80'S AFIB, SBP 98-120'S. HCT CHECK AT 7PM AND MIDNOC STABLE AT 31. CONTINUES TO RECEIVE IVF AT 100C/H. NO PERIPHERAL EDEMA NOTED.\n\nGI- ABD SOFT NT ND POSITIVE BS. NO STOOL . NO C/O NAUSEA. GI TEAM SAW PATIENT LAST EVENING AND DEFERRED REPEAT EGD DUE TO NO NEW S/S BLEEDING, AND HCT STABLE. PATIENT AND FAMILY SPOKE TO GI TEAM, AND PT WILL BE RESCOPED TODAY IF HIS HCT FALLS AGAIN OR SHOWS ACTIVE BLEED.\n\n PT ASSISTED TO EDGE OF BED TO VOID IN URINAL Q2-4H. ADEQUATE CLEAR YELLOW URINE OUTPUT.\n\nACCESS- 2 #18 PIV'S PATENT, SITES WNL.\n\n DAUGHTER, WIFE AND BROTHER AT BEDSIDE LAST EVENING. SPOKE TO GI TEAM. DAUGHTER CALLED TO CHECK UP ON PATIENT.\n\nDISPO/ PT REMAINS IN MICU, FULL CODE. HCT CHECKS Q6H, DUE AT 6AM. IF HCT STABLE ? CALL OUT TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405332, "text": "Nursing Note 0700-1900\nSee Nursing Transfer Note for shift note\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405333, "text": "NURSING NOTE:7P-7A\nEVENT: PT HAD BEEN CALLED OUT TO TRANSFER TO FLOORS HOWEVER CHECK OF HCT WAS 24.7 FROM 29.1. CALL-OUT WAS CANCELLED, RECEIVED BLOOD TRANSFUSION X2 AND REPEAT EGD TO BE DONE IN AM.\n\n PT ALERT AND ORIENTED X3. WITH VAGUE COMPLAINTS EARLY IN NOC. C/O DIZZINESS, WEAKNESS AND COOL SWEATS. DR MADE AWARE.\n\nCV- HR 60-70'S AFIB. HR UP TO 120'S WHEN ASSISTED TO EDGE OF BED TO VOID, HOWEVER BACK TO BASELINE WITH REST. SBP 80'S-120. HCT CHECKED AT 11PM WAS 24.7 DOWN FROM 29.1. TRANSFUSED TWO UNITS PRBC'S. REPEAT LABS TO BE DRAWN AT 0500. IVF NS AT 100CC/H ALSO STARTED LAST EVENING DUE TO NPO STATUS. CALCUIM LEVEL AT WAS 7.9 AND WAS REPLETED WITH 2GM IV.\n\nRESP- LUNG SOUNDS CLEAR. RR 12-20. SATS HIGH 90'S.\n\nGI- ABD SOFT POSITIVE BS. NO STOOL. KEPT NPO FOR REPEAT EGD THIS AM TO FOLLOW UP ON ULCERS SINCE HCT DROPPED. NO OBVIOUS SIGNS OF BLEEDING OVER NOC. CONTINUESON PROTONIX GTT AT 8MG/H.\n\n PT VOIDS IN URINAL. NEEDS TO DANGLE AT BEDSIDE IN ORDER TO VOID. CLEAR YELLOW URINE ADEQUATE AMONUTS.\n\nACCESS- TWO #18 PIV. POOR VENOUS ACCESS FOR BLOOD DRAWS OR FUTRUE IV'S IF NEEDED. DR AWARE.\n\nDISPO- REMAINS IN MICU, FULL CODE. REPEAT LABS TO BE DRAWN AT 0500. REPEAT EGD THIS MORNING.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405334, "text": "NSG ADDENDUM\nPT WAS ASSISTED OOB TO COMMODE, WITH MINIAML ASSISTANCE. HE HAD A LARGE BLACK TARRY STOOL, GUIAC POSITIVE. ASSITED BACK TO BED WITHOUT INCIDENCE.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405335, "text": "Micu -B Nursing Progress Note\nNeuro- Alert and oriented x3, appropriate, compliant. Conversing w/ family and business contacts by phone most of day. Sleeping/resting intermittently.\nCV- VSS- 98-1121/50-60, HR 80-90's afib w/ ^ 100 when standing/ @ commode.\nF/E- IV changed to D5.45NS @100/hr; u/o adequate/voiding. +~1000 cc today including IV + blood products.\nGI- Remains NPO. IV as above, protonix IV 8mg/hr cont. 5am HCT 29.5, 12n=26.7. Transfused w/ 2uPRBC over 2-3 hr each.\nPost HCT to be drawn p end 2nd unit infuses ~1800. 4 black tarry stools out/small to mod amt. No c/o dizziness, mild c/o of very slight lightheadedness when changing position to void or commode wh/ resolves <2 min. Plan to re-endoscope this evening to visualize ? etiology of cont decreasing HCT.\n, wife and daughter visiting this am and late this afternoon. Pt has very active occupational lifestyle; runs own construction business. Family has verbalized in the past the need to decrease his workload but pt is reluctant due to his desire to be busy and cont to run business. Pt informed that stress and overwork is a strong possibility in contributing to his present GI status.\nA/P-- Very stable yet HCT decreasing despite transfusion. pm HCT to be done p 2u transfusion completed.\nEndoscopy this evening.\nStongly encourage stress management w/ patient/family.\n" } ]
19,011	110,160	58-year-old gentleman admitted for treatment of a complex pancreatic pseudocyst situation secondary to gallstone pancreatitis. He had been at an outside hospital for 2 weeks prior to his transfer to us where he had evidence of a lower extremity DVT. Upon transfer to us, he had clear-cut pulmonary embolism identified and this was treated with anticoagulation. In the antrum we accessed the pancreas via CT and found it to be stable with a complex multi-loculated cystic architecture that appears to be growing slightly in size while here at . We also recognized a bile duct stone on imaging and he had an ERCP performed prior to this procedure. He was doing well except from a respiratory standpoint where he had decompensation and evidence of an advancing pulmonary embolism. For this reason, a DVT filter was placed 3 to 4 days prior to this procedure. He continued to have respiratory distress but was doing well other than that. On the night prior to this operation, he had an acute decompensation and moved from an alkalotic state to an acidotic state. He required massive amounts of fluid resuscitation and had a progressive lactic acidosis. He had a tender tense abdomen as well.He was seen early in the morning of the and felt that he had an acute abdominal catastrophe requiring emergent exploration. He went to the operating room on the morning of with the intent of performing exploratory laparotomy. The presumed diagnosis was ruptured pseudocyst with secondary diagnosis of dead bowel. Over the next three weeks patient remained in ICU for postop care. On patient was transfered to the floors for further care. remainder of hospital course was uneventful, he continued to be stable on TPN, tolerating regular diet. On POD 51/39 patient was cleared for discharge to rehabilitation center for further recovery.	hct 27.7. on iv leprudin infusing with q6hr ptt. RSC TLC and R radial aline . Midline incision w/ lg. LLL bronchial/diminished.GI: abd firm, distended, tender. Cont Lepiruden for DVT, titrated to PTT. DP/PT pulses dopplerable. DP/PT pulses dopplerable. CA REPLETED W/ TUMS. no bm, sounds present.gu: good response to lasix.incision: dsgs changed, small amt sero-sang from upper midline incision, small amt -sang from around rt side Jp insertion site. Abdomen firmly distended; +BS. Pt w/ general anasarca; pitting edema. Pt w/ general anasarca; pitting edema. G/J tubes .GU: foley patent, cyu, lasix as above. Cont SIMV onoc. febrile to 102.2. cvp 16-18.pulm: bs clear. Cont vent wean and diuresis as tolerated. Resp CarePt. One unit ffp infusing, one more ordered. Vasopressin weaned off as MD. Pt w/ generalized edema. SICU NN: See carevue for specifics. Dr. notified. amts.Plan: diurese, wean support as tolerated. ^^ standing lopressor dose ..DSG changes CONDITION UPDATEVSS. U/O QS VIA FOLEY - DIURESED W/ LASIX MD' ORDERS. Resp. Ativan PRN. NGT to lcws. ABD CONT TO BE SOFTLY DISTENDED. Trazodone and lorazepam w/ +effect. Aline dampens.Resp: Weaned to PS 5-PEEP- 5,MD aware of ABG. Resp CarePt remains on PSV, ps weaned tol well. Doppler pulses. Right PT dopplerable. ABG: pH 7.41, PaCO2 56, PaO2 166, bicarb 37, BE 9. Started trazodone to relieve agitation. Resp Care,Pt. Resp Care,Pt. ET to vent, cpap. Swann and cordis d/ by MD. Patient afebrile. resp. to wean as tol. SICU NN: See carevue for specifics. SICU NN: See carevue for specifics. NGT to lcws. Converted to afib this am. Dr. notified. JP 1 and 2 with serosanguinous drainage. HEparin currently given sq.GI/ Abd: NPO. carept. HCT stable. Lepirudin infusing as ordered. remains intubated/vented/sedated.continue with high ph...resp. J tube with tube feeds, tolerating. continue towean as toerated. wound tid. See carevue. See carevue. abd wound tid. Respiratory CarePt changed to cpap/ps tol well 735/63/138/36/7. PAC noted. Afebrile.GI: Tube feed tolerated at goal via PEJ. PERRL. BP wnl. Pt w/ generalized edema (+). Pt in A.fib this AM, but converted to sinus brady/NSR (Dr. aware). ABG: pH 7.36, PaCO2 60, PaO2 160, bicarb 35, BE 6 (Dr. aware of ABG). ABG's showing gradual correction of Metabolic Alkilosis. hypo bs x4, fib on with liq soft stool.Heme- rec 2 prbc this am for hct 23- post hct this pm 28- rec 2 ffp for inr >2.5- pm inr 2.2, cont lepirudin gtt.Plan- cont wean vent as tol, ativan and dilaudid prn- wean as tol. Suctioned for tan thick secretions in moderate amount.Please refer to careview for abg's.CV: SR to ST no ectopy, Concurrent with temp spike to 102.5 became tachycardic and hypertensive. RESTARTED ON LEPRIDUM GTT. Updated Dr. and will cont. Cont lepirudin gtt as indicated. CXR done. Hct stable, some a-fib noted. Self extubated in pm, and immed Reintubated. MDI's given. Remains with generalized edema. Mouth care Q2hours. RLE>LLE. Pan cx'd. intubated. FOLLOW PTT FOR LEPRIDUM GTT. Dopplerable pulses. LS CLEAR TO COARSE WITH OCC WHEEZES. +PP VIA DOPPLER. HIT status noted. Tolerating tube feedings thus far. : pt with open area on right heal. Dsg changed X1 By RN. Cont with DSD as indicated. Anticoagulated on lepirudin . WILL FOLLOW COAGS.RESP-REMAINS INTUBATED. Tolerating well. SICU NN: See carevue for specifics. +BS Mult BM's today. REspiratory CarePT. W+D. PERRL. PERRL. Remains on amiodorone and lopressor given through NGT. Resp CarePt. Resp CarePt. Afebrile with normal wbc. to make spont. AM ABG, PCO2 ~ hich and Pt starting to chronically compensate. Suctioning mod. SICU NN: See carevue for specifics. suction with bilious returns. CONDITION UPDATEVSS. ABd wound still drng mod amts of sersang drng. FOCUS UPDATEVSS. REMAINS ON AMIO IN NSR. BP wnl. Perrl. no BM.gu: u/o qs.plan: wean vent as tol. WEAN FROM VENT AS TOLERATES. Sxn'd for mod amts. pt continues in afib and icu resident Dr aware. BS are clear & dim more to bases ant. Occ. Occ. Clamped prn meds. AFEBRILE. +PP via doppler only.Resp: Remains on CPAP . Hemodynamics stable.P: F/U w/ repeat ABG. Normalregional LV systolic function. Mild mitral annularcalcification.TRICUSPID VALVE: Mild [1+] TR. Noaortic regurgitation is seen. MAE.CV: HR-NSR no noted ectopy. IndeterminatePA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Lungs remain coarse to diminshed at the bases.GI/GU: Unchanged.Endo: RISSID: Remains on mult abx WBC's normal afebrile.Plan: Cont with current plan of care. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. There is moderate global right ventricular free wallhypokinesis. Moderate global RV free wallhypokinesis.AORTA: Simple atheroma in ascending aorta. A small amount of free intraabdominal ascites and a significant periportal edema is noted. CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: At the visualized portions of the lung bases, again seen are bilateral lower lobe pulmonary arterial filling defects consistent with pulmonary emboli. Within the abdomen, there has been interval removal of a left-sided drainage catheter with a partial fistulous tract which does not appear to connect with the intraperitoneal cavity. There remains a left retrocardiac opacity and some hazy opacity within the left upper lung. Left basilar atelectais and moderate- sized left pleural effusion. Thus, bilateral, mostly basal densities persist in the vasculature give the impression of perivascular haze. Right subclavian catheter terminates in the SVC. Normal heart size, some coronary artery calcification noted, the central line tip is included at the distal SVC level. Unchanged fluid collection posterior to the pancreatic head. A left subclavian catheter has been placed, terminating within the superior vena cava. CT ABDOMEN WITH ORAL AND IV CONTRAST (CT ANGIOGRAM PROTOCOL): Small right and left basal pleural effusions, moderate atelectasis of the left lower lobe posteriorly and to a lesser extent the dependent portion of the right lower lobe. SUPINE CHEST RADIOGRAPH: A right-sided subclavian line is now seen with its tip terminating in the right superior vena cava. Unchanged intrahepatic biliary ductal dilatation and attenuation of a patent portal vein.	164	[ { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512592, "text": "please see careview for details.\n\nneuro: \n\ncv: remains on , occasional pause. no a fib.\n febrile to 102.2. cvp 16-18.\n\npulm: bs clear. sx q 2 for thick white small amts. alkalotic this am, plan is to switch from Lasix to diamox for future diuresis.\n\ngi: tol tube feeds at 80/hr. no bm, sounds present.\n\ngu: good response to lasix.\n\nincision: dsgs changed, small amt sero-sang from upper midline incision, small amt -sang from around rt side Jp insertion site. other dsgs clean when changed.\n\nplan: ct today to evaluate abdomen in face of fever.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512593, "text": "SICU-B NPN 7a-7p\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nNo events\nNEURO: no focal neuro deficits noted. Fentanyl gtt changed to midaz gtt w/ fentanyl boluses PRN for pain w/ increased pt. comfort. Occasional c/o pain r/t ETT and positioning, relieved w/ fentanyl.\n\nCV: HD stable. HR NSR 60s-80s, frequently flipping into Afib, 90s-110s, cont on amio gtt 0.5mg/min pending discussion w/ primary team re: changing to POs. Cont Lepiruden for DVT, titrated to PTT. Diuresed w/ lasix 20mg x 1, good response. PM lytes pending w/ diuresis.\n\nRESP: changed to CPAP w/ PS 12, peep weaned to 5, abg w/ cont contraction alkalosis->becoming more acidotic on CPAP. LSCTA bilaterally.\n\nGI: TFs increased q6ht. Goal 110cc/hr. Abd obese, firm, nontender. +BS/-BM. Dulcolax supp x 1, effects pending.\n\nGU: foley draining CYU, excellent response to laisx, to recieve 250mg diamox this pm.\n\nENDO: humalog sliding scale PRN.\n\nID: tmax 102.3, 650mg tylenol w/ some reduction. Starting linezolid and increasing levoflax dose, cultures pending.\n\n: grossly edematous, no breakdown noted. RSC TLC and R radial aline . Midline abd incision c/d w/ sm amt s/s drainage, JPs, G and J tube .\n\nSOC: family in to visit, updated on POC and pt. condition. Spoke w/ social work.\n\nA: tolerating CPAP after diuresis, now w/ contraction alkalosis, HD stable. ^ comfort w/ versed gtt.\nP: cont to monitor for pain, fentanyl PRN as needed. F/u pm labs. Monitor fever curve, f/u culture data. Cont vent wean and diuresis as tolerated. Support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512669, "text": "NPN (NOC):\n\nRESP: PT RESTED ON \"5&5\". RR TEENS TO 20'S, VT'S 300'S TO 400'S. AM ABG: 144/69/7.40/44/+14. BS'S COURSE AT THE BASES. SX'D FOR MOD TO LG AMTS OF SECRETIONS. AFEBRILE.\n\nCV: HEMODYNAMICALLY STABLE . LEPIRUDEN CONTINUES. AM PTT 52. NO S/ OF BLEEDING NOTED BUT AM HCT IS 23% DOWN FROM 28% YESTERDAY. DR. IS AWARE. SPECIMEN SENT TO BB.\n\nNEURO: PT HAS BEEN AWAKE MUCH OF THE NIGHT. IS OREINTED. STATES HE IS HOPEFUL THAT HE CAN BE OFF VENT BY TODAY.\n\nGI: TOL STR TF WELL. NOW AT GOAL (90 CC PER HR.) NO FURTHER STOOL .\n\nF/E: UO AQEQUATE. CA AND MG REPLACED IN AM.\n\nPLAN: ? TM TRIAL IN AM?\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512670, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiratory acidemia with excellent oxygenation.\n\nRSBI = 64.1 on 0-PEEP and 5 cm PSV.\n\nPlan: continue trach collar trials.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512671, "text": "npn\nPt is a+o and follows commands, tol oob to chair via but able to pivot back to bed with phys. therapy. jpx 2 to bulb sxn, g tube to gravity- bili drg- feedng via j tube. bm x2. lasix 20 mg x1 with good response. trach collar since 830 am- tol well, ? to rest . + cough- thin white mucous. lungs clear upper- bases. care to cover abd wound with ostomy drg bag. Plan: cont to , trach collar as tol, transfer when stable, labs pr md orders\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512672, "text": "Respiratory Therapist\nBreath sounds diminished, coarse crackles, suctioned for moderate thick yellowish, Trach Mask trial started at 0900 am per nurse request, patient claims doing okay after starting, Passy Muir Valve on, sat 99 f22, up to now patient is still on Trach Mask doing fine, Requested the ventilator to be pulled away and orders not to put patient back on ventilator without having a resident seing patient first.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-14 00:00:00.000", "description": "Report", "row_id": 1512673, "text": "NPN (NOC):\n\nRESP: PT OFF VENT . RR TEENS, REG, NONLABORED. BS'S FAIRLY CLEAR, NO SPUTUM NOTED. AFEBRILE. AM PCO2 90, BUT THIS WAS TAKEN WHILE PT WAS SLEEPING. REPT PCO2 AFTER PT AWAKE FOR ~ 45 MINUTES DOWN TO THE LOW 70'S.\n\nCV: NO RUNS OF AD NOTED. SBP'S 180'S TO 190'S VIA ART LINE BUT SIGNIFICANTLY BY CUFF. PTT 52, LEPIRUDIN CONT. NO S/ OF BLEEDING NOTED.\n\nNEURO: SLEPT MUCH BETTER TONOC THAN LAST NOC.\n\nGI: TOL TF WELL. LOOSE STOOL X2.\n\nGU: UO ADEQUATE. CA REPLETED W/ TUMS.\n\n: ABD DSG CAHNGED X 1 AS OUTLINED BY NURSE.\n\nPLAN: OOB AGAIN TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-14 00:00:00.000", "description": "Report", "row_id": 1512674, "text": "npn\nPt remains a+o and mae- oob to chair- pivot with assist. tube feed at goal via j tube- tol well, g tube to gravity. bm x2. trach collar with passamir valve on, lungs clear upper- bases- suction prn, thick tan, also coughing up thick sputum. abd wound w-d packing changed prn- about q 4-6 with aquaseal at base and 4x4 over that- edges pink- drg brown. covered with ostomy bag.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512601, "text": "Respiratory Therapist\nNo significant improvements today this morning patient was in rapid A-Fib Albuterol MDI hold off first round per nurse request, patient went to CT today at noon, suctioned throughout the day for small thick white, treated once with albuterol MDI, breath sound mostly diminished, had an episode of hypotension while down in CT, will stay vented until most issues are dealt with.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512602, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt on midazolam gtt @ 4mg/hr. Easily to voice. Opens eyes spontaneously at times. PERRLA (3mm; brisk). Pt moves all extremities and follows commands. Cooperative w/ care. Pt mouthing that he has \"back pain.\" Fentanyl 50mcg IV x2 and 100mcg IV x1 given w/ + effect. Tmax 100.1. HR 70-80s (NSR) w/ frequent bursts of rapid A.fib (hr 120-130s); SBP (blood pressure cuff) drops to 60-80s when in rapid A.fib. Total of 7.5mg IV metoprolol given per Dr. for rapid A.fib (5mg metoprolol IVP by HO prior to going to CT; and 2.5mg IV metoprolol pushed by RN when pt back in SICU). HR converted back to 70s (NSR), but then would go back into rapid A.fib after few minutes. Upon returning from CT/CTA of abdomen/pelvis, A-line waveform very dampened; systolic 70-80s (Dr. at bedside); per Dr. , not start levophed gtt d/t ?accuracy of . Pt w/ strong radial pulses at that time and uo adequate; also pt very edematous. HO at bedside to monitor. Dr. and Dr. attempted to place new A-line; unsuccessful after multiple attempts. At approx 1630, Dr. came up to SICU to place A-line. SBP cont to be 70-80s; per Dr. , levophed gtt started and NS 500cc IVB x1 given for hypotension. Dr. able to place A-line in left brachial artery. Levophed gtt infused for approx 2hrs; titrated off at 1840 (goal MAP >60). CVP 7-15. Pt w/ general anasarca; pitting edema. DP/PT pulses dopplerable. Diuretics not ordered. Lepirudin gtt cont; decreased to 0.1mg/kg/hr this AM for PTT >80. PTT this afternoon was 75.3. Venodyne boot on LLE only; DVT on RLE. Lungs coarse; clear at times. Suctioned for small amount thick, white secretions. SIMV 50%, Vt 650x18, PEEP 5, PS 15. Pt does not breath over the vent. Weak cough. Abdomen firmly distended; +BS. TF held this AM for CTA; resumed post CTA. No emesis. No BM/flatus. G-tube to gravity bag w/ 400cc liquid, brownish-yellow drainage. TF at goal rate via J-tube. Insulin gtt cont @ 5units/hr; fs checked q1hr. Foley w/ clear, amber urine. UO >/= 35cc/hr. Midline abdominal incision w/ staples ; 4small open areas (wound bed pink; large amount serosang drainage). Abdominal wound packed w/ NS wet to dry dsg (done this AM). DSD over packing changed x2. DSD over G/J/and left JP drain changed x2 d/t large amount thick, brown drainage around insertion site. JP drain x2 w/ small amount dark brown, liquid drainage. wife calledx1; updated w/ plan of care. (social worker) spoke w/ pt's wife. ?family meeting tomorrow or Monday w/ pt's wife, 3 sons, Dr. , and Dr. .\n Plan: Monitor VS, I's and O's, labs. Cont insulin, lepirudin, midazolam gtt. Fentanyl prn for pain. FS q1hr when on insulin gtt. Monitor coags q6hr. Keep MAP >60. Follow up CTA, culture results. Update pt and family w/plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512603, "text": "SICU-B NPN 7p-7a\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nNo events\nNEURO: remains on versed gtt, fentanyl PRN for pain w/ good effect. Cont to c/o pain in abd upon palpation, also w/ intermittent back pain. PERRL, no focal neuro deficits noted.\n\nCV: HD stable, MAP 62-70 w/o further fluid bolusing or levophed. HR NSR 70s, no ectopy noted. Cont grossly edematous, no diuresis d/t borderline BP. Lepiruden adjusted for supratherapeutic PTT.\n\nRESP: Remains of SIVM, FiO2 decreased to 40% w/ adequate oxygenation, rate down to 16, ABG pending. Not overbreathing vent. LS coarse, not suctioning much. LLL bronchial/diminished.\n\nGI: abd firm, distended, tender. Cont TF via J tube @ goal. No BM, +BS. JPs w/ dk red/brown output, cont to ooze copious amt thick brown drainage from drain sites. Midline incision w/ lg. amt brown s/s drainage, DSD changed frequently; incision w/ staples , pink w->dry changed.\n\nGU: u/o borderline, no further diuresis or fluid given. Grossly positive LOS.\n\nENDO: cont insulin gtt\n\nID: tmax 102.5, tylenol given, pan cultured, plan to tap abd fluid collection seen on CT yesterday. Cont abx, unchanged.\n\n: no breakdown noted, incisions as above.\n\nSOC: no calls\n\nA: HD stable, cont full vent support, ? worsening infection/sepsis.\nP: follow up am labs, monitor fluid balance. Goal MAP >60, levophed if needed. Monitor temps, cont abx, plan to tap and culture abd fluid today. F/u family meeting, support to pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512604, "text": "Resp Care\nPt remains on MV in SIMV mode with changes as documented on Careview. No RSBI this am due to hyptotension/hypercarbia. BBS-CTA and diminished. No change post BD therapy. Sx'ed for scant amt thick white secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512605, "text": "Respiratory Therapist\nPatient stays on the same setting no wean done went to CT again today for about one hour, got regular MDI treatment, breath sounds coarse bilateral rhonchi, ETT tube retaped and rotated from right to left side of the mouth, suctioned for copious thick white.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512606, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt lightly sedated on midazolam gtt @ 4mg/hr. Easily to voice. Opens eyes spont at times. PERRLA (3mm; brisk). Follows commands and moves all extremities. Pt unable to lift up BLE d/t edema. Tmax 101.7; Tylenol 650mg given x2 via J-tube. SBP 90-110s/40-60s. Pt in and out of A.fib. HR up to 110-120s at times (A.fib) and SBP drops to 88-90s; MAP maintained >60 off levophed. Metoprolol 2.5mg IV q6hr ordered. RN notified Dr. that pt's SBP decreased to high 80-90s after metoprolol given. 200mg . Cont to monitor. CVP 10-18. Hct 23.7; transfused 2units PRBC. Lepirudin off since 0500 for percutaneous drainage of RUQ abd fluid collection. 2units FFP given prior to procedure d/t elevated PTT. Procedure done in CT; pigtail drain placed; +dark blood drainage (Dr. and pt's primary team aware). Pt w/ general anasarca; pitting edema. DP/PT pulses dopplerable. Venodyne boot on LLE only. Calcium repleted. Pt on metronidazole, linezolid, and levofloxacin. Lactic acid 4.6; Dr. notified. Lungs coarse; suctioned for small amount thick, white secretions. Vent setting changed to AC: 40%, Vt 650x16, PEEP 5. ABG showed compensated metabolic alkalosis. Sputum sent for culture and Gram stain. Abdomen firmly distended; very tender to palpation. Fentanyl 50mcg IV given x5 w/ + effect. TF has been on hold since 0800 for procedure. Insulin gtt off. J-tube clamped. G-tube to gravity bag w/ large amount yellow-brown drainage. Fecal incontinence bag changed x1; large amount liquid brown stool (guaiac negative). Foley w/ clear, amber urine. UO qs. Abdominal incision w/ staples ; 4 small open areas w/ pink wound bed. Open areas packed w/ 2x2 gauze soaked in NS and covered w/ DSD; large amount brown drainage. DSD over J/G tubes changed x2 d/t copious amount brown drainage. JP drains x2 w/ small amount dark brown drainage; DSD changed. RUQ pigtail drain w/ large amount dark, bloody output. Paper tape used for dsg. Pt T&R freq to maintain integrity. wife, 2 sons, and brother visited; updated w/ plan of care. wife and sons spoke w/ primary team. ?family meeting on Monday w/ Dr. , Dr. , (social worker), and RN.\nPlan: Monitor VS, I's and O's, labs. Monitor drainage from wound, around drain sites, and in pigtail drain. Monitor BP after metoprolol given. Follow up on cultures. Cont antibiotics and midazolam gtt. Cont to hold Lepirudin gtt per primary team d/t large amount dark bloody drainage from pigtail drain. Update family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512598, "text": "SICU-B NPN 7a-7p\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nEVENTS: ? midline abd incision dehiscence\nNEURO: Comfortably sedated on 4mg/hr, occas boluses fent for pain. No focal neuro deficits.\n\nCV: HD stable, BP trending down t/o day, MAP alwaly >65, CVP 12-18. Diuresed x 1 w/ fair effect, further diuresis held d/t ? sepsis. Cont grossly edematous. HR NSR 60s-70s, no ectopy, cont PO amio. Lepiruden w/ therapeutic PTT.\n\nRESP: Attempted CPAP trial 15/5, pt. tachypnic w/ c/o difficulty breathing, resumed SIMV @ prior settings, not overbreathing, ABG w/ good oxygenation/ventilation. LS coarse, dim @ bases. Sxn'd for thick white sputum.\n\nGI: abd firm, distended, tender to palpation along r side of midline incision, incision draining s/s fluid, SICU team in to eval, ? dehiscence w/ tracking, awaiting surgical resident. TFs @ goal, changed to 2/3 strength. +BS/+RF No stool, starting colase and milk of mag. G/J tubes .\n\nGU: foley patent, cyu, lasix as above. +1.5L since MN.\n\nENDO: to start insulin gtt for consistently ^'d BG.\n\nID: febrile, 101.4, pan cultured. WBC trending up.\n\n: incisions as above. Mild erythema surrounding JP and G/J tube sites. All dsgs changed. No breakdown noted.\n\nSOC: family in to visit, to arrange family meeting w/ Dr. and all involved diciplines.\n\nA: HD stable, cont full vent support, unable to adequately diurese. ? of wound dehiscence and worsening sepsis.\nP: f/u pm labs, monitor hemodynamics, goal MAP >65. F/u surgical eval of abd incision. Cont versed/fent for comfort. regimen. Cont SIMV onoc.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512599, "text": "RESP CARE: Pt remains intubated/on vent per carevue. On SIMV all shift. Lungs dim bilat. Sxd thick white/pale yellow. RSBI-181. continue on full support\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512600, "text": "focus hemodynmics\ndata: neuro: opens eyes to name and attempts to pull at et tube when untied. mouthing words and asking to pass his water. informed he had a catheter and nodded he forgot. perla #3 bilaterally. moves all extremities with help due to extremities being edematous.\n\nresp: remains intubated. on simv with ips. suctioned for thick yellow sputum. 02sats 96-100%. abgs good. wgt continues to up.\n\ncardiac: in nsr no ectopy seen. hct 27.7. on iv leprudin infusing with q6hr ptt. wbc 11.3. amiordone 400mg via tube fdg.\n\ngu: foley patent and draining amber colored urine. scrotum edematous and elevated on towel. urine amber in color.\n\ngI abd grossly distended and taut to touch. jp's oozing lg amt of bloody ?purelent drainage around the tubes. dr aware. tube fdgs at 110cc/hr. 2/3str impact with fiber. open abd incision with wet to dry dsg. stool x1 very large brown stool.\n\naction: labs as ordered. fentanyl for pain x2.on flagyl and linzolid iv. tube fgs at 110cc/hr. versed gtt infusiing insulin gtt with q1hr blood sugars. temp 102.4 and tylenol via tube given. update to wife this am. wife wishes to have 3 sons at the family mtg.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512594, "text": "Respiratory Therapy\n\nPt remains orally intubated weaned to PSV. Currently on +15PSV/+5PEEP w/ Vt ~500 RR ~20 maintaining Ve ~10-11L. BS slightly coarse, suctioned for small amounts of thick white sputum. SpO2 remained 90s. ABG acceptable. Remains fluid overloaded +17L. See resp flowsheet for specifics.\n\nPlan: maintain support; continue to wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512595, "text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt cont on versed gtt increased for agitation including tonguing and biting on ETT and attempting to pull it out. Easily awakens to voice and spontaneously awakens and opens eyes at times. Follows commands. Denies pain except on turning and repositioning. HR NSR 70s and BP wnl. Leperudine gtt continues with PTT at goal. Abdomen very firm and distended. Ducolax suppository with no results (+flatus) and then fleet enema also with no results. Dr. aware. Pt denies abdominal discomfort, nausea, or constipation. Tube feeds at goal via J-tube and only small amounts green bilious out of G-tube. Lungs clear with diminished bases and suctioned for small amounts of thick white secretions-mostly with yankaar in back of throat. PaCO2 high on gases and Dr. aware. No changes on vent at this time. Abdomen with staples pink and oozing serosanguinous drainage. Dressing changed with dry sterile dressing. Emotional support provided. Please refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512596, "text": "Resp Care\nPt. remains intubated/sedated overnight on PSV for most of the evening. Resp. acidois worsening overnight, Dr. aware.\nThis morning switched back to SIMV with good effect abgs normalizing, hyperoxygenated.\nBs: coarse bilat. sxn'd for thick white, sm-mod. amts.\nPlan: diurese, wean support as tolerated. Would recommend resting on SIMV overnight, PSV wean during the day.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512597, "text": "Respiratory Care Note\nPt received on SIMV as noted. BS clear bilaterally, but diminished with increased aeration after MDI. BS are slightly coarse at the end of shift than earlier. Pt placed on PSV 15/5 for 1 hour, but placed back on SIMV secondary to tachypnea of 30. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-15 00:00:00.000", "description": "Report", "row_id": 1512675, "text": "Nursing Progress Note\n7 pm - 7 am\nCV\n converting to afib at 2200..rates in the 100-110's...given 5 mg iv lopressor times 2 ..Dr. aware... SBP 120-130's/60's...\nRESP\non 70% trach collar..C02 range 77-94..( higher when asleep ) But awake and conversant throughout night...FI02 decreased to 50% at 0600..lungs diminished at bases .. using yankauer ..suctioned via trach for minimal amounts of sputum ..requesting P-M valve during the night\nGI\nRemains on goal tube feedings ..bedpan times 2 but without stool\nGU\ndiuresed with 40 mg of iv lasix .. D/T decreased urine output\nEndocrine\nsliding scale ..fixed insulin dose ..\n\nABD dsg changed times 2 for large amounts of foul smelling drainage ..JP on left to bulb sxn ..~~100 cc output ..G-tube to gravity with minimal drainage\n\ndenies pain during dsg changes ..25 mg of trazadone for sleep\nA/P AFIB ..? ^^ standing lopressor dose ..DSG changes\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512649, "text": "CONDITION UPDATE\nVSS. LOWGRADE TEMP. ALERT,FOLLOWING COMMANDS. DENIES PAIN. VERY RESTLESS, CONSTANTLY MOVING ON BED. PRN ATIVAN GIVEN MD'S ORDERS W/ LITTLE EFFECT. LUNGS COARSE TO CLEAR UPPER BASES, DIMINISHED AT BASES. NO VENT CHANGES - ABG ACCEPTABLE THIS AM. OCC SUCTIONING FOR THICK, TAN SPUTUM. ABD CONT TO BE SOFTLY DISTENDED. NO CHANGE IN ABD WOUND BASED ON PREVIOUS DOCUMENTATION AND REPORT. MIN BROWN DRAINAGE OUT JP 1, SM AMT OF BILIOUS DRAINAGE OUT GTUBE. NO DRAINAGE NOTED FROM PIGTAIL. TOLERATING TFEED AT GOAL VIA JTUBE. U/O QS VIA FOLEY - DIURESED W/ LASIX MD' ORDERS. LOOSE STOOL X2.\nCONT TO MAINTAIN PT - PT HIGH RISK FOR FALLS. PAIN MANAGEMENT. MAINTAIN INTEGRITY. MONITOR FOR S/S OF INFECTION OR BLEEDING. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512650, "text": "Resp Care\nPt remains on MV as noted on Careview with no vent changes this shift. RSBI 76. BBS-slightly coarse, improving with sx for thick, tan secretions. Bases diminished. Pt very active throughout night. Bag and mask at . Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512651, "text": "nursing note\nneuro: Pt alert,agitated and restless throughout day. Started trazodone to relieve agitation. Pt appear less agitated although still attempting to pull at lines remains restrained for safety.\nCV: Pt SR with rare PAC's. HR within the 70's. Lepirudin gtt continued at same rate. Aline dampens.\nResp: Weaned to PS 5-PEEP- 5,MD aware of ABG. Suctioned for thick white-yellow.\nInteg: , reddened buttocks from loose stool.\nGI/GU: BM X2,soft and large.BSX4. Ab incision irrigated TID with NS. Lasix PRN for goal negative 2L. JP#1 drainage small amounts of cloudy drainage.\nPsychosocial: wife and family member visited with pt in afternoon. Case manager in to address family about rehab options and further plan of care.\n\nPlan: Continue with trazodone administration for agitation. Ativan PRN. Wean vent as tolerated, await speech consult for PMV. Question with team about conversion to coumadin. Wound care. Lasix for goal negative 2L.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512652, "text": "Resp Care\nPt remains on PSV, ps weaned tol well. Pt had PMV trial with speech tol well. Plan to place pt on TM.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512653, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Trazodone and lorazepam given for restlessness/anxiety. Pt very restless in bed; pt pulling at JP drains and foley catheter. Pt attempting to sit up in bed and putting left leg over siderails. Pt closely monitored by RN overnight. Bilat wrist restraints in place; CSM on BUE (see CareVue for documentation). Trazodone and lorazepam w/ +effect. Pt opens eyes spont; opens eyes to voice when asleep. Follows commands. MAE. PERRLA (3-4mm bilat; brisk). Mouths words. Pt asked for wife several times overnight; RN explained to pt that it is night-time and that his wife will visit tomorrow. Emotional support provided.\nCV: Low grade temp (99.8). Pt in NSR w/ occasional PAC's (HR 60-70s), but at approx 2430 pt went into A.fib (HR 90-110s). Dr. notified. Metoprolol 5mg IV x2 w/ +effect; pt converted back to NSR w/ PAC's. A-line waveform very dampened; A-line flushed without effect. 100-140s/40-80s. QTc 0.33 sec. CVP 6-11. Continue Lepirudin gtt at 0.05mg/kg/hr. Pt w/ generalized edema. RLE>LLE; BLE warm to touch. Left DP/PT and right DP pulses weakly palpable. Right PT dopplerable. Furosemide 20mg IV BID ordered. Per Dr. , goal is for pt to be negative 1L/24hrs. Pt's 24hr net I&O balance: negative approx 1,131cc.\nPulm: Lungs clear, diminished at bases. Pt tolerated CPAP 40%, PEEP 5, PS 5. RR 17-20s. O2 sat >/= 98%. Pt suctioned for small amount thick, white secretions.\nGI: Abdomen softly distended w/ +BS. 3/4 strength Impact w/ fiber @ 90cc/hr via J-tube; no residuals noted. Loose/liquid BM x2 overnight; brown/golden stool (guaiac negative).\nEndo: FS q6hr w/ RISS. NPH 5units .\nGU: Foley w/ clear, yellow urine. UO >/= 45cc/hr.\nInteg: Pt's abdominal wound open w/ large amount brown drainage. Upper part of wound covered w/ DSD; lower part covered w/ Xeroform and DSD (dsg order from Dr. and primary team). Hydromorphone 1mg given for abdominal/incisional pain w/ good effect per pt. JP #1 w/ cloudy, liquid output. Right heel w/ abrasion; pink; no drainage noted. Venodyne boot on LLE only. MPB off all night d/t pt becomes more restless/agitated when MPB on. Pt's buttocks reddened, but . Aloe Vesta cream applied. T&R frequently to maintain integrity.\nPlan: Monitor VS, I's and O's, labs. Monitor neuro/resp status. Goal negative 1L/24hrs. Cont Lepirudin gtt; goal PTT 50-70. Trazodone/ Ativan for restlessness and anxiety. Provide emotional support. Pt needs to be reminded frequently that he is in the hospital. Update pt and family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512654, "text": "Resp Care\nPt remains on MV in CPAP/PS mode. BBS-Clear, diminished bases. No change post BD therapy. Pt very agitated/restless and pulling at tubes. RSBI 46. POC: Pt to be placed on ATC again today as tolerated. PMV trial to be repeated as tolerated. Bag and mask at . Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512655, "text": "Addendum to NPN:\nHct 28.2. PTT 53.5 (no change in lepirudin gtt rate). CPAP 40%, PEEP 5, PS 5 overnight. ABG: pH 7.41, PaCO2 56, PaO2 166, bicarb 37, BE 9. ?trach collar today w/ Passe Muir valve. Mg 1.9; repleted w/ 2grams magnesium sulfate. NSR w/ PAC's after 5mg metoprolol x2. Abd dsg changed x2.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512656, "text": "Resp Care\nPt was placed had 1st TM trial tol very well. Plan to continue on TM as tol. Sx for small wht.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512623, "text": "Addendum to NPN\nRepeat abg revealed PO2 of 76 and CO2 of 76. Discussed w/ Resident and plan to increase support to 15PS w/ 5PEEP. Will discuss plan to place tracheostomy tomorrow with wife. Versed increased since no plan to extubate and 1mg dilaudid given for turning/ changing sheets.\n\nA: Worsening ventilation.\n\nP: Increase vent support. ? trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512624, "text": "Resp Care\n\nPt received on PSV 15/5 and was placed on SBT with possible attempt to extubate however pt became more labored with slight respiratory acidosis present on repeat ABG. Pt currently vented on previous vent settings with Vt around 500cc and RR in the low 20s. BS clear to slightly course sxing for small amts of loose white secretions. ETT secured/patent. Will cont with vent support with possible trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512554, "text": "Admit note\nPt admitted from floor with sudden onset SOB and sats 60's.\nSee Careview for details...\nNeuro: Pt arrived AAOx3, MAE, pleasant and cooperative, remains alert throughout night and easily awakened when sleeping.\n\nCV: Aline inserted by Dr on arrival without difficulty. VSS, HR 70-90 Afib with bursts of 120-130's, Trace edema to LE's good pulses, Pt denies CP, EKG done on arrival and seen by Dr , 2gms Calcium Gluconate given for Ionized calcium 1.12, Heparin cont at 1600units/hr\n\nResp: Pt put on Bipap on arrival. See careview for settings, sats 98-99%, denies SOB, Lungs with crackles at bases, Pt to CT scan for chest CT, positive for bilat PE's, Dr aware, AM ABG 7.26/104/158/14 Dr and Dr notified. Fio2 to 40% and PS increased to 12, Pt alert, ABG to be drawn 1hr after changes\n\nGI: Abd lrg and firm, nontender, +BS, no BM, NPO\n\nGU: Adequate clear yellow urine via foley\n\nSkin warm dry and intact, turn pt throughout night, PM care given\n\nPlan: Monitor resp status, ABG, VS, Neuro status\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512555, "text": "Respiratory Care Note:\n Received patient from floors this shift. Patient remains on NIV this shift. For specific settings, please see carevue. Patient taken to CT without incident, positive for bilateral PE's. CXR this am is pending. CXR showed bibasilar and r. middle lobe atelectasis. Patient remained afebrile. BS are diminished. Both tanks switched out on vent. Plan is to continue support.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512556, "text": "Resp Care\nPt on NIV, then intubated in unit due to PCO2 of 115. PT transport4ed to Cath Lab for filter placement. Pt is a retainer and team would like to keep PCO2 around 60-70. Weaned FIO2 to 60%. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512617, "text": "Resp Care\nPt remains on MV as noted on Careview with no setting changes this shift. BBS-coarse and diminished, with no change post BD therapy. Sx'ed for thick, white secretions. Pt currently in a-fib, resting quietly in NAD. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512618, "text": "Rsp Care\n\nPt's mode of ventilation was changed to CPAP/PSV. PS was eventually was weaned to with adequate MV and TV's. However follow op 7.29/62/85/31 and was placed back on 15 of PSV. BS are with scattered rhonchi and suctioning thick white sputum\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512570, "text": "SICU NN: See carevue for specifics. Patient sent to OR at 0800 for exploratory lap, open chole, pancreas debridment, drainage of pancreatic pseudocyst, placement of G and J tubes. Patient returned at 1215. Patient sedated on propofol. When propofol held patient follows simple commands and nods head appropriately. Patient denies pain by nodding head. Patient moves all extremities weakly. Pupils equal round and briskly reactive. Patient remains intubated. Frequent abg's following lactate levels and metabolic acidosis. Rate increased to decrease CO2 and compensate for met. acid. with good result. FIO2 decreased from 100% to 60% following abg's with adequate PO2 levels. Lungs coarse throughout. Small amount secretions present. Ganz maintained as per policy. Cardiac outputs done as MD. . Central line intact. Levophed titrating to maintain map >60. Vasopressin weaned off as MD. started as ordered. RSR on cardiac monitor. TEE done at bedside by cardiology. Doppler pulses. One unit ffp infusing, one more ordered. NPO. NGT to lcws. G and J tubes to gravity. Bowel sounds hypoactive. Midline abdominal incision clean, dry and intact. Two to abdomen draining serosanguinous drainage. Foley intact, decreased urine outputs, md's aware. Fluid bolus given at 1400 as ordered. Skin intact. Blood sugars wnl. Magnesium repleted as ordered. MD's aware of all lab results. Family in to visit today, spoke with md's. Restraints in place as ordered for patient safety.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512571, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: opens eyes when propofol off and follows commands. PERRL. MAE. Please refer to flowsheet.\n\nResp: Breath sounds coarse and equal bilaterally. Sat's >97%. Suctioning through ETT for thick white secretions in moderate amount. Overnight following abg's, lactate, and mixed venous sat's. Lactate trending down, and mixed venous sat. 72-75%. Mouth with poor dentition is unchanged. Peak pressures in 30's.\n\nCV: SR occ. PAC noted. Aline intact with good waveform. Well perfused with brisk cap refill < 2sec's. Pulmonary htn with PA pressures decreasing mildly overnight. Cont to CO and wedge q 4 hours MD request. PA cath. with good waveform. REmains on levophed, currently tolerating slow wean with goal of MAP 65-75. Amiodorone continues at 0.5 mg/ min.\n\nHEme: INR 1.9 and transfused 2 units of FFP. Well tolerated. HCT stable. Cont to follow PT/INR q 6 hours. possibly restart heparin today. DVT right leg. Sequential on left and multipodis boots. HEparin currently given sq.\n\nGI/ Abd: NPO. Hypo active bowel sounds. Abd dressing with moderate amount of serosanguinous drainage (OR dressing intact). JP 1 and 2 with serosanguinous drainage. J and G tube to gravity. G tube with bilious drainage ~100cc. Jtube scant amount of bilious drainage. NGT to Low cont. wall suction in good placement and draining bilious. No stool thus far today. Firmly distended though improved.\n\nGU: Foley cath to gravity UOP >50cc/hour amber to yellow in color.\n\nEndo: Following glucose q 6 hours, RISS. No insulin required overnight.\n\nID: Cultures with no growth thus far. On vancomycin, flagyl, levofloxacin, fluconazole. Need to repeat sputum culture.\n\nSocial: Wife called and updated, verbalizing understanding. Will cont to update and support.\n\nPLan: Cont to follow glucose q 6 hours, RISS. Cont to follow abg/lactate, and mixed venous labs MD order. Lactate trending down. ABG cont to improve overnight. PT/ INR q 6 hours. Cont to wean levophed as tolerated with Map 65-75. Cont to update and support family. D/C plan is ongoing.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512572, "text": "SICU NN: See carevue for specifics. Patient intubated on fentanyl for pain control. Patient following commands. Pupils equal round and briskly reactive. Moving all extremities. Vent assist control, no issues. ABG's Q4h as ordered. Lactate decreasing. Converted to afib this am. Dr. notified. rate increased and bolus given. Patient remains in afib. Low dose levophed infusing to maintain map's 60-65. NPO. NGT to lcws. G and J tube to gravity. Abdominal incision with dsd intact, no drainage. Foley intact with adequate urine outputs. Skin intact. Restraints in place for patient safety. Low grade temps, antibiotics as ordered. Sliding scale for insulin coverage. Family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512573, "text": "resp. care\npt. remains intubated/vented/sedated.\ncontinue with high ph...resp. rate weaned\nto 18 with no spont. efforts. continue to\nwean as toerated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512640, "text": "Respiratory Care\nPt changed to cpap/ps tol well 735/63/138/36/7. Plan to continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512581, "text": " 15/07\n NEURO PT REMAINS ON FENT AT 100 MCG PER HOUR FOR REELAXATION AND PAIN CONTROLL AND TO TOL VENT SUPPORT PT ON HAND RESTRAINTS TO REMIND NOT TO PULL TUBES TOL WELL ORDER IN POE PT MAE IN GOOD SPIRITS PLEASE CAREVIEW FOR DETAILS\n HEART S1S2 SB ALT WITH AF RATES 80 TO 90 DURING AF POOR BP AND CO SELF LIMITING K DEPENDENT ON GOOD SUPPRESSION M 2/6 M AREA PRESSURES ELEVATED BUT STABLE CO FAIR 4.8 TO 5.6 SIDE DEPENDENT RIGHT SIDE UP BETTER RESULTS NOTED MD AWARE OF ALL RESULTS 3 PLUS EDEMA THRU OUT FLUID OVERLOADED POSSIBLY AM LASIX MD VSS LOW GRADE TEMP PLEASE SEE CAREVIEW\n RESP ON CMV PAP 32 TO 38 LUNGS RALES FINE AT BASES NOTED ABG WNL SCANT SPUTUM NOTED CPT TOL WELL\n GI POS B/S JP IN PLACE TOL T/F WELL G TUBE DRAINAGE FAIR AMOUNT U/ LOW MD RED BUTT AREA TIGHT FLUID FILLED\n PLAN SUPPORTIVE LASIX MONITOR WEAN LEVO TO OFF FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512582, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on ventilatory support, easily awaken, sleepy. WE only weaned FI02 from 50 to 40%. AM ABG acceptable. We are sxtn rotinely and as needed small to mod amt of thick white from ETT and occ orally, strong assist cough. Plan: Try fluid removal, and wean vent settings as tolerate. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512583, "text": "Nursing Note\nPlease see Carevue for complete assessment and specfics:\n\nNEURO: On fentanyl gtt, Open eyes spontaneously. PERRLA 3 and brisk. Nods and shakes head appropriately to questions asked. Follows commands with all 4 ext.\n\nGI: Abd obese soft, +BS. TF thru J tube adv to 30cc/hr. G-tube to gravity draining bilious fluid. JP #1 draining grey thick liquid. No drainage from JP#2.\n\nCARDIAC: TMax 100.8 by blood. Swann and cordis d/ by MD. HR 60-70's NSR no ectopy. Continues with gtt and Heparin gtt.\n\nGU: Foley draining qs clear yellow urine. Lasix 20mg x1 with good effect.\n\nRESP: LS clear. Deep sxn for small amts of thick white secretions. Mouth sxn for large amts of clear secretions.\n\nINTEG: Scrotum extremely edematous elev on towel. Inc staples with no drainage. JP sites cdi.\n\nPSYCH/SOCIAL: Son at bedside in the am, pt more interactive and calm with his presence. 2mg x1 for anxiety.\n\nPLAN: Continue to diurese, Possibly wean vent tomorrow, Monitor hemodynamics, Provide extra reassurance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512584, "text": " 1530\n NEURO A/O COMMUNICATES WELL AROUND ETT MAE LIMITATION EDEMA AT LIMBS DECREASING ROM RELAXED GOOD PAIN CONTROL WITH FENT AT 100 SLEEPS SHORT PERIODS\n RESP VENT CMV TOL WELL REMAINS INTUBATED FOR FLUID OVERLOAD RESOLVING SCAT SPUTUM CLEAR FIELDS\n HEART S1S2 SB CONTROLED DOPPLER PULSES VSS M PR .14 QRS .08 QTC WNL FOR AGE AND GENDER\n ABD POS B/S NO STOOL TOL T/F WELL NO ISSUES DRAINS IN PLACE HEALING\n PLAN SUPPORTIVE MONITOR FLUID LOSS ROM AND T/P\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512659, "text": "Resp Care\nPatient required ventilation overnight due to increasing co2. Currently on simv 550 x 12 40% 5/5 with improved abgs. Plan is to switch back to trach collar later today.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512660, "text": "Resp Care\nPt was placed on TM tol well, plan to monitor abg's, may stay on TM ph<7.30.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512619, "text": "see careview for details\nfocus data update\n\nNEURO: pain med changed to dilaudid with improved pain control\n\nRESP: vent setting's changed from cmv to cpap, pt weaned from to finally pt tol for 1 1/2 hr's, returned to over noc to rest pt, trach planned for am, pt's wife request that we wait 24 hr's to see if we can extubate pt, ICU team aware, MIS team aware, Anesthesia aware and will notify OR, ABG's monitored closely\n\nCV: lasix gtt increased, pt tol diuresis well, lepirudin theraputic level,\n\nGI: inc of large amt's liq feces, fecal inc bag applied peri-rectal area excoriated, pt on theraputic bed, banna flakes added to tube feeds, abd wound continues to drain copius amt's of purulent/sangernous drg\n\nGU: diuresising well\n\nA/P: continue emotional and educational support to both pt and family, continue to wean pt\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512620, "text": "SICU NN: See carevue for specifics. Patient sedated on versed . Dilaudid for signs and symptoms of pain prn with good result. Patient moves all extremities. Patient follows simple commands. ET to vent, cpap. RSR. BP wnl. Abdominal incision with dehisence, multiple pouches covering incision with serosanguinous drianage. One pigtail catheter and two jp's in place to abdomen. G tube to gravity. J tube with tube feeds, tolerating. One soft bm this shift. Foley-lasix infusing titrating with goal of making patient one to two liters negative. . Restraints in place for patient safety related to et tube and multiple lines. Triadyne rotating bed in rotation mode. Pneumatic boot on left leg only due to dvt in right. No visitors or phone calls. Lytes repleted as ordered. Lepirudin infusing as ordered. Administered antibiotics as ordered. Patient afebrile. Patient sleeping comfortably.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512621, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on spontaneous ventilation. No vent changes done. RSBI done ~52. BS are dim more to bases and clear. Plan: Continue to diurese and likely assess for etubation or trach?. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512641, "text": "Nursing Update\nCV/HEME: No A Fib, but sinus brady in 50's x2hours after receiving lopressor. BP stable. Labs stable. Cont on lepuridin gtts.\n\nPAIN/SEDATION: Dilaudid effective for abdominal pain, ativan for restlessness with only fair effect.\n\nID: Contact precautions maintained. Afebrile.\n\nGI: Tube feed tolerated at goal via PEJ. GT draining bile, JP's 1&2 draining greyish serous fluid, no drainage via pigtail. Abdominal incision draining maroon fluid to collection device. sounds auscultated over 4 quads. Sm liquid brown BM.\n\nMonitored closely overnoc, DR in close attendance.\nSee carevue flowsheets for detailed data.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512642, "text": "Resp Care,\nPt. changed to A/C overnoc after periods of apnea on IPS. Changed back to IPS 15 this am. VT 500's RR 8. RSBI 38 this am. Cont. to wean as tol. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512643, "text": "npn\n pt cont freq agitated- ativan prn, facial grimace with activity- dilaudid prn, Haldol started this am. bilat wrist rest. on. follows commands and mae on bed.\n\nResp- tol ips of 15 and peep 5- cont metabolic alk- diamox tid. lungs clear upper- bases, suction thick tan secretions via trach.\n\nGI- tube feed at 110/hr - 2/3 strength impact with fiber. tol well, f.i.b - small amount loose stool. plan pr surgical team to irrigate abd. wound tid. jp x2, pigtail x1 and g tube to gravity. with bili drg- tube feed via j tube.\n\nPlan wean vent as tol, decrease ativan as tol irrg. abd wound tid.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512644, "text": "Respiratory Care Note\nPt received on PSV 15/5 as noted with no vent changes this shift. BS diminished throughout with increased aeration after MDI. VT's 700's with RR 8-12. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512645, "text": "NURSING UPDATE\nCV/HEME: NO ARRYTHMIAS, BP STABLE. HCT 26.9. K+ REPLETED.\n\nRENAL/GU: RESPONDED VERY WELL TO LASIX 20MG IV, RESULTED IN 1400CC NEGATIVE FLUID BALANCE FOR YESTERDAY.\n\nGI: TUBE FEED TOLERATED @ GOAL. JP'S AND PIGTAIL DRAINING GREYISH SEROUS, GT DRAINING BILE, MAROON SLUDGE DRAINING VIA ABDOMINAL WOUND, IRRIGATED WITH N/SALINE X1.\n\nPAIN SEDATION: AGITATED MOST OF NOC, SETTLED FOR 3 HOURS ONLY. ATIVAN FOR AGITATION, AND DILAUDID FOR ADOMINAL DISCOMFORT WITH MODERATE TO POOR EFFECT.\n\nNURSE THROUGHOUT NOC FOR CONTINOUS SAFETY MONITORING.\nDR IN CLOSE ATTENDANCE.\nSEE CARVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512646, "text": "Resp Care,\nPt. remains on IPS 15 overnoc. Periods of prolonged apnea during noc after sedation. ABG 7.32/60/133/32. VT 700's, RR 10. Agitated most of noc. RSBI 46 this am. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512647, "text": "Respiratory Care Note\nPt received on PSV 15/5 as noted. PS weaned to 10 - follow up ABG 7.36/60/160/35/6. Pt tolerating well with VT 500's and RR high teens. BS are coarse bilaterally and decreased which clear and improve in aeration after suctioning and MDI's. Plan to continue on PSV and wean PS as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512648, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt restless/anxious in bed. Attempting to pull at trach, IV lines, foley, and drains. Pt also attempting to sit up bed; repositioned frequently. Pt restrained bilat wrists; see CareVue for documentation. Total 8mg lorazepam given. Hydromorphone given for abdominal pain (total 5mg given). PERRLA (2-3mm bilat; brisk). Pt follows commands; MAE. Mouths words at times, but difficult to understand. Emotional support given to pt. RN monitored pt closely during shift. Afebrile. HR 50-90s. Pt in A.fib this AM, but converted to sinus brady/NSR (Dr. aware). When in A.fib, SBP decreased to 80-90s (SICU team aware). ABP 90-150s/50-90s. QTc 0.42 sec. CVP 10-22. Pt w/ generalized edema (+). DP/PT pulses dopplerable. Furosemide 20mg IVx2; goal neg 2L/24hrs. Lepirudin gtt cont @ 0.05mg/kg/hr. Lungs clear, diminished at bases. CPAP 40%, PEEP 5, PS decreased to 10. ABG: pH 7.36, PaCO2 60, PaO2 160, bicarb 35, BE 6 (Dr. aware of ABG). Pt w/ strong cough; productive for small amount thick, tan secretions. O2 sat >/= 98%. No c/o SOB. Abdomen softly distended w/ +BS. 2/3 strength Impact w/ fiber at 110cc/hr via J-tube; no residuals noted. G-tube to gravity bag w/ 100cc green, bilious drainage. Fecal incontinence bag came off this AM; stool is softly formed. BMx2; soft, golden-color stool. FS checked q6hr w/ RISS; BS 133-151. NPH 5units ordered . Abdominal wound irrigated x2 w/ NS; large amount of liquid, mucoid, dark-brown drainage noted. Large drainage bag over abdominal incision . JPx2 to bulb suction. JP#1 w/ small amount light-brown drainage. JP#2 w/ small amount cloudy, light tan drainage. Right pigtail drain w/ dark brown drainage. DSD over all drains changed x1. Triadyne bed changed to Atmos-air (SICU) bed. ; no redness/breakdown noted on pt's back/sacral area. T&R frequently to maintain integrity. wife, son, and sister-in-law visited. Family spoke to RN and Dr. regarding pt's condition and plan of care. Emotional support provided.\n Plan: Monitor VS, I's and O's, labs. Goal negative 2L today. Monitor for A.fib. Lorazepam for restlessness/anxiety. Hydromorphone for pain. Irrigate abdominal wound w/ NS TID (done at 1000 and 1800 this shift). Cont Lepirudin gtt; goal PTT 50-70. Wean vent settings as tolerated. Update pt and family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512661, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nOverall status unchanged. Placed on trach mask this am. Pt cont with ^^ PC02's when sleeping Pt aroused and ABG rechecked current PC02 is 63 no noted change in mental status. Cont to be diuresed goal 1-1.5 liters negative. S/P CT scan today. Plan: Cont to monitor resp status and Heme status cont to monitor diuresis and check lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-06 00:00:00.000", "description": "Report", "row_id": 1512662, "text": "Nursing note (1900-0700) 04:30\n\n\nNeuro.\nPt alert, mouthing words, periods of aggitation noted, medicated with Trazadone and Ativan with slight effect. Pt making confused statements, not always able to express needs.\n\nResp.\nPt remains on trach mask with good SpO2 and adequate abg. Able to expectorate white thick secretions easily.\n\nCVS.\nHR 80's A-Fib, on Lopressor and .\nBP 120's/80's, a-line dampened, nibp in place also.\n\nGI/GU.\nPt tollerating TF's well, +BS with loose brown stool managed via mushroom cath.\nFoley patent for clear yellow urine, pt with good response to extra dose of lasix overnight, pt 1100cc -ve at 12mn.\n\n.\nWound dressing to abdomen left overnight.\n\nSocial.\nNo calls or visits overnight.\n\nID.\nContinues on anti-biotic coverage, WCC 8, pt a-febrile.\n\nPlan.\nRepleat lytes as needed.\nPt to go to OR at some point for wound closure.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-06 00:00:00.000", "description": "Report", "row_id": 1512663, "text": "Neuro:Pt alert but confused. Able to make needs known. Denies pain.\n\nCV: afebrile, HR 90-110's, A-fib. Med with lopressor 5mg IVP with no response for a-fib. SBP 140-150's\n.\nRESP: pt on trach mask, Continues to have CO2 >70. O2 sats >96%. Tolerating Passy muir valve.\n\nGI: NPO for ? ct scan.\n\nGU: foley draining adequate amounts of clear yellow urine.\n\nENDO: blood sugars WNL.\n\n: abd dressing to be changed q4hrs. packing with sterile gauze. ? vac dressing.\n\nPLAN: Awaiting VAC placement on abdominal dressing. ? transfer to floor or rehab.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512664, "text": "update\nNeuro: mae, awake and alert, not always oriented to time or place. when passe muir valve in, pt stated he wanted to go to the nuclear power plant at the beach.\n\ncv: A fib all shift, bp stable, see flow sheet for details.\n\nPulm: bs clear, decr in left base. sx q 2-3 hrs for thin white, coughing , regurgitated green bile, did not aspirate it. trach cuff up for protection of airway from aspiration. po2 132, pco2 68, fio2 decr to 40%. albuterol tx q 6hr.\n\ngi: gt to gravity, draining green bilious. sounds present, tube feeds restarted at 90 cc without problem. mushroom cath in place, draining liquid stool hem neg.\n\ngu: lasix with good response.\n\nwound: dsg changed q 4 and packed with ls gauze, large amts brown mucous ddrainage from wound.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512611, "text": " 19/07\n NEURO ALERT COMMUNICATES WELL NO ACUTE DISTRESS LOW DOSE SEDATION TOL WELL VERSED MAE WELL NO PAIN ON MOTION OPENLY STATES WANTS ETT OUT IF UN TIED WILL PULL TUBE OUT\n RESP ETT CMV 12/650 PEEP 5 .40 FI02 CLEAR FIELDS NOTED THICH SPUTUM NOTED STRONG COUGH\n HEART S1S2 PULES POS 2 THRU OUT NSR BP WNL EDEMA REMAINS 3 PLUS TIGHT EXTREMITES\n GI POS B/S STOOLING NO ISSUES NOTED FIRM ABD WITH WEAPING ABD WOUND JP AND PIG TAIL IN PLACE TOL T/F WELL\n PLAN SUPPORTIVE PLEASE SEE CAREVIEW FOR DETAILS T/P CPT P/T FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512612, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. RSBI 260 with desat to 89%. Returned to AC w/sat 99% without further intervention. BBS-coarse, improving with sx for thick white secretions. Diminished BS t/o w/no changed noted post BD therapy. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512613, "text": "see careview for details\nfocus data update\n\nNEURO: OPENING EYES SPONTANEOUSLY, MOVING B/L UPPER EXT'S, FENTANYL FOR PAIN, VERSED GTT FOR COMFORT\n\nRESP: VENT SETTINGS UNCHANGED, R/T GENERALIZED ANASARCA, SX FOR COPIOUIS AMT'S OF THICK WHITE SECRETIONS BOTH ORALLY AND ETT,\n\nCV: TMAX 101.5, BOTH ICU AND SURGICAL TEAMS AWARE, CX'S STILL PENDING, NO NEW CULTURES ORDERED, MED WITH TYLENOL, LEPIRUDEN GTT AND LASIX GTT INFUSING\n\nGI: FIRM AND ABD DISTENDED. UPPER POLE OF INCISION FISTULA NOTED THAT COMMUNICATES WITH PIGTAIL, DRAINAGE BAG APPLIED TO INCISION\n\nGU: ADEQUATE HOURLY U/O, AWAITING LASIX GTT\n\nA/P: CONTINUE PLAN OF CARE, GOAL LITER'S NEG FOR 24 WITH LASIX GTT, CONTINUE BOTH EDUCATRIONAL AND EMOTIONAL SUPPORT TO BOTH PT AND FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512614, "text": " 1500\n NEURO PT ALERT WILL FOLLOW COMANDS MAE WITH RESTRICTIONS OF TIGHT FLUID FILLED EXTREMITES C/O ABD PAIN ON VERSED WITH FENT SUPPLEMENTS DOES WELL\n RESP VENT ETT CMV .40 FIO2 12/650 5 TOL WELL THICK SPUTUM BROWN IN COLOR RHONCHI THRU OUT\n HEART S1S2 DISTANT TONES POOR PULSES THRU OUT NSR VSS LOW GRADE TEMP PLEASE SEE CAREVIEW FOR DETAILS\n GI POS HYPOACTIVE B/S NOTED TOL T/F AT THIS TIME STOOLING ABD WOUND OPEN IN 3 MAJOR AREAS WITH DARK RED FLUID FOUL ORDOR COVERED WITH BAGS FOR COLLECTION LG AMOUNTS MD AWARE U/O FAIR ON LASIX TITRATING TWO JP SCANT PIG TAIL LG AMOUNTS NOTED SAME AS FLUID FROM ABD WOUNDS\n SHOWING SIGNS OF WEARING NEW BED ORDERED Q2 SIGN CARE AND ROTATION SUPPORTIVE CARE FAMILY CARE\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512615, "text": "Respiratory Therapist\nBreath sounds coarse bilateral crackles, suctioned for moderate thick white, treated three times with Albuterol MDI, ABGs at 1539 showed fully compensated respiratory acidosis with hyperoxemia, started on lasix, still has edematous limbs, will stay intubated, and monitored.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512616, "text": "Respiratory Therapist\nUpdate: Patient tried on CPAP at 1730, after 20 minutes had to be put back on previous initial settings: AC 650 x 12 40% +5.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512568, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: Lightly sedated on propofol drip awakens to name, follows commands consistently. MAE. PERRL. Currently sedated on propofol drip at 50 mcg/kg/min. ativan 2mg IV, and morphine 2mg given overnight.\n\nEvents:\n\nResp: Vent changes made accordingly, and remains on AC, TV 650, peep 8, RR 18, fi02 .70. Breath sounds coarse and equal bilaterally. sat's .98% until 0100, Temp spiked to 102.5 po. Rigors noted, biting on ETT with sat drop to 88 %. Suctioned for tan thick secretions in moderate amount.\nPlease refer to careview for abg's.\n\nCV: SR to ST no ectopy, Concurrent with temp spike to 102.5 became tachycardic and hypertensive. 10 mg IV lopressor given with good effect and bp came down to 140/60. Probable sepsis, given total of 4 liter NS, and levophed drip started and currently at 0.5 mcg/kg/min.\nHCT 25.9 and given one unit PRBC's due to bp persistently decreasing to lowest of 73/40 briefly. Mean bp >60 with levo and NS. Heparin increased to 1600 units /hour earlier in shift for goal of 60-80. Currently off at 0700 due to scheduled OR time of 0830. Aline with good waveform.\n\nPA line placed at 0630. CXR done at 0730 to confirm line placement.\n\nGI/ Abd: Active bs. NGT to low cont suction with bilious color drainage. Bruising noted around umbilicus and abdomen with increased firmness and guarding to examination this morning. Lactate increased to 7.2 from 1.4 earlier in shift. No stool.\n\nGU: UOP ,30cc/hour. Foley to gravity.\n\nID: TMAx 104.2 po. Tylenol given at 0100. Cooling blanket on at 0100. ON levofloxacin, flagyl, and vancomycin.\n\nEndo: glucose q 6 hours, RISS. no insulin required.\n\nSocial: Wife called and updated by surgeon. Cont to update and support family.\n\nPlan: Cont to follow abgs, labs. Provide abx coverage as ordered. Hemodynamics monitor keep map >60. Plan to go to OR this am for exploratory laparotomy.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512569, "text": "Respiratory Care\nPt continues to be orally intubated/ventilated at this time. Pt to this OR this am after spiking temps. S/P choylecystecomy/pancreatic debridement/placement of G/J tube. Pt returned w/o incident. Currently on A/C 650/18/8/.80. BS: coarse bilaterally. Suctioned for scant bld-tinged secretions. Poor Pa02/Fi02 ratio at this time. Hope to wean Fi02 further t/o the night. Will continue to closely monitoer and support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512635, "text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. Pt to OR today for trache, #8 portex placed. No vent changes made so far this shift. Sxn for white secretions. Albuterol MDI given Q4. Cont current support, ? back to PSV soon.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512636, "text": "Neuro: Pt alert but remains slightly sedated on versed gtt at 4mg/hr. MAE, follow directions consistantly. Pt med with dilaudid at noon for transfer to OR for trach with good effect.\nCV: afebrile, HR initially 70's NSR with no ectopy, presently 100's Afib. SBP 90-100, CVP 11-13. Extremities with edema, dopplerable pulses. Lytes repleated this eve. Lepirudin to restart at 1800.\nRESP: lungs coarse to dim at bases. Remains on AC 550X18 40% Peep-5. Occasional suctioning of frothy secretions. Pt to OR at 12noon for trach. Tol well, ABG acceptable.\nGI: Tol tube feed at goal, restarted on return from OR. No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nENDO: blood sugars WNL.\nPLAN: Attempt to wean vent overweekend. Cont to monitor coags with liperudin.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512637, "text": "Respiratory Care\nPt. trached and remains on ventilatory support. ABG's showing gradual correction of Metabolic Alkilosis. Tol RSBI trial this a.m. Suctioned for min-mod amounts of thick yellow secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512638, "text": "NURSING UPDATE\nCV:\nEPISODE OF AFIB X2HOURS EARLY NOC, CONVERTED TO NSR RATE 60'S AND REMAINED STABLE SINCE. LEPIRUDIN GTTS CONT, INR 2.4 AND HCT 22 THIS AM, FFP 2U AND PRBC'S 2U TRANSFUSED. K+ AND MG+ REPLETED.\n\nRESP:\nBS FAIRLY CLEAR THROUGHOUT, SXN SMALL WHITE. NO VENT CHANGES. METABOLIC ALKALOSIS PERSISTS. SCANT AMOUNT OF PINK DRAINAGE @ TRACH SITE.\n\nNEURO:\nALERT AND FOLLOWING COMMANDS, ORIENTATION UNDETERMINED. RESTLESS AND FIDGETY ON VERSED GTTS, WEANED OFF AND MEDICATED WITH ATIVAN PRN WITH MUCH BETTER EFFECT. BIL WRIST RESTRAINTS MAINTAINED.\n\nGI:\nTUBE FEED TOL @ GOAL VIA PEJ. MEDICATED WITH DILAUDID PRN FOR C/O ABDOMINAL/INCISIONAL PAIN WITH GOOD EFFECT. JP#1 DRAINING GREYISH SLUDGE, JP#2 DRAINING GREYISH SEROUS, PIGTAIL DRAINING MAROON, GT DRAINING GREEN BILE, ABDOMINAL WOUND DRAINAGE DEVICE COLLECTING SLUDGY MAROON. SOUNDS HYPOACTIVE. INCONTINENT X2 SLIGHTLY GUAIAC POSITIVE STOOL, FIB APPLIED.\n\nGU:\nHUO 70-140CC CLEAR YELLOW.\n\nPT MONITORED CLOSELY @ BEDSIDE. CONTACT PRECAUTIONS MAINTAINED.\nDR IN CLOSE ATTENDANCE THROUGHOUT SHIFT.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512639, "text": "npn\n pt opens eyes spont, mouths words like \"water\" \"hot\". mae on bed. Frequently anxious and pulling at drains and taking gown off. bilat soft wrist rest. on. ativan prn. facial grimace with activity- dilaudid prn.\n\nResp- tol cmv vent weaned to ips of 15 with peep 5- abg metabolic alkalosis- ph wnl, md aware- lungs clear upper- decrased at bases, suction thick tan to white secretions via trach.\n\nAbd- tol tube feed via j tube, cont abd jp x2, pigtail drain x1 and g tube to gravity. abd wound covered with ostomy type drsg to drg bag- pink to dark red thick drg. hypo bs x4, fib on with liq soft stool.\n\nHeme- rec 2 prbc this am for hct 23- post hct this pm 28- rec 2 ffp for inr >2.5- pm inr 2.2, cont lepirudin gtt.\n\nPlan- cont wean vent as tol, ativan and dilaudid prn- wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512607, "text": "condition update\nD: pt remains on versed at 4mg/hr. pt openes eyes and follows commands. pupils are equal and reactive to light. pt moves all extremities.\ncardiac: pt remains off levo and map is greater than 60. pt switches between afib and nsr with rate of 110-68. most of the night pt remained in nsr. cvp 16-18.\nresp: abg's are unchanged. please see flowsheet. pt remains on cmv with rate of 12. breath sounds are clear after suctioning and mdis. pt suctioned for thick yellow sputum.\n: pt with open area on right heal. 2 x 1 in size. right foot elevated on pillow. no other areas of breakdown noted. abd wound continues to drain a large amt of red/brown drainage. pigtail continues to drain a large amt of maroon thick drainage. hct of pigtail fluid was 11. serial hcts done and hct remains stable at 26.\ngi: tube feeds restarted and pt with no residual. gtube drained large amts of green/brown drainage. bilateral jp's patent and draining minimal drainage.\ngu: urine output remains adequate 40-100cc/hr.\na: medicate for pain as needed with fentanyl. continue to monitor pigtail drain and hcts as ordered. ? reevaluate to restart anticoagulation therapy today.\nr: 50mcgs of fentanyl effective in relieving pain. hct remains stable at this time. pt appears comfortable on current vent settings. pigtail continues to drain large amounts of maroon drainage.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512608, "text": "Resp Care\nPt remains on MV w/settings as noted on Careview. RSBI 120's this am, pt returned to AC mode. Hct stable, some a-fib noted. BBS-CTA and diminished w/no change post BD therapy. Sx'ed for sm amts thick white secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512609, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT LIGHTLY SEDATED ON MIDAZ GTT. OPENS EYES SPONT. PERRL. FOLLOWS COMMANDS.\n\nCV-HR 70'S, SINUS, NO ECTOPY. SBP STABLE. W+D. +PP VIA DOPPLER. + PITTING EDEMA THROUGHOUT. RESTARTED ON LEPRIDUM GTT. WILL FOLLOW COAGS.\n\nRESP-REMAINS INTUBATED. NO VENT CHANGES MADE TODAY. O2 SAT 98%. LS CLEAR TO COARSE WITH OCC WHEEZES. SXN PRN FOR THICK WHITE SPUTUM.\n\nGI-ABD OBESE, FIRM, DISTENDED. +BS. TOL TF AT GOAL VIA J-TUBE. G-TUBE TO GRAVITY WITH BROWN BILIOUS DRG. JP AX WITH SM AMT BROWN DRG. PERC DRAIN WITH DARK MAROON DRG. SPEC SENT FOR AMYLASE. ABD DSG REINFORCED. HAS FIB IN PLACE WITH LOOSE BROWN STOOL.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS AMBER URINE. + SCROTAL EDEMA.\n\nCOMORT-FENT PRN.\n\nENDO-REMAINS ON INSULIN GTT.\n\nID-TMAX 100.6. REMAINS ON ABX.\n\nA-VENTED, ALT IN GI.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. ASSESS PAIN. DSG CHANGES. INSULIN GTT. FOLLOW PTT FOR LEPRIDUM GTT. CARE. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512610, "text": "Respiratory Therapist\nNo vent changes made at this point, ABGs at 1640 showed fully compensated metabolic alkalosis with mild hyperoxemia. Breath sounds coarse expiratory rhonchi, suctioned for moderate thick white,extremities exhibit pitting edema, patient was treated today in three occasion with Albuterol inhaler.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512577, "text": "see careview for details\nfocus data update\n\nneuro: awake and anxious at times, medicated with ativan and fentanyl gtt, mae's, perla\n\nresp: abg's monitored, vent setting's unchanged, increase suctioning noted for thick white secretions\n\ncv: increased anasarca noted, a-line restarted in right radial, left subclavian multi-lumen patent, right pa cath patent, c.o. improved\nlevo d/c, decreased, pt converted into nsr, heperin gtt titatrated to ptt, lyte replacement given, am labs pending\n\ngi: tol tropic tube feeds into j-tube, g-tube to gravity, jp's to ssx,\nabd dsg's changed, minimal billary drainage noted @ g-tube site, all other dressing's clean, dry and \n\ngu: urine remains amber, adequate hourly u/o\n\na/p: continue to assess and tx, continue both educational and emotional support\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512578, "text": "resp care note\n\nPt is better sedated today as intubation may continue for few days. AC 18 x 650\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512564, "text": "SICU NPN 0700-1900.\nS: Pt. intubated. Nodding head appropriately to questions.\nO:\nCV- HR 60-80 SR with very occasional PVCs. BP 120-170/60-80. Hypertensive event with minimal response to 7.5 mg IV Lopressor. Also given hydralazine and morphine with minimal response. Hypertension appeared to normalize when placed back on AC ventilation.\n\nPulm- On CPAP RR 17-30. ABG showed metabolic alkalosis. MV increased with fever and placed back on AC of 50% 650x16 PEEP 5. ABG much improved on this setting. Spo2 96-100% on AC ventilation. Breath sounds throughout the day have become increasingly diminished as abdominal girth increases. Lactic acid 1.2 Pt was on HCL gtt for 5 hours. Labs have improved. Suction q2h for thick yellow secretions.\n\nID- Febrile. T max 103.4. Pan cx'd. 1 gm Tylenol given pngt with moderate response. Ice packs to groin. Cooling blanket on.\n\nLine Access- Left SC TLC placed this am. CXR done. Left femoral TLC d/c.\n\nNeuro- On propofol. Continually follows commands and moves all extremities.\n\nGI- Abdomen very firm and distended appearing to increase as day progresses. Team aware. Bladder pressure 26. Positive BS x4Q. No stool. No flatus.\n\nNutr- Awaiting feeding tube placement tomorrow.\n\nGU- Foley draining greater than 30cc/hour clear amber urine.\n\nPain- Occasionally complaining of abdominal pain. Medicated with morphine for relief.\n\nEndo- ssri coverage. Calcium and potassium repleated.\n\n Three Sons in to visit today and updated with plan of care. Son took pt's wedding band home this afternoon. Wife in to visit this evening and updated with plan of care.\n\nA: Hyperthermic and hypertensive. Pan cx'd.\n\nP: Continue to measure temperature and assess for signs and symtoms of infection. Cooling blanket prn. Continue to assess bladder pressures. Continue to monitor ptt while on heparin gtt. Offer support to patient and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512565, "text": "Resp Care\nPt remains intubated on A/C. MDI's given. Pt placed on PSV, but after 2 hrs had to be placed back on A/C. No other changes made.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512566, "text": "SICU NURSING PROGRESS NOTE 0700-1900\nTHE ABOVE NOTE WRITTEN BY IS ACCURATE AND CORRECT OF THE EVENTS FOR THE DAY. MR N. HAS IMPROVED IN HIS RESP STATUS . HE REMAINS WITH FUO.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512567, "text": ",rrt\npt. remained on current settings until ~ 0100 hrs when became anxious, biting et tube, sats < to low 90's, rr>40's, placed oral airway, temp shown to be @ 104, began breath stacking, b/l b.s. noted/diminished b/l/coarse/wet attempted to bag with no difficulty after peak pressure > to >40's, inhaler given, placed nss ~10cc down tube to check for mucus plug, sx'd small white/thick mucus, placed on heated circuit earlier @ 2300-2/20, due to coarse b.s. thick beige sc's noted,fi02 > per abg's along with peep > to +8, will monitor fi02 @ 70%/peep@ +8.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512629, "text": "REspiratory Care\nPT. intubated on ventilatory support. Pt. started shift on CPAP/PS 5/5 gradually over shift CO2 climbed , PS increased to 15, CO2 remained high and pt. began to experience periods of apnea, ventilatory support returned to A/C mode. Sx numerous times for copious clear/white frothy secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512579, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info:\n\nNeuro: No changes and consistent with previous assessment. MAE on command. PERRL. Opens eyes spontaneously. Anxious at times and medicated with prn lorazapam with good effect. Pain management is with fentanyl currently infusing at 100 mcg/hour.\n\nResp: Breath sounds clear and equal bilaterally. Coarse at times and suctioned for thick cream color secretions. Orally suctioned for thick clear secretions. Sat's >98%. Abg sent and no changes made on current settings.\n\nCV: SR to afib. Currently on amiodorone at 0.5mg/min. AMiodorone 150mg bolus given x 1 for consistent afib, now going in and out of afib with rate response of 70-80's. BP drops r/t decrease in atrial kick to 80's/40's. Levophed restarted at 0.02 mcg/kg/min with good effect and bp returned to 116/60 range. SR rate 50-60's. Aline with good waveform. Well perfused with brisk cap refill. PA line is at 50 cm.\n\nHEme: To check HCT this afternoon. Following PTT q 6 hours, currently on heparin at 1800 units/hour.\n\nGI/ Abd; Abdomen is firmly distended. Tube feedings are currently impact with fiber infusing at 20cc/hour through Jtube. Gtube is to gravity, amber color drainage. No stool thus far. sounds are hypoactive.\n\nGU: Foley to gravity, amber color urine. UOP is 25-60cc/hour at present. Updated Dr. and will cont. to follow closely.\n\nID: On vancomycin, flagyl, and levofloxacin.\n\nEndo: Cont to follow glucose q 6 hours, RISS.\n\nSocial: Wife / spokesperson in and updated at bedside. Verbalizing understanding. cont to update, support, educate.\n\nPlan: Cont to follow PT/PTT q 6 hours. Glucose q 6 hours, RISS coverage. Cont to follow PA line/ CO q 4 hours. Possible to begin diuresing tomorrow r/t + 22.5L at present, ? intravascularly depleted r/t low UOP and BP. Tolerating tube feedings thus far. Cont to update and support family/ spokesperson. D/C plan is ongoing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512580, "text": "Respiratory Therapist\npatient awake and alert most of the day, breath sounds coarse, regular MDI treatments given, patient has fluid overload issues,will be diuresed tommorrow, no vent changes have been made, no wean, patient will stay on the vent at least until the above issue get resolved.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512630, "text": "Resp care\nABGs in Met Alk, Ventilation satisfactory, Copious frothy secretions. Self extubated in pm, and immed Reintubated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512631, "text": "Neuro: Pt alert despite versed gtt at 4mg/hr. Mouthing words, follows directions. Having abd/incisional pain with movement, Med with dilaudid X3 today with moderate effect.\nCV: low grade temp 99.3,HR initially 80's NSR with occasional PVC, presently 100-110's Sinus tach, SBP 90-100's most of day. Presently high 80's-low 90's. Extremities with generalized edema. Dopplerable pulses. CVP 10-13. Continues on lasix gtt at 7mg/hr, unable to increase due to SBP 80's this eve. Continues on lepirudin gtt, Remains in sinus.\nRESP: lung coarse to dim at bases, Pt extubated self at 1600, Pt reintubated imediately, Remains on AC 100% since extubation, 550X18 peep 5. ABG pending. Occasional suctioning of thick tan secretions.\nGI: tol tube feed at goal, 2 very small stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nENDO: blood sugars elevated, Requiring coverage per RISS.\nPLAN: NPO after midnight for trach tomorrow. Continue to monitor SBP and output for goal 1-2 liters negative lasix gtt.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512632, "text": "SICU NN: See carevue for specifics. Patient alert at times, sedated on versed and dilaudid iv push prn. Patient appears comfortable and pain free. Patient moves all extremities. Patient follows all commands. Patient does attempt to pull out lines and tubes when restraints removed. Safety maintained. ET to vent. Plan trach tomorrow. Patient alternates between afib and rsr on monitor. Anticoagulated on lepirudin . BP wnl. Central line and arterial line. Peg gravity bilious. Pej tube feeds held at midnight for trach in am. Two . One pigtail catheter. Midline abdominal incision with dehisence, some staples . Large drainage pouch covering incision with creamy serosanguinous drainage in moderate to large amounts. Abdomen obese. Foley and patent. . Generalized anasarca, upper extremites with decreased edema from previous shifts. Lasix infusing as ordered. Electrolytes repleted as ordered. Afebrile. No phone calls or visitors this pm. Patient sleeping. HIT status noted. Bed in rotation mode. Mouth care Q2hours. Compression sleeve to left leg only. Comfort measures provided.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512633, "text": "Respiratory Care\nPT trach on ventilatory support, tol CPAP/PS well all shift. Good RSBI this a.m. RSBI = 80. Sx for thin yellow secretions\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512634, "text": "Respiratory Care\nNote above written on wrong pt.\n\nCorrected note:\nPt. intubated on ventilatory support. ABG's still indicate a metabolic alkalosis. Suction for small to mod. amounts thin white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512657, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt is alert. Given prn trazadone X2 for agitation with good results. Medicated with dilaudid X2 for pain. Follows commands appropriately. Pt pulls at lines and tubes redirects well. No ativan given this shift.\nCV: Remains on lepirudin gtt. HR 70-110's. Pt flipping in and out of NSR and afib. lopressor increased to 25mg . Afebrile. Remains with generalized edema. RLE>LLE. +PP bilate +CSM.\nResp: Pt on Trach mask since 8am. Tolerating well. ABG's remain with ^ PC02's. Lungs clear to coarse in Bilat upper lobes. Sats remain >95%.\nGI/GU: Remains on TF at goal tolerating 34/str well. ABD remains soft and distended. +BS Mult BM's today. Foley patent drng clear yellow urine.\nEndo: RISS\nInteg: Abd dsg c/d/i. Dsg changed X1 By RN. Wound bed drng mod amts brown drng no foul odor noted + granulation to site. Cont with DSD as indicated. Change PRn.\nPlan: Cont with trach mask as tolerated. Cont lepirudin gtt as indicated. Cont to monitor heme status and monitor abd wound bed for infection. Cont with current plan of care as indicated.\nSoc: Family requested to speak with MD or a member of MD team. MD but unit this pm called pt's wife's home # and got no response. Email sent to MD today re: Family request to speak with him. cont to monitor\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512658, "text": "SICU NN: See carevue for specifics. Patient alert and oriented x . Communicates by mouthing words. Ativan and dilaudid given twice this shift for pain control and agitation. Patient putting legs over side rails and pulling at lines and tubes. Restraints in place for safety and patient reoriented as needed. Safety maintained. Tolerated trach collar until 0200 when abg showed CO2 74, patient placed back on vent, imv 12 as per Dr. to rest patient for remainder of shift. Patient oxygenating well with PO2 of 112. While on trach collar patient able to effectively expectorate thick white secretions. RSR with pac's with occasional brief episodes of afib. Patient maintained on lepirudin with therapeutic coag's as per am labs. BP wnl. Arterial line brachial and positional at times. Abdominal incision open packing with guaze, moderate to large amount of maroon/pink creamy drainage, shown to Dr. . Two and one pigtail catheter . G tube to gravity and tolerating tube feeds via J tube. One bm and patient was able to ask for bedpan. . Generalized edema though decreased from prior shifts with patient. Lasix around the clock with good response. Turn and positioned x 2. Afebrile with normal wbc. No phone calls or visitors. measures provided.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512559, "text": "Respiratory Therapy\nPt remains orally intubated on AC. Please see carevue for specifics. BS clear with very diminished LLL. Pt awake, not breathing over set rate and minimally over set volume.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512560, "text": "npn\nNeuro- propofol gtt- opens eyes to voice, withdraws to stim, bilat wrist restraints on 2nd to ett\n\nResp- cmv vent- pco2 66 this am- weaned fio2 to .40, lungs cont coarse bilat and at bases, suction thick white secretions. ct this pm showing cont bilat pe.\n\n\nABD- abd obese- ngt placed with bilat drg, abd ct done this pm- see radiology report. npo. + bs.\n\nHeme- heparin gtt at 1250u/hr- ptt 60-69- goal 60-80, 1 unit prbc this am for hct 23- repeat hct 26 post prbc.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512561, "text": "Respiratory Care Note:\n Patient remains intubated and sedated on full vent support. Transported to CT scan today of abdomen. BS=bilat, decreased lower lobes bilat. Suctioned for small amounts of pale secretions. Plan to maintain supportive care at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512562, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported on AC. Few changes made overnight. ABG's remain persistently metabolic alkalotic. BS's some coarseness, sxing small amts white secretions. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512585, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 37/28. BLBS diminished but coarse, suctioned for small to moderate amounts of thick white sputum; copious amounts of white oral secretions. MDI given as ordered to good effect. RSBI attempted this AM = >150 w/ notable desaturation to high 70s, SpO2 increased rapidly when returned to current vent settings. Remains fluid +. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512563, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info\n\nNeuro: Sedated on propofol drip, opens eyes to name and follows commands. MAE. Perrl. No changes from previous assessment. Appears Comfortable.\n\nResp: Breath sounds clear to coarse and equal bilaterally. ABG's with compensated metabolic alkalosis. Cont to follow and adjust vent accordingly. Sat's >98% all shift. Suctioning mod. amount thick white secretions through ETT q 2 hours and prn.\n\nCV: SR no ectopy. Well perfused with brisk cap refill < 2seconds. Aline with good waveform. Remains on amiodorone and lopressor given through NGT. BP stable with mean >60.\n\nHeme: PT/PTT q 6 hours, goal PTT 60-80, heparin drip currently at 1300 units/ hour. HCT stable at 25.\n\nGI: NPO. Obese with active bowel sounds. NGT to low cont. suction with bilious returns. Clamped prn meds. No stool thus far.\n\nGU/ Lytes: Foley to gravity, uop >30cc/hour. Electrolytes replenished.\n\nEndo: Follow glucose q 6 hours, RISS.\n\nSocial: No contact from family thus far tonight.\n\nPlan: Cont to follow glucose q 6 hours, RISS. Cont to follow pt/ptt and adjust heparin drip to maintain goal PTT 60-80. possibly travel today r/t fluid collection in abdomen ?drain placement. Cont to follow labs/ electrolytes. Maintain bp mean >60. Cont to update and support family/ spokesperson. D/c plan is ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512625, "text": "Nursing Progress NOte\nPlease see carvue for specifics:\nNeuro: Pt remains on versed gtt for sedation. Pt is to voice and follows simple commands and localize pain.\nCV: HR NSR no noted ectopy. SBP 95-110's. MAP >60. Remains on lasix gtt goal is to be 2Liters negative. Lytes repleted as needed. ABd wound still drng mod amts of sersang drng. Current crit is 27.7. PT remains grossly fluid overloaded. +PP via doppler only.\nResp: Remains on CPAP . Despite PC02 in 60's which pt is beginning to compensate for. Rsbi this am 87. ? Possible trach tomorrow. Lungs remain clear to diminised at the bases. Sats >95%.\nGi/Gu: Abd soft and distended. + BS no BM over noc. Pt remains on TF at goal. Gastric tube to gravity drng bilious drng. Foley patent drng light yellow urine\nEndo: RISS\nID: Remains on mult abx\nInteg: Open abd wound still drng mod amts of serosang drng.\nPlan: Cont with current plan of care. ? Trach tomorrow. Cont to monitor respiratory status and hemodynamics.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512626, "text": "Respiratory Care Note:\n\nPt remain orally intubated and sedated on spontaneous ventilation. No vent change done during shift. RSBI done ~ 88. BS are clear & dim more to bases ant. AM ABG, PCO2 ~ hich and Pt starting to chronically compensate. Plan: ? another elect extubation or Trach tomorrow. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-18 00:00:00.000", "description": "Report", "row_id": 1512586, "text": "Respiratory Therapist\nPatient still on assist control, start diuresing but still positive,breath sounds: bilaterally coarse, suctioned for moderate thick yellow, a few MDI treatment given, Patient desaturated at several occasions, RSBI not possible on him, when tried Apnea ventilation quicks in.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-18 00:00:00.000", "description": "Report", "row_id": 1512587, "text": "FOCUS UPDATE\nVSS. REMAINS ON AMIO IN NSR. NO VENT CHANGES. DIURESED W/ 20MG IV LASIX W/ GOOD RESPONSE. 2.5 L NEGATIVE. TOLERATES TFEED AT INCREASED RATE. CONT ON HEPARIN AND FENTANYL. , BUT GROSS ANASARCA.\nCONT CLOSE CARDIAC MONITOR. WEAN FROM VENT AS TOLERATES. ADVANCE TFEED TO GOAL. STRICT I/O'S. ORDER THERAPEUTIC BED. C\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512588, "text": "Resp Care\nPt. remains intubated/sedated with no change overnight. Occ. sets off high pressure alarms coughing.\nBs: coarse bilat.with scattered rhonchi, improve with sxn. Sxn'd for mod amts. of thick white q4.\nno abgs.\nPlan: rsbi dc'd d/t only 3 breaths noted in 1 min.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512589, "text": "neuro: \n\ncv: continuous with pt in NSR, no ectopy. vss. cvp 16-18.\n\npulm: sx 2 2-3 hrs for sm-mod amts thick white. sats 96-100%. bs clear,\n\ngi: tube feeds acvanced to 60/hr, tol well, no resid. no BM.\n\ngu: u/o qs.\n\nplan: wean vent as tol. pulm toileting\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512590, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Attempted PSV wean (w/ PEEP increase necessary d/t desaturation to high 80s on PSV (+10PSV/+8PEEP)). ABG revealed mild respiratory acidosis, pt placed back on SIMV/PSV per team. Currently on SIMV 650/18/+10PSV/+5PEEP/.50% Fio2; appears comfortable. BS slightly coarse, suctioned for small amounts of thick white sputum from ETT, copious amounts of thick white oral secretions suctioned ~q4. PIP/Pplat = 29/24. ETT secure/patent. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; continue to assess readiness to wean...\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512591, "text": "Resp Care\nPt. remains intubated/sedated on SIMV mode. Occ. noted to be overbreathing when stimulated, otherwise no efforts noted.\nBs: coarse bilat. Sxn'd q4 for thick white.\nabgs: metabolic alkalosis with adequate oxygenation.\nPlan: cont. to support. Possibly cut rate back to allow pt. to make spont. efforts.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512665, "text": "CONDITION UPDATE\nVSS. AFEBRILE. AFIB RATE CONTROLLED, CONVERTED TO NSR THIS EVENING. ALERT AND ORIENTED TO PERSON/PLACE - NOT TIME. PASSE MUIR VALVE ON ENTIRE SHIFT, W/O INCIDENT. DENIES SOB. O2 SAT ACCEPTABLE ON TRACH MASK. LUNGS CLEAR TO COARSE. ABLE TO COUGH UP LG AMTS OF THICK, WHITE SPUTUM. ABD SOFTLY DISTENDED - POSITIVE SOUNDS. LG AMT OF LOOSE, THICK STOOL OUT VIA MUSHROOM CATH. ABD INCISION OPEN - TISSUE PINK, LG AMT OF BROWN, MUCOUS LIKE DRAINGE. DRESSING CHANGED TO VAC DRESSING BY DR . JP'S , PATENT. GTUBE TO GRAVITY W/ BILIOUS DRAINAGE OUT. U/O QS VIA FOLEY. ONE TIME LASIX, 20MG IVP X1.\nMONITOR FOR S/S OF INFECTION. MAINTAIN INTEGRITY. PAIN MANAGEMENT. PT . CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512666, "text": " \n NEURO PT A/O MOST OF THE TIME OCC PERIODS OF MILD AGITATION AND COFUSION REGARDING SITUATION DOES WELL WITH CONVERSATION\n HEART S1S2 NSR VSS A LINE IN PLACE NO TEMP NOTED PULSES POS 3 THRU OUT W/D\n ABD OPEN ABD WOUND DRESSED D/I DRAINS IN PLACE FIRM NO ISSUES U/O QS\n RESP NON LABORED CLEAR STRONG COUGH NOTED T/C SAO2 100\n PLAN SUPPORTIVE IN NATURE MONITOR FLUID STATUS I/O CLOTTING STUDIES FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-04-12 00:00:00.000", "description": "Report", "row_id": 1512667, "text": "admit note\nplease see flowsheet for details\n\npt arrived to unit at approx 0830 from 9. Pt had been on 9 was found to be pale this am, a blood gas was sent and pco2 was 116. Pt was transferred to sicu. On arrival to sicu pt's temp was 94.9 and bair hugger was placed on pt, as well as warm blankets. temp increased to 96 by 0830. otherwise vs were stable pt was transiently in/out of afib with rate 60s-120. po was given and iv lopressor. pt continues on lepirudin gtt and ptt was 56 today which is with in goal, gtt was not titrated. pt continues in afib and icu resident Dr aware. pt given po lopressor 25 mg at 1800. aline plaved at admission to unit, lytes repleated\n\npt initially placed on ventilator a/c mode, frequent abgs were assessed and co2 decreased to 60-65 on cpap with pressure support, ls are coarse bilaterally, suctioned periodically for moderate tan thick drainage, o2dat 100%, pt had cxr today and CTA of chest-awaiting results.\n\nGu: abd CTA awaiting results, pt stooling brown liquid stool ? secondary to 2 bottles baricat given prior to CTA, abd obese BS present, yellow clear urine > 30cc hr.\n\n: wound RN up to evaluate wounds, recommendations are allyvn to left buttock open area, to abd wound aqacel to heavily draining areas covered by damp ns dressing (not saturated) followed by dsd using hypofix tape which is all in pt 's room.\n\nplan: continue to monitor resp status, wean ventilator as tolerated, continue with care program, awaiting CTA results of chest and abd\n" }, { "category": "Nursing/other", "chartdate": "2187-04-12 00:00:00.000", "description": "Report", "row_id": 1512668, "text": "Respiratory Care: Pt remains on current vent settings, PS 5 P 5 .40. Will do RSBI in early am and plan to place pt on trach collar as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512557, "text": "npn\nNeuro- a+o despite increasing pco2 this am- mae on bed, mso4 prn, ativan prn started after pt intubated. bilat soft wrist rest. on after intubated.\n\nResp- Resp acidosis abg with comp- bipap mask on until the noon abg when pco2 increased to 115- had been 80's and 90's- intubated by anesthesia and cxr done post intubation. multi vent changes done to get pco2 down. _ see resp flow sheet. lungs coarse bilat and at bases. suction thick white to clear secretions.\n\nHemodynamics- a line sbp 90's to 120's with map >60, in and out of a fib with some sinus runs mixed with pac's then back to a fib- pt had been in a fib pre transfer to sicu. Groin line placed by md x2 leaking or clotted off.\n\nHeme- heparin gtt 1200 u/hr with 10 am ptt 80.1- gtt off when pt in the cath lab for ivc filter then unable to restart 2nd to need for ctr line- heparin gtt restarted 1200u at 6pm. to cath lab 130 pm for ivc filter -tol well. right groin cdi, + right dp/pt.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512627, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile. HR was in NSR for most of the shift. Went into afib for a few hours with rate 100-120 lopressor 5mg iv was given with no effect and BP did dip down to a systolic 88-90's so evening dose was held. Lasix gtt was increased to make goal of negative 1.5-2L, lytes were checked this afternoon and repleted per orders.\n Vent was weaned down to CPAP 5/5 and when pt went into afib O2 sat also noted to drop to 90's abg was drawn, primary surgical team was notified and no vent changes were made. CPT done and O2 sats back up to 97%. Pt has required frequent suctioning for frothy white/clear secretions.\n Wife came in this morning and spoke with surgical resident re:plan for trach-she is aware that pt will be re-evaluated in am if plan will be to extubate or to schedule trach.\n Wound nurse came by to evaluate pt's incision. Wound pouch was placed and put to gravity d/t lge output.\nPLAN:\n lasix gtt titrate to negative 1.5-2L by midnight\n Pulmonary toilet with rotating bed\n Replete lytes prn while diuresing\n ?extubate in am\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512628, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Unchanged. Remain on versed gtt. Follows commands. Is to voice. MAE.\nCV: HR-NSR no noted ectopy. SBP stable. Remains on lasix gtt at 7cc/hr. Goal is to be 1-2liters negative.\nResp: Pt with increased secretions. PC02 in 70's Vent changed to Cpap which increased CO2 to 62 pt began to have episodes of apnea and placed back on rate. Lungs remain coarse to diminshed at the bases.\nGI/GU: Unchanged.\nEndo: RISS\nID: Remains on mult abx WBC's normal afebrile.\nPlan: Cont with current plan of care. ? possible trach vs extubation. Family meeting today.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512574, "text": "see careview for details\nfocus data update\n\n\nNEURO: PT EASILY , NODS APPRORIATELY TO QUESTIONS, MAE'S\nPERLA, FENTANYL GTT DECREASED TO 59 MCG, PT DENIES PAIN\n\nRESP: B/L BS DECREASED, CPAP TRIAL PT DESATURATED QUICKLY, VENT SETTINGS REMAIN ON CMV, PT REQUESTING ETT BE REMOVED, REASSURED WE'LL REMOVE TUBE AS SOON AS POSSIBLE, AND WE'LL RETRAIL CPAP LATER IN DAY\nSX'D FOR THICK WHITE SECRETIONS,\n\nCV: A-LINE DAMPEND, CHANGED OVER WIRE, A-LINE CONTINUES TO BE POSITIONAL, SWANZ LINE PATENT, TX WITH I UPRBC', LABS MONITORED CLOSELY, LYTE REPLETION GIVEN, TYLENOL GIVEN X1, REMAINS IN A-FIB, AMIORARONE GTT , PT , COMPRESSION BOOT ONLYON LEFT LOWER EXT, UNABLE TO WEAN LEVO GTT R/T DECREASED MAP\n\nGI: NGT TO LWS FOR THICK BILIARY DRG FLUSHED X1 WITH NS, G-TUBE TO GRAVITY DRG, J-TUBE TO GRAVITY, ABD JP'S TO SSX, ABD DSG CLEAN,DRY AND INTACT, ABD DISTENDED\n\nGU: BLADDER PRESSURE 24, HOURLY U/O MARGINAL, AMBER IN COLOR\n\nA/P: INPROVED CARDIAC OUTPUT, STABLE CONTINUE TO MONITOR AND TX, BOTH EMOTIONAL AND EDUCATIONAL SUPPORT GIVEN TO PT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512575, "text": "Respiratory Therapist\nPatient remains vented, is on Assist-Control, FiO2 kept at 50% although ABGs showed PaO2 around 130, no reduction in FiO2 was not made due to the fact that patient had Oxygenation issue due to PE, an issue for not moving toward extubation is the patient's hemodynamics. Breath sounds clear, patient produced very minimal secretions, was treated with Albuterol MDI twice.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512576, "text": "SICU NN: See carevue for specifics. Patient sedated on a fentanyl infusion. Patient is easily . Patient follows commands and is trying to talk around et tube. Patient nodding head appropriately to questions. Ativan prn for comfort. Restraints for patient safety. ET to vent. ABG's done as ordered. RSR alternating with afib frequently, MD's notified. BP labile depending on rhythm, titrating levophed to maintain map >60-65. Febrile, pan cultured, tylenol prn, md notified. Trophic tube feeds started as ordered, tolerating. G to gravity. Tube feeds to J. NGT by md. sounds. Dressing clean dry and to abdominal incision. Two JP's draining brown liquid. Foley , urine output decreased to 20-30/hr. CVP decreased from patient baseline. Fluid boluses and albumin given as ordered. CO/CI obtained as ordered and results relayed to md. . Patient denies pain by nodding. Repleting lytes as ordered. Family visited today. Sliding scale insulin coverage. All lines . Bladder pressures q shift. Administering antibiotics as ordered. Safety maintained.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512558, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: Alert and following commands consistently. No changes from previous assessment.\n\nResp: Breath sounds clear and equal bilaterally. Suctioning via ETT for thick white secretions. Cont to monitor blood gases and make vent changes accordingly. Sat's consistently >99%.\n\nCV: Afib to SR overnight with variable HR 120 to as low as 64 while in SR. Bursts of RAF to 140's with BP 78/40. Examined by DR. and Bolus NS 500cc x 1, Phenylephrine drip started at very low dose and titrated to keep mean bp >60. Diltiazem 10mg given x 1. Lopressor 10mg IV q 6hours. Well perfused with brisk cap. refill. Aline with good waveform. Stable throughout the shift.\n\nHeme: HCT 23.3 this am. Dr. updated and team, no new orders at this time. On heparin at 1250 units /hour. Cont to follow Pt/Ptt q 6 hours.\n\nGI: Abd obese, active bowel sounds. No stool thus far. NPO.\n\nGU: UOP dropped off to 30's, bolus 500cc NS x 1 given with good effect UOP increased to >50cc/hour.\n\nEndo: Follow glucose q 6 hours with RISS.\n\nSocial: Wife called and updated, verbalizing understanding. Planning on visiting today at some point.\n\nPlan: cont to follow abg's q 6 and prn, follow pt/ptt q 6 hours. Cont to monitor I and O and hemodynamic status, possible cardioversion in morning. Cont to update and support wife/ spokesperson. D/c plan is ongoing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512622, "text": "NPN: Review of Systems\nNeuro: Pt initially on 4mg/hr versed. Sedated. Did not follow commands consistently, or interact at all. Versed decreased to 3mg/hr. Pt opens eyes spontaneously, moves all extremities and communicates by mouthing words and nodding. Denies pain, but very fidgety in bed. Soft wrist restraints on d/t ETT and Pt moves hand torward it.\n\nResp: Currently on 5PS and 0 peep, with FIo2 of 40%. Breathing unlabored in the 20s w/ tidal volumes approx 350. Sao2 decreased over the course of the day from upper nineties to 93-95%. Pt denies SOB.Sxning thin white seretions. Decreased BS on left side. Initial ABG approx. 45 minutes after vent change=7.31/66/81 and 35/3. New ABG pending.\n\nCV: Tmax=99.4 NSR w/ MAP 60s-70s. No ectopy. K+ and CA++ being repleted. DP/PT pulses palpable bilaterally.\n\nGI: Abdomen obese. Gastric tube to gravity and draining bilious fluid. 2/3 strength impact w/ fiber infusing at goal rate of 110cc/hr. No BM. Continues to get intermittent octreotide. Abdominal incision w/ drainage bags over open sites-> s/s fluid. Scant drainage from pigtail drain and JPS to bulb suction.\n\nGU: LAsix increased to 6mg/hr from 5mg/hr. Urine light yellow. (-) approx 1400cc so far.\n\nID: Continues on antibiotics,\n\nHeme: Lepirudin infusing as ordered.\n\nEndo: Blood sugar=199-> 8 units regular insulin given .\n\n: No pressure wounds present. Triadyne roation turned off right now b/c Pt uncomfortable with it.\n\nSocial: Wife and sister at bedside. Wife feels communication btwn her and the staff has been good.\n\nA: Breathing comfortably on decreased support. Hemodynamics stable.\n\nP: F/U w/ repeat ABG. Monitor per plan.\n" }, { "category": "Echo", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 80325, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Recent pulmonary embolism.\nBP (mm Hg): 85/60\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:46\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npropofol given for sedation, as patient was intubated.\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA and extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Simple atheroma in ascending aorta. There are complex (>4mm) atheroma\nin the aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Indeterminate\nPA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. The patient appears to be in sinus rhythm.\nEvaluation of the left atrial appendage were suboptimal due to limited\nvisualization of the LAA.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. Views of the left atrial appendage are\nsuboptimal. The right atrium is dilated. No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses and cavity size are\nnormal. . Overall left ventricular systolic function is mildly depressed.\nThere are no focal wall motion abnormalities. The right ventricular cavity is\nmoderately dilated. There is moderate global right ventricular free wall\nhypokinesis. There are simple atheroma in the ascending aorta. There are\ncomplex (>4mm) atheroma in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets are mildly thickened. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Biventricular systolic dysfunction with mild global hypokinesis of\nthe left ventricle and moderate global hypokinesis of the right ventricle.\n\n\n" }, { "category": "Echo", "chartdate": "2187-03-05 00:00:00.000", "description": "Report", "row_id": 80362, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 67\nWeight (lb): 235\nBSA (m2): 2.17 m2\nBP (mm Hg): 144/90\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 12:01\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\nModerately dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\n1.The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic arch is moderately dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n6.The mitral valve leaflets are mildly thickened. No mitral regurgitation\nseen.\n7.There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2187-04-21 00:00:00.000", "description": "Report", "row_id": 204377, "text": "Atrial fibrillation./ atrial flutter\nDiffuse nonspecific low amplitude T waves\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2187-04-18 00:00:00.000", "description": "Report", "row_id": 204378, "text": "Atrial fibrillation. Non-specific ST-T wave changes. Compared to the previous\ntracing of the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2187-04-16 00:00:00.000", "description": "Report", "row_id": 204379, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2187-04-11 00:00:00.000", "description": "Report", "row_id": 204380, "text": "Atrial fibrillation with rapid ventricular response with PVCs\nExtensive ST-T changes may be due to myocardial ischemia\nSince previous tracing,rapid atrial fibrillation, ventricular premature\ncomplexes, and ST-T wave changes are present\n\n" }, { "category": "ECG", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 204381, "text": "Sinus rhythm. Normal ECG. Since the previous tracing of atrial ectopy\nis absent and the QTc interval appears less prolonged.\n\n" }, { "category": "ECG", "chartdate": "2187-03-09 00:00:00.000", "description": "Report", "row_id": 204382, "text": "Sinus rhythm\nSupraventricular extrasystoles\nLong QTc interval\nSince previous tracing, long Q-Tc interval and atrial premature complexes seen\n\n" }, { "category": "ECG", "chartdate": "2187-03-04 00:00:00.000", "description": "Report", "row_id": 204383, "text": "Sinus rhythm\nModest low amplitude inferior T waves - are nonspecific and could be within\nnormal limits\nSince previous tracing of , atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2187-03-03 00:00:00.000", "description": "Report", "row_id": 204384, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response although baseline artifact\nmakes assessment difficult\nDiffuse nonspecific ST-T wave changes\nSince previous tracing of , atrial fibrillation and sinus tachycardia\npresent\n\n" }, { "category": "ECG", "chartdate": "2187-02-27 00:00:00.000", "description": "Report", "row_id": 204615, "text": "Sinus rhythm\nNormal ECG\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2187-03-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 903016, "text": " 4:33 PM\n CT ABDOMEN W/O CONTRAST; CT GUIDANCE DRAINAGE Clip # \n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL\n Reason: please drain anterior liver collection. please leave drain i\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst and markedly distended abd\n\n REASON FOR THIS EXAMINATION:\n please drain anterior liver collection. please leave drain in\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE OF AN INTRA-ABDOMINAL FLUID COLLECTION.\n\n CLINICAL HISTORY: Pancreatic pseudocyst, intraabdominal fluid\n collection, drain.\n\n PREPROCEDURE ABDOMEN FINDINGS: Images of the abdomen were obtained without\n contrast. Images of the lower thorax demonstrate bilateral pleural effusions\n and consolidation involving the left lower lobe. There is an intra-abdominal\n fluid collection anterior to the liver extending across midline and extending\n to the inferior aspect of the liver. High-density material seen layering\n within it in the dependent position suggesting the presence of blood. Two\n drains are present within the region of the pancreas.\n\n CT-GUIDED DRAINAGE PLACEMENT: The patient was unable to give consent, and so\n the patient's wife, , was contact and she gave consent via the\n telephone. She was notified of the risks and benefits of the procedure. The\n fluid collection was identified using CT guidance. 1% lidocaine was used as a\n local anesthetic. A nurse fentanyl to ensure patient\n comfort. An 8 French drainage catheter was inserted into the fluid\n collection. CT fluoroscopy images were obtained, which confirmed the proper\n placement of the catheter. Approximately 150 cc of bloody fluid were\n aspirated. The patient tolerated the procedure satisfactorily. There were no\n complications. The attending physician, . , was present throughout\n the entire procedure.\n\n IMPRESSION:\n 1. Successful placement of an 8 French drainage catheter into an intra-\n abdominal fluid collection.\n 2. Left lower lobe consolidation, which may represent either pneumonia or may\n be infarct related to the patient's recent pulmonary emboli.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-11 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 901383, "text": " 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst\n REASON FOR THIS EXAMINATION:\n please eval pancreas and pseudocyst for evolving cyst, infection, and necrosis.\n PLEASE USE CT PANCREATIC PROTOCOL C FINER CUTS/HIGHER RESOLUTION and GIVE PO\n AND IV CONTRAST.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatic pseudocyst, please evaluate for evolving cyst\n infection and necrosis.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained through the abdomen prior to and\n following the administration of 150 ml of intravenous Optiray in the arterial\n and venous phases. Venous images were obtained to the level of the pubic\n symphysis. Coronal and sagittal reformations are provided.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: At the visualized\n portions of the lung bases, again seen are bilateral lower lobe pulmonary\n arterial filling defects consistent with pulmonary emboli. In comparison with\n the examination of , the thrombus burden within the left lower lobe\n pulmonary artery appears to have propagated somewhat with new thrombus\n visualized more proximal within the left lower lobe pulmonary artery. There\n is progression of atelectasis and opacities at the lung bases bilaterally with\n small pleural effusion, left greater than right, and wedge shaped hypodense\n area in left lower lobe subpleural region. Although these findings may\n represent atelectasis, evolving pulmonary infarct cannot be entirely excluded.\n The visualized portions of the heart and pericardium appear unremarkable.\n\n There is continued focal biliary ductal dilatation within the left lobe, a\n finding that is approximately unchanged. The portal vein and splenic veins\n appear markedly narrowed, a finding that is new since the previous\n examination, but appear patent. The gallbladder is collapsed and edematous\n with enhancing mucosa. There is interval increase in perihepatic fluid,\n including a new loculated fluid collection about the tip of the left lobe of\n the liver seen indenting the liver capsule and additional collections\n extending along the falciform ligament and within the hepatic hilum.\n\n A nasogastric tube is in place within the gastric body. The stomach is\n displaced anteriorly by a large pancreatic pseudocyst. In comparison with the\n examination of , the size of multiple pseudocysts has\n (Over)\n\n 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n increased. A pseudocyst located dorsal and superior to the pancreatic body\n measures 7.1 x 10.2 cm (previously 9.0 x 5.2 cm). A pseudocyst located\n inferior to the pancreatic body (series 4, image 61), measures 6.9 x 10.8 cm\n (previously 9.6 x 8.5 cm). A pseudocyst located posterior to the pancreatic\n head measures 8.5 x 4.8 cm (previously 7.1 x 3.2 cm). Again, noted is a\n heterogeneous pattern of enhancement of the pancreatic parenchyma, with a\n focal area of hypoenhancement in the pancreatic body just to the left of\n midline suggestive of an area of focal pancreatic necrosis.\n\n The superior mesenteric artery, celiac trunk and its branches are patent. The\n aorta is normal in caliber.\n\n CT appearance of the kidneys is unchanged with symmetric nephrograms\n bilaterally and with stable round, hypodense lesions that are too small to\n accurately characterize within the left kidney. An IVC filter is in place.\n\n The spleen and splenule appear unremarkable. There is interval increase in\n ascites located adjacent to the spleen and tracking within the left paracolic\n gutter. Additional fluid is seen within the right paracolic gutter and\n layering between loops of bowel in the low abdomen.\n\n The large and small bowel loops are normal in caliber. There is no free\n intraperitoneal air. A small fat containing umbilical hernia appears\n unchanged.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\n catheter and air consistent with Foley catheter insertion. The prostate and\n seminal vesicles, rectum and sigmoid colon appear unremarkable. Since the\n examination of , there is increase in ascites layering within the\n pelvis and low abdomen. A left femoral venous access catheter has been placed\n in the interval.\n\n There is increase in diffuse subcutaneous fat stranding consistent with\n anasarca.\n\n BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or\n sclerotic osseous lesions.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate interval\n increase in size and multiple pancreatic pseudocysts. The narrowing of the\n portal vein at its confluence with the superior mesenteric vein, as well as\n narrowing of the splenic vein, are well appreciated on the multiplanar\n reformations.\n\n (Over)\n\n 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Continued pulmonary embolus involving the right and left lower lobe\n pulmonary arteries, with evidence of probable propagation of clot within the\n left pulmonary artery.\n\n 2. Severe pancreatitis with interval increase in size of multiple individual\n pancreatic pseudocysts. Continued focal area of hypoenhancement within the\n pancreatic body consistent with pancreatic necrosis.\n\n 3. Interval increase in ascites and perihepatic fluid collections.\n\n 4. Marked narrowing of the portal vein and splenic vein, possibly due to\n inflammation and mass effect from adjacent pseudocysts, without evidence of\n frank occlusion.\n\n 5. Mild segmental intrahepatic biliary ductal dilatation within the left lobe\n appears stable.\n\n 6. Anasarca.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 901580, "text": " 7:14 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new R IJ PAC, eval position, r/o PTX\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n new R IJ PAC, eval position, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:24 A.M., \n\n HISTORY: Pulmonary emboli and pancreatitis. Right IJ line.\n\n IMPRESSION: AP chest compared to and 21:\n\n Tip of a new right transjugular Swan-Ganz catheter projects over the right\n descending pulmonary artery. Mild pulmonary edema has worsened. There is no\n pneumothorax. Bibasilar atelectasis and small left pleural effusion are\n stable. Tip of the endotracheal tube at the thoracic inlet is approximately 7\n cm above the carina, 3 cm above optimal placement. Tip of left central venous\n catheter projects over the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902227, "text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess lungs, difficulty maintaining PaO2 on previous\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n please assess lungs, difficulty maintaining PaO2 on previous vent setting post\n diuresis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 58-year-old man with prior episodes of pulmonary emboli. Patient\n with difficulty with ventilation.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube tip has migrated more distally and is 4 cm above the\n carina. There is a left-sided central venous catheter with the distal tip\n slightly perpendicular to the wall of the mid SVC. The Swan-Ganz catheter has\n been removed. Feeding tube has also been removed. The cardiac silhouette and\n mediastinum are within normal limits and unchanged from prior. There are low\n lung volumes due to poor inspiratory effort. There remains a left\n retrocardiac opacity and some hazy opacity within the left upper lung. No\n signs of overt pulmonary edema is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902385, "text": " 1:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pneumonia\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis now w/ fever to 101.9F\n REASON FOR THIS EXAMINATION:\n Please assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58-year-old man with pulmonary emboli and pancreatitis.\n\n CHEST, AP SUPINE: Film is somewhat underpenetrated. The position of the\n endotracheal line and right subclavian line is unchanged. The left subclavian\n line has been removed.\n\n Atelectasis in the left lung is present and there are probably bilateral\n effusions. Atelectasis in the left base is seen, no obvious infiltrates\n present but a left posterior infiltrate cannot be entirely excluded.\n\n IMPRESSION: Probable bilateral effusions, infiltrates not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901239, "text": " 6:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pahtology\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n REASON FOR THIS EXAMINATION:\n Assess for pahtology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with pulmonary emboli, chronic pancreatitis.\n Desaturating in the 60s.\n\n COMPARISON: .\n\n CHEST AP: The left costophrenic angle has been excluded from this study.\n There is interval improvement in the linear atelectasis previously seen in the\n right lower lobe. There is persistent right middle lobe and left basilar\n linear opacities. No frank consolidation is visualized. There are no pleural\n effusions. The heart size, mediastinal and hilar contours are unremarkable.\n There is no pleural effusion on the right side.\n\n IMPRESSION:\n\n Multifocal atelectasis and/or infarcts.\n\n" }, { "category": "Radiology", "chartdate": "2187-03-09 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 901254, "text": " 10:07 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/o PE\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hx PE with acute desat\n REASON FOR THIS EXAMINATION:\n R/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old man with history of pulmonary emboli and acute\n desaturation.\n\n TECHNIQUE: Multidetector axial images of the chest were obtained without and\n with IV contrast. 150 cc Optiray. Multiplanar reformatted images were\n obtained.\n\n COMPARISON: Abdominal CT of .\n\n CT CHEST: There are multiple bilateral pulmonary emboli. On the right, there\n is embolus in the interlobar branch right pulmonary artery. Filling defects\n are observed in the right upper and lower lobe lobar, segmental and\n subsegmental vessels. On the left, there is an embolus filling the lingular\n artery. Emboli are also seen extending into the left lower lobe segmental and\n subsegmental arteries. Correlation with the patient's recent abdominal CT\n demonstrates patency of the segmental left lower lobe pulmonary arteries. On\n this exam, they are filled with embolus. The heart size is at upper limits of\n normal. Aortic and coronary calcifications are identified. There is no\n axillary, mediastinal, or hilar lymphadenopathy. Wedge-shaped opacities in\n the lingula and bilateral lower lobes are consistent with infarcts. There is\n also a small amount of subsegmental atelectasis at the bases. There are no\n pleural or pericardial effusions. Visualized portions of the upper abdomen\n are remarkable for a large amount of ascites and partial visualization of a\n pancreatic pseudocyst. These findings are better evaluated on the recent\n abdominal CT.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n Bilateral pulmonary emboli involving interlobar, lobar, segmental and\n subsegmental vessels, with associated pulmonary infarcts. Although right lower\n lobe emboli wre present on the prior abdominal CT of , the\n left lower lobe emboli are new.\n\n These findings were discussed with Dr. at 11 p.m., .\n\n\n (Over)\n\n 10:07 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/o PE\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2187-03-02 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 900635, "text": " 2:26 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: R/O CBD stone\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatitis. Imaging suggests CBD stone\n ERCp performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with pancreatitis.\n\n ERCP: 14 ERCP images were obtained by Dr. and demonstrated a small\n filling defect in the upper third portion of the CBD. Otherwise,\n cholangiogram was normal. The pancreatic duct was normal. By report,\n sphincterectomy was performed, and a small amount of sludge was extracted.\n\n Please also refer to the official ERCP report by endoscopist.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901291, "text": " 12:42 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 1256\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Intubation.\n\n An endotracheal tube is in place, terminating about 4 cm above the carina. The\n lung volumes are slightly low. There has been interval worsening of bibasilar\n areas of opacification, and there are probable small pleural effusions.\n\n IMPRESSION:\n\n 1. Worsening bibasilar opacities, which may relate to atelectasis,\n aspiration, or evolving pneumonia.\n\n 2. Endotracheal tube in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2187-02-27 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 899815, "text": " 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst\n REASON FOR THIS EXAMINATION:\n please evaluate pnacreas area\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND INTRAVENOUS CONTRAST (CT\n ANGIOGRAPHY PROTOCOL).\n\n TECHNIQUE: Multidetector, multiphasic CT scan of the abdomen and pelvis with\n oral and intravenous contrast:\n\n RECONSTRUCTIONS: Reconstructed images in the sagittal and coronal plane are\n also included.\n\n CLINICAL DETAILS: Transfer from outside hospital, recent pancreatitis.\n Comparison is made with preceding ultrasound of .\n\n CT ABDOMEN (MULTIPHASIC SCAN):\n\n Low-density filling defect noted in the included portion of the right lower\n lobe pulmonary artery and at least one of the segmental branches to the left\n lower lobe (posteromedial) in keeping with acute pulmonary embolus.\n\n Minor left posterobasal atelectasis, minimal dependant atelectasis at the\n right lung base and minor rim of left basal pleural fluid. Wedge-shaped area\n of subpleural atelectasis noted in the left lateral lung base.\n\n Within the abdomen, there is gross edema of the pancreas throughout its\n length. Though edematous, most of the gland shows heterogenous post-contrast\n enhancement. There is a focal area measuring up to 3 cm along the proximal\n anterior portion of the pancreatic body just to left of midline does not show\n contiguous postcontrast enhancement and contains a heterogenous areas of low\n and fat density consistent with an area of focal pancreatic necrosis . The\n more distal oedematous body and tail show enhancement.\n There are several acute peripancreatic fluid collections, the largest extend\n anteriorly and slightly inferiorly from this area in the proximal body towards\n the lesser sac and measures up to 9.6- cm AP x 7.5-cm transverse and also\n tracts more cranially in the retrogastric area where it measures up to 9- cm\n transverse x 5.1-cm AP. Smaller peripancreatic fluid collections present\n anterior and posterior to the pancreatic head and neck, measuring up to 7-cm\n transverse x 3.2-cm posterior to the pancreatic head. No well- organized\n collection is demonstrated. No pancreatic main ductal dilatation or\n pancreatic calcification on the unenhanced CT.\n\n (Over)\n\n 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Though attenuated by the pancreatic edema and peripancreatic fluid\n collections, the splenic vein, portal veins are patent. The superior mesentry\n vein widely patent. The adjacent arterial structures are patent and\n unremarkable. A small amount of free intraabdominal ascites and a significant\n periportal edema is noted.\n\n The liver is normal in size, no focal lesion demonstrated. Two minor (3mm)\n areas of intrahepatic segmental biliary dilatation noted in segment II of the\n liver without obvious cause. The central right and left bile ducts are\n nondilated, CBD is nondilated, proximal CBD to lower hepatic duct measures\n less than 5 mm in diameter. Mild circumferential rim enhancement of the\n visible portion of the upper CBD which may be reactive to the periportal edema\n and pancreatitis. In the mid CBD there is a 2-mm calcific density, likely\n represent a small non obstructing calculus. The gallbladder is contracted, no\n obvious gallstones, there is circumferential edema of the wall measuring up to\n 8 mm, which maybe secondary to the current pancreatitis.\n\n Spleen is normal in size, incidental 1.5-cm splenule noted in the left upper\n quadrant, both adrenal glands. Kidneys are normal apart from a subcentimeter\n cyst in the posterior interpolar cortex of the left kidney. Normal caliber\n abdominal aorta with moderate atherosclerotic plaque.\n\n No abnormal large or small bowel loop dilatation. Transition point suggest\n obstruction.\n\n CT SCAN OF PELVIS WITH ORAL AND INTRAVENOUS CONTRAST: Moderate amount of\n pelvic ascites.\n\n No bone lesions demonstrated on bone window settings.\n\n CONCLUSION:\n\n 1. Pulmonary embolus involving the included portion of the right lower lobe\n pulmonary artery and at least one segmental branch in the left lower lobe.\n These findings have been discussed with the referring resident Dr. \n . We gather that the patient is on anticoagulation treatment for a\n known deep venous thrombosis.\n\n 2. Severe pancreatitis with generalized edema of the pancreatic gland and an\n area of focal pancreatic necrosis in the proximal anterior body measuring up\n to 3 cm. Several adjacent acute peripancreatic fluid collections as described,\n the largest measures up to 10 cm.The remainder of the pancreas though\n oedematous shows post contrast enhancement.\n\n (Over)\n\n 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. No gallstones or pancreatic ductal calculi or dilation.\n A 2-mm nonobstructing calculus noted in the mid portion of the non dilated\n CBD.\n\n 4. Two areas of mild (<3mm) segmental intrahepatic biliary dilatation in\n segment II without obvious underlying cause.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 901280, "text": " 8:32 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: please assess for presence and position of DVT clot. patient\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with\n REASON FOR THIS EXAMINATION:\n please assess for presence and position of DVT clot. patient has evolving PEs\n and is planned for filter placement today.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old male with pulmonary embolism and concern for deep venous\n thrombosis.\n\n FINDINGS: Grayscale and Doppler son of the bilateral common femoral,\n superficial femoral, deep femoral, and popliteal vessels were performed. There\n is intraluminal echogenic material within the right popliteal vein which also\n demonstrates absence of flow and abnormal waveform consistent with thrombosis.\n The vessels of the left lower extremity demonstrate normal compressibility,\n augmentation, waveform and flow.\n\n IMPRESSION: Right popliteal DVT. No evidence of DVT in the left lower\n extremity.\n\n The results of this study were discussed with Dr. at time 9:30 on\n .\n\n" }, { "category": "Radiology", "chartdate": "2187-02-27 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 899786, "text": " 9:04 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: HX OF PANCREATITIS\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic psuedocyst and continued ab pain\n REASON FOR THIS EXAMINATION:\n RUQ - please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdominal ultrasound.\n\n INDICATION: Patient with pancreatic pseudocyst and ongoing abdominal pain.\n For evaluation.\n\n TECHNIQUE: Grayscale imaging of the abdomen was performed.\n\n COMPARISON: None.\n\n REPORT: There is moderate ascites present. The liver is markedly echogenic.\n Portal vein is patent with hepatopetal flow. The gallbladder is abnormal and\n appears markedly thick-walled. In addition, within the gallbladder there is\n evidence of some ring-down artifact. No discrete pericholecystic fluid is\n seen and there is no evidence of gallstones. The gallbladder is not\n distended. No intra- or extra-hepatic biliary dilatation is seen. No focal\n hepatic masses are seen, though some focal areas of hepatic sparing or fat\n sparing are seen. The right kidney measures 12.1 cm. The left kidney\n measures 13.8 cm. The spleen is not enlarged and measures 10.9 cm.\n The pancreas is not seen due to overlying gas.\n CONCLUSION:\n 1. Markedly echogenic liver consistent with fatty infiltration. More severe\n forms of liver disease including cirrhosis or fibrosis cannot be excluded by\n this examination.\n 2. Markedly thick-walled gallbladder with ring-down artifact. While this may\n reflect the patient's generalized hypoproteinemic or fluid overload state\n (given presence of ascites), the ring-down artifact at least raises the\n possibility of diffuse adenomyomatosis of the gallbladder wall.\n 3. Moderate ascites.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 901094, "text": " 5:15 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate, effusion.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man transfer from OSH for pancreatic pseudocyst, PE. desat at\n rest.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transfer from outside hospital for pancreatic pseudocyst and PE.\n Patient desaturated at rest. Evaluate for effusion or infiltrate.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: Again, the lung volumes are low. Allowing for this\n factor, the heart size is normal. Mediastinal and hilar contours are normal.\n There is bibasilar linear atelectasis, increased compared to . No\n frank consolidation or congestive failure. There is likely a small left\n effusion posteriorly. Osseous structures are unremarkable.\n\n IMPRESSION: Slightly increased atelectasis compared to .\n Otherwise unchanged appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2187-02-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 899757, "text": " 10:46 PM\n CHEST (PA & LAT) Clip # \n Reason: baseline cxr, r/o infiltrate.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man transfer from OSH for pancreatic pseudocyst with fevers.\n REASON FOR THIS EXAMINATION:\n baseline cxr, r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST OF \n\n CLINICAL INDICATION: Fevers. Pancreatic pseudocyst.\n\n There are no prior films for comparison.\n\n The lung volumes are low. Allowing for this factor, the heart size is normal.\n The aorta is tortuous, and the pulmonary vascularity is normal. There are\n bibasilar atelectatic changes. Note is also made of a small left pleural\n effusion posteriorly.\n\n IMPRESSION: Bibasilar atelectasis and small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901269, "text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n evaluate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Pulmonary embolism. Oxygen desaturation.\n\n The heart is upper limits of normal in size and stable allowing for rightward\n patient rotation. Atelectatic changes in the right lung base have nearly\n resolved in the interval. There are worsening patchy opacities in the left\n lower lobe, for which the differential diagnoses include atelectasis,\n aspiration, and evolving pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905771, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute pulmonary process\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n REASON FOR THIS EXAMINATION:\n eval acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Tracheotomy, decreasing oxygen saturation, evaluate acute\n pulmonary process.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n semi-upright position. Comparison is made with a previous similar examination\n dated . Position of the tracheostomy cannula is unchanged and\n no pneumothorax is identified. Also a right subclavian approach central\n venous line is in unchanged position. The patient is slightly rotated to the\n right, but paying attention to this change in position, no significant\n interval change can be found in the appearance of the lungs. Thus, bilateral,\n mostly basal densities persist in the vasculature give the impression of\n perivascular haze. Also a left-sided pleural density conceals partially the\n diaphragmatic contours.\n\n IMPRESSION: No significant interval change in a patient with history of\n pulmonary embolic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 904730, "text": " 11:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancr\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst s/p cystectomy now w/ open wound\n draining necrotic material\n REASON FOR THIS EXAMINATION:\n PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancreatico-cutaneous\n fistula\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with pancreatic pseudocyst, status post\n cystectomy, now with open wound draining necrotic material. Assess for\n pancreaticocutaneous fistula.\n\n COMPARISON: CTA abdomen dated .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases through the\n pubic symphysis following administration of oral and 50 cc of IV Optiray\n contrast. Multiplanar reformations were performed.\n\n CT ABDOMEN WITH IV CONTRAST: Images of the lower thorax again demonstrate\n bilateral pleural effusions, left greater than right, with consolidation\n involving the left lower lobe. Within the abdomen, there has been interval\n removal of a left-sided drainage catheter with a partial fistulous tract which\n does not appear to connect with the intraperitoneal cavity. Two right-sided\n JP drains remain in place with their tips located in the pancreatic bed. In\n the upper abdomen, there is a 4-cm defect in the ventral wall which appears to\n have communication with the inferior small fluid collection representing a\n draining open wound. The previously identified large fluid collection in the\n right upper quadrant anterior to the liver has significantly decreased in size\n measuring 18 x 6 cm transverse x approximately 6 cm AP, previously 22 cm x 8\n cm. Fluid collections within the pancreatic bed and left lower quadrant are\n also smaller. There is remaining enhancing pancreatic parenchyma in the\n anterior head, neck and distal body and tail. Small areas of decreased\n enhancement in the tail measuring 1.1 x 1.4 cm is consistent with necrosis.\n The SMA, celiac axis, and their branches appear patent. There is stable\n moderate periportal edema. The liver is normal in size without focal mass.\n The hepatic portal veins and inferior vena cava are patent. The spleen,\n adrenal glands, and opacified loops of large or small bowel are normal.\n Kidneys enhance symmetrically and excrete contrast normally. There are two\n hypoattenuating lesions within the left kidney which are too small to\n characterize, but likely small cysts. Note is made of diffuse inflammatory\n stranding throughout the mesentery. There are numerous retroperitoneal and\n mesenteric lymph nodes which do not meet CT criteria for pathologic\n enlargement. There is no free intraperitoneal air. IVC filter is identified\n below the level of the right renal vein.\n\n (Over)\n\n 11:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancr\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH IV CONTRAST: There has been interval decrease in fluid\n within the pelvis and cul-de-sac. A Foley catheter is seen in a nondistended\n bladder. The rectum, sigmoid colon, and pelvic loops of bowel are normal.\n There is no inguinal or pelvic lymphadenopathy.\n\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are identified.\n\n Again identified is generalized subcutaneous edema likely due to third space\n loss or anasarca.\n\n CT RECONSTRUCTIONS: Sagittal and coronal reconstructions were essential in\n delineating the anatomy and pathology.\n\n IMPRESSION:\n 1. Interval decrease in size of a fluid attenuating collection in the right\n upper quadrant anteriorly adjacent to the liver edge and extending to the left\n of midline. Fluid collections within the pancreatic bed and pelvis are also\n decreased in size.\n 2. 4-cm midline defect in the upper abdominal wall with connection to an\n inferior fluid collection likely representing a draining wound. No evidence\n of extraluminal air to indicate a pancreaticocutaneous fistula.\n 3. Persistent left lower lobe consolidation/collapse with associated\n bilateral pleural effusions, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907001, "text": " 10:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process, mucus plug\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n\n REASON FOR THIS EXAMINATION:\n acute process, mucus plug\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, decreasing oxygen saturation.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: In the interval, there has been near total\n complete opacification of the left hemithorax. Allowing for the degree of\n patient rotation, there is no shift of the mediastinal structures. These\n findings are consistent with a combination of an increasing moderate/large\n left pleural effusion with left lung atelectasis. Tracheostomy tube remains in\n stable position. There appears to be perihilar haziness on the right\n suggestive of mild congestive heart failure, which is improved in the\n interval. Probable left pleural effusion persists. No pneumothorax is seen.\n\n IMPRESSION:\n 1. New near total opacification of the left lung, likely due to combination of\n an increasing moderate/large pleural effusion and atelectesis.\n 2. Mild improvement in right lung pulmonary edema.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2187-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907026, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy tube, decreasing oxygen saturation, status post\n aggressive pulmonary toilet.\n\n COMPARISON: at 23:13.\n\n UPRIGHT AP VIEW OF THE CHEST: There has been interval improvement in aeration\n of the left upper lung field since the prior examination consistent with\n interval lung re-expansion. There continues to be opacification of the left\n lung base consistent with a moderate-sized left pleural effusion and basilar\n atelectasis. There is upper zone vascular redistribution and perihilar\n haziness consistent with mild pulmonary edema. There is no pneumothorax.\n\n IMPRESSION: Interval improvement in aeration of the left lung with re-\n expansion. Left basilar atelectais and moderate- sized left pleural effusion.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2187-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 903972, "text": " 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach - check position\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm, severe pancreatitis s/p trach\n REASON FOR THIS EXAMINATION:\n s/p trach - check position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 58-year-old man, status post withdrawal of the line by 6 cm.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n There is new tracheostomy tube seen in place. The tip of the right subclavian\n IV catheter is identified in the distal SVC.\n\n No evidence of pneumothorax is identified. There are continued opacities in\n both lower lobes indicating pneumonia versus aspiration. There is continued\n small left pleural effusion. The heart is normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 905846, "text": " 1:21 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n Reason: PE??\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hx PE with pCO2 of 119\n\n REASON FOR THIS EXAMINATION:\n PE??\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia. Pancreatic pseudocyst with rupture, status post\n drainage and partial pancreatic resection.\n\n TECHNIQUE: Axial CT imaging of the chest, abdomen, and pelvis performed after\n the intravenous administration of 150 cc of Optiray. Nonionic contrast was\n used due to patient debility. Comparison made to .\n\n CT OF THE CHEST WITH CONTRAST: An endotracheal tube ends in the lower\n trachea. No pulmonary embolism is seen on this examination limited by patient\n body habitus, streak artifact, and a slightly suboptimal timing of contrast\n administration. The heart, pericardium, and great vessels are unremarkable.\n Scattered mediastinal lymph nodes are seen, none reaching pathologic size by\n CT criteria. Small bilateral hilar lymph nodes are seen, presumably reactive\n in nature. Pulmonary parenchymal opacity is seen at both lung bases (left\n greater than right) representing atelectasis and/or consolidation. A small\n effusion is present on the left.\n\n CT OF THE ABDOMEN WITH CONTRAST: Surgical change related to the patient's\n history of exploratory laparotomy with external drainage of a pancreatic\n pseudocyst and pancreatic necrosectomy are seen. A percutaneous gastrostomy\n tube is in place.\n\n The degree of pancreatic enhancement in the remaining pancreatic head, body,\n and tail are unchanged. A fluid collection in the anterior peritoneal cavity\n inferior to the liver with a percutaneous drainage catheter in place has\n decreased in size (3B:173), measuring 17.3 x 3.9 cm (18.6 x 5.7 cm on\n ). A separate fluid collection in the left abdomen tracking along\n the left mesentery into the more central mesentery has also decreased in size\n (3B:207). A fluid collection in the expected location of the distal body of\n the pancreas (3B:163) that also contains a percutaneous drainage catheter has\n slightly increased in size measuring 4.1 x 3.4 cm (3.6 x 2.6 cm ). A\n small collection posterior to the head of the pancreas is unchanged in size\n and configuration.\n\n Intrahepatic biliary ductal dilatation is unchanged. The portal vein appears\n slightly attenuated at the porta hepatis; however, portal venous flow is seen\n in the liver.\n\n (Over)\n\n 1:21 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n Reason: PE??\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The spleen, adrenal glands, and kidneys are normal in appearance. An IVC\n filter is in place.\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder and rectum are normal in\n appearance.\n\n No bone lesions worrisome for malignancy are seen.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Interval decreased size of fluid collections inferior to the liver and the\n left central abdomen. Unchanged fluid collection posterior to the pancreatic\n head. A fourth fluid collection in the distal pancreatic bed containing a\n percutaneous drainage catheter has slightly increased in size.\n\n 3. Bilateral pulmonary parenchymal opacity (left greater than right)\n suggestive atelectasis or consolidation with small bilateral effusions.\n\n 4. Unchanged intrahepatic biliary ductal dilatation and attenuation of a\n patent portal vein.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 902430, "text": " 5:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line plcmt\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis now w/ fever to 101.9F and s/p new\n Right subclavian line\n REASON FOR THIS EXAMINATION:\n line plcmt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with PEs and pancreatitis and fever, now with new\n right-sided subclavian line placement.\n\n Comparison is made to the prior study of , at 1:20 p.m.\n\n SUPINE CHEST RADIOGRAPH\n\n A right-sided subclavian line is seen with its tip terminating in the right\n atrium. Recommend withdrawal by 6 cm. There is no evidence of pneumothorax.\n Allowing for technical differences, the chest radiograph is unchanged compared\n to the prior study performed six hours earlier.\n\n IMPRESSION:\n 1. Right-sided subclavian line with tip ending in right atrium. Recommend\n withdrawal by 6 cm. No evidence of pneumothorax.\n\n These findings were discussed with the houseofficer.\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901570, "text": " 2:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP single view.\n\n INDICATION: Pulmonary embolism, pancreatitis, evaluate for infiltrates.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position and is analyzed in direct comparison with a similar previous\n study of . The patient remains intubated, the ETT in unchanged\n position. The same holds for a previously described left subclavian approach\n central venous line and an NG tube. No evidence of pneumothorax. Cardiac and\n mediastinal structures are unchanged. As before, hazy densities exist in the\n lung bases partially obliterating the diaphragmatic contour and resulting in\n slight blunting of the lateral pleural sinuses.\n\n IMPRESSION: Stable chest findings in patient with history of pulmonary\n embolism.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902688, "text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post withdrawal of subclavian line for interval change.\n\n PORTABLE AP CHEST. The right subclavian line appears to terminate in the SVC.\n The ET tube is in good position. Left basilar atelectasis persists. There\n are no effusions. There is no pneumothorax.\n\n IMPRESSION:\n 1. Right subclavian catheter terminates in the SVC.\n 2. Left basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 901487, "text": " 11:07 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n COMPARISON: .\n\n INDICATION: Line placement.\n\n A left subclavian catheter has been placed, terminating within the superior\n vena cava. There is no evidence of pneumothorax. An endotracheal tube\n remains in satisfactory position. Nasogastric tube is in place and terminates\n in the stomach. Cardiac and mediastinal contours are stable. There has been\n interval worsening of opacity in the left retrocardiac region. Small pleural\n effusions and a right basilar opacity are without interval change.\n\n IMPRESSION:\n 1. Central venous catheter and nasogastric tube in satisfactory position. No\n pneumothorax.\n 2. Bibasilar opacities and small pleural effusions with interval worsening of\n left lower lobe opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902448, "text": " 8:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess for proper CVL placement\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm\n REASON FOR THIS EXAMINATION:\n Please assess for proper CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man status post withdrawal of central venous line by\n 6 cm.\n\n COMPARISON: , at 17:45.\n\n SUPINE CHEST RADIOGRAPH: A right-sided subclavian line is now seen with its\n tip terminating in the right superior vena cava. There is no evidence of\n pneumothorax. The remainder of the chest radiograph is unchanged.\n\n IMPRESSION:\n 1. Right-sided subclavian line with tip ending in the right superior vena.\n Otherwise, unchanged chest radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 902242, "text": " 7:51 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check CVL\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest.\n\n HISTORY: Status post central line placement.\n\n FINDINGS: Compared to prior study from three hours earlier.\n\n There has been interval placement of a right subclavian central line with the\n distal tip at the cavoatrial junction. No pneumothoraces are seen. The left-\n sided central venous catheter, and endotracheal tube are in unchanged position\n and appropriately sited. There remains very low lung volumes crowding the\n pulmonary vascular markings at the bases. There is likely an underlying\n element of pulmonary edema. There remains some hazy opacity within the left\n lung, however this is obscured by the overlying ventilation apparatus.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-22 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 902842, "text": " 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst and markedly distended abd\n REASON FOR THIS EXAMINATION:\n Please evaluate pancreatic bed and abdomen/pelvis. PLEASE GIVE PO AND IV\n CONTRAST\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MULTIDETECTOR CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND INTRAVENOUS\n CONTRAST (CT ANGIOGRAM PROTOCOL).\n\n RECONSTRUCTIONS: Multiplanar reconstructions in sagittal and coronal planes\n are also included.\n\n CLINICAL DETAILS: Post-drainage of pancreatic pseudocyst. Comparison is made\n with previous imaging.\n\n CT ABDOMEN WITH ORAL AND IV CONTRAST (CT ANGIOGRAM PROTOCOL):\n\n Small right and left basal pleural effusions, moderate atelectasis of the left\n lower lobe posteriorly and to a lesser extent the dependent portion of the\n right lower lobe. As on preceding recent CTs, there is evidence of some\n filling defects in segmental branches in the left lower lobe in keeping with\n recent pulmonary embolus. Normal heart size, some coronary artery\n calcification noted, the central line tip is included at the distal SVC level.\n\n Within the abdomen, there is a large amount of fluid in the right upper\n quadrant anteriorly medial to the liver and anterior to the pancreatic bed. At\n its largest, this measures up to 22 cm transverse x approximately 8 cm AP,\n extending to the left of the midline. There is a possible contiguous\n component tracking along the inferior posterior aspect of the liver which\n measures up to 10 cm x 6 cm transverse.\n\n Interval upper midline laparotomy and drainage of the large pancreatic\n pseudocyst the region of the proximal pancreatic body.\n\n There is remaining enhancing pancreatic parenchyma in the anterior head, neck,\n distal body and tail. A small residual cystic area along the anterior aspect\n of the proximal pancreatic body measures up to 4.8 cm transverse x 3.1 cm AP\n (series 5, image 59) and also small residual peripancreatic fluid attenuating\n collections along the posterior inferior aspect of the pancreatic head which\n measure up to 5.7 cm transverse x 2.9 cm AP (much smaller than on the prior\n CT). No abnormal dilatation of the main pancreatic duct. A hypoattenuating\n rim of fluid is noted along the anterior aspect of the pancreatic head (series\n 5, image 52).\n\n (Over)\n\n 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are two percutaneously placed JP drains. The tip of one lies in the\n left upper quadrant and inferior to the pancreatic tail (series 5, image 70)\n and the second located in the region of the lesser sac at the midline (series\n 5, image 70). The proximal portion of these drainage catheters pass through\n the largest anterior abdominal collection described above but there may not be\n side hole drainage points at that level.\n\n The liver is normal in size. The collection described in the anterior right\n upper quadrant exerts mass effect on the left lobe of the liver. Patent\n hepatic portal veins and inferior vena cava. Mild periportal edema noted. No\n intrahepatic biliary dilatation on the current CT. The spleen, both adrenal\n glands are normal. Both kidneys are normal in size, two sub 8-mm ovoid\n hypodensities in the left kidney are unchanged, too small to characterize but\n likely small cysts.\n\n An IVC filter in situ, the superior tip of which lies below the level of the\n renal vein.\n\n No abnormal large or small bowel loop dilatation. Incidental 5-cm splenule\n noted in the left upper quadrant inferior to the spleen.\n\n CT ANGIOGRAM:\n\n Atherosclerotic abdominal aorta. Celiac, superior mesenteric, inferior\n mesenteric, both renal arteries are patent. Splenic artery, splenic vein and\n superior mesenteric veins are patent.\n\n CT SCAN PELVIS (WITH ORAL AND IV CONTRAST):\n\n Urinary catheter in the bladder which was empty at the time of scanning. A\n small localized fluid collection in the right inferior pelvis measures up to\n 5.4 cm transverse x 3.2 cm AP.\n\n No bone lesions demonstrated on bone window setting.\n\n Generalized subcutaneous edema noted, likely due to third space loss or\n anasarca.\n\n RECONSTRUCTIONS: Multiplanar reconstructions in sagittal and coronal planes\n are also included.\n\n CONCLUSION:\n\n 1. Large fluid attenuating collection in the right upper quadrant anteriorly\n (Over)\n\n 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adjacent to the liver edge and extending to the left of midline.\n\n Small residual fluid attenuating collection along the anterior aspect of the\n proximal pancreatic body and posterior to the pancreatic head improved\n compared to previous imaging. If required CT guided percutaneous of this\n right anterior collection should be possible.\n\n 2. The remaining pancreatic tissue in the body, distal tail and anterior head\n shows post-contrast enhancement. There remains a hypoattenuating area in the\n region of the residual collection, likley an area of necrosis in the\n pancreatic body measuring up to 4 cm.\n\n 3. Filling defects in segmental arterial branches in the left lobe in keeping\n with a previously documented pulmonary embolus. Small bibasilar pleural\n effusions and moderate posterior bibasilar atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901635, "text": " 12:41 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval pac position\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n eval pac position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pulmonary emboli and pancreatitis, evaluate pulmonary artery\n catheter position.\n\n COMPARISON: at 7:24 a.m.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube terminates 7.8 cm from the carina.\n Nasogastric tube and left subclavian venous access catheter in unchanged\n position. The pulmonary artery catheter has been pulled back and now\n terminates in the intrapericardial right pulmonary artery. Mild pulmonary\n edema has improved in the interval with continued linear and nodular opacities\n within the left lung, possibly representing residual asymmetric pulmonary\n edema or consolidation. Bibasilar atelectasis and small left pleural effusion\n are stable. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 903833, "text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT position, lung collapse\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm, severe pancreatitis post\n self-extubation now reintubated\n REASON FOR THIS EXAMINATION:\n ETT position, lung collapse\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Reintubation.\n\n An endotracheal tube is present, with the tip terminating approximately 2.5 cm\n above the carina. Cardiac and mediastinal contours are stable. There has\n been interval worsening of left lower lobe opacity and development of patchy\n opacities in the left mid and right lower lung zones. There is also a new\n layering left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2187-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907122, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat, opacification of LLL.\n\n REASON FOR THIS EXAMINATION:\n interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:56 a.m., \n\n HISTORY: Tracheostomy. Decreasing oxygen. Left lower lobe opacification.\n\n IMPRESSION: AP chest compared to at 4:27 a.m.\n\n Perihilar opacification in the left mid and upper lung and interstitial edema\n in the right lung have decreased, consistent with improving heart failure.\n Persistent left lower lobe consolidation could be pneumonia or atelectasis.\n Small left pleural effusion decreased. Moderate cardiac enlargement stable.\n Tracheostomy tube in standard position. No pneumothorax.\n\n\n" } ]
19,879	136,832	A/P: 56m with HTN, DM2, ESRD on HD presents with lightheadedness and hypotension likely due to volume shifts and hypovolemia. . #Hypotension: The most likely explanation is a combination of dialysis, diarrhea, and multiple blood pressure medications. He had no additional signs to support sepsis or adrenal insufficiency. His exam, ECG, and enzymes don't support ACS or cardiogenic shock. A TTE showed mild LVH, normal EF, and diastolic dysfunction. After IVFs and withholding his medications, his blood pressure became normo-, then hypertensive. The hypertension was eventually controlled by re-instituting his regular medications and increasing his dose of lisinopril. . #Chest pain: His ECG showed T wave changes consistent with LVH and these changes were not dynamic with the pain. In addition though he had mildly elevated troponin, he had no CK elevation and has concurrent renal failure. He was continued on asa and labetalol and atorvastatin was started. . #Diarrhea: A C. Diff toxin assay was negative, and his diarrhea did not continue during his hospitalization. . # ESRD: He tolerated HD without further hypotension or complications. . # DM2: He continued his home regiemn of glargine and sliding scale insulin; diet.	Left ventricular hypertrophy and consider alsobiventricular hypertrophy. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. The left ventricular inflow pattern suggests impaired relaxation.There is a trivial/physiologic pericardial effusion. Left atrial abnormality.Right axis deviation. Left ventricular hypertrophy and consider biventricularhypertrophyy. Left ventricularhypertrophy and consider biventricular hypertrophy. Left ventricularhypertrophy and consider biventricular hypertrophy. Left ventricularhypertrophy and consider biventricular hypertrophy. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. There is mild symmetric left ventricularhypertrophy. Left ventricular hypertrophy and consider also biventricularhypertrophy. Rightaxis deviation. Rightaxis deviation. Borderline first degree A-V delay. Borderline first degree A-V delay. Borderline first degree A-V delay. Trivial mitral regurgitationis seen. Atrial premature beat. The aortic valve leaflets are mildlythickened. Right axis deviation. Right axis deviation. Clinical correlation issuggested. Clinical correlation issuggested. Sinus bradycardia. Diffuse St-T waveabnormalities could be due to left ventricular hypertrophy, ischemia orpossibly hyperkalemia. HYPERKALEMIC K+ 6.4 -> 5.7 POST TREATMENT. Sinus rhythmLeft atrial abnormalityLeft ventricular hypertrophyST-T wave abnormalities consistent with left ventricular hypertrophySince previous tracing of , no significant change EKG DONE, 2 SLNTG GIVEN W/O EFFECT. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ST-T wave abnormalities arenon-specific and could be due to left ventricular hypertrophy or possibleischemia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 73Weight (lb): 145BSA (m2): 1.88 m2BP (mm Hg): 462/65HR (bpm): 70Status: InpatientDate/Time: at 10:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. Since the previous tracing nosignificant change.TRACING #6 Diffuse ST-T wave abnormalities could be due to left ventricularhypertrophy, ischemia or possibly hyperkalemia. Since the previous tracing of further ST-T waveabnormalities are present.TRACING #2 add: k = 6.1. kayexalate given ekg done HO aware. Pulmonary vasculature is within normal limits. ST-T wave abnormalities arenon-specific but could be due to left ventricular hypertrophy or ischemia.Clinical correlation is suggested. KAYEXALATE GIVEN IN EW X2. Clinicalcorrelation is suggested. (REG DAYS M/W/F)S/O:SEE CARVUE FOR COMPLETE OBJ DATA.NEURO: A&O X3, MAE.CV: ARRIVED TO CCU W/ C/O CP AND SOB. DSD QD, CHANGED EVE.ACCESS: 2 #18 PERIPHERALSA: HYPOTENSIVE, HYPERKALEMIA, S/P VOLUME RESUSITATION W/ ESRD ON HD.CHEST PAIN AND SOB RESOLVED W/ MORPHINE AND NTG GTT. Since the previous tracing of T waves are less prominent.TRACING #5 The left ventricular cavity size is normal. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Diffuse ST-T wave abnormalities could be due to leftventricular hypertrophy, ischemia or possibly hyperkalemia. PT PAIN FREE. Diffuse ST-T wave abnormalities could be due in part to leftventricular hypertrophy, ischemia or hyperkalemia. Clinical correlation is suggested. Clinical correlation is suggested. No AS. The soft tissue and osseous structures are within normal limits. Normal LV cavity size. Right ventricular chambersize and free wall motion are normal. IMPRESSION: No acute pulmonary process identified. The heart and mediastinal contours are normal. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. ON HD SINCE AFTER FAILED RENAL TRANSPLNT, HAS NON-WORKING FISTULAS IN BOTH UPPER EXTREMITIES.D/C'D FROM TO HOME W/ SERVICES AFTER RECENT SURGICAL AMPUTATIONS.AT HOME THIS AM W/ HYPOTENSION (SBP 60) EMS-> EW. no significant change.TRACING #4 Since the previous tracing earlier this date ST-T wave changes havedecreased.TRACING #3 NO BM SINCE ARRIVAL. BS W/ BIBASILAR CRACKLES. REC'D 4 LITERS IN EW. PAIN , 6MG OF IV MORPHINE GIVEN W/ GOOD EFFECT. PLACED ON PRECAUTIONS, PT WAS RECENTLY EXPOSED TO C-DIFF AT REHAB.GU: ANURIC ON HDSKIN: INC WOUNDS HEALING WELL. COMPARISON: None. NOW HYPERTENSIVE CONTROLLED W/ IV NTG GTT.P: AWAITING HD ON MONDAY, MONITOR CARDIO PULM STATUS, FOLLOW K+. CK MB SENT, K+ 5.7.RESP: O2 SAT 100% ON 2-3LNC. ADMIT TO CCU, NEEDS HD ON MONDAY. SBP CLIMBING TO 170'S STARTED ON IV NTG. Overall leftventricular systolic function is normal (LVEF>55%). Evaluate for pneumonia or CHF. No previous tracing available for comparison.TRACING #1 CCU NPN 1900-070056 Y/O MALE W/ DM, HTN, ESRD, DIABETIC NEUROPATHY, SEVERE PVD S/P MULTIPLE AMPUTATIONS. Since the previoustracing earlier this date. The lungs are clear. SEE ADMIT NOTE FOR FULL DETAIL. PORTABLE AP CHEST RADIOGRAPH: There is a hemodialysis catheter within the right subclavian vein, with the tip positioned in the right atrium. There is no aortic valve stenosis. No pleural effusion or pneumothorax is seen. LEFT TOE REMOVED, AND LEFT INDEX FINGER REMOVED D/T OSTEOMYLITIS 3 WEEKS AGO AT . O2 OFF, SAT REMIANS 98%.GI: TOLERATING PO'S, REPORTEDLY HAD DIARRHEA FOR "5 DAYS".	11	[ { "category": "Nursing/other", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 1523590, "text": "add: k = 6.1. kayexalate given ekg done HO aware.\n" }, { "category": "Nursing/other", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 1523591, "text": "CCU NPN 1900-0700\n56 Y/O MALE W/ DM, HTN, ESRD, DIABETIC NEUROPATHY, SEVERE PVD S/P MULTIPLE AMPUTATIONS. ON HD SINCE AFTER FAILED RENAL TRANSPLNT, HAS NON-WORKING FISTULAS IN BOTH UPPER EXTREMITIES.\n\nD/C'D FROM TO HOME W/ SERVICES AFTER RECENT SURGICAL AMPUTATIONS.\n\nAT HOME THIS AM W/ HYPOTENSION (SBP 60) EMS-> EW. SEE ADMIT NOTE FOR FULL DETAIL. HYPERKALEMIC K+ 6.4 -> 5.7 POST TREATMENT. REC'D 4 LITERS IN EW. ADMIT TO CCU, NEEDS HD ON MONDAY.(REG DAYS M/W/F)\n\nS/O:\nSEE CARVUE FOR COMPLETE OBJ DATA.\n\nNEURO: A&O X3, MAE.\nCV: ARRIVED TO CCU W/ C/O CP AND SOB. EKG DONE, 2 SLNTG GIVEN W/O EFFECT. SBP CLIMBING TO 170'S STARTED ON IV NTG. PAIN , 6MG OF IV MORPHINE GIVEN W/ GOOD EFFECT. PT PAIN FREE. CK MB SENT, K+ 5.7.\n\nRESP: O2 SAT 100% ON 2-3LNC. BS W/ BIBASILAR CRACKLES. O2 OFF, SAT REMIANS 98%.\n\nGI: TOLERATING PO'S, REPORTEDLY HAD DIARRHEA FOR \"5 DAYS\". NO BM SINCE ARRIVAL. KAYEXALATE GIVEN IN EW X2. PLACED ON PRECAUTIONS, PT WAS RECENTLY EXPOSED TO C-DIFF AT REHAB.\nGU: ANURIC ON HD\nSKIN: INC WOUNDS HEALING WELL. LEFT TOE REMOVED, AND LEFT INDEX FINGER REMOVED D/T OSTEOMYLITIS 3 WEEKS AGO AT . DSD QD, CHANGED EVE.\nACCESS: 2 #18 PERIPHERALS\n\nA: HYPOTENSIVE, HYPERKALEMIA, S/P VOLUME RESUSITATION W/ ESRD ON HD.\nCHEST PAIN AND SOB RESOLVED W/ MORPHINE AND NTG GTT. NOW HYPERTENSIVE CONTROLLED W/ IV NTG GTT.\nP: AWAITING HD ON MONDAY, MONITOR CARDIO PULM STATUS, FOLLOW K+.\n\n\n" }, { "category": "Echo", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 82661, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 73\nWeight (lb): 145\nBSA (m2): 1.88 m2\nBP (mm Hg): 462/65\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The left ventricular inflow pattern suggests impaired relaxation.\nThere is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2156-09-21 00:00:00.000", "description": "Report", "row_id": 198214, "text": "Sinus rhythm\nLeft atrial abnormality\nLeft ventricular hypertrophy\nST-T wave abnormalities consistent with left ventricular hypertrophy\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 198215, "text": "Sinus rhythm. Left atrial abnormality. Right axis deviation. Left ventricular\nhypertrophy and consider biventricular hypertrophy. ST-T wave abnormalities are\nnon-specific and could be due to left ventricular hypertrophy or possible\nischemia. Clinical correlation is suggested. Since the previous tracing no\nsignificant change.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 198216, "text": "Sinus rhythm. Atrial premature beat. Left atrial abnormality. Left ventricular\nhypertrophy and consider biventricular hypertrophy. ST-T wave abnormalities are\nnon-specific but could be due to left ventricular hypertrophy or ischemia.\nClinical correlation is suggested. Since the previous tracing of \nT waves are less prominent.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198217, "text": "Sinus rhythm. Left atrial abnormality. Right axis deviation. Left ventricular\nhypertrophy and consider biventricular hypertrophy. Diffuse St-T wave\nabnormalities could be due to left ventricular hypertrophy, ischemia or\npossibly hyperkalemia. Clinical correlation is suggested. Since the previous\ntracing earlier this date. no significant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198218, "text": "Sinus rhythm. Borderline first degree A-V delay. Left atrial abnormality. Right\naxis deviation. Left ventricular hypertrophy and consider also biventricular\nhypertrophy. Diffuse ST-T wave abnormalities could be due to left ventricular\nhypertrophy, ischemia or possibly hyperkalemia. Clinical correlation is\nsuggested. Since the previous tracing earlier this date ST-T wave changes have\ndecreased.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198219, "text": "Sinus rhythm. Borderline first degree A-V delay. Left atrial abnormality. Right\naxis deviation. Left ventricular hypertrophy and consider biventricular\nhypertrophyy. Diffuse ST-T wave abnormalities could be due in part to left\nventricular hypertrophy, ischemia or hyperkalemia. Clinical correlation is\nsuggested. Since the previous tracing of further ST-T wave\nabnormalities are present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198460, "text": "Sinus bradycardia. Borderline first degree A-V delay. Left atrial abnormality.\nRight axis deviation. Left ventricular hypertrophy and consider also\nbiventricular hypertrophy. Diffuse ST-T wave abnormalities could be due to left\nventricular hypertrophy, ischemia or possibly hyperkalemia. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2156-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 924689, "text": " 3:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man on HD hypotensive with dry cough\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man on hemodialysis, hypertensive with dry cough.\n Evaluate for pneumonia or CHF.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: There is a hemodialysis catheter within the\n right subclavian vein, with the tip positioned in the right atrium. The heart\n and mediastinal contours are normal. Pulmonary vasculature is within normal\n limits. The lungs are clear. No pleural effusion or pneumothorax is seen.\n The soft tissue and osseous structures are within normal limits.\n\n IMPRESSION: No acute pulmonary process identified.\n\n" } ]
54,911	173,885	SICU course - Mr. was admitted to the SICU with fulminant liver failure following a TIPS procedure complicated by a bleed requiring embolization of segment 8 and revision of his TIPS. On initial admission, his GCS was 3. He was transferred from Hospital intubated and on levophed for blood pressure support. A full workup for transplant listing was initiated which included serologies, liver duplex, ECHO, CT Torso, CT head and placement of a Dobhoff tube postpyloric for feeding. An initial CT scan of his head was negative for any significant pathology and it was felt that his current mental status was likely due to his liver failure. Neurology was consulted for evaluation of his mental status and during that time he had a tonic-clonic seizure for which he was loaded and maintained on Keppra. An initial diagnostic paracentesis of his abdomen excluded spontaneous bacterial peritonitis and CVVH was initiated for his acute renal failure after his acute decompensation at Hospital. He was intially treated with zosyn at Hospital during his decompensation and shortly after the start of zosyn, he developed neutropenia. His zosyn was discontinued here, and cefepime was started emprically for his pneumonia. A BAL culture eventually grew yeast and he was started on fluconazole for coverage. Hematology was consulted regarding his neutropenia and a bone marrow biopsy was performed on which eventually showed agranulocytosis, likely acute reaction to acute illness or medication. He continued to remain neutropenic and coagulopathic from his liver disease with intermittent need for trasnfusions. He also remained on CVVH for fluid removal, with an inability to tolerate HD due to labile blood pressures. His mental status improved and on , he was arousable and able to follow commands. On he continued to require ventilatory support, but was awake and following commands. He underwent a therapeutic paracentesis for 7 liters of ascitic fluid. The cefepime was discontinued with no positive culture data and levofloxacin was started for neutropenic prophylaxis. He underwent a second paracentesis on for 2.2 liters. He continued to remain neutropenic with a WBC of 0.7 with the continuation of his neupogen and he continued to require intermittent CVVH for fluid removal. Attempts to wean him from ventilatory support failed and he continued to remain coagulopathic from his liver disease. A repeat bone marrow biopsy was performed on and during this time had a hypotensive episode requiring neosynephrine for blood pressure support. He was eventually weaned from his requirement for neosynephrine. The bone marrow biopsy did not demonstrate any signs of a malignant process and on his WBC started to increase (1.4). He remained intubated with an inability to be weaned, likely secondary to his deconditioned state. His neutropenia continued to improve with a WBC of 2.7 on and 5.5 on . Although he had a normal WBC on , he remained neutropenic and developed a neutropenic fever to 101.6 that morning with hypotension requiring neosynephrine and empiric vancomycin, meropenem, and micafungin was started and later stopped without positive culture data. Multiple cultures were sent with only positive cultures growing yeast, the last of which was from a BAL. He continued to remain coagulopathic with a need for intermittent blood product transfusions and on ventilatory support for his deconditioned respiratory failure. He also remained on neosynephrine without a clear etiology. On , it was decided at liver allocation meeting that Mr. was not a liver transplant candidate. Dr. had an extensive meeting with the family to notify them that he would not be listed for liver transplant and his care was transitioned to the MICU service at this time. ===================== MICU Course	FINDINGS: The right IJ catheter ends in the mid SVC. Unchanged size of the cardiac silhouette, unchanged bilateral pleural effusions and bilateral areas of opacities in the lung parenchyma, likely corresponding to areas of atelectasis. Bilateral pleural effusions, left more than right, with subsequent areas of atelectasis. An IVC filter within the infrarenal IVC is noted. The surface morphology appears nodular, consistent with cirrhosis. The right and left internal jugular central venous catheters terminate within the SVC. There is interval significant decrease in the left pleural effusion. There are low lung volumes with bilateral pleural effusions, left greater than right. There are low lung volumes with bilateral pleural effusions, left greater than right. There are low lung volumes with bilateral pleural effusions, left greater than right. The remnant left lung tissue seen predominantly in the anterior aspect of the left hemithorax demonstrates diffuse ground-glass opacities. The Dobbhoff tube can be seen in the superior most part of the image and appears to be projecting in area consistent with left bronchus. INDICATION: Status post line placement, hepatorenal syndrome, new right IJ CVC placement. Within the right upper quadrant of the abdomen, there are two serpiginous opacities which join at their inferior extent, representing contrast medium within the biliary or portal venous system. Some air is now present within the left lung, though a large left hemothorax is still present with mediastinal shift. Moderate right pleural effusion, unchanged from exam. Moderate right pleural effusion, unchanged from exam. Moderate right pleural effusion, unchanged from exam. The distal tip of the endotracheal tube is approximately 4.2 cm proximal to the carina, similar to prior exam. The left IJ catheter ends at the junction of the right and left brachiocephalic veins. Large left pleural effusion with hemorrhagic component displacing mediastinal structures with right-sided displacement of the mediastinal structures. Large left pleural effusion with hemorrhagic component displacing mediastinal structures with right-sided displacement of the mediastinal structures. Enlarging left and stable moderate right pleural effusions. There are unchanged bilateral large pleural effusions and a left retrocardiac opacity. The right IJ catheter ends in the mid SVC. There is again seen bilateral pleural effusions and a left retrocardiac opacity. There is straightening of thoracic kyphosis. Left internal jugular line ends in the upper SVC, right internal jugular line ends close to the estimated location of the superior cavoatrial junction. FINDINGS: In comparison with the study of , the right IJ catheter has been removed. Furthermore, diffuse foci of patchy opacification are visualized throughout bilateral lungs. ET tube is in standard placement, feeding tube loops in the stomach and passes out of view, left supraclavicular dual-channel central venous line ends in the upper SVC. There is increased opacification of the left hemithorax with aerated lung is no longer visible on that side. Nasogastric tube has been removed, and a new post-pyloric tube terminates in the second portion of the duodenum. Unchanged moderate right pleural effusion. Left jugular line ends near the junction of brachiocephalic veins. Left jugular line ends at the thoracic inlet. CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are bilateral moderately sized pleural effusions with adjacent relaxation atelectasis. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is a large amount of intra-abdominal fluid with density suggestive of a combination of ascites and hemoperitoneum. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Large amount of free fluid is again visualized in the pelvis, with Hounsfield units suggesting a combination (Over) 7:32 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: evaluate pleural effusions and ?PNA Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL FINAL REPORT (Cont) of ascites and hemoperitoneum. Bilateral parenchymal opacities are unchanged and likely represent a combination of pulmonary edema and atelectasis. IMPRESSION: Unchanged pulmonary edema and atelectasis. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Unchanged bilateral parenchymal opacities, likely to represent a combination of pulmonary edema and atelectasis. FINDINGS: Indwelling devices are unchanged in position except for slight advancement of the endotracheal tube, which now terminates 3 cm above the carina. Mild left pleural effusion with retrocardiac atelectasis. Borderline size of the cardiac silhouette with minimal pulmonary edema. A left internal jugular catheter tip projects over the midline in the brachiocephalic vein, unchanged. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Left pleural effusion. IMPRESSION: Nodular cirrhotic liver, TIPS stent in situ, which is patent with normal flow. Mild (1+) MR. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets. The main portal vein is patent with normal hepatopetal flow. Right ventricular function.Height: (in) 72Weight (lb): 215BSA (m2): 2.20 m2BP (mm Hg): 119/70HR (bpm): 60Status: InpatientDate/Time: at 11:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The gallbladder is distended without gallstones. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV wall thickness. Mild atelectasis at the right lung base. Visualized portions of the IVC are unremarkable in appearance, with normal flow. Normal tricuspid valvesupporting structures. A right internal jugular catheter tip projects over the mid to low SVC. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right ventricular function.Height: (in) 72Weight (lb): 215BSA (m2): 2.20 m2BP (mm Hg): 119/70HR (bpm): 60Status: InpatientDate/Time: at 11:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Conclusions: Residual multifocal patchy and linear opacities in the mid and lower lungs, probably reflecting foci of atelectasis.	45	[ { "category": "Radiology", "chartdate": "2166-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172767, "text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with left hemothroax.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n End-stage liver disease, left hemothorax, evaluate for change.\n\n Some air is now present within the left lung, though a large left hemothorax\n is still present with mediastinal shift.\n\n IMPRESSION: Some re-expansion of left lung. Mediastinal shift persists.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1171996, "text": " 12:36 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p line placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatorenal syndrome. New right IJ CVC\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH.\n\n INDICATION: Status post line placement, hepatorenal syndrome, new right IJ\n CVC placement.\n\n COMPARISON: Chest radiograph , at 04:15.\n\n FINDINGS:\n\n Frontal chest radiograph performed at 12:57 was reviewed. Radiograph was\n performed with patient supine. The patient is intubated. The distal tip of\n the endotracheal tube is approximately 4.2 cm proximal to the carina, similar\n to prior exam. Left internal jugular venous catheter is present, tip of which\n projects over the left brachiocephalic vein. New right internal jugular\n venous catheter is present. The tip of this projects over the right\n cavo-atrial junction. Nasogastric tube is in place, the tip of which is\n outside the field of view, below the hemidiaphragm. TIPS shunt within the\n right upper quadrant is demonstrated. Unchanged branching densities adjacent\n to this are noted. There is bilateral basal atelectasis. Bilateral pleural\n effusions, moderate on the right and large on the left are seen. Volume loss\n on the left appears somewhat worse, though this may be exaggerated by\n projection. Density along the lung apices are compatible with pleural\n calcification.\n\n IMPRESSION: Support hardware similar to prior examination with the additional\n finding of a new right IJ central venous catheter, the tip of which is\n projected over the right cavo-atrial junction. Pleural effusions, larger on\n the left than the right with associated volume loss again seen, somewhat more\n prominent on the left than on the earlier radiograph.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171153, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with decompensated liver failure s/p TIPS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHER\n\n INDICATION: Decompensated liver failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient position is\n substantially changed. With this limitation in mind, there is no relevant\n change. Bilateral pleural effusions, left more than right, with subsequent\n areas of atelectasis. Small lung volumes. No signs of overt pulmonary edema.\n The monitoring and support devices are unchanged, tips projects over the\n expected position. No focal parenchymal opacities have newly occurred in the\n interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170068, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, evaluate for interval change.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Bilateral pleural effusions are moderately large and are unchanged\n since . There is an increase in the degree of vascular indistinctness\n and perihilar opacity since suggesting worsening pulmonary edema.\n The cardiac size is at the upper limits of normal, allowing for projection.\n The nasoenteric tube tip is not included in the field of view of the\n radiograph but is well below the gastroesophageal junction. The tip of the\n right internal jugular central venous catheter is projected over the level of\n the cavoatrial junction, the tip of the left internal jugular central venous\n catheter is projected over the expected location of the upper superior vena\n cava. The endotracheal tube is in satisfactory position. Multiple biliary\n stents and contrast within the biliary system of the right lobe of the liver\n are unchanged in appearance since .\n\n IMPRESSION:\n 1. Moderately large bilateral pleural effusions.\n\n 2. Worsening pulmonary edema.\n\n 3. Satisfactory position of medical devices.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170550, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWJ 10:21 AM\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1171577, "text": " 2:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p Bronchoscopy and HD line exchange, r/o PTX\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure.\n REASON FOR THIS EXAMINATION:\n s/p Bronchoscopy and HD line exchange, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:30 P.M. .\n\n HISTORY: End-stage liver disease and respiratory failure following\n bronchoscopy and line exchange.\n\n IMPRESSION: AP chest compared to 10:37 a.m.\n\n Large left and moderate right pleural effusion persists. Consolidation at the\n right lung base has improved minimally. Heart size normal. ET tube and left\n internal jugular line are in standard placements respectively. Feeding tube\n passes into the stomach and out of view. No pneumothorax or mediastinal\n widening.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171617, "text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: End-stage liver disease and respiratory failure after\n left thoracocentesis.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 10:33 p.m.\n\n There is interval significant decrease in the left pleural effusion. Apical\n loculation of pleural effusion is re-demonstrated. No definitive pneumothorax\n is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1169065, "text": " 3:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval dobhoff placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH/HCV cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with HCV cirrhosis, presents with decompensated\n liver failure and massive bleeding after TIPS. Evaluate Dobbhoff placement.\n The Dobbhoff tube can be seen in the superior most part of the image and\n appears to be projecting in area consistent with left bronchus.\n\n COMPARISON: CT torso from .\n\n FINDINGS: One Supine abdominal radiograph demonstrates the Dobbhoff tube in a\n position projecting over the left bronchus. Significant amount of\n intra-abdominal fluid makes it difficult to discern the loops of bowel. There\n does not appear to be any significantly dilated loops to suggest ileus or\n obstruction. An IVC filter projects over the likely location. There is a\n metal stent seen in the location of the portal vein. Bilateral pedicle screws\n are seen at L1 through L3.\n\n IMPRESSION:\n 1. Dobbhoff tube projecting over the left bronchus. This finding was called\n to Dr. 4 p.m. on . NG tube seen with side port beyond\n the gastroesophageal junction and the tip curling into the greater curvature\n of the stomach.\n\n 2. Bowel gas is difficult to discern with significant amount of ascites.\n There are no clearly dilated loops of large or small bowel to suggest\n obstruction or ileus.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170660, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evaluation\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with MI and cardiogenic shock.\n REASON FOR THIS EXAMINATION:\n interval evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MI with cardiogenic shock. Evaluate interval change.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right IJ catheter ends in the mid SVC. The left IJ catheter\n ends at the junction of the right and left brachiocephalic veins. The\n endotracheal tube terminates 3 cm above the carina. A feeding tube extends\n below the diaphragm and out of the field of view. A TIPS stent with apparent\n extension stents is seen. The lumbar spinal hardware is not completely\n visualized. There are unchanged moderate bilateral pleural effusions as well\n as unchanged pulmonary edema. Bibasilar atelectasis is unchanged. Within the\n right upper quadrant of the abdomen, there are two serpiginous opacities which\n join at their inferior extent, representing contrast medium within the biliary\n or portal venous system.\n\n IMPRESSION:\n 1. Unchanged moderate bilateral pleural effusions.\n 2. Unchanged bibasilar atelectasis.\n 3. Unchanged pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1172471, "text": " 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and dropping hcts concerning for bleed (came\n in with bleeding after TIPS procedure) as well as CXR concerning for hemothorax\n where line placed.\n REASON FOR THIS EXAMINATION:\n ?hemothorax and abdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXCf 2:20 PM\n 1. Large left pleural effusion with hemorrhagic component displacing\n mediastinal structures with right-sided displacement of the mediastinal\n structures.\n 2. Moderate right pleural effusion, unchanged from exam.\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage fluid.\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of liver failure status post TIPS on\n , currently with dropping hematocrit level. Assess for bleed.\n\n COMPARISONS: CT from and serial chest x-rays dating back to\n .\n\n TECHNIQUE:\n\n MDCT-acquired contiguous images from thoracic inlet to pubic symphysis were\n obtained without IV or p.o. contrast or oral contrast at 5-mm slice thickness.\n Coronally and sagittally reconstructed images were displayed at 5-mm slice\n thickness.\n\n FINDINGS:\n\n CT OF THE CHEST: There is a large left pleural effusion, distributed in\n almost entire left hemithorax, leading to right-sided displacement of\n mediastinal structures. The remnant left lung tissue seen predominantly in\n the anterior aspect of the left hemithorax demonstrates diffuse ground-glass\n opacities. The left pleural effusion demonstrates layering of the fluid with\n dependent area measures 40 Hounsfield units in attenuation, consistent with\n hemorrhagic component. There is moderate right pleural effusion measuring 15\n in attenuation with adjacent areas of compressive atelectasis, essentially\n unchanged from exam. The visualized portions of the right\n (Over)\n\n 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lung demonstrates diffuse opacities which are likely infectious in etiology.\n The heart is of normal size without pericardial effusion. The right and left\n internal jugular central venous catheters terminate within the SVC. The\n endotracheal tube terminates several centimeters above the carina.\n\n CT OF THE ABDOMEN: There is massive ascites within the abdomen, unchanged\n from exam. There is hyperdense fluid material in the most\n dependent area within the left upper abdomen measuring 70 Hounsfield units in\n attenuation suggestive of the hemorrhagic component. The liver is markedly\n diminished in size. The surface morphology appears nodular, consistent with\n cirrhosis. A TIPS shunt is in unchanged position. Within limitations of a\n non-contrast exam, spleen, adrenal glands, and kidneys appear unremarkable.\n\n An IVC filter within the infrarenal IVC is noted. Intra-abdominal aorta is\n notable for calcified atherosclerotic disease without aneurysmal changes.\n\n CT OF THE PELVIS:\n\n A Foley catheter is in place. Large amount of fluid within the pelvis is\n noted. There is no free air. The rectum is displaced posteriorly and there\n is an adjacent area of hyperdense fluid measuring 50 Hounsfield units in\n attenuation, consistent with hemorrhagic fluid.\n\n OSSEOUS STRUCTURES:\n\n No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n\n 1. Large left pleural effusion with hemorrhagic component with right-sided\n displacement of the mediastinal structures.\n\n 2. Moderate right pleural effusion, unchanged from exam.\n\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage.\n\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n\n (Over)\n\n 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1172472, "text": ", A. MED MICU-7 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and dropping hcts concerning for bleed (came\n in with bleeding after TIPS procedure) as well as CXR concerning for hemothorax\n where line placed.\n REASON FOR THIS EXAMINATION:\n ?hemothorax and abdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Large left pleural effusion with hemorrhagic component displacing\n mediastinal structures with right-sided displacement of the mediastinal\n structures.\n 2. Moderate right pleural effusion, unchanged from exam.\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage fluid.\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2166-01-27 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 1170668, "text": " 8:11 AM\n DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: EVAL TIPS PATENCY\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n EVAL TIPS PATENCY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with cirrhosis, liver failure and GI bleed.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: No focal liver lesion is identified. No biliary dilatation is seen\n and the common duct measures 0.5 cm. The gallbladder is contracted. The\n pancreas is unremarkable but is only partially visualized. The spleen is\n unremarkable and measures 11.9 cm. A large amount of ascites is seen in the\n abdomen.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main portal vein is patent with a velocity of 35 cm/sec. The\n right and left portal veins are patent and demonstrate reverse flow toward the\n TIPS shunt. The TIPS shunt is patent with velocities of 114, 168, and 114\n cm/sec in the proximal, mid and distal portions respectively.\n\n IMPRESSION:\n 1. Patent TIPS shunt with appropriate flow seen in the portal veins.\n 2. Large amount of ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169680, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position.\n Unchanged size of the cardiac silhouette, unchanged bilateral pleural\n effusions and bilateral areas of opacities in the lung parenchyma, likely\n corresponding to areas of atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170551, "text": ", J. SICU-B 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171280, "text": " 6:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for pulm edema\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with decreased oxygen saturations.\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n WET READ: 9:01 PM\n Lines stable. Again seen are bibasilar opacities, with increased opacity of\n right lung which may reflect interval development of edema.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:06 P.M. \n\n HISTORY: Hypoxia. Evaluate possible pulmonary edema.\n\n IMPRESSION: AP chest compared to through 6:\n\n Large left pleural effusion has increased between and ,\n stable since earlier in the day. Focal opacification of the base of the right\n lung is more obvious now than it was on earlier studies and could be due to\n pneumonia.\n\n Heart size is normal. ET tube is in standard placement, feeding tube passes\n into the stomach and out of view. Left internal jugular line ends in the left\n brachiocephalic vein. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169133, "text": ", J. SICU-B 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fluid overload, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged pulmonary edema and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172084, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure with b/l pleural effusions\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:03 A.M. ON \n\n HISTORY: End-stage liver disease and respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n Large left pleural effusion obscures the entire left lung and exaggerates what\n could be relatively mild pulmonary edema. There is at least a small if not\n larger right pleural effusion, but a lower portion of the right lung is\n consolidated either by atelectasis or pneumonia. Heart size is normal. There\n is no pneumothorax. ET tube is in standard placement. Left internal jugular\n line ends in the upper SVC, right internal jugular line ends close to the\n estimated location of the superior cavoatrial junction. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170814, "text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change, volume overload\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver failure and volume overload, to assess for change.\n\n FINDINGS: In comparison with the study of , the right IJ catheter has been\n removed. Other monitoring and support devices remain in place. Diffuse\n bilateral pulmonary opacifications persist, consistent with bilateral pleural\n effusions and bibasilar atelectasis.\n\n TIPS stent is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170974, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change, volume overload\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and pleural effusions\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:11 A.M., \n\n HISTORY: Liver failure and pleural effusions. Question volume overload.\n\n IMPRESSION: AP chest compared to through 4:\n\n Bilateral pleural effusions, large on the left moderate on the right continue\n to increase producing at least moderate atelectasis in both lower lungs. I\n doubt that there is pulmonary edema. No pneumothorax. Heart size normal. ET\n tube is in standard placement, feeding tube loops in the stomach and passes\n out of view, left supraclavicular dual-channel central venous line ends in the\n upper SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172414, "text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n alcoholic cirrhosis, acute renal failure and pneumonia transfered from OSH for\n evaluation for liver transplant now s/p 23 days in the SICU with respiratory\n failure, liver failure, renal failure, transferred to MICU for further\n management.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiorgan failure with pneumonia. Evaluate for interval change.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The ET tube ends 4.5 cm above the carina. The right IJ catheter\n ends in the mid SVC. The left IJ catheter ends in the left brachiocephalic\n vein. The feeding tube passes into the stomach and out of the field of view.\n The TIPS stent is again seen in the right upper quadrant of the abdomen. The\n right pleural effusion has markedly increased in size and now compresses the\n left lung and shifts the midline structures to the right. The degree of\n increase in size of the effusion over two days raises concern for hemothorax.\n The moderate right pleural effusion is unchanged. Right basilar atelectasis\n is unchanged.\n\n IMPRESSION:\n\n 1. Drastically increased left pleural effusion, raising concern for\n hemothorax.\n\n 2. Unchanged moderate right pleural effusion.\n\n 3. Unchanged right basilar atelectasis.\n\n These findings were reported to Dr. at 2:35 p.m. via telephone on\n the day of the study.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171906, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:15 A.M., \n\n HISTORY: End-stage liver disease and respiratory failure following left\n thoracentesis.\n\n IMPRESSION: AP chest compared to :\n\n Large left pleural effusion has increased relative to . This\n obscures much of the left lung which may be more consolidated. There is\n persistent consolidation at the right base. No pneumothorax. Feeding tube\n passes into the stomach and out of view. Left jugular line ends near the\n junction of brachiocephalic veins. ET tube in standard placement. Heart is\n normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172670, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD, ventilator dependence, possible hemothorax from CVL\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Possible hemothorax, assess for change.\n\n One view. Comparison with the previous study done . There is\n increased opacification of the left hemithorax with aerated lung is no longer\n visible on that side. Pleural calcification is projected in the mid left\n chest. A moderate right pleural effusion is unchanged. Increased density in\n the underlying lower right lung is stable. Mediastinal structures are shifted\n to the right as before. An endotracheal tube, feeding tube and bilateral\n internal jugular catheters remain in place.\n\n IMPRESSION: Opacification of the left hemithorax likely due to accumulation\n of pleural fluid as well as increased density in the underlying left lung.\n There is a stable moderate right pleural effusion and persistent increased\n density in the lower right lung which may represent parenchymal consolidation\n as well.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171550, "text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with EtOH and HCV cirrhosis with decompensated liver failure s/p TIPS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:37 A.M., \n\n HISTORY: Alcoholic and HCV cirrhosis. Liver failure. Status post TIPS.\n\n IMPRESSION: AP chest compared to through 6:\n\n Large left pleural effusion is stable, moderate right pleural effusion may\n have increased, and there may be more consolidation at the base of the right\n lung. Heart is normal size and mediastinal veins are not particularly\n distended suggesting that the pleural effusion could be due to ascites rather\n than volume overload. Findings in the right lung are concerning for\n pneumonia. The left lung base is obscured by a combination of overlying heart\n shadow and pleural effusion.\n\n Feeding tube passes into the stomach and out of view. ET tube is in standard\n placement. Left jugular line ends at the thoracic inlet. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1171208, "text": " 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:21 PM\n Increasing large L and stable moderate R pleural effusions.\n Bibasilar consolidation.\n Cirrhosis with severe ascites. Conventional vascular anatomy.\n TIPS, no active extravasation.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with alcoholic cirrhosis, liver failure and\n massive bleeding after TIPS.\n\n COMPARISON: \n\n TECHNIQUE: Helical MDCT images were acquired from the lung bases through the\n iliac crests without and with intravenous contrast, per the triphasic liver\n protocol. Three-minute delayed images were also obtained through the abdomen.\n Sagittal and coronal multiplanar reformations were generated. 3D\n volume-rendered images and liver/splenic volume calculations were performed at\n a separate workstation by the Advanced Imaging Lab.\n\n FINDINGS: Again noted are multifocal opacities at the lung bases, consistent\n with pneumonia. Increasing large left and stable moderate right pleural\n effusions are present. These measure 20-30 in attenuation, suggestive of\n complex proteinaceous or hemorrhagic fluid. There is associated compressive\n atelectasis.\n\n The heart size is normal, without pericardial effusion. The visualized lower\n lobe pulmonary arteries are patent. Calcifications are present in the left\n anterior descending coronary artery.\n\n ABDOMEN: Again noted is severe ascites, which has decreased from 30-15 in\n attenuation, suggesting resolving hemoperitoneum. The liver is markedly\n nodular, shrunken, and heterogeneous, consistent with cirrhosis. A few\n nonspecific hypodensities are noted in the liver, but there are no suspicious\n arterially enhancing foci. A TIPS shunt extends from the portal vein to the\n IVC, with contrast opacification of the lumen, and no evidence of active\n extravasation. Note is made of a recanalized umbilical vein, as well as\n numerous periportal, gastrohepatic, perisplenic, and periesophageal venous\n collaterals. Hepatic vascular anatomy is conventional. The main, right, and\n (Over)\n\n 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left hepatic and portal veins, superior mesenteric vein, splenic vein, and IVC\n are patent.\n\n The gallbladder is partially collapsed, with mild reactive wall edema. There\n is mild fatty infiltration of the pancreas. There is no intra- or\n extra-hepatic biliary ductal dilatation. The spleen is borderline enlarged at\n 13 cm.\n\n The adrenals are normal. The kidneys enhance and excrete contrast promptly\n and symmetrically. A 6-mm hyperdense focus in the left interpole (2:45) does\n not demonstrate significant contrast enhancement, and likely represents a\n hemorrhagic cyst. There are no renal stones, masses, or hydronephrosis. A\n large exophytic cyst at the right upper pole measures 6.7 x 4.0 cm.\n\n Nasogastric tube has been removed, and a new post-pyloric tube terminates in\n the second portion of the duodenum. Evaluation of the bowel is limited by\n extensive ascites, which results in centralization of bowel loops, with\n diffuse reactive wall edema. There is no transition point to suggest\n obstruction. No extraluminal air collections are identified.\n\n PELVIS: A Foley catheter is noted within a collapsed bladder. The colon is\n filled with fluid. Rectal tube is in place. Ascitic fluid is noted tracking\n into the scrotal sacs, right greater than left. Diffuse body wall edema is\n also present.\n\n Scattered calcifications are noted in the abdominal aorta and iliac arteries,\n with patent branch vessels. IVC filter is in place below the level of the\n renal arteries. Multiple prominent retroperitoneal nodes are present, likely\n reactive.\n\n The bones are diffusely demineralized. There are no suspicious lytic or\n sclerotic osseous lesions. There is straightening of thoracic kyphosis.\n Bridging osteophytes are present at L1-L2. Again noted is a compression\n deformity of L2, with near-complete loss of height and mild retropulsion into\n the spinal canal. The thecal sac outline is slightly flattened; please note\n that CT cannot visualize intrathecal detail. Laminectomy changes and\n posterior pedicle screws are again seen transfixing L1 and L3, without\n evidence of hardware complications.\n\n IMAGING LAB: Calculated liver volume is 954.019 cm3, and calculated splenic\n volume is 425.227 cm3.\n\n IMPRESSION:\n 1. Cirrhosis, splenomegaly, and varices. Changes of chemoembolization and\n TIPS. Resolving hemoperitoneum, without evidence of active extravasation.\n (Over)\n\n 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Enlarging left and stable moderate right pleural effusions.\n 3. Bibasilar consolidation, consistent with pneumonia.\n 4. L2 compression fracture and L1-L3 posterior fixation.\n 5. Post-pyloric tube placement.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171612, "text": " 10:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after left thoracocentesis.\n\n Portable AP chest radiograph was reviewed in comparison to \n obtained at 2:30 p.m.\n\n The ET tube tip is 4 cm above the carina. The Dobbhoff tube tip is most\n likely in the proximal jejunum/distal duodenum. The left internal jugular\n line tip is unchanged. The TIPS catheter is in place.\n\n As compared to the prior study, there is no change in bilateral\n consolidations, bilateral pleural effusions and pulmonary edema, although the\n degree of pulmonary edema can be slightly worse than on the prior radiograph.\n No interval development of pneumothorax is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1168923, "text": " 11:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate pleural effusions/PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, getting transferred with decompensated liver failure\n after TIPS\n REASON FOR THIS EXAMINATION:\n please evaluate pleural effusions/PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decompensated liver failure.\n\n FINDINGS: No previous images. There is mild enlargement of the cardiac\n silhouette with pulmonary vascular congestion. Patchy areas of opacification\n bilaterally could represent foci of pneumonia. There are bilateral pleural\n effusions with atelectatic changes at the bases.\n\n Endotracheal tube tip lies approximately 3.8 cm above the carina. Right IJ\n catheter extends to the mid portion of the SVC and the nasogastric tube\n extends well into the stomach. A TIPS shunt is in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1168960, "text": " 7:32 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate pleural effusions and ?PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n evaluate pleural effusions and ?PNA\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with hepatic encephalopathy.\n\n COMPARISON: Portable chest radiograph from .\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet\n to the pubic symphysis without intravenous contrast. Multiplanar reformatted\n images were prepared.\n\n CONTRAST: Oral contrast was administered. No IV contrast was administered.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are bilateral moderately\n sized pleural effusions with adjacent relaxation atelectasis. Furthermore,\n diffuse foci of patchy opacification are visualized throughout bilateral\n lungs. These findings are consistent with multifocal pneumonia. Otherwise,\n no discrete nodules are visualized.\n\n The cardiac silhouette is enlarged but with no pericardial effusion. The\n right internal jugular line is visualized with the catheter tip at the\n superior vena cava. An endotracheal tube tip appears in place. Within the\n confines of a non-contrast study, the great vessels and aorta appear\n unremarkable.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is a large amount of\n intra-abdominal fluid with density suggestive of a combination of ascites and\n hemoperitoneum. The liver appears shrunken and consistent with cirrhosis.\n Hyperdense foci are visualized through segments VII and VIII of the liver\n consistent with recent embolization of the region due to liver laceration. The\n TIPS catheter is visualized from the main portal vein to the inferior vena\n cava, and appears intact.\n\n An NG tube appears in place. Within the confines of a non-contrast study and\n large amount of free intra-abdominal fluid, the stomach, visualized loops of\n large and small bowel, bilateral kidneys, spleen, and pancreas appear\n unremarkable. An IVC filter appears in place. The abdominal aorta is\n unremarkable. There is no visualized overt mesenteric or retroperitoneal\n lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Large amount of free fluid is\n again visualized in the pelvis, with Hounsfield units suggesting a combination\n (Over)\n\n 7:32 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate pleural effusions and ?PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of ascites and hemoperitoneum. A Foley catheter is visualized in the bladder.\n Otherwise, within the confines of a non-contrast study and large amount of\n intrapelvic fluid, the bladder and rectum appear unremarkable.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous lesions. L2\n vertebral body compression fracture with L1-L3 posterior fixation and\n bilateral pedicular screws through L1 and L3. There is grade 1\n anterolisthesis of L5 on S1.\n\n IMPRESSION:\n 1. Large amount of intra-abdominal and intrapelvic free fluid with Hounsfield\n units suggesting a combination of ascites and hemoperitoneum consistent with\n patient's known ascites and recent liver laceration.\n 2. Bilateral patchy airspace consolidations are suggestive of multifocal\n pneumonia. There is also bilateral moderate pleural effusions with adjacent\n relaxation atelectasis.\n 3. Shrunken liver consistent with cirrhosis with hyperdense material in\n segment VII and VIII consistent with recent embolization. TIPS catheter is\n visualized in place from the main portal vein to the inferior vena cava.\n 4. L2 compression fracture with L1 through L3 posterior fixation and\n bilateral pedicular screws through L1 and L3.\n 5. Gastric tube and endotracheal tube tips remain in place.\n\n These findings were discussed by Mark Ashkan with Dr. at 11:20\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2166-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170474, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 64-year-old man with respiratory failure. Evaluate for interval\n change.\n\n FINDINGS: Endotracheal tube, feeding tube, bilateral central venous catheters\n and tips are all unchanged. The cardiac silhouette is within normal limits.\n There is again seen bilateral pleural effusions and a left retrocardiac\n opacity. Overall, there has been no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170371, "text": " 4:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening effusions\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ? worsening effusions\n REASON FOR THIS EXAMINATION:\n ? worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 64-year-old male with worsening effusions.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral central venous catheters and feeding tube are\n unchanged in position. There are unchanged bilateral large pleural effusions\n and a left retrocardiac opacity. Overall, there has been no interval change.\n A TIPS is seen in the right upper abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169486, "text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with continued needs for intubation, acute liver failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: acute liver failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged monitoring and support devices. Unchanged low lung volumes\n with bilateral pleural effusions, areas of extensive basal atelectasis and\n minimal overhydration. Unchanged borderline size of the cardiac silhouette.\n No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1168958, "text": " 7:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracraneal process\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n r/o intracraneal process\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb TUE 9:51 AM\n No evidence for acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 64-year-old male with hepatic encephalopathy. Evaluate\n for acute intracranial process.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, cerebral\n edema, or mass effect. There is moderate prominence of ventricles and sulci\n due to cerebral atrophy. Calcifications are seen in the carotid and vertebral\n arteries.\n\n Visualized bones structures are grossly unremarkable. The visualized portions\n of the paranasal sinuses and mastoid air cells are well aerated. The scout\n image demonstrates -intestinal tube and an oral endo-tracheal tube.\n\n IMPRESSION: No evidence for an acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1168959, "text": ", J. MICU-7 7:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracraneal process\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n r/o intracraneal process\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n No evidence for acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-19 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1169755, "text": " 5:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p 7.5L paracentesis, with derecruitment pictures on\n ventilator\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: ENYa SUN 8:53 PM\n Interval decrease in bilateral lower lung opacities, compatible with interval\n 7.5 paracentesis. No PTX. Hazy bibasilar opacities likely atelectasis in\n etiology.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n Comparison study of earlier the same date.\n\n FINDINGS: Indwelling devices are unchanged in position except for slight\n advancement of the endotracheal tube, which now terminates 3 cm above the\n carina. Cardiomediastinal contours are within normal limits for technique.\n Increase in lung volumes and improved aeration at both lung bases. Residual\n multifocal patchy and linear opacities in the mid and lower lungs, probably\n reflecting foci of atelectasis. Small pleural effusions have apparently\n slightly improved in the interval.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169291, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man w/ ESLD, undergoing pre-transplant workup. s/p bronch \n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pre-transplant workup, evaluation for interval change\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Mild left pleural effusion with retrocardiac atelectasis. Mild\n atelectasis at the right lung base. Borderline size of the cardiac silhouette\n with minimal pulmonary edema. No evidence of pneumonia. Unchanged monitoring\n and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169779, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with continued required intubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Endotracheal tube tip terminates approximately 4 cm above the\n carina. Other indwelling devices are unchanged in position.\n Cardiomediastinal contours appear similar, but there is new pulmonary vascular\n congestion, accompanied by apparently increasing layering moderate bilateral\n pleural effusions. Band-like opacity in the right mid lung region probably\n reflects a combination of loculated fluid in the minor fissure with adjacent\n area of atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1170194, "text": " 9:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, ?mucous plugging\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with increased secretions, difficulty pulling volumes\n REASON FOR THIS EXAMINATION:\n interval change, ?mucous plugging\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:19 P.M. \n\n HISTORY: Increasing secretions. Question mucus plugging.\n\n IMPRESSION: AP chest compared to through 29:\n\n Aeration has improved slightly since probably due to a remission\n of pulmonary edema. Lung bases remain consolidated due to pneumonia or\n atelectasis. There are no findings to suggest airway impaction, but that\n diagnosis is not excluded by conventional radiographs. Moderate bilateral\n pleural effusions are slightly smaller, as is the cardiac silhouette. ET\n tube, left internal jugular line, right internal jugular line, and feeding\n tube are in standard placements respectively. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1168954, "text": " 6:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: please perform LIVER DUPLEX\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man preop for liver transplant\n REASON FOR THIS EXAMINATION:\n please perform LIVER DUPLEX\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND ABDOMEN, LIVER OR GALLBLADDER\n\n INDICATION: 64-year-old man preop for liver transplant.\n\n FINDINGS:\n\n There is a large amount of intra-abdominal ascites. The liver is small with a\n nodular contour consistent with cirrhosis. No focal liver lesions are seen.\n No intrahepatic duct dilatation is seen. The patient has a TIPS stent in\n situ, which is seen to be patent. There is reversal of flow in the left\n portal vein consistent TIPS placement. Reversed flow is also seen in the\n right anterior portal vein. The main portal vein is patent with normal\n hepatopetal flow. Normal flow demonstrated in all three hepatic veins. The\n main hepatic artery is patent with normal flow. The splenic vein was\n visualized with normal flow; however, the SMV could not be seen. Visualized\n portions of the IVC are unremarkable in appearance, with normal flow. The\n gallbladder is distended without gallstones.\n\n IMPRESSION:\n Nodular cirrhotic liver, TIPS stent in situ, which is patent with normal flow.\n The main portal vein is patent with normal flow. The hepatic veins and hepatic\n artery patent with normal flow. Large amount of intra-abdominal ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169908, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with b/l pleural effusions\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old male with bilateral pleural effusions, evaluate for\n change.\n\n COMPARISON: Chest radiograph .\n\n SINGLE PORTABLE SEMI UPRIGHT VIEW OF THE CHEST: There is interval slight\n increase in bilateral pleural effusions now large on the left and moderate on\n the right, with associated compressive atelectasis. Position of support lines\n is unchanged. Osseous structures appear unremarkable.\n\n IMPRESSION: Slight increase in now large left and moderate right effusions\n with associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169607, "text": " 10:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fulminant liver failure, intubated\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fulminant liver failure. Intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. There is minimally improved ventilation of\n the basal lung zones, right more than left. However, the pre-existing areas\n of atelectasis are visible in almost unchanged manner. Unchanged size of the\n cardiac silhouette, no newly appeared focal parenchymal opacities of the lung\n parenchyma.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1169020, "text": " 12:53 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with line placement bilateral (RIJ switched, LIJ dialysis line)\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Line placement, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the tip of the right\n internal jugular vein catheter is now projecting over the lower SVC. A newly\n introduced left internal jugular vein catheter projects with its tip over the\n midline, obviously in the brachiocephalic vein.\n\n Unchanged bilateral parenchymal opacities, likely to represent a combination\n of pulmonary edema and atelectasis. Presence of a small left pleural effusion\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169132, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fluid overload, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg WED 10:08 AM\n PFI: Unchanged pulmonary edema and atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fluid overload, evaluate for interval change.\n\n COMPARISON: CXR and .\n\n FINDINGS: The endotracheal tube ends 4.1 cm above the carina. A right\n internal jugular catheter tip projects over the mid to low SVC. A left\n internal jugular catheter tip projects over the midline in the brachiocephalic\n vein, unchanged. The feeding tube coils in the stomach with the tip beyond\n the inferior portion of the image. Bilateral parenchymal opacities are\n unchanged and likely represent a combination of pulmonary edema and\n atelectasis. There is probably a small left pleural effusion. No\n pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.\n\n IMPRESSION: Unchanged pulmonary edema and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1169083, "text": " 5:00 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: POSTPYLRORIC DOBHOFF for tube feeds\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH/HCV cirrhosis, transferred with decompensated liver failure\n REASON FOR THIS EXAMINATION:\n POSTPYLRORIC DOBHOFF for tube feeds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with alcohol and HCV cirrhosis transferred for\n decompensated liver failure.\n\n Post-pyloric Dobbhoff tube placement.\n\n FINDINGS: The patient had a Dobbhoff tube already in place by the time he\n entered the fluoroscopy suite, coiled within the body of the stomach. At this\n point, under fluoroscopic guidance, the tip of the Dobbhoff tube was advanced\n to a post-pyloric position. The tip position was confirmed with injection of\n Optiray contrast in the enteric feeding tube. The tip was seen at a location\n consistent with the third portion of the duodenum. At this point enteric tube\n was taped in place.\n\n IMPRESSION: Advancement of enteric tube into post-pyloric position likely\n projecting likely within the third portion of duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170277, "text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver cirrhosis; ? interval change\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:39 A.M., ON \n\n HISTORY: Cirrhosis, question interval change.\n\n IMPRESSION: AP chest compared to through 29:\n\n Large left pleural effusion has increased, moderate right pleural effusion and\n severe bibasilar atelectasis are stable. Heart size is normal. ET tube, left\n internal jugular line, right internal jugular line are in standard placements\n and a feeding tube passes into the stomach and out of view. No pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2166-01-14 00:00:00.000", "description": "Report", "row_id": 92504, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 215\nBSA (m2): 2.20 m2\nBP (mm Hg): 119/70\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Markedly dilated RV cavity. RV\nfunction depressed. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. TR present - cannot be quantified. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion. Ascites.\n\nConclusions:\n\n\n" }, { "category": "Echo", "chartdate": "2166-01-14 00:00:00.000", "description": "Report", "row_id": 92505, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 215\nBSA (m2): 2.20 m2\nBP (mm Hg): 119/70\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\n\n\n" } ]
86,199	101,299	63 YO F w metastatic breast cancer p/w reaccumulated pleural effusion and dyspnea s/p pluerex catheter placement on the left. The patient's respiratory status worsened upon transfer to the intensive care unit and she was intubated. Goals of care discussion were ongoing and it was understood that the patient did not want to ventilated for a prolonged period. The patient was actively treated with antibiotics and also received pulse dose steroids for multiple days. There were no improvement in her symptoms. Pt respiratory condition worsened and she became more and more dependent on the ventilator. After 5 days on the ventilator, the family had another discussion with the primary team. It was understood that Ms was not going to improve in the short term and it was against her wishes to be ventilator dependent for a prolonged period of time. The patient was terminally extubated and she passed away on .	Extensive right pleural effusion with right basal atelectasis, mild left pleural effusion with retrocardiac atelectasis. PFI REPORT 1) Right IJ catheter in the mid to low SVC. As before, there is right upper lobe consolidation, large right and small left pleural effusions. FINDINGS: Right greater than left bilateral pleural effusions are unchanged in appearance with slight increase in degree of predominantly right upper and left lower lung opacities concerning for superimposed areas of pneumonia. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is unchanged; mediastinal and hilar lymphadenopathy is better appreciated on recent chest CT. A partially loculated large right pleural effusion is stable, but a moderate left pleural effusion is increased. IMPRESSION: Unchanged right greater than left pleural effusions with a slight increase in degree of widespread opacification concerning for pneumonia superimposed on malignancy features. STUDY: Right upper extremity venous ultrasound. COMPARISON: Chest radiograph of most recently . Interval development of moderate pulmonary edema and increased left effusion. The airways are patent to the segmental levels, but in the right middle and lower lobes, the middle lobar, right lower lobar, and bronchus intermedius are somewhat narrowed by circumferential soft tissue which may represent lymphadenopathy/metastatic disease. ONE VIEW OF THE CHEST: The lungs are low in volume and show a right middle and bilateral lower lobe opacities with right greater than left pleural effusions. Moderate pericardial effusion. There is unchanged appearance of left Port-A-Cath, right IJ catheter, endotracheal tube and nasogastric tube with incompletely visualized left possible PleurX catheter. Right mastectomy. Extensive right upper lobe opacities with diffuse air bronchograms. Right IJ catheter tip is at the cavoatrial junction. COMPARISON: Chest CTA on . Large right pleural effusion and small-to-moderate left pleural effusion are unchanged. Multiple dense vertebral bodies and ribs are consistent with recently discovered metastatic disease. A left chest port device has been accessed, and the catheter tip terminates in the unchanged position in the cavoatrial junction. Left pleural catheter placement appears satisfactory. Left upper and perihilar opacities have worsened from , but stable from the prior study. Left lower lobe retrocardiac atelectasis has worsened. There is a left chest port device, with the catheter terminating at the cavoatrial junction. Mild pulmonary edema. A left-sided Porta-catheter terminates in the distal SV/cavoatrial junction. Right greater than left pleural effusions are also again seen. Right IJ catheter tip remains at the cavoatrial junction. There is mild pulmonary edema. TECHNIQUE: MDCT helical acquisition was performed through the chest before and after the uneventful administration of IV contrast. The left Pleurx catheter is unchanged. A large multinodular thyroid goiter demonstrates substernal extent, and places slight mass effect on both the trachea and the esophagus. These consolidations somewhat mask the interstitial septal thickening and nodularity, especially in the right lower lobe. CTA CHEST WITH IV CONTRAST: The IV contrast bolus is adequate for assessment of pulmonary embolus. Since the previous tracing of atrial fibrillation isresolved. FINDINGS: Right upper lobe consolidation, loculated right pleural effusion, right lower lobe atelectasis, diffuse left pulmonary reticulonodular opacity probably representing the lymphangitic spread, and a small left pleural effusion are relatively unchanged since . Bilateral right greater than left pleural effusions are unchanged with a left pleural drain in place. Trivial mitral regurgitation is seen. Noaortic regurgitation is seen. FINDINGS: Right internal jugular catheter has been withdrawn and now is in the mid to low SVC. IMPRESSION: 1) Right IJ catheter in the mid to low SVC. There is moderate pulmonaryartery systolic hypertension. Prominentmoderator band/trabeculations are noted in the RV apex.AORTA: Normal aortic diameter at the sinus level. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. Mild mitralannular calcification. Mild [1+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is normal in size. Trivial pericardialeffusion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Stable small left pleural effusion with unchanged position of left Pleurx catheter. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Endotracheal tube, nasogastric tube, and left Port-A-Cath are unchanged in appearance. Sinus tachycardia, rate 120. Sinus tachycardia, rate 120. PATIENT/TEST INFORMATION:Indication: Shortness of breath.Height: (in) 62Weight (lb): 124BSA (m2): 1.56 m2BP (mm Hg): 118/72HR (bpm): 97Status: InpatientDate/Time: at 16:11Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Heart and mediastinum within normal limits. Compared to the previous tracing of therhythm is sinus. Stable right upper lobe consolidation. FINAL REPORT INDICATION: Right IJ line adjustment. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. There is a trivial/physiologic pericardialeffusion.Compared with the prior study (images reviewed) of , detectedpulmonary artery systolic hypertension is higher. Left-sided Pleurx catheter inserted. ST-T wave abnormalities are improved. Low precordial voltage. The bilateral multifocal areas of opacification persist with bilateral pleural effusions. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. The mitral valve leaflets are mildly thickened.There is no mitral valve prolapse. The left-sided Pleurx catheter has a circuitous course as it traverses the lateral chest wall, its tip is projected over the left retrocardiac space, the position is unchanged since . Sinus rhythm. Lines and tubes are unchanged in position. Thetricuspid valve leaflets are mildly thickened. Satisfactory position of medical devices. Normal tracing. Otherwise, normal tracing. Sclerotic appearance to the vertebral bodies is suggestive of metastatic disease. IMPRESSION: No change in right upper lobe, lingula, and left lower lobe pneumonia. The tips of the right internal jugular and left subclavian central venous catheters project over the lower SVC, the endotracheal tube tip is at the level of the clavicles, and the nasogastric tube tip is well below the diaphragm, not included in the field of view of the radiograph.	27	[ { "category": "Radiology", "chartdate": "2147-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163446, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pleural effusions and\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer w/ concern for lymphangitic\n spread and chronic malignant pleural effusions, with pneumonia and hypoxic\n respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pleural effusions and pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:47 PM\n Unchanged right greater than left pleural effusions with a slight increase in\n degree of widespread opacification concerning for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for change. Pleural effusion and pneumonia in patient\n with metastatic breast cancer and concern for lymphangitic spread of malignant\n effusion.\n\n TECHNIQUE: Portable supine radiograph of the chest.\n\n COMPARISON: Chest radiograph of most recently .\n\n FINDINGS: Right greater than left bilateral pleural effusions are unchanged\n in appearance with slight increase in degree of predominantly right upper and\n left lower lung opacities concerning for superimposed areas of pneumonia.\n There is unchanged appearance of left Port-A-Cath, right IJ catheter,\n endotracheal tube and nasogastric tube with incompletely visualized left\n possible PleurX catheter. Cardiomediastinal silhouette is unremarkable.\n\n IMPRESSION: Unchanged right greater than left pleural effusions with a slight\n increase in degree of widespread opacification concerning for pneumonia\n superimposed on malignancy features.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163447, "text": ", 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pleural effusions and\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer w/ concern for lymphangitic\n spread and chronic malignant pleural effusions, with pneumonia and hypoxic\n respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pleural effusions and pneumonia\n ______________________________________________________________________________\n PFI REPORT\n Unchanged right greater than left pleural effusions with a slight increase in\n degree of widespread opacification concerning for pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162812, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluation of Pulmonary process\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic Breast Ca to liver, lung spine s/p worsening\n lymphangitic spread to the lungs and intubation w/ possible overlying PNA\n REASON FOR THIS EXAMINATION:\n Evaluation of Pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic breast cancer with lymphangitic spread to the lungs.\n Superimposed pneumonia.\n\n COMPARISON: .\n\n SUPINE CHEST RADIOGRAPH: Lines and tubes are in unchanged position. There is\n no pneumothorax. The lungs are not significantly changed, particularly the\n right upper and left lower lobe opacities, loculated right-sided pleural\n effusion, right lower lobe atelectasis, diffuse left pulmonary reticular\n nodular opacity and small left-sided pleural effusion. The left Pleurx\n catheter is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1163078, "text": " 7:37 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: ? DVT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer, now with a more swollen right\n arm.\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 11:45 AM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with metastatic breast cancer, now with right arm\n swelling.\n\n STUDY: Right upper extremity venous ultrasound.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler son imaging was performed of\n the bilateral subclavian, right internal jugular, right axillary, right\n brachial, right basilic, and right cephalic veins. Normal compressibility,\n flow, and augmentation were demonstrated.\n\n IMPRESSION: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1163079, "text": ", 7:37 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: ? DVT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer, now with a more swollen right\n arm.\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-11 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1161838, "text": " 1:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: BREAST CA, TACHY, O2 REQUIREMENT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with breast cancer, recently found malignant pleural\n effusions, now with worsening oxygen requirement and persistent tachycardia\n REASON FOR THIS EXAMINATION:\n please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc MON 3:18 AM\n No evidence of pulmonary embolism to the segmental levels. Diffuse increase in\n opacification involving the entire right upper lobe, right middle lobe, and\n right lower lobe. In addition opacfication in the lef lower lobe, left upper\n lobe. Moderate loculated right pleural effusion increased since prior,\n moderate layering left effusion, increased since prior. Moderate pericardial\n effusion. Right mastectomy.\n\n Overall favor new infectious process with differential include atypical\n infections including fungal infection. An aspect of this opacity may also be\n related to radiation pneunomitis and disease burden.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female with breast cancer, malignant pleural effusions\n with worsening oxygen requirement and persistent tachycardia, evaluate for\n pulmonary embolus.\n\n COMPARISON: Chest CTA on .\n\n TECHNIQUE: MDCT helical acquisition was performed through the chest before\n and after the uneventful administration of IV contrast. Low-dose pre-contrast\n 5-mm collimation axial as well as post-contrast 2.5-mm axial images were\n reviewed as well as a series of reformation images.\n\n CTA CHEST WITH IV CONTRAST: The IV contrast bolus is adequate for assessment\n of pulmonary embolus. There is no evidence of pulmonary embolus to the\n subsegmental level on the right or in the left upper lobe, and no evidence of\n segmental PE in the left lower lobe.\n\n There has been interval significant increase in bilateral pleural effusions,\n somewhat loculated on the right and layering on the left. There is associated\n compressive atelectasis. There is new diffuse airspace consolidation, but\n especially in the right upper lobe, with a lesser degree in the right lower\n lobe and middle lobe. In the superior segment of the left lower lobe, there\n is also a new heterogeneous airspace consolidation. These consolidations\n somewhat mask the interstitial septal thickening and nodularity, especially in\n the right lower lobe. However, this suggests underlying lymphangitic spread\n of carcinomatosis.\n\n The patient has undergone remote right mastectomy. There is no axillary\n (Over)\n\n 1:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: BREAST CA, TACHY, O2 REQUIREMENT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lymphadenopathy. However, mediastinal lymphadenopathy is confluent and\n extensive, making measurement of an individual node difficult. This is most\n pronounced in the subcarinal and bilateral hilar stations. The airways are\n patent to the segmental levels, but in the right middle and lower lobes, the\n middle lobar, right lower lobar, and bronchus intermedius are somewhat\n narrowed by circumferential soft tissue which may represent\n lymphadenopathy/metastatic disease.\n\n There is a left chest port device, with the catheter terminating at the\n cavoatrial junction. A large multinodular thyroid goiter demonstrates\n substernal extent, and places slight mass effect on both the trachea and the\n esophagus.\n\n Limited images of the upper abdomen demonstrate an apparent low-density left\n liver lesion measuring 2.9 x 2.5 cm (3:85).\n\n Osseous structures again demonstrate extensive metastatic disease throughout\n the thoracic spine, most pronounced in T1, T3, T5, T7, T9-L1, but also\n involving multiple ribs and the sternum.\n\n IMPRESSION:\n\n 1. New development of multifocal airspace consolidation, especially in right\n upper lobe representing pneumonia, likely explanation of increased O2\n requirement.\n\n 2. Increased bilateral pleural effusions, with loculation on the right, and a\n large left layering effusion causing compressive atelectasis.\n\n 3. Interstitial septal thickening and nodularity, especially in the right\n lower lobe as well as confluent adenopathy in the mediastinum and hila which\n is suspicious for lymphangitic spread of carcinomatosis.\n\n 4. Widespread metastatic disease in a pattern similar to two weeks ago,\n involving the bony thorax extensively and likely left lobe of the liver.\n\n Dr. the acute findings with Dr. at 3:15 a.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2147-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162068, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with malignant pleural effusions s/p pleurex \n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female with malignant pleural effusion and history of\n breast cancer.\n\n COMPARISON: Chest radiograph .\n\n SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour\n is unchanged; mediastinal and hilar lymphadenopathy is better appreciated on\n recent chest CT. A partially loculated large right pleural effusion is\n stable, but a moderate left pleural effusion is increased. Multifocal\n infectious consolidation which increased. However, perihilar opacities have\n increased in a pattern suggesting contribution by pulmonary edema. A left\n chest port device terminates with the catheter at the cavoatrial junction in\n unchanged position. Multiple dense vertebral bodies and ribs are consistent\n with recently discovered metastatic disease.\n\n IMPRESSION:\n\n 1. Increaed multifocal lung infection.\n\n 2. Interval development of moderate pulmonary edema and increased left\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163256, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pneumonia and pleural\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer with chronic b/l malignant\n pleural effusions (also with Left pleurex), new RUL pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pneumonia and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer with malignant effusions and right upper\n lobe pneumonia.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Monitoring and support devices remain in place. Multiple bilateral areas of\n opacification involving the right upper zone and left mid and lower zones\n persists, consistent with widespread pneumonia. Little overall change in the\n bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161958, "text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 63 yr old s/p pleurax catheter placement\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p pleurax catheter placement\n REASON FOR THIS EXAMINATION:\n 63 yr old s/p pleurax catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a 63-year-old female post-pleurx catheter placement, also\n history of breast cancer, malignant pleural effusion, new widespread pulmonary\n opacities.\n\n COMPARISON: CTA chest early the same morning and chest radiograph three days\n prior.\n\n SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is\n normal, with hilar and mediastinal lymphadenopathy better appreciated on CT\n performed earlier the same day. Multifocal widespread pulmonary opacities are\n worst in the right upper lobe, with lesser degrees in the superior segment of\n the left upper lobe, and at the right lung base. Right greater than left\n pleural effusions are also again seen. Left pleural catheter placement\n appears satisfactory. A left chest port device has been accessed, and the\n catheter tip terminates in the unchanged position in the cavoatrial junction.\n\n Osseous structures demonstrate extensive densities, which correlate with known\n blastic metastases.\n\n IMPRESSION: Post-left pleural catheter placement with otherwise no\n significant short interval change since CT chest earlier same morning.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162380, "text": " 6:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PLACEMENT OF CVL,ETT,OG TUBE S/P INTUBATION\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n Placement of CVL\n ______________________________________________________________________________\n WET READ: SPfc WED 8:54 PM\n Right IJ ends at the upper cavo-atrial junction. Left port-a-cath ends in the\n SVC. ETT ends 2.2cm above the carina. NG tube enters the stomach and extends\n beyond the field of view. There is no pneumothorax. As before, there is\n right upper lobe consolidation, large right and small left pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess lines and tubes.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Right IJ catheter tip is at the cavoatrial junction. ET tube tip is 2.5 cm\n above the carina. NG tube tip is coiled in the stomach. The tip is out of\n view. There is no pneumothorax. Multifocal consolidations and pleural\n effusions are unchanged. Cardiomediastinal silhouette is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161568, "text": " 5:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with dyspnea and hypoxia\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with dyspnea and hypoxia.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show a right middle and bilateral lower lobe\n opacities with right greater than left pleural effusions. The right\n suprahilar opacity is more prominent as compared to the prior exam. There is\n mild pulmonary edema. A left-sided Porta-catheter terminates in the distal\n SV/cavoatrial junction. Cardiac silhouette is difficult to assess due to\n adjacent pleural effusions, but is grossly stable.\n\n IMPRESSION:\n\n Right suprahilar opacity is more prominent, which could be secondary to\n increase in size of pulmonary mass/consolidation with superimposed edema.\n\n Right greater than left bilateral pleural effusions have increased since the\n prior exam.\n\n Bilateral lower lobe opacities may represent atelectasis with possible\n consolidation.\n\n\n Mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162255, "text": " 5:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression of pna\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with met breast ca, recurrent pleural effusion, and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for progression of pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Metastatic breast carcinoma, recent pleural effusion, evaluation\n of progression.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive right upper lobe opacities with diffuse air bronchograms.\n A similar pattern of opacity is noted around the left hilus and left upper\n lobe periphery. Extensive right pleural effusion with right basal\n atelectasis, mild left pleural effusion with retrocardiac atelectasis. The\n size of the cardiac silhouette is unchanged. No newly appeared focal\n parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162411, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube/line placement, interval change\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman intubated with resp failure\n REASON FOR THIS EXAMINATION:\n eval for tube/line placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure, intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is in standard position, 4.2 cm above the carina. NG tube tip is\n out of view below the diaphragm. Right IJ catheter tip remains at the\n cavoatrial junction. There is no pneumothorax. Cardiomediastinal contours\n are unchanged. Large right pleural effusion and small-to-moderate left\n pleural effusion are unchanged. Right upper lobe consolidation and right\n lower lobe opacities are stable. Left upper and perihilar opacities have\n worsened from , but stable from the prior study. Left lower lobe\n retrocardiac atelectasis has worsened. Left central catheter remains in\n place.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162514, "text": ", 2:18 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval RIJ placement.\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer.\n REASON FOR THIS EXAMINATION:\n please eval RIJ placement.\n ______________________________________________________________________________\n PFI REPORT\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162620, "text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assessment of plueral effusions, PNA\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with Metastatic Breast Ca to spine liver and lung w/\n worsening lymphangitic spread to lung seen on CT, worsening pleural effusions\n s/p pluerex on Lt as well as possible PNA now intubated\n REASON FOR THIS EXAMINATION:\n Assessment of plueral effusions, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic breast carcinoma to lungs (with lymphangitic spread),\n spine, and liver. Left-sided Pleurx catheter inserted. Evaluate for\n effusions and pneumonia.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Right upper lobe consolidation, loculated right pleural effusion,\n right lower lobe atelectasis, diffuse left pulmonary reticulonodular opacity\n probably representing the lymphangitic spread, and a small left pleural\n effusion are relatively unchanged since . The tips of the right\n internal jugular and left subclavian central venous catheters project over the\n lower SVC, the endotracheal tube tip is at the level of the clavicles, and the\n nasogastric tube tip is well below the diaphragm, not included in the field of\n view of the radiograph. The left-sided Pleurx catheter has a circuitous\n course as it traverses the lateral chest wall, its tip is projected over the\n left retrocardiac space, the position is unchanged since .\n\n IMPRESSION:\n 1. Stable small left pleural effusion with unchanged position of left Pleurx\n catheter.\n 2. Diffuse left pulmonary reticulonodular opacity likely reflects\n lymphangitic spread.\n 3. Stable right upper lobe consolidation.\n 4. Satisfactory position of medical devices.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162513, "text": " 2:18 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval RIJ placement.\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer.\n REASON FOR THIS EXAMINATION:\n please eval RIJ placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:37 PM\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ line adjustment.\n\n TECHNIQUE: Semi-upright portable radiograph of the chest.\n\n COMPARISON: Multiple chest radiographs most recently at\n 0:33 hours.\n\n FINDINGS: Right internal jugular catheter has been withdrawn and now is in the\n mid to low SVC. Endotracheal tube, nasogastric tube, and left Port-A-Cath are\n unchanged in appearance. Bilateral diffuse opacities have increased in\n density. Bilateral right greater than left pleural effusions are unchanged\n with a left pleural drain in place. Sclerotic appearance to the vertebral\n bodies is suggestive of metastatic disease. Patient is status post right\n mastectomy. Hazy opacity throughout both lungs is suggestive of some degree\n of pulmonary vascular congestion or edema.\n\n IMPRESSION:\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n These findings were relayed by Dr. to Dr. at 15:10 on .\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163045, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. The bilateral multifocal areas of opacification\n persist with bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162940, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in RUL infiltrate and pl\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer with possible lymphangitic\n spread, with worsening hypoxic respiratory failure secondary to possible\n lymphangitic spread, PNA, and pleural effusions\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in RUL infiltrate and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, .\n\n CLINICAL INFORMATION: Interval change, right upper lobe infiltrate,\n respiratory failure, pneumonia.\n\n Comparison is made to multiple prior examinations.\n\n There is little appreciable change. There is multifocal airspace\n opacification, right upper lobe, lingula, and left lower lobe.\n\n Lines and tubes are unchanged in position. Heart and mediastinum within\n normal limits.\n\n IMPRESSION:\n\n No change in right upper lobe, lingula, and left lower lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163018, "text": " 5:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? worsening pleural effusion or pneumonia\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer to the lungs intubated due to\n hypoxia now with worsening WBC\n REASON FOR THIS EXAMINATION:\n ? worsening pleural effusion or pneumonia\n ______________________________________________________________________________\n WET READ: AJy SUN 8:59 PM\n little interval chnage in multifocal airspace opacities and loculated right\n pleural effusion. lines and tubes similarly stable.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer with worsening WBC.\n\n FINDINGS: In comparison with the study of earlier in the date, there is\n little change. Monitoring and support devices remain in place. Multifocal\n areas of consolidation are again seen bilaterally along with the bilateral\n pleural effusions better seen on the CT of .\n\n\n" }, { "category": "Echo", "chartdate": "2147-12-12 00:00:00.000", "description": "Report", "row_id": 90207, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 62\nWeight (lb): 124\nBSA (m2): 1.56 m2\nBP (mm Hg): 118/72\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 16:11\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , detected\npulmonary artery systolic hypertension is higher. Trivial pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2147-12-13 00:00:00.000", "description": "Report", "row_id": 237867, "text": "Artifact is present. Sinus tachycardia. Otherwise, normal tracing. Compared\nto the previous tracing there is no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-11 00:00:00.000", "description": "Report", "row_id": 237868, "text": "Sinus tachycardia, rate 120. Compared to tracing #1 there is no diagnostic\ninterval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-12-10 00:00:00.000", "description": "Report", "row_id": 237869, "text": "Sinus tachycardia, rate 120. Poor R wave progression in leads V1-V3. Compared\nto the previous tracing of , except for the increase in rate, there is\nno other diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-08 00:00:00.000", "description": "Report", "row_id": 237870, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrhythm is sinus. There is no evidence of a bypass tract on the current\ntracing.\n\n" }, { "category": "ECG", "chartdate": "2147-12-18 00:00:00.000", "description": "Report", "row_id": 237864, "text": "Baseline artifact. Sinus tachycardia. Low precordial voltage. Late R wave\nprogression. Since the previous tracing of atrial fibrillation is\nresolved. ST-T wave abnormalities are improved.\n\n" }, { "category": "ECG", "chartdate": "2147-12-15 00:00:00.000", "description": "Report", "row_id": 237865, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the rhythm has changed.\n\n" }, { "category": "ECG", "chartdate": "2147-12-14 00:00:00.000", "description": "Report", "row_id": 237866, "text": "Artifact is present. Sinus tachycardia. Atrial and ventricular ectopy.\nCompared to the previous tracing ectopic beats are new.\nTRACING #2\n\n" } ]
11,242	116,244	The patient was admitted and treated for diabetic ketoacidosis. She was begun on an insulin drip and eventually weaned to subcutaneous insulin. She received aggressive IV fluid and electrolyte repletion. No precipitating event was elucidated for her diabetic ketoacidosis. A repeat chest x-ray revealed a small right pleural effusion of unclear etiology. She was discharged to home in good condition.	Left atrialabnormality. Baseline artifact. Technically limited study. Vertical axis. Compared to the previous tracing of there is no significant change.	1	[ { "category": "ECG", "chartdate": "2147-02-22 00:00:00.000", "description": "Report", "row_id": 308741, "text": "Technically limited study. Sinus tachycardia. Vertical axis. Left atrial\nabnormality. Baseline artifact. Compared to the previous tracing of \nthere is no significant change.\n\n" } ]
25,019	171,458	This is an 87 y.o. male with multi-infarct dementia who presented with 1 week of failure-to-thrive (decreased po intake, lethargy, more frequent falls, unwillingness to ambulate). U/A positive for increased WBC, gram positive organisms = Coag pos Staphlococcus. Left hip ulcer positive for multiple organisms. Mental status in setting of end-stage multi-infarct dementia, h/o neurosyphyllis, infection: Patient's mental status has improved slightly during this admission, as he is more alert and sometimes responsive to direct questioning, with treatment of underlying infections, electrolyte disturbances (hypernatremia on admission to 156) and aggressive nutrition and augmentation with TPN. His overall prognosis, however, remains extremely poor given overwhelming infection in the setting of end stage dementia. His ulcer has improved from a Grade4 ulcer to a Grade 3, still with ulcer to muscle. It has not improved over the past week and surgical options are limited given poor nutritional state/overall poor prognosis. His UTI has been treated with levofloxacin and levo has been maintained because of overwhelming infection. It is likely that his infection is static given no real change in fevers, leukocytosis but complete resolution of infection is unlikely. He appears to be at his baseline mental status which is alert and sometimes responsive to direct questioning with simple one-word answers	A final chest x-ray was obtained. A final chest x-ray was obtained. A final chest x-ray was obtained. A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. The PICC was trimmed to length and a 4 FR introducer sheath under fluoroscopic guidance into the superior vena cava. A .018 guidewire was advanced under fluoroscopy into the superior vena cava. A Stat-Lock was applied and the line was heplocked. The film demonstrates the tip to be in the lower superior vena cava, ready for use. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance into the superior vena cava. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. Since no suitable superficial veins were visible ultrasound was used for localization of a suitable vein. Hard copies of ultrasound images were obtained documenting patent vein before and after establishing an access. PROCEDURE: The procedure was performed by Drs. Needs PICC line for intravenous antibiotics. Patient needs IV line for antibiotics and TPN. Hard copy images of ultrasound scan were obtained documenting patent vein before and after establishing an access. A repeat tracing of diagnostic quality issuggested. pt is a full code.dispo-> ?transfer to medicine later today. After local anesthesia with 2 ml of 1% lidocaine the brachial vein was entered under ultrasonographic guidance with a 21 gauge needle. also of note, the pt's hypotension resolved s/p the transfusion of 2u prbc's.review of systemsrespiratory-> lung sounds diminished d/t a poor respiratory effort. The PICC line was trimmed to length and advanced over a 5 French introducer sheath under fluoroscopic guidance into the superior vena cava. FINAL REPORT HISTORY: This is a patient with osteomyelitis. currently, sbp ranging 90-110's s/p blood transfusion.neuro-> intermittently agitated and combative. After local anesthesia with 2 ml of 1% lidocaine, the basilic vein was entered under ultrasonographic guidance with a 21 gauge needle. The film demonstrates the tip to be in the superior vena cava. After local anesthesia with 3 ml of 1% Lidocaine, the right brachial vein was entered under ultrasound guidance with a 21 gauge needle. Admitting Diagnosis: FAILURE TO THRIVE ******************************* CPT Codes ****************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. RADIOLOGISTS: Procedure was performed by Drs. The left upper arm was prepped in a sterile fashion. 1:11 PM PICC LINE PLACMENT SCH Clip # Reason: need for abx/TPN Admitting Diagnosis: FAILURE TO THRIVE ******************************* CPT Codes ****************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 87 year old man with end stage dementia/FTT, urosepsis REASON FOR THIS EXAMINATION: need for abx/TPN FINAL REPORT INDICATION: 87 year old male with urosepsis requiring antibiotics and TPN. PHYSICIANS: The procedure was performed by Drs. The right arm was prepped and draped in the usual sterile fashion. A Stat-Lock was applied and the line was hep-locked. , , and , with Dr. attending physician present and supervising. IMPRESSION: Successful placement of a 45 cm long PICC line with tip in the superior vena cava, ready for use. the pt is currently restrained w/mitts in place. he is severely contracted but able to move his ue's.gi-> abd is soft, nontender w/+bs. and with Dr. (attending radiologist) being present and supervising throughout the procedure. The catheter was flushed. The catheter was flushed. The catheter was flushed. IMPRESSION: Successful placement of 47 cm total length double lumen PICC line with tip in the superior vena cava, ready for use. The brachial vein was patent and compressible. he is receiving free water repletion via a d5 infusion.heme-> morning hct ~30 s/p 2u prbc's. PROCEDURE AND FINDINGS: The patient was placed supine on the angiography table and his right arm was prepped in sterile fashion. Based on the markers on the guidewire, it was determined that a length of 47 cm would be suitable. Dr. , the attending radiologist, was present and supervising throughout the procedure. IMPRESSION: Successful placement of a 55 cm long PICC line with tip in the superior vena cava, ready for use. TECHNIQUE AND FINDINGS: The patient was placed supine on the angiography table. The sheath was removed. The sheath was removed. The sheath was removed. after he made several attempts to pull out his central line, he was restrained and mitts were applied for his own safety. 9:51 AM PICC LINE PLACMENT SCH Clip # Reason: iv abx. ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** MEDICAL CONDITION: 87 year old man with end stage dementia/FTT, urosepsis/osteomyletis--iv abx REASON FOR THIS EXAMINATION: iv abx. pt is maintaining sats >96% on room air.cardiac-> hr 60-70's, sr w/no noted ectopy. The basilic vein was patent and compressible. pt did take his po meds last evening w/o incident.gu-> uop is adequate; the pt is ~3.5 liters tfb positive d/t aggressive fluid/volume repletion.f/e-> pt is hypernatremic but his sodium level is slowly coming down.	6	[ { "category": "Nursing/other", "chartdate": "2136-07-23 00:00:00.000", "description": "Report", "row_id": 1588595, "text": "pmicu npn 7p-7a\n\n\n the pt was intermittently agitated and combative this morning. after he made several attempts to pull out his central line, he was restrained and mitts were applied for his own safety. when left alone, he is calm, but the restraints remain in place. also of note, the pt's hypotension resolved s/p the transfusion of 2u prbc's.\n\nreview of systems\n\nrespiratory-> lung sounds diminished d/t a poor respiratory effort. pt is maintaining sats >96% on room air.\n\ncardiac-> hr 60-70's, sr w/no noted ectopy. currently, sbp ranging 90-110's s/p blood transfusion.\n\nneuro-> intermittently agitated and combative. the pt is currently restrained w/mitts in place. he is alert but demented and unable to consistently follow commands. he is severely contracted but able to move his ue's.\n\ngi-> abd is soft, nontender w/+bs. -bm. tolerating soft solids. pt did take his po meds last evening w/o incident.\n\ngu-> uop is adequate; the pt is ~3.5 liters tfb positive d/t aggressive fluid/volume repletion.\n\nf/e-> pt is hypernatremic but his sodium level is slowly coming down. he is receiving free water repletion via a d5 infusion.\n\nheme-> morning hct ~30 s/p 2u prbc's. there have been no overt signs of any active bleeding.\n\naccess-> #18g angio in the right arm and a right ij tl are aptent and intact.\n\nsocial-> pt's dtr stayed in the waiting area. another dtr and son visited late last noc. children were encouraged to elect a spokesperson since the family is large. in addition, the family may benefit from a social work consult since 2 of the dtrs are caring for each parent separately, and both parents appear to be significantly impaired. pt is a full code.\n\ndispo-> ?transfer to medicine later today.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-07-22 00:00:00.000", "description": "Report", "row_id": 1588594, "text": "MICU Nursing Admit Note 1800-1900\n\n87 yo man admit from home, demented, emaciated, numerous contractures, and pressure sores on lower extrem, brought to ED today for no po's for 24hrs.\n\nPMH: dementia,+RPR, h/o ETOH abuse, CAD, MI, failure to thrive,\n\nSOCIAL: lives with dtr has been his caretaker for ~20years\n\nALLERGIES: valium, ace inhibitor(angio edema)\n\nREVIEW OF SYSTEMS:\nNEURO: arrived to MICU alert orient to person, answer simple yes/no question, mental status wax/wane to mumbling incoherently, multiple contractures.\nCV: HR 60-70 SR, BP 90-100/, recieved 3L NS bolus in ED\nRESP: RR 14-18 nonlabored, breath sounds decreased\nID: temp 98 pr, wbc 8.5, fully cultured in ED, +UTI, given IV levaquin and vanco in ED\nGI: abd soft +bs\nGU: foley with cloudy yellow urine\nF/E: Na 156, free water repletion with D5W at 60cc/hr\nHEME: hct 26, type/cross send to be transfused\nSKIN: left hip with 4cmx5cm stage 2-3 douderm applied, pressure sores between knees and bony prominences where legs are rubbing\nACCESS: #18, RIJ triple lumen\nSOCIAL: lives with dtr\n\nPLAN: supportive care, replete free water deficit, palliative care consult, social work consult.\n\n" }, { "category": "Radiology", "chartdate": "2136-08-03 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 832113, "text": " 1:11 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: need for abx/TPN\n Admitting Diagnosis: FAILURE TO THRIVE\n ******************************* CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with end stage dementia/FTT, urosepsis\n REASON FOR THIS EXAMINATION:\n need for abx/TPN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 year old male with urosepsis requiring antibiotics and TPN.\n\n PROCEDURE:\n\n The procedure was performed by Drs. , , and , with Dr. \n attending physician present and supervising. The right arm was prepped and\n draped in the usual sterile fashion. Since no suitable superficial veins were\n visible, ultrasound was used for localization of a suitable vein. The basilic\n vein was patent and compressible. After local anesthesia with 2 ml of 1%\n lidocaine, the basilic vein was entered under ultrasonographic guidance with a\n 21 gauge needle. A .018 guidewire was advanced under fluoroscopy into the\n superior vena cava. Based on the markers on the guidewire, it was determined\n that a length of 47 cm would be suitable. The PICC was trimmed to length and\n a 4 FR introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final chest x-ray\n was obtained. The film demonstrates the tip to be in the lower superior vena\n cava, ready for use.\n\n A Statlock was applied and the line was locked.\n\n IMPRESSION:\n\n Successful placement of 47 cm total length double lumen PICC line with tip in\n the superior vena cava, ready for use.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2136-08-15 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 833327, "text": " 9:51 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: iv abx.\n Admitting Diagnosis: FAILURE TO THRIVE\n ***************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with end stage dementia/FTT, urosepsis/osteomyletis--iv abx\n\n REASON FOR THIS EXAMINATION:\n iv abx.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a patient with osteomyelitis. Needs PICC line for intravenous\n antibiotics.\n\n RADIOLOGISTS: Procedure was performed by Drs. and \n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n TECHNIQUE AND FINDINGS: The patient was placed supine on the angiography\n table. The left upper arm was prepped in a sterile fashion. Since no suitable\n superficial veins were visible ultrasound was used for localization of a\n suitable vein. The brachial vein was patent and compressible. After local\n anesthesia with 2 ml of 1% lidocaine the brachial vein was entered under\n ultrasonographic guidance with a 21 gauge needle. Hard copies of ultrasound\n images were obtained documenting patent vein before and after establishing an\n access. A 0.018 guidewire was advanced under fluoroscopy into the superior\n vena cava. Based on the markers on the guide wire it was determined that the\n length of 55 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed. The catheter was flushed. A\n final chest x-ray was obtained. The film demonstrates the tip to be in the\n superior vena cava. The line is ready for use. A Stat-Lock was applied and the\n line was heplocked.\n\n IMPRESSION: Successful placement of a 55 cm long PICC line with tip in the\n superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2136-07-26 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 831298, "text": " 11:15 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: double lumen, could not be placed at bedside\n Admitting Diagnosis: FAILURE TO THRIVE\n ***************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with urosepsis and failure to thrive\n REASON FOR THIS EXAMINATION:\n double lumen, could not be placed at bedside\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decubitus ulcer with osteomyelitis. Patient needs IV line for\n antibiotics and TPN. IV team could not advance PICC line at bedside.\n\n PHYSICIANS: The procedure was performed by Drs. and \n with Dr. (attending radiologist) being present and supervising\n throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiography table\n and his right arm was prepped in sterile fashion. Since no suitable\n superficial veins were visible, ultrasound was used for localization of a\n suitable vein. After local anesthesia with 3 ml of 1% Lidocaine, the right\n brachial vein was entered under ultrasound guidance with a 21 gauge needle.\n Hard copy images of ultrasound scan were obtained documenting patent vein\n before and after establishing an access. A 0.018 guidewire was advanced under\n fluoroscopy into the superior vena cava. Based on the markers on the guidewire\n it was determined that a length of 45 cm would be suitable. The PICC line was\n trimmed to length and advanced over a 5 French introducer sheath under\n fluoroscopic guidance into the superior vena cava. The sheath was removed. The\n catheter was flushed. A final chest x-ray was obtained. The film demonstrates\n the tip to be in the superior vena cava just above the atrium. The line is\n ready for use. A Stat-Lock was applied and the line was hep-locked. There\n were no immediate complications.\n\n IMPRESSION: Successful placement of a 45 cm long PICC line with tip in the\n superior vena cava, ready for use.\n\n" }, { "category": "ECG", "chartdate": "2136-07-22 00:00:00.000", "description": "Report", "row_id": 313410, "text": "The tracing is marred by baseline artifact precluding adequate interpretation.\nThe limb leads appear misattached. A repeat tracing of diagnostic quality is\nsuggested.\n\n" } ]
66,710	184,546	Respiratory symptoms: Cough, URI symptoms since 1-2 weeks. Patient denies noticing any dyspnea, but desatting to 80s off BIPAP. Leukocytosis, but afebrile, no tachycardia. Mets SIRS criteria. Was placed on CAP coverage and diuresed for suspected new onset CHF (BNP ), eventually broadened to vanc/cefepime and placed on a lasix gtt. Over the course of the admission, we were unable to wean the patient from bipap; he would desaturate into the low 80s/high 70s whenever on 100% FiO2 face mask. He remained tachypneic with increased work of breathing on the bipap machine with a PEEP of 10. His chest xray showed continued interval progression of his lung pathology, with worsening multifocal infiltrates and probable development of ARDS. The patient remained DNR/DNI throughout. A family meeting was held to discuss goals of care; at that point, we felt that we either needed to pursue intubation with full therapeutic management (ARDSnet volumes, aggressive suctioning for secretions, etc) or be made CMO as he was approaching 4 days on bipap without any improvement and was already maximized on other therapies. Ultimately, on the family decided in conjunction with the patient to make him CMO. He was placed on a morphine gtt and actually maintained on the bipap until his whole family arrived. Eventually, the morphine gtt was increased and his bipap was removed. He expired peacefully on at 8:15pm.	Mild mitral annularcalcification. Moderate (2+) mitral regurgitationis seen. There is nopericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.Moderate mitral regurgitation. Regular supraventricular tachycardia. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild regional LVsystolic dysfunction. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level. There is mild symmetric leftventricular hypertrophy with normal cavity size. Mild [1+]TR. There is mild regional leftventricular systolic dysfunction with basal inferior akinesis and mid-inferiorhypokinesis. There is moderate pulmonary artery systolic hypertension. Themitral valve leaflets are mildly thickened. Atrial premature beats. Sinus rhythm. Sinus rhythm. Sinus rhythm. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Compared to the previous tracing of the rate has slowed and therhythm is more clearly sinus. Calcified tips of papillary muscles. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Low limb leadvoltage. Moderate pulmonary hypertension.Compared with the prior study (images reviewed) of , inferiorhypokinesis is new and mitral regurgitation is more prominent. Left bundle-branchblock. Compared to the previous tracing of atrial fibrillation is new. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Compared to theprevious tracing of there is no significant change.TRACING #1 Hypertension.Height: (in) 72Weight (lb): 205BSA (m2): 2.15 m2BP (mm Hg): 131/63HR (bpm): 114Status: InpatientDate/Time: at 11:06Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Probable atrial fibrillation with a rapid ventricularresponse. Compared to the previous tracing of therhythm has changed.TRACING #3 Rightventricular chamber size and free wall motion are normal. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- akinetic; mid inferior - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Atrial fibrillation with a rapid ventricular response. The remaining segments contract normally (LVEF = 45%). Compared to theprevious tracing of the same date there is no significant change.TRACING #2 PATIENT/TEST INFORMATION:Indication: Abnormal ECG. compared tothe previous tracing of the same date the rhythm has changed.TRACING #4 Coronary artery disease. If clinically indicated, a repeat tracingmay better clarify the rhythm. Artifact is present. Artifact is present. Artifact is present. Congestive heart failure.	7	[ { "category": "Echo", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 104698, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Congestive heart failure. Coronary artery disease. Hypertension.\nHeight: (in) 72\nWeight (lb): 205\nBSA (m2): 2.15 m2\nBP (mm Hg): 131/63\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 11:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. There is mild regional left\nventricular systolic dysfunction with basal inferior akinesis and mid-inferior\nhypokinesis. The remaining segments contract normally (LVEF = 45%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nModerate mitral regurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , inferior\nhypokinesis is new and mitral regurgitation is more prominent. Findings\ndiscussed with Dr. at 1351 hours.\n\n\n" }, { "category": "ECG", "chartdate": "2198-01-28 00:00:00.000", "description": "Report", "row_id": 310424, "text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch\nblock. Compared to the previous tracing of atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2198-01-27 00:00:00.000", "description": "Report", "row_id": 310425, "text": "Sinus rhythm. Atrial premature beats. Left bundle-branch block. Low limb lead\nvoltage. Compared to the previous tracing of the rate has slowed and the\nrhythm is more clearly sinus.\n\n" }, { "category": "ECG", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 310426, "text": "Regular supraventricular tachycardia. Left bundle-branch block. compared to\nthe previous tracing of the same date the rhythm has changed.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 310427, "text": "Artifact is present. Probable atrial fibrillation with a rapid ventricular\nresponse. Left bundle-branch block. If clinically indicated, a repeat tracing\nmay better clarify the rhythm. Compared to the previous tracing of the\nrhythm has changed.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2198-01-25 00:00:00.000", "description": "Report", "row_id": 310428, "text": "Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing of the same date there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2198-01-25 00:00:00.000", "description": "Report", "row_id": 310429, "text": "Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing of there is no significant change.\nTRACING #1\n\n" } ]
25,385	143,928	She was admitted to the hospital, to the Intensive Care Unit bed. Vascular consult and medical consults were requested. She was seen by vascular surgery who recommended that she continue on subcutaneous heparin and have a Venodyne placed on the right lower extremity. The left lower extremity was to be elevated. She was to have an inferior vena cava filter placement. The medical consult did recommend coverage with antibiotics due to her elevated temperature, prior history of infection. She was started on Ceftriaxone, Gentamycin, Vancomycin and Meropenem while the cultures were pending. It was also requested that infectious disease be consulted. On , she was brought to the operating room for placement of an inferior vena cava filter. She tolerated this procedure well. Postoperatively, she was seen by infectious disease who felt that she did likely not have a pseudomonas pneumonia. She did have signs consistent with a urinary tract infection and, therefore, it was recommended that the Foley be changed and repeat urinalysis and urine culture were sent. They also recommended a dermatology consult for some bulbous formation on her left hip region. She continued to be monitored in the Intensive Care Unit. Her vital signs were stable. Her temperature did come down. She was able to be transferred to the floor on . Due to a falling hematocrit of 27, she did receive a unit of packed red blood cells on after her hematocrit rose to 33. She was restarted on her tube feedings and tolerated these well. Neurologically, she continued to be at her baseline. Infectious disease did continue to follow and on a chest CAT scan, on , this showed a new right lower lobe consolidation. All urine cultures showed yeast but grew out no bacteria. She was continued only on the Gentamycin and the other antibiotics were stopped. Dermatology did see the patient for the blisters, primarily on the left hip region and felt these were likely due to friction and pressure and recommended local wound care. The infectious disease team checked on the chest CT with cardiologist and felt that the picture was most consistent with atelectasis, and therefore, recommended that the Gentamycin could be discontinued. She continued to be afebrile with stable vital signs and neurologically stable. She will be transferred to rehabilitation hospital when a bed is available.	cxr on admission is c/w a rll infiltrate and the pt did receive abx coverage.cardiac-> hemodynamically stable. Within the right lower lobe, there has been interval development of new consolidation with air bronchograms present. RLQ suture line C&D. the pt remains on full code.dispo-> ?transfer to the floor or possibly back to s/p filter placement. NPN 0700-1900Events: Pt to OR for IVC filter placement for L DVT.Neuro: Only response to pain - opens eyes. In the imaged portion of the upper abdomen, again identified are hepatic cysts, stable since the prior study. TECHNIQUE: Helically aquired contiguous axial images were obtained from the lung apices to the lung bases before and after the administration of 100 cc of IV Optiray. S/p right IJ CVL. A tracheostomy is again noted. NPO except po meds. The visualized portion of the spleen, kidneys, adrenal glands, and stomach appear within normal limits. g-tube in place although enteral feeding is on hold pnding filter placement. The heart appears to be within normal limits as far as can be judged on portable examination. Respiratory CarePt. urine u/a c+s sent. The airways are patent to the level of segmental bronchi bilaterally. Tiny punctate calcification is noted within the pancreas, unchanged since the prior exam. Tracheostomy tube in stable position. sbp ranging 100-120's.neuro-> pt withdraws to painful stimuli and will open her eyes to noxious stimuli only. New devlopment of right lower lobe consolidation. The right sided plate atelectasis appears rather unchanged. left flank blisters some have burst.cleansed and covered with opsite. PLAN IS TO CONT ON TRACH MASK VENTILATION WITH TRANSFER BACK TO . The right lung a plate atelectasis is seen probably involving the right middle lobe area. Tracheal cannula is in place. BP 94-122/49-67. A tracheostomy tube is seen within the trachea, in stable position. Status post IVC filter placement. this is apparently the pt's baseline.gi-> abd is soft, nontender w/+bs. -bm overnoc.gu-> foley is patent and intact. R groin insertion site for IVC filter, site C&D. +500mls today.Skin: Head suture line C&D. PA AND LATERAL CHEST: AP single view portable exam has been obtained with the patient in supine position. Pupils < equal, R < L. PRL.CV: HR 80s-90s, nsr, no ectopy. Received Fentanyl 50mcg, Versed 1 mg, Kefzol 2gms and 400mls fld in OR.ID: Afebrile. Again seen are prominent lymph nodes within the prevascular and precarinal regions, which are slightly decreased in size since the prior study, and none of which meet CT criteria for pathologic enlargement. the pt was eventually after difficulty weaning from ventilatory support and a g-tube was placed as well. PT RETURNED AFTER 2HRS AT FOR LRG DVT IN LOWER EXTREMETY. Airway is paatent Available for comparison is a previous chest examination obtained on . Resp Carept was suctioned for small amts of thick yellow. the pt is receiving maintainence fluids. 2:39 PM OR VASCULAR A-GRAM Clip # Reason: IVC FILTER, DVT Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ******************************* CPT Codes ****************************** * PERCU PLCT IVC FILTER S&I VENOGRAPHY IVC S&I * **************************************************************************** FINAL REPORT For complete report please see operative note in CareWeb Clinical Lookup. CT CHEST W/O&W IV CONTRAST: The pulmonary arterial vasculature is well visualized down to the segmental branches. Parenchymal densities in the left lower lobe exists could represent aspiration pneumonitis. IMPRESSION: Atelectasis right base; cannot rule out superimposed pneumonia here. L DVT: L leg elevated without venodyne boot. There are parenchymal densities in the left lower lung in retrocardiac position obliterating partially the diaphragmatic contour as well as that of the descending aorta. Nonionic contrast was used secondary to the rapid bolus requirement needed per protocol. +corneal reflexes, +gag. Movement noted in UE bilat, and RLL, not in LLL. IMPRESSION: Improved atelectasis at the right base. from antibiotics. 2) Interval improvement in consolidation within the left lower lobe. Tracheal cannula was in place already at that time. FOR IVC FILTER, AND WILL RETURN TO THE ICU FOLLOWING PROCEDURE. hr 80-90's, sr w/no noted ectopy. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in delineating the absence of a pulmonary embolism. return to rehab or transfer out to floor today. There continues to be left lower lobe consolidation, which appears slightly improved since the prior study. she was suctioned x1 for a mod amt of thick, tan sputum. PT CURRENTLY IN O.R. coccyx rash noted cleansed and zinc cream applied..plan : ? Pt receiving 75mls/hr IV NS. no stools.integ blister noted on right flank intact. There is poor definition of the left hemidiaphragm, without significant chagne from prior films. There is slight improvement in the atelectatic changes at the right base since . Multiplanar reconstructions were performed. due to her recent head bleed, the decision was made not to anticoagulate overnoc.pmh: hypothyroidism; ^chol; sah s/p craniotomy and clipping; s/p trach; s/p g-tubeallergies: amoxicillin; ?vancomycinreview of systemsrespiratory-> pt is and receiving 40% o2 via a trach mask. (Over) 9:54 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) IMPRESSION: 1) No CT evidence of pulmonary embolism.	11	[ { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593618, "text": "pmicu nsg admision/progress note 1a-7a\n\n\n the pt is an unfortunate 57yow woman who was initially admitted to on with a sah secondary to aneurysms and is s/p a craniotomy and clipping. the hospital course was c/b persistent fevers, treatment for pseudonomas pnx, evacuation of an epidural fluid collection, and a possible drug rash d/t vancomycin. the pt was eventually after difficulty weaning from ventilatory support and a g-tube was placed as well. she was transferred from to on and returned to the ew just two hours later after a left le dvt was discovered at the rehab. the pt was subsequently transferred to the micu for observation and will undergo an ivc filter placement by vascular surgery later today. due to her recent head bleed, the decision was made not to anticoagulate overnoc.\n\npmh: hypothyroidism; ^chol; sah s/p craniotomy and clipping; s/p trach; s/p g-tube\n\nallergies: amoxicillin; ?vancomycin\n\nreview of systems\n\nrespiratory-> pt is and receiving 40% o2 via a trach mask. rr 20's, nonlabored while maintaining sats >97%. she was suctioned x1 for a mod amt of thick, tan sputum. she has an excellent cough and is able to expectorate most of the sputum from her trach. cxr on admission is c/w a rll infiltrate and the pt did receive abx coverage.\n\ncardiac-> hemodynamically stable. hr 80-90's, sr w/no noted ectopy. sbp ranging 100-120's.\n\nneuro-> pt withdraws to painful stimuli and will open her eyes to noxious stimuli only. perrl @ 6mm. +corneal reflexes, +gag. no movement of extremities noted. this is apparently the pt's baseline.\n\ngi-> abd is soft, nontender w/+bs. g-tube in place although enteral feeding is on hold pnding filter placement. the pt is receiving maintainence fluids. -bm overnoc.\n\ngu-> foley is patent and intact. urine is yellow w/^sediment. uop is adequate.\n\nid-> tmax on admission to the ew was 101; the pt was in the ew and received iv abx coverage.\n\naccess-> #20g angio in the left hand.\n\nsocial-> pt's husband did speak to the ew nurse via the phone last evening and was reportedly very upset by her return to the hospital. he will be in to visit later today. the pt remains on full code.\n\ndispo-> ?transfer to the floor or possibly back to s/p filter placement.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593619, "text": "\nPT MAINTAINED ON 40% TRACH MASK AND DOING WELL IN TERMS OF VITALS AND SATURSATIONS. PT RETURNED AFTER 2HRS AT FOR LRG DVT IN LOWER EXTREMETY. PT CURRENTLY IN O.R. FOR IVC FILTER, AND WILL RETURN TO THE ICU FOLLOWING PROCEDURE. PLAN IS TO CONT ON TRACH MASK VENTILATION WITH TRANSFER BACK TO .\n" }, { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593620, "text": "NPN 0700-1900\nEvents: Pt to OR for IVC filter placement for L DVT.\n\nNeuro: Only response to pain - opens eyes. At times, eyes open spontaneously. Movement noted in UE bilat, and RLL, not in LLL. Pupils < equal, R < L. PRL.\n\nCV: HR 80s-90s, nsr, no ectopy. BP 94-122/49-67. L DVT: L leg elevated without venodyne boot. good pedal pulses bilat. R groin insertion site for IVC filter, site C&D. R venodyne boot in place.\nPt returned from OR at 1500. Received Fentanyl 50mcg, Versed 1 mg, Kefzol 2gms and 400mls fld in OR.\n\nID: Afebrile. ID consult to determine further antibiotics.\n\nResp: Trach to trach mask at 40% o2 humidified. o2 sats 99-100%. Pt freq coughs up mod - copius thick yellow secretions. LS coarse, diminished at bases. RR 14-21.\n\nGI: +BS, abd soft, no stool. NPO except po meds. FS 104-105, no insulin.\n\nGU/flds: uo 25-45 mls/hr, urine with sediment. Pt receiving 75mls/hr IV NS. +500mls today.\n\nSkin: Head suture line C&D. RLQ suture line C&D. Blisters on upper flank/back seen by ID. Broken blisters on coccyx as well as rash, ? from antibiotics. Cleaned with soap and water and Trip abx cr.\n\nSocial: husband here all day, and daughter joined later. Very supportive family.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593621, "text": "Respiratory Care\nPt. remained on 40% trach collar overnight with O2 sats 97-99%, NARD Breath sounds clear bilaterally. Possible transfer back to rehab/floors later today.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593622, "text": "Neuro: responds to pain. opens eyes spontaneously. moves extremities on bed. Not following commands.pupils slightly unequal responding to light.\ncv/resp vss nsr no ectopy. trach mask with mod secretions thick/yellow sx. twice. o2 sats 100% on 40% trach collar.\ngi/gu remains without tube feeds. ?plan to resume today. foley replaced with #14fr 5cc balloon. urine u/a c+s sent. no stools.\ninteg blister noted on right flank intact. left flank blisters some have burst.cleansed and covered with opsite. coccyx rash noted cleansed and zinc cream applied..\nplan : ? return to rehab or transfer out to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593623, "text": "Resp Care\n\npt was suctioned for small amts of thick yellow. Airway is paatent\n" }, { "category": "Radiology", "chartdate": "2193-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834096, "text": " 7:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman SAH s/o craniectomy, clipping. S/p right IJ\n CVL.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 57-year-old woman with subarachnoid hemorrhage status post\n clipping. Evaluate for infiltrate.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: The film is rotated. Tracheostomy tube in stable\n position. There is a large band like density in the right base, most likely\n representing atelectasis. There is also some patchy increased density in the\n region of the right cardiophrenic angle, which could reflect atelectasis\n versus pneumonia. There is poor definition of the left hemidiaphragm, without\n significant chagne from prior films. The pulmonary vascularity is normal in\n appearance without redistribution. No pneumothorax.\n\n IMPRESSION: Atelectasis right base; cannot rule out superimposed pneumonia\n here.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-09-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 834536, "text": " 11:15 AM\n CHEST (PA & LAT) Clip # \n Reason: rule out pneumonia\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with right lower lobe consolidation\n\n REASON FOR THIS EXAMINATION:\n rule out pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right lower lobe consolidation, evaluate for pneumonia.\n\n PA AND LATERAL CHEST: AP single view portable exam has been obtained with the\n patient in supine position. Tracheal cannula is in place. No pneumothorax is\n noted. The heart appears to be within normal limits as far as can be judged on\n portable examination. There are parenchymal densities in the left lower lung\n in retrocardiac position obliterating partially the diaphragmatic contour as\n well as that of the descending aorta. The remaining portions of the left lung\n are free and there is no evidence of pulmonary vascular congestion. The right\n lung a plate atelectasis is seen probably involving the right middle lobe\n area. Available for comparison is a previous chest examination obtained on\n . Tracheal cannula was in place already at that time. The right sided\n plate atelectasis appears rather unchanged. The left base retrocardiac area\n was already obscured at that time but is now better visualized with improved\n penetration. Parenchymal densities in the left lower lobe exists could\n represent aspiration pneumonitis. Followup is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-12 00:00:00.000", "description": "PERCU PLCT IVC FILTER S&I", "row_id": 834171, "text": " 2:39 PM\n OR VASCULAR A-GRAM Clip # \n Reason: IVC FILTER, DVT\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ******************************* CPT Codes *****************************\n PERCU PLCT IVC FILTER S&I VENOGRAPHY IVC S&I \n ***************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb Clinical Lookup.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-13 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 834319, "text": " 9:54 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with epidural fluid collection, persistant fevers and\n postive pseudomonas cultures of sputum despite ABx therapy, dvt s/p ivc\n filter placement\n REASON FOR THIS EXAMINATION:\n assess pulmonary parenchyma for pneumonia, rule out PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fevers, positive blood cultures despite antibiotic\n therapy. Status post IVC filter placement. Evaluate for pulmonary embolism\n and pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Helically aquired contiguous axial images were obtained from the\n lung apices to the lung bases before and after the administration of 100 cc of\n IV Optiray. Nonionic contrast was used secondary to the rapid bolus\n requirement needed per protocol. Multiplanar reconstructions were performed.\n\n CT CHEST W/O&W IV CONTRAST: The pulmonary arterial vasculature is well\n visualized down to the segmental branches. No intraluminal filling defects\n are identified. Heart, pericardium, and remaining great vessels are otherwise\n unremarkable. There is no pleural or pericardial effusion identified. Again\n seen are prominent lymph nodes within the prevascular and precarinal regions,\n which are slightly decreased in size since the prior study, and none of which\n meet CT criteria for pathologic enlargement. No new axillary, hilar or\n mediastinal lymphadenopathy is identified.\n\n A tracheostomy tube is seen within the trachea, in stable position. There\n continues to be left lower lobe consolidation, which appears slightly improved\n since the prior study. Within the right lower lobe, there has been interval\n development of new consolidation with air bronchograms present. No other\n parenchymal consolidation or pulmonary nodules are seen. The airways are\n patent to the level of segmental bronchi bilaterally.\n\n In the imaged portion of the upper abdomen, again identified are hepatic\n cysts, stable since the prior study. Tiny punctate calcification is noted\n within the pancreas, unchanged since the prior exam. The visualized portion\n of the spleen, kidneys, adrenal glands, and stomach appear within normal\n limits.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the absence of a pulmonary embolism.\n\n (Over)\n\n 9:54 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) No CT evidence of pulmonary embolism.\n\n 2) Interval improvement in consolidation within the left lower lobe. New\n devlopment of right lower lobe consolidation. These findings may be\n suggestive of aspiration or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834450, "text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with right lower lobe consolidation\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 2:20 PM.\n\n INDICATION: Follow-up pneumonia.\n\n There is slight improvement in the atelectatic changes at the right base since\n . The lungs are otherwise clear. Increased density at the left base\n with loss of visualization of the left diaphragm raising the question of an\n underlying effusion and/or consolidation in the left lower lobe. A\n tracheostomy is again noted.\n\n IMPRESSION: Improved atelectasis at the right base.\n\n Increased density at the left base for which follow-up PA and lateral views of\n the chest are suggested.\n\n\n" } ]
85,958	105,391	69 yo male with PMHX of HTN, Hyperlipidemia, and negative cardiac history who presented with chest pain on exertion. Stress test performed on was positive and cath on revealed three vessel disease with left main stem involvement. Hemaology was consulted preoperatively for elevated PTT(150)and ACT(360) with questionable etiology/anticoagulation management. The decision was made to proceed with off-pump coronary artery bypass grafting to avoid possible anticoagulation issues with the cardiopulmonary bypass. He was taken to the operating room on where he underwent an urgent off-pump coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft obtuse marginal and right coronary arteries. See operative note for full details. He was transferred to the CVICU in stable condition. POD1 the patient was extubated and weaned off all vasoactive medications. Chest tubes and pacing wires were removed per cardiac surgery protocol. He was transferred to step down unit in stable condition on POD1. Hematology had various coagulopathy studies pending at the time of discharge and plts were 261 PTT 82.6 adn Factor V; Factor IX; Factor ; Factor XII were pending. These will be followed up at clinic appointment. He is to be on Plavix for 3 months for Off pump CABG. He was working with physical therapy for strength and mobility. At the time of discharge on POD 4 he was ambulating without assistance, tolerating a full oral diet and his incisions were healing well. It was felt that he was safe for discharge home with VNA services and all appropriate follow up appointments were arranged.	A right IJ line extending to the low SVC, bilateral chest tubes, and a mediastinal drain are in unchanged position. Trivial MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Right internal jugular line ends at low SVC. Compared to the previoustracing of the patient no longer has ventricular premature beats.The slight non-specific T wave changes noted at that time have largelyregressed. Mild wave-like opacities in bilateral lungs signify mild pleural effusion, decreased since . Two chest tubes and a mediastinal drain are present and unchanged in position. The cardiac silhouette and mediastinum is normal. The patient is status post median sternotomy and mildly enlarged heart and sternal sutures are intact. PATIENT/TEST INFORMATION:Indication: Off-pump CABGStatus: InpatientDate/Time: at 11:24Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Low normal LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Trivial mitral regurgitationis seen.There is no pericardial effusion.Post-procedure:The patient is in sinus rhythm, on no inotropes.Preserved biventricular systolic fxn.Trace AI. Simple atheroma in descending .AORTIC VALVE: Normal aortic valve leaflets (3). Hilar and cardiomediastinal contours are stable. : Normal ascending diameter. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 79/24,100/24, and 100/32 cm/sec. Mild vascular congestion is unchanged. Normal sinus rhythm. Mediastinal and hilar contours are stable. Mediastinal surgical clips and sternotomy wires are in unchanged alignment. PA AND LATERAL CHEST: A right IJ line has been removed. FINDINGS: In comparison with earlier in this date, there has been removal of chest tubes. FINDINGS: Intact midline sternal wires are seen. There are new moderate bilateral pleural effusions and associated basilar atelectasis. Trace aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Very faint lucency at left lung apex is most likely a tiny pneumothorax. Very faint lucency at left lung apex is most likely a tiny pneumothorax. No TEE related complications.Conclusions:Pre-procedure:No spontaneous echo contrast is seen in the left atrial appendage.Overall left ventricular systolic function is low normal (LVEF 50-55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic .The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis. There are small bilateral pleural effusions which persist. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 74/21, 89/26, and 103/31 cm/sec. Mild bibasilar atelectasis is also noted. The ICA/CCA ratio is 1.6 These findings are consistent with less than 40% stenosis. Right IJ catheter extends to the lower portion of the SVC. ECA peak systolic velocity is 111 cm/sec. Chest tubes and mediastinal drains remain in stable position. Compared to the previous tracingof there is no change. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is antegrade left vertebral artery flow. Bony structures are within normal limits. IMPRESSION: Since minimal bilateral pleural effusions are smaller and bibasal atelectases, left side more than right have improved. Atelectatic changes are seen at the bases and there is mild engorgement of pulmonary vessels. These findings are consistent with less than 40% stenosis. SEMI-ERECT PORTABLE AP CHEST: The patient has been intubated, and an orogastric tube has been removed. Tracing is within normal limits. There is antegrade right vertebral artery flow. On the right there is moderate heterogenous calcified plaque seen in the ICA. Sinus rhythm with ventricular trigeminy. ECA peak systolic velocity is 120 cm/sec. On the left there is moderate heterogenous calcified plaque seen in the ICA. Intraventricular conduction delay.Occasional ventricular premature beats. Left ICA less than 40% stenosis. Impression: Right ICA less than 40% stenosis. Preop chest radiograph. Findings: Duplex evaluation was performed of bilateral carotid arteries. Sinus rhythm. The patient was undergeneral anesthesia throughout the procedure. IMPRESSION: Improved aeration with overall increased lung volumes, though some basal atelectasis and small bilateral effusions persist. Evaluate for pleural effusion. Left chest tube is in place and there is no evidence of pneumothorax. IMPRESSION: Interval extubation and removal of orogastric tube. CCA peak systolic velocity is 64 cm/sec. No definite pneumothorax is appreciated. There is no new focal opacity to suggest pneumonia. Lungs are clear. Bilateral bibasal atelectases, left side more than right have improved. 6:21 AM CHEST (PORTABLE AP) Clip # Reason: decreased hct Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED MEDICAL CONDITION: 69 year old man with POD 2 s/p CABG REASON FOR THIS EXAMINATION: decreased hct FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Single erect portable radiograph of chest was compared to prior radiographs through to . There is increased veiled opacity over the lung bases bilaterally, implying new effusions, moderate in size. CCA peak systolic velocity is 66 cm/sec. A-V conduction delay. Prolonged P-R interval. The tip of the endotracheal tube lies at the clavicular level, approximately 8.5 cm above the carina. The ICA/CCA ratio is 1.6. There is no pneumothorax. There is no pneumothorax. There is no focal opacity to suggest pneumonia. However, overall aeration of the lungs is improved compared to two days prior. Continued enlargement of the cardiac silhouette with retrocardiac opacification consistent with atelectasis and possible effusion. I certifyI was present in compliance with HCFA regulations.	11	[ { "category": "Radiology", "chartdate": "2102-12-22 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1215405, "text": " 7:40 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op for CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with HTN/HLD found to have 3VD on cath today awaiting CABG\n monday\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n CLINICAL HISTORY: 69-year-old man with hypertension, found to have\n three-vessel disease on cardiac catheterization. Awaiting CABG. Preop chest\n radiograph.\n\n FINDINGS: No previous studies for comparison.\n\n The cardiac silhouette and mediastinum is normal. Lungs are clear. There is\n no focal consolidation, pleural effusions or signs of pulmonary edema. No\n pneumothoraces are identified. Bony structures are within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1215656, "text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD s/p Off-Pump CABG. Please at \n with abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PRX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: Intact midline sternal wires are seen. The tip of the endotracheal\n tube lies at the clavicular level, approximately 8.5 cm above the carina.\n Right IJ catheter extends to the lower portion of the SVC. Nasogastric tube\n extends to the stomach. Left chest tube is in place and there is no evidence\n of pneumothorax. Atelectatic changes are seen at the bases and there is mild\n engorgement of pulmonary vessels.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215998, "text": " 2:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 2 s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative with chest tube removal.\n\n FINDINGS: In comparison with earlier in this date, there has been removal of\n chest tubes. No definite pneumothorax is appreciated. Continued enlargement\n of the cardiac silhouette with retrocardiac opacification consistent with\n atelectasis and possible effusion. Atelectatic changes are also seen at the\n right base.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215752, "text": " 1:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: bleeding\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABGx3\n REASON FOR THIS EXAMINATION:\n bleeding\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male status post CABG.\n\n COMPARISON: .\n\n SEMI-ERECT PORTABLE AP CHEST:\n\n The patient has been intubated, and an orogastric tube has been removed. A\n right IJ line extending to the low SVC, bilateral chest tubes, and a\n mediastinal drain are in unchanged position. There is increased veiled\n opacity over the lung bases bilaterally, implying new effusions, moderate in\n size. There is no pneumothorax. Mild vascular congestion is unchanged.\n There is no new focal opacity to suggest pneumonia. Hilar and\n cardiomediastinal contours are stable.\n\n IMPRESSION: Interval extubation and removal of orogastric tube. Chest tubes\n and mediastinal drains remain in stable position. There are new moderate\n bilateral pleural effusions and associated basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2102-12-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1216280, "text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 4 s/p CABG off pump\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male postop day #4 status post CABG. Evaluate for\n pleural effusion.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST:\n\n A right IJ line has been removed. There is no pneumothorax. Mediastinal\n surgical clips and sternotomy wires are in unchanged alignment. There is no\n focal opacity to suggest pneumonia. There are small bilateral pleural\n effusions which persist. Mild bibasilar atelectasis is also noted. However,\n overall aeration of the lungs is improved compared to two days prior.\n\n IMPRESSION: Improved aeration with overall increased lung volumes, though\n some basal atelectasis and small bilateral effusions persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215935, "text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: decreased hct\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT NO ASSESSMENT NEEDED \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 2 s/p CABG\n REASON FOR THIS EXAMINATION:\n decreased hct\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Single erect portable radiograph of chest was compared to prior\n radiographs through to .\n\n Right internal jugular line ends at low SVC. Two chest tubes and a\n mediastinal drain are present and unchanged in position. Mild wave-like\n opacities in bilateral lungs signify mild pleural effusion, decreased since\n . Bilateral bibasal atelectases, left side more than right\n have improved. The patient is status post median sternotomy and mildly\n enlarged heart and sternal sutures are intact. Mediastinal and hilar contours\n are stable. Very faint lucency at left lung apex is most likely a tiny\n pneumothorax.\n\n IMPRESSION: Since minimal bilateral pleural effusions are\n smaller and bibasal atelectases, left side more than right have improved. Very\n faint lucency at left lung apex is most likely a tiny pneumothorax.\n\n" }, { "category": "Echo", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 93771, "text": "PATIENT/TEST INFORMATION:\nIndication: Off-pump CABG\nStatus: Inpatient\nDate/Time: at 11:24\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\n: Normal ascending diameter. Simple atheroma in descending .\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPre-procedure:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic .\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\nThere is no pericardial effusion.\n\nPost-procedure:\nThe patient is in sinus rhythm, on no inotropes.\nPreserved biventricular systolic fxn.\nTrace AI. No MR. .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-22 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1215367, "text": " 2:27 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op for CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with 3 vessel CAE awaiting CABG on monday.\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason: 69 year old man with 3 vessel CAE waiting CABG.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is moderate heterogenous calcified plaque seen in the ICA. On\n the left there is moderate heterogenous calcified plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 79/24,100/24, and 100/32 cm/sec. CCA peak systolic\n velocity is 66\n cm/sec. ECA peak systolic velocity is 120 cm/sec. The ICA/CCA ratio is 1.6\n These findings are consistent with less than 40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 74/21, 89/26, and 103/31 cm/sec. CCA peak systolic\n velocity is 64 cm/sec. ECA peak systolic velocity is 111 cm/sec. The ICA/CCA\n ratio is 1.6. These findings are consistent with less than 40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA less than 40% stenosis.\n Left ICA less than 40% stenosis.\n\n" }, { "category": "ECG", "chartdate": "2102-12-22 00:00:00.000", "description": "Report", "row_id": 249131, "text": "Sinus rhythm with ventricular trigeminy. A-V conduction delay. No previous\ntracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 249129, "text": "Normal sinus rhythm. Tracing is within normal limits. Compared to the previous\ntracing of the patient no longer has ventricular premature beats.\nThe slight non-specific T wave changes noted at that time have largely\nregressed.\n\n" }, { "category": "ECG", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 249130, "text": "Sinus rhythm. Prolonged P-R interval. Intraventricular conduction delay.\nOccasional ventricular premature beats. Compared to the previous tracing\nof there is no change.\n\n" } ]
17,122	176,368	82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. . 1. Hypotension/Hypertension: Developed hypotension the ED, requiring admission to CCU,likely secondary to overaggressive preload inhibition in setting of moderate AS and increased atenolol levels in setting of ARF. Pt required inotrop/pressor support for ~24 hours with dop gtt at 4-5. She was easily weaned off pressors. No evidence of CNS or cardiac ischemia. No evidence of distributive shock. Blood cultures neg. Does have UTI, but not uroseptic. Lactate improved from 3.3 to 1.3. Antihypertensives were held in the setting of hypotension; they were continued to be held on transfer to the floor. Within 24 hours of being on the floor, pt developed hypertension to 200s systolic, during which she developed flash pulmonary edema. See next issue for details. Pt was started on nitro drip and restarted on po lopressor w/ improved blood pressure. Hydralazine was subsequently added and nitro drip was titrated down. Pt was subsequently restarted on imdur and valsartan; nitro drip and hydralazine were discontinued. Pt's home antihypertensive regimen of lopressor, valsartan, and imdur were titrated for optimal bp control. . 2. Pump: 82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. Possible etiologies include high output failure in setting of UTI/fever, hypertension in setting of diastolic dysfunction. Pt was admitted cold and wet in class IV HF, secondary to recent fluid boluses in the form of heparin bolus and IVF bolus. She diuresed very well with IV lasix. She was transiently on dopamine drip in the CCU for blood pressure support, which helped with diuresis. Pt was hypoxic on admission and required positive pressure vent with BiPAP for ~24 hours. She was continued on CPAP at night. On floor day 1, pt developed flash pulmonary edema in the setting of severe hypertension off antihypertensives. She was noted to be hypoxic to 70s on 4L, with increase to mid 90s on 100% NRB. She was started on nitro gtt, lopressor, and hydralazine for BP control. CXR confirmed worsened pulmonary edema. She was given lasix for diuresis. After adequate diuresis and BP control, pt was able to be weaned down on her oxygen requirement. Pt was restarted on heart failure regimen of lopressor, valsartan, imdur; nitro gtt was weaned and hydralazine discontinued. Pt was diuresed with IV lasix daily for goal 1L daily, with signficant respiratory improvement. Pt should continue to be diuresed w/ IV lasix for 48 hours for goal negative 500cc daily prior to being switched to a po lasix regimen. . 3. CAD: Pt is s/p NTSEMI last month and is s/p PTCA to prox and mid LAD . Pt was continued on asa, plavix, and statin. On admission was noted to have a slight troponin bump likely from demand ischemia and decompensated heart failue. She was restarted on bb, , and imdur, which were titrated. . 4. Rhythm: S/P sucessful DCCV . Pt remained in sinus. Dopamine drip did not cause reversion to AF. Amiodarone was held initially in the setting of bradycardia, but was restarted. She recieved oral and IV vit K at Rehab for INR of 10. Subsequently had suptherapeutic INR. She was restarted on heparin gtt and restarted coumadin 5mg daily for goal INR 2.0-3.0. Pt is being discharged on lovenox bridge . 5. Resp: Initially presented with large Aa gradient, attributed to pulmonary edema. She was hypoxic on admission, requiring BiPAP for ~24 hours. With diuresis, she had decreasing O2 requirements. Supplemental oxygen should continue to be weaned down, with further diuresis. . 6. ID: Pt was febrile to 101 in ED. Pt was noted to have UTI by UA. On day of last discharge she was noted to have >100,000 Staph aureus, which was attributed to contamination and not treated. Admission urine culture once again grew out >100,000 Staph aureus, found to be MRSA sensitive to vanco, gent, tetracyclin, and nitrofurantoin. Pt initially received emperic ceftriaxone and vancomycin. Ceftriaxone was subsequently discontinued. Pt was continued on vancomycin (renally dosed, q48h dosing) to complete a 10 day course. Vanco trough levels should be checked 30 minutes prior to 3rd dose of vanco. She should get a trough level on . Pt's blood cultures remained negative. Repeat UA on the day before discharge is negative, with a urine culture that is negative to date. . 7. Renal: Pt has had ARF since , secondary to contrast nephropathy vs. CHF (poor forward flow). Baseline is 1.0 to 1.3. She received 240mL contrast at time of cath. Creatinine improved with dopamine drip and treatment of heart failure. . 8. Anemia: She has a severe iron deficency anemia without evidence of acute bleed. Last C-scope 3-4 years ago, by report. Received 1U PRBC for goal hct >30. Hct remained stable. . 9. Gout: Stable. Continued on allopurinool . 10. OSA: CPAP at night at outpt settings. Pt was seen by pulmonary consult service who stated that pt has secondary pulmonary hypertension in the setting of left heart failure. Pt should follow up with Dr. for outpatient sleep study. . 11. Cerumen impaction: Pt was noted to have bilateral cerumen impaction preventing her from inserting her hearing aides. She was started on hydrogen peroxide.	CXR SHOWS PULM EDEMA. Moderate(2+) mitral regurgitation is seen. W/CHF, and was treated with NIPV untill adaquatly diureased. Moderate PA systolic hypertension.PERICARDIUM: Trivial/physiologic pericardial effusion. There isa trivial/physiologic pericardial effusion. Heparin gtt adjusted per nomogram.Arterial line dc'd.Afebrile. S/p PCI w/ hypotension.Height: (in) 60Weight (lb): 200BSA (m2): 1.87 m2BP (mm Hg): 79/44HR (bpm): 75Status: InpatientDate/Time: at 09:52Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is perivascular haze and diffuse bilateral interstitial and alveolar opacities consistent with CHF. Trace aortic regurgitation is seen. Mild mitralannular calcification. AREAS CLEANSED AND DSD WITH NON ADH DSG APPLIED. afebrileLungs: BS clear in upper lobes some rales in bases. MD NOTIFED OF ABD WOUNDS AND IN TO ASSESS.ID: AFEBRILE. STARTED ON VANCO AND CEFTRIAXONE FOR ELEVATED TEMP IN EW. BP 160/ and was rx with 2MSO4 and IV NTG. The tricuspid valve leaflets are mildlythickened. LOW BP AFTER NTG IV. D/CD FROM ON TO REHAB. COMPARISON: Radiograph dated . Pt placed on CPAP and a foley was placed. replete lytes as indicated. IMPRESSION: CHF. REASON FOR THIS EXAMINATION: eval for chf FINAL REPORT INDICATION: Increased lower extremity edema. No echocardiographicsigns of tamponade.Conclusions:The left atrium is moderately dilated. There is mild to moderateaortic valve stenosis. TOL WELL BY PT. Moderate (2+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. AT THAT TIME R/I NSTEMI. There is persistent left midzone discoid atelectasis. MAP > 60 after one unit PRBC MAP consistantly > 65. post transfusion hct is 31. palp DP . BS CL/ RALES IN ABSES. BP subsequently down to 90/ and was placed on Dopa 2.5mcgs/kg. on 6l NC initially, on home bipap tolerating well .GI: ABD obese. Possible left ventricular hypertrophy.Non-specific ST-T wave changes. There is moderate pulmonary artery systolic hypertension. There is a probable right-sided pleural effusion and possible small left-sided effusion. TraceAR.MITRAL VALVE: Mildly thickened mitral valve leaflets. DRAINING SM AMTS SEROSANG. TOL PO'S AND MEDS. WOUND CLEASER AND DSD APPLIED. Segmental atelectasis at the right lung base is noted. Baseline artifactSinus rhythm be Normal ECG but baseline artifact makes assessment difficultSince previous tracing of , prolonged Q-Tc interval and T wave changesabsent No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Normal aortic arch diameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. Sinus rhythm. soft with BS. Nasal cannula or face mask when awake. Since the prior study, there has been placement of a left subclavian line, the tip is in the mid superior vena cava. HR 68-74 NSR. RECEIVED 1 UNIT PRBC WITH LASIX GIVEN BETWEEN. Breathsounds are with rales at bases other wise clear. PER NSG JUDGEMENT. SOURCE WHICH HAS SCABING AND DRIED CLOTT. NON PRODUCTIVE COUGH NOTED.GI: APPETITE EXCELLENT. Mild to moderate[+] TR. Moderate AS. Interval improvement in the magnitude of bilateral pulmonary vascular congestion. IMPRESSION: Worsened CHF. There is mild symmetric leftventricular hypertrophy with normal cavity size and systolic function(LVEF>55%). Urine and Blood clutures done for WBC of 17.Tx to CCU -CV - HR 60-70's nsr with rare pvc. IMPRESSION: Interval placement of the left subclavian CVP line. Dopamine slowly weaned to off.NSR/SB with no ectopy. Small brown formed stool guiac negative.GU: foley to gravity. CURRENT SBP 110-120 WITH MAP'S 66-75. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are moderately thickened. SINGLE FRONTAL VIEW OF THE CHEST: There is stable cardiac enlargement. output low initially with unit of PRBC output improved. There are low lung volumes. DNEIES SOB. NOW PRESENTS ON DOPAMINE.. CON'T ATTEMPTS TO WEAN DOAPMINE, FOLLOW HCT. pt has rt shoulder pain, when touch pain is > 5 if not disturbed pt has no pain in arm.CV: sinus brady. + BSGU: U/O EXCELLENT. PT APPEARS WITH LOW SATS. ECHO done at bedside this AM. Baseline artifactSinus rhythmBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific andmay be within normal limits but clinical correlation is suggestedSince previous tracing of , Q-Tc interval appears longer but baselineartifact makes comparison difficult Late transition. NO ABVIOUS S/S OF BLD. LUQ ABD HAS WOUND AREA? ABG'S ON CPAP THIS AM WNL. Sinus rhythmConsider left ventricular hypertrophy by voltageLateral ST-T wave abnormalities - cannot exclude in part ischemia - clinicalcorrelation is suggestedSince previous tracing of , rate faster and further ST-T wave changespresent Compared to the previous tracing no significantchange. AM BUN CREAT PENDINGSKIN: LOWER ABD HAS 3 AREAS OF TAPE ABRASION. K+/MG WNL DESPITE DIURESIS.SOCIAL: DAUGHTER IN ON EVES AND UPDATED ON POC. cre and BUN still high.Skin : intact some redness in coccyx area skin prep applied.A pt has sleep apnea tolerated bipap well.P: turn frequently. MAE.Pain: pt denies chest pain or pain with deep breath. 2841 CURRENTLY -546. The lung apices are partially obscured by the patient's head. Cardiac and mediastinal contours are stable. K+ WNL.RESP: PT ON OWN CPAP @ 6L. AM HCT PENDING. Just had an A-line placed to monitor and obtain ABG's. Cont on Dopamine 4.5mcgs/kg/min. BP is labile 90-140/50. MAELABS/ HEME: HCT 27.6 HOUSE STAFF NOTIFED. PATIENT/TEST INFORMATION:Indication: Left ventricular function. DENIES SOB OR CP. Slight SOB at rest-speaking in word sentences. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Attempted to wean to 4ln/p but O2 sat dropped to 88%.GI - abd is obese with +bs.GU - Diuresing well after Lasix in EW approx 1000cc clear yellow urine.Heme - Hct 31.6 PT 14.1 PTT 53.2 INR 1.3Neuro - Alert and oriented x3.A: 85yof with diastolic dysfunction and tenuous fluid status and labile bp.P: At present, HO placing TLC, cont montitor HR and BP and attempt to wean Dopamine, Cont aggressive diruesis weaning cpap as able monitor coags, Turn and position for comfort, keep pt and family informed per multidisciplinary rounds.	14	[ { "category": "Echo", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 66610, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p PCI w/ hypotension.\nHeight: (in) 60\nWeight (lb): 200\nBSA (m2): 1.87 m2\nBP (mm Hg): 79/44\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 09:52\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS. Trace\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are moderately thickened. There is mild to moderate\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate\n(2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\na trivial/physiologic pericardial effusion. There are no echocardiographic\nsigns of tamponade.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865498, "text": " 1:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with increased LE edema.\n\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increased lower extremity edema.\n\n COMPARISON: Radiograph dated .\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is stable cardiac enlargement. There\n are low lung volumes. There is perivascular haze and diffuse bilateral\n interstitial and alveolar opacities consistent with CHF. There is persistent\n left midzone discoid atelectasis. The lung apices are partially obscured by\n the patient's head. There is a probable right-sided pleural effusion and\n possible small left-sided effusion.\n\n IMPRESSION: CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865796, "text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for flash pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF w/acute SOB\n REASON FOR THIS EXAMINATION:\n evaluate for flash pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF with increasing shortness of breath.\n\n Portable upright frontal radiograph. Comparison is made to two studies\n performed on . There has been an increase in the amount of perihilar\n haziness and mild upper zone vascular redistribution compared to the study of\n 8:45 p.m. on . In addition, there has been an increase in small\n bilateral pleural effusions. No focal consolidation is seen. There is no\n pneumothorax. Cardiac and mediastinal contours are stable.\n\n IMPRESSION: Worsened CHF.\n\n" }, { "category": "Radiology", "chartdate": "2134-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865520, "text": " 7:32 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line placement, r/o pneumothorax, evaluate for inte\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF, hypotension s/p L subclavian line placement\n REASON FOR THIS EXAMINATION:\n evaluate line placement, r/o pneumothorax, evaluate for interval change in\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old with CHF and hypotension, status post subclavian line\n placement, evaluate the line placement.\n\n FINDINGS: AP portable study of the chest was obtained at 20:46 hours and is\n compared to prior study of earlier the same day. Since the prior study, there\n has been placement of a left subclavian line, the tip is in the mid superior\n vena cava. There has been some improvement in the degree of bilateral\n pulmonary vascular congestion since the prior study. Cardiomegaly is\n unchanged. No significant pleural effusion or pneumothoraces are noted.\n\n IMPRESSION: Interval placement of the left subclavian CVP line. Interval\n improvement in the magnitude of bilateral pulmonary vascular congestion.\n\n Segmental atelectasis at the right lung base is noted.\n\n" }, { "category": "ECG", "chartdate": "2134-05-06 00:00:00.000", "description": "Report", "row_id": 139079, "text": "Sinus rhythm. Late transition. Possible left ventricular hypertrophy.\nNon-specific ST-T wave changes. Compared to the previous tracing no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2134-05-04 00:00:00.000", "description": "Report", "row_id": 139080, "text": "Sinus rhythm\nConsider left ventricular hypertrophy by voltage\nLateral ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , rate faster and further ST-T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 139081, "text": "Baseline artifact\nSinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific and\nmay be within normal limits but clinical correlation is suggested\nSince previous tracing of , Q-Tc interval appears longer but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 139082, "text": "Baseline artifact\nSinus rhythm\n be Normal ECG but baseline artifact makes assessment difficult\nSince previous tracing of , prolonged Q-Tc interval and T wave changes\nabsent\n\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486666, "text": "NSG NOTE\n\nCV: CON'T ON DOPAMINE @ 5 MCG/KG/MIN SEVERAL ATTEMPTS MADE TO WEAN,BUT MAP'S DROPPED TO 57-58. HR 68-74 NSR. CK 38. DENIES SOB OR CP. CURRENT SBP 110-120 WITH MAP'S 66-75. K+ CHECKED SEVERAL TIMES OVERNOC IN LIGHT OF AGGRESSIVE DIURESIS. K+ WNL.\n\nRESP: PT ON OWN CPAP @ 6L. TOL WELL ( DID NOT TOL UNIT BIPAP) O2 SATS 98% WHILE AWAKE,BUT SATS DROPPED TO 90% WITH SLEEP. RR STAYED 17. PT APPEARS WITH LOW SATS. ABG'S ON CPAP THIS AM WNL. DNEIES SOB. BS CL/ RALES IN ABSES. NON PRODUCTIVE COUGH NOTED.\n\nGI: APPETITE EXCELLENT. TOL PO'S AND MEDS. ABD SOFT NON TENDER. + BS\n\nGU: U/O EXCELLENT. > 100CC/HR RECEIVED LASIX 20 MG DURING BLD TRANSFUSION. 2841 CURRENTLY -546. AM BUN CREAT PENDING\n\nSKIN: LOWER ABD HAS 3 AREAS OF TAPE ABRASION. DRAINING SM AMTS SEROSANG. AREAS CLEANSED AND DSD WITH NON ADH DSG APPLIED. LUQ ABD HAS WOUND AREA? SOURCE WHICH HAS SCABING AND DRIED CLOTT. WOUND CLEASER AND DSD APPLIED. MICOSTATIN POWDER ORDERED AND APPLIED TO ALL SKIN FOLDS. MD NOTIFED OF ABD WOUNDS AND IN TO ASSESS.\n\nID: AFEBRILE. STARTED ON VANCO AND CEFTRIAXONE FOR ELEVATED TEMP IN EW. CULT PENDING.\n\nNEURO: A/O X3 FOLLOWS COMMANDS. MAE\n\nLABS/ HEME: HCT 27.6 HOUSE STAFF NOTIFED. NO ABVIOUS S/S OF BLD. NO STOOL TO GUIAC. RECEIVED 1 UNIT PRBC WITH LASIX GIVEN BETWEEN. TOL WELL BY PT. AM HCT PENDING. K+/MG WNL DESPITE DIURESIS.\n\nSOCIAL: DAUGHTER IN ON EVES AND UPDATED ON POC. SHE IS CONTACT PERSON FOR PT.\n\nA/P; 82 YR OLD ADM TO ON CAD, S/P 2 STENTS TO LAD X2 WEEKS AGO AT . AT THAT TIME R/I NSTEMI. D/CD FROM ON TO REHAB. DEVELOPED SOB WHILE AT REHAB. CXR SHOWS PULM EDEMA. LOW BP AFTER NTG IV. NOW PRESENTS ON DOPAMINE.. CON'T ATTEMPTS TO WEAN DOAPMINE, FOLLOW HCT. PER NSG JUDGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486667, "text": "Respiratory care:\nPatient received on mask ventilation. 50%. Patient uncomfortable on vent. Patient placed on her own Cpap machine (12cm) with 6 L bleed in. Patient looks more comfortable on her own machine. Sats in mid to high 90's when awake but then fall to 88-90% when asleep. Patient easily arousable allowing sats to increase. ? need of a new sleep study. Breathsounds are with rales at bases other wise clear. Please see respiratory section of carevue for further data.\nPlan: Continue on her own cpap machine as tolerated. Change over to ? Nasal cannula or face mask when awake.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486668, "text": "See carevue for objective data.\n\nAwake and alert anxious at times. Dopamine slowly weaned to off.\nNSR/SB with no ectopy. Crackles at bases. Slight SOB at rest-speaking in word sentences. Maintaining sat on 6L NC. ECHO done at bedside this AM. No diuresis ordered as of yet today. Urine output 40-50cc's an hour. CVP: .\nTaking diet well. Heparin gtt adjusted per nomogram.\nArterial line dc'd.\nAfebrile. Receiving ceftriaxone/vanco as ordered.\n\nContinue to monitor and support hemodynamics,emotional support,\nmonitor PTT and other lab data, and continue to support pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2134-05-04 00:00:00.000", "description": "Report", "row_id": 1486669, "text": "Neuro: oob in chair at start of shift . chair to commode x2 . walked a few steps. chair to bed. pt is able to walk but is week. MAE.\n\nPain: pt denies chest pain or pain with deep breath. pt has rt shoulder pain, when touch pain is > 5 if not disturbed pt has no pain in arm.\n\nCV: sinus brady. MAP > 60 after one unit PRBC MAP consistantly > 65. post transfusion hct is 31. palp DP . afebrile\n\nLungs: BS clear in upper lobes some rales in bases. on 6l NC initially, on home bipap tolerating well .\n\nGI: ABD obese. soft with BS. no N/V. Small brown formed stool guiac negative.\n\nGU: foley to gravity. output low initially with unit of PRBC output improved. cre and BUN still high.\n\nSkin : intact some redness in coccyx area skin prep applied.\n\nA pt has sleep apnea tolerated bipap well.\n\nP: turn frequently. BIPAP at bed timed. replete lytes as indicated. Kexalate not given K is 4.8 at present.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 1486664, "text": "Respiratory Care:\nPt admit via ambulance from Rehab. W/CHF, and was treated with NIPV untill adaquatly diureased. Then she will be able to go onto her OWN CPAP equipt that she uses daily some time later. Just had an A-line placed to monitor and obtain ABG's. See CareVue for more Info.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 1486665, "text": "CCU Nursing Progress Note\nS: I just wasn't feeling well this morning when I woke up.\n\nO: 85yof with extensive PMH admitted to CCU with chief c/o epigastric pain with chest pressure and SOB. Report from Rehab reports that pt recieved a 20,000unit bolus of heparin last night followed by an increase in the Heparin drip by 200units each hour over night. Heparin stopped at 8am and PTT was >200. Vitamin K was administered. At 11:30am, pt c/o being sick BP reported 88/40, rx with 150cc ivf. AT 12noon, pt reports chest pressure, epigastric pain and sob, with a BP 160/100 and rales noted. Rx with 20mg IV Lasix, iisl ntg and cp resolved.\nEMT's called for Tx to \nIn EW - rx with 80mg IV Lasix for rales and O2 sat 88% on RA. Pt placed on CPAP and a foley was placed. BP 160/ and was rx with 2MSO4 and IV NTG. BP subsequently down to 90/ and was placed on Dopa 2.5mcgs/kg. Urine and Blood clutures done for WBC of 17.\n\nTx to CCU -\nCV - HR 60-70's nsr with rare pvc. BP is labile 90-140/50. Cont on Dopamine 4.5mcgs/kg/min. Attempting to wean Dopa, but BP will drop to 90/ Aline placed and is equal to ausc.\n\nResp - On cpap 50% with rales l base maintaining O2 sat 95-100%. Attempted to wean to 4ln/p but O2 sat dropped to 88%.\n\nGI - abd is obese with +bs.\n\nGU - Diuresing well after Lasix in EW approx 1000cc clear yellow urine.\n\nHeme - Hct 31.6 PT 14.1 PTT 53.2 INR 1.3\n\nNeuro - Alert and oriented x3.\n\nA: 85yof with diastolic dysfunction and tenuous fluid status and labile bp.\n\nP: At present, HO placing TLC, cont montitor HR and BP and attempt to wean Dopamine, Cont aggressive diruesis weaning cpap as able monitor coags, Turn and position for comfort, keep pt and family informed per multidisciplinary rounds.\n" } ]
30,158	109,420	On arrival into our intensive care unit the patient was found to be profoundly hypothermic with a core body temperature of 88 degree Fahrenheit. He was profusely bleeding from the abdomen, the nares and the orogastric tube. An arterial blood gas showed a pH of 6.8. He as aggressively resuscitated with fluids, packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate and many attempts at warming using a Bair Hugger device, that and room heating were performed. The patient's core temperature eventually reached 34.9 degrees, but he became progressively more difficult to ventilate. CXR done on admission was unremarkable, however, when the patient had increased difficulty ventilating, bilateral tube thoracotomies were performed. From the right chest tube, the patient had sanguinous discharge. He had continued difficulty with ventilation, and at this point his abdomen was quickly prepped and the retention sutures from his prior surgery were removed and patient was eviscerated. Next, the patient became somewhat easier to ventilate, however, his oxygen saturation continued to deteriorate and the patient became bradycardic, eventually displaying only agonal complexes with no blood pressure. The patient had bilateral chest tubes that had been placed previously, but there was blood clotted in the right chest tube. The team was concerned that the patient had a right hemothorax or a right tension pneumothorax or perhaps cardiac tamponade since the path of the knife was largely unknown. Preparation of the patient's chest from neck to distal abdomen was very rapidly prepped with Betadine. Using a scalpel an incision was made in the 5th intercostal space on the right side from mid axilla to sternum. This incision was carried down through intercostal space into the right pleura. Upon entering right pleura, a small amount of blood was noted, but there was no evidence of a gross right hemothorax or a right tension pneumothorax. The patient continued to be in cardiopulmonary arrest and therefore the incision was carried across the midline into the left and a formal clamshell thoracotomy was performed involving both the right and left hemithoraces. The chest wall was elevated and quickly both hemithoraces quickly examined. There was no evidence of hemothorax on the right or the left side. The pericardium was quickly opened and opened cardiac massage was performed. There was no evidence of hemopericardium or cardiac tamponade. The patient responded with reasonable blood pressure tracings upon open cardiac massage. While there was no spontaneous electrical activity noted, nor was there spontaneous cardiac contraction noted. The open cardiac massage and full code was performed for an additional 15 minutes. Multiple ampules of epinephrine, bicarbonate, calcium and atropine were administered, none of which resulted in resumption of a cardiac rhythm or adequate perfusion. At 7:35 p.m. the code was called and the operation was terminated.	Resuscitated w/ multiple UPRBC, FFP, platelets, cryoprecipitate, warmed LR/NS. The patient is intubated with the tip of the ET tube is approximately 1 cm above the carina and could be withdrawn approximately 2 cm. Respiratory decompensation repeatedly w/ pH remaining <7.0 despite aggressive resusciation w/ bicarb, fluids, 100% FiO2/increased PEEP. Esophageal temp 28.9 upon arrival, bleeding freely from abdominal wound, nares, OGT. A single AP view of the chest is obtained supine on at 05:41 hours. The tip of the vascular sheath is just included in the film above the medial portion of the right clavicle. ET tube tip approximately 1 cm above carina. CT x 2 placed w/ return of frothy red fluid bilaterally. Nasogastric tube is present with its tip below the diaphragm. Mild increase is seen in the interstitial markings bilaterally, which may represent fluid overload or early interstitial edema. Tmax reached 34.9. There is likely a small left pleural effusion. Several clips are noted in the skin in the midline. This could be withdrawn approximately 2 cm. Increased interstitial markings bilaterally may represent fluid overload or interstitial edema. Vigorous attempt to re-warm using Level one for all fluids, Hugger, OR heating pad. INDICATION: Possible retained sponge. Bowel gas pattern is unremarkable. Abdomen opened at bedside in attempt tamponade of bleeding and assess for further trauma. Dr , Dr. at bedside for entirety of effort. Single AP view of the abdomen which does not include the areas of the diaphragms shows no radiopaque foreign material. Received directly from their PACU via ground ambulance transport to TSICU, intubated. IMPRESSION: 1. 5:28 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for infiltrate, effusion, lap sponge packing Admitting Diagnosis: S/P STAB WOUND MEDICAL CONDITION: 30 year old man s/p stabbing transfer in from OSH REASON FOR THIS EXAMINATION: Please evaluate for infiltrate, effusion, lap sponge packing, ETT placement FINAL REPORT EXAMINATION: AP chest. 5:28 AM PORTABLE ABDOMEN Clip # Reason: Please evaluate for lap sponge packing Admitting Diagnosis: S/P STAB WOUND MEDICAL CONDITION: 30 year old man s/p stabbing transfer in from OSH REASON FOR THIS EXAMINATION: Please evaluate for lap sponge packing FINAL REPORT EXAMINATION: Supine abdomen. Increased retrocardiac density on the left side, likely represents atelectasis or airspace disease. INDICATION: Stabbing. Dr. was paged at 13:35 hours without response . NPN, 1900-070030 y/o male stabbing victim transferred from 0450.Single stab wound to right abdomen, taken to OR at for ex lap, repair of liver lac. Priest and family in after pt pronounced @ 0735 PEA cardiac arrest following sudden desat to 40's, unresponsive to all resuscitative measures. No large pneumothorax is seen in this projection. Bony structures are unremarkable. No prior films are available for comparison. 2.	3	[ { "category": "Radiology", "chartdate": "2191-04-30 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1007830, "text": " 5:28 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for lap sponge packing\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p stabbing transfer in from OSH\n REASON FOR THIS EXAMINATION:\n Please evaluate for lap sponge packing\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Supine abdomen.\n\n INDICATION: Possible retained sponge.\n\n Single AP view of the abdomen which does not include the areas of the\n diaphragms shows no radiopaque foreign material. Bowel gas pattern is\n unremarkable. Several clips are noted in the skin in the midline. Bony\n structures are unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007829, "text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate, effusion, lap sponge packing\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p stabbing transfer in from OSH\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate, effusion, lap sponge packing, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Stabbing.\n\n A single AP view of the chest is obtained supine on at 05:41 hours. No\n prior films are available for comparison. The heart is not enlarged. The\n patient is intubated with the tip of the ET tube is approximately 1 cm above\n the carina and could be withdrawn approximately 2 cm. Mild increase is seen\n in the interstitial markings bilaterally, which may represent fluid overload\n or early interstitial edema. Increased retrocardiac density on the left side,\n likely represents atelectasis or airspace disease. There is likely a small\n left pleural effusion. No large pneumothorax is seen in this projection. The\n tip of the vascular sheath is just included in the film above the medial\n portion of the right clavicle. Nasogastric tube is present with its tip below\n the diaphragm.\n\n IMPRESSION:\n\n 1. ET tube tip approximately 1 cm above carina. This could be withdrawn\n approximately 2 cm.\n 2. Increased interstitial markings bilaterally may represent fluid overload\n or interstitial edema.\n\n Dr. was paged at 13:35 hours without response .\n\n" }, { "category": "Nursing/other", "chartdate": "2191-04-30 00:00:00.000", "description": "Report", "row_id": 1651318, "text": "NPN, 1900-0700\n30 y/o male stabbing victim transferred from 0450.\nSingle stab wound to right abdomen, taken to OR at for ex lap, repair of liver lac. Received directly from their PACU via ground ambulance transport to TSICU, intubated. Esophageal temp 28.9 upon arrival, bleeding freely from abdominal wound, nares, OGT. Vigorous attempt to re-warm using Level one for all fluids, Hugger, OR heating pad. Tmax reached 34.9. Resuscitated w/ multiple UPRBC, FFP, platelets, cryoprecipitate, warmed LR/NS. CT x 2 placed w/ return of frothy red fluid bilaterally. Respiratory decompensation repeatedly w/ pH remaining <7.0 despite aggressive resusciation w/ bicarb, fluids, 100% FiO2/increased PEEP. PEA cardiac arrest following sudden desat to 40's, unresponsive to all resuscitative measures. Abdomen opened at bedside in attempt tamponade of bleeding and assess for further trauma. Dr , Dr. at bedside for entirety of effort. Priest and family in after pt pronounced @ 0735\n" } ]
197	129,890	Patient presents with nearly a 1 week course of nausea, vomiting and worsening abdominal pain, and presented to the ED. He had copious amounts of NG output, and a CAT scan consistent with a high-grade small bowel obstruction. The patient preoperatively underwent aggressive resuscitation with IV fluids and electrolyte corrections with potassium and magnesium. Patient's creatinine improved from a creatinine of 3 to 1.7, and the potassium also corrected from 2.7 to 3.1. Central line was placed for resuscitation. The patient consented for exploratory laparotomy, possible bowel resection, possible ostomy. The patient understood risks of procedure. Following the procedure the pt was transfered to the SICU. POD#1 Pt stayed in the SICU with NGT in place. He continued to receive fluids which helped lower his cr value from 3.0 -> 1.7. This value continued to improve during his hospital course. Cardiology was consulted due to TWI/ST depression with borderline long QT. This was most likely due to low K value of 2.6 and low calcium. No ischemic causes were identified or suspected. Aggressive repletion of electrolytes was continued. Pt was NPO, sedated and intubated, was on Kefzol and flagyl. Pt was extubated later in the day on POD #1. POD#2 extubated, NGT with no flatus, UE u/s showed no DVT POD#3 NPO, d/c beta blockers, started ambulating, started course of kefzol due to erythema present at abdominal wound, no systemic signs of sepsis, no fevers POD#4 ABX changed to levo and flagyl, NPO, less erythema at wound site POD#5 NPO, NGT until flatus, levo/flagyl stopped, changed back to kefzol, less erythema at wound site POD#6 NGT d/c, +flatus, Abx continued, erythema at wound resolved, diet advanced to sips/clears POD#7 +flatus, experienced loose stools later that evening POD #8, diet continued to advance	CT ABDOMEN WITHOUT IV CONTRAST: Small focus of ground glass opacity at the right base likely reflects subsegmental atelectasis. creat 1.7 and bun 49.gI abd softly distended. CT PELVIS WITHOUT IV CONTRAST: The bladder, prostate, seminal vesicles appear within normal limits. IMPRESSION: No left upper extremity DVT identified. obstruction No contraindications for IV contrast WET READ: BTCa TUE 4:18 PM Small bowel obstruction with gastric and proximal small bowel distension. Sinus rhythmNonspecific T wave abnormalities - cannot exclude in part ischemia - clinicalcorrelation is suggestedSince previous tracing of , T wave changes slightly less prominent Placed on A/C overnoc. Resp Care,Pt. Productive cough.NEURO: A&Ox3. Sinus rhythmDiffuse nonspecific T wave abnormalities - cannot exclude in part ischemia -clinical correlation is suggestedNo previous tracing available for comparison FINDINGS: The gallbladder is normal in appearance without intraluminal stones. venodynes.respnse: monitor closely post op. protonix as ordered. focus hemodymicsneuro: admitted to the sicu from the or. pneumo FINAL REPORT SINGLE AP PORTABLE VIEW CHEST TO ASSESS LINE PLACEMENT. Findings worrisome for small bowel obstruction versus ileus. NURSING NOTEPLEASE SEE CAREVUE FOR SPECIFICSCV: BP stable, systolic 130-150s. 3:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ? Sub segmental atelectasis at the right base. Decompressed loops of sigmoid colon and pelvic small bowel are mostly unremarkable. Sinus arrhythmia. ast 44 and alt 95.action: post op q15min-q1hr vital signs. ngt to lcws. FINDINGS: Right internal jugular vein catheter tip is at cavoatrial junction. There is normal compressibility, respiratory variation, and response to augmentation of the left axillary, paired brachial veins, basilic and cephalic veins. neuro signs q2hrs. The visualized heart and pericardium are unremarkable. 11:03 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: L. PALM SWELLING, ? There are small mesenteric and retroperitoneal lymph nodes, which do not meet CT size criteria for pathologic enlargement. vented and attempt to extubate today. The unopacified liver, gallbladder, pancreas, spleen, and adrenal glands are normal. Compared to the previous tracingof no change. + BS. High-grade small-bowel obstruction with transition point identified in the right lower abdominal quadrant. Pt remains NPO. A transition point is identified in the right lower quadrant (series 2, image 56), with fecalization of small bowel contents with proximal and decompressed loops of small bowel and colon seen distally. There are low lung volumes with bibasilar discoid atelectasis. TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis were obtained following the administration of oral but not intravenous contrast . expressing he has abd pain and fentanyl gtt started and very comfortable.resp breath sounds clear. There is normal compressibility of the left internal jugular vein with normal waveforms and response to augmentation. IMPRESSION: 1. IMPRESSION: 1. Evaluation of the visceral organs is limited secondary to lack of intravenous contrast. iv flagyl and iv cefazolin given. K 4.0. Right nare NGT to lcws putting out small amount light brown liquid drainage. Pt using pump appropriately and cough pillow as needed.GI/ENDO: Abdomen soft, slightly distended. bp 110-130's. intubated with 7.5 et tube. intubated and on iv propofol gtt. Recieving Sodium Phos for Phos of 2.4. No breakdown on backside noted. In the patient's left palm, there is a 3 x 5 x 5 mm hypoechoic nodule without vascularity present. k repleted. RSBI 66 this am. LCTAB, slightly coarse at times. to wean and extubated this am when more awake. NSR HR 70-90s. obstruction FINAL REPORT (Cont) urgent attention. There are no sizable pleural effusions. BONE WINDOWS: A nonspecific sclerotic focus with nonaggressive features is noted in the right ischium, likely a bone island. LINE PLACEMENT Clip # Reason: ? o2sats 99-100%.cardiac: in nsr. No intra- or extra-hepatic biliary duct dilatation identified. No intraluminal filling defects are seen. Plan to cont. Allowing for this factor, there are multiple dilated fluid-filled loops of small bowel with moderate distention of the stomach and proximal bowel loops. NG tube tip is in the stomach. PEERLA 3mm. admitted from OR intubated #7.5 ET taped at 22@lip. Monitor pain, temp, skin integrity. Multiplanar reconstructions were performed. No BM. The right kidney measures 9.7 cm. The liver is mildly echogenic consistent with fatty liver. Pt c/o cramping abdominal pain (), fentanyl drip discontinued and started on Dilaudid PCA, dose 0.12mg with hour total 1.2mg. No osseous findings suspicious for malignancy are identified. Mild echogenic appearance of the liver consistent with fatty liver. no ectopy seen. No ectopy noted.RESP: Pt extubated well today with no problems, maintaining sat's 98-100%. FINDINGS: Both grayscale and color Doppler ultrasound examination was performed. goal is to extubate today. Currently on 1L NC sat'ing 97-99%. The pancreas is not well visualized secondary to overlying bowel gas. The left kidney measures 11.1 cm. 10:03 PM CHEST PORT. Findings were discussed with Dr. at the time of dictation. Findings were relayed to the ED dashboard at time of dictation and marked for (Over) 3:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?	10	[ { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 950657, "text": " 3:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with Abd Pain\n REASON FOR THIS EXAMINATION:\n ? obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa TUE 4:18 PM\n Small bowel obstruction with gastric and proximal small bowel distension.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old male with abdominal pain.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis\n were obtained following the administration of oral but not intravenous\n contrast . Multiplanar reconstructions were performed.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Small focus of ground glass opacity at the\n right base likely reflects subsegmental atelectasis. The visualized heart and\n pericardium are unremarkable. Evaluation of the visceral organs is limited\n secondary to lack of intravenous contrast. Allowing for this factor, there\n are multiple dilated fluid-filled loops of small bowel with moderate\n distention of the stomach and proximal bowel loops. A transition point is\n identified in the right lower quadrant (series 2, image 56), with fecalization\n of small bowel contents with proximal and decompressed loops of small bowel\n and colon seen distally. There is no evidence of bowel wall thickening, free\n intraperitoneal air or fluid. The unopacified liver, gallbladder, pancreas,\n spleen, and adrenal glands are normal. No calculi or evidence of\n hydronephrosis is seen within either kidney. There are small mesenteric and\n retroperitoneal lymph nodes, which do not meet CT size criteria for pathologic\n enlargement.\n\n CT PELVIS WITHOUT IV CONTRAST: The bladder, prostate, seminal vesicles appear\n within normal limits. Decompressed loops of sigmoid colon and pelvic small\n bowel are mostly unremarkable. There is no free pelvic fluid and no inguinal\n or pelvic lymphadenopathy.\n\n BONE WINDOWS: A nonspecific sclerotic focus with nonaggressive features is\n noted in the right ischium, likely a bone island. No osseous findings\n suspicious for malignancy are identified.\n\n IMPRESSION:\n 1. High-grade small-bowel obstruction with transition point identified in the\n right lower abdominal quadrant. No evidence of bowel wall thickening, free\n intraperitoneal air or fluid.\n 2. Sub segmental atelectasis at the right base.\n\n Findings were relayed to the ED dashboard at time of dictation and marked for\n (Over)\n\n 3:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n urgent attention.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-24 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 950950, "text": " 11:03 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: L. PALM SWELLING, ? ARM CLOT\n Admitting Diagnosis: EXPLORATORY LAPAROTOMY FOR SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with unilateral swelling\n REASON FOR THIS EXAMINATION:\n ? clot\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old man with unilateral left upper extremity swelling,\n evaluate for DVT.\n\n FINDINGS: Both grayscale and color Doppler ultrasound examination was\n performed. There is normal compressibility of the left internal jugular vein\n with normal waveforms and response to augmentation. There are normal\n waveforms and response to augmentation of the left subclavian vein as well.\n There is normal compressibility, respiratory variation, and response to\n augmentation of the left axillary, paired brachial veins, basilic and cephalic\n veins. No intraluminal filling defects are seen.\n\n In the patient's left palm, there is a 3 x 5 x 5 mm hypoechoic nodule without\n vascularity present.\n\n IMPRESSION: No left upper extremity DVT identified.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 950588, "text": " 9:27 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: r/o acute pancreatitis/cholecystitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with n/v for 6 days, abnormal LFT's and hi lipase\n REASON FOR THIS EXAMINATION:\n r/o acute pancreatitis/cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Complete abdominal ultrasound.\n\n INDICATION: 45-year-old male with nausea and vomiting times six days and\n abnormal LFTs.\n\n COMPARISON: There are no studies available for comparison.\n\n FINDINGS: The gallbladder is normal in appearance without intraluminal\n stones. The liver is mildly echogenic consistent with fatty liver. However,\n other forms of liver disease and more advanced liver disease, including\n significant hepatic fibrosis/cirrhosis cannot be excluded on this study. No\n intra- or extra-hepatic biliary duct dilatation identified. The pancreas is\n not well visualized secondary to overlying bowel gas. The left kidney\n measures 11.1 cm. The right kidney measures 9.7 cm. There are no masses,\n stones, or hydronephrosis present within the kidneys.\n\n Of note, there are multiple diffuse dilated small bowel loops throughout the\n entire abdomen which display peristaltic activity.\n\n There is no free fluid identified within the abdomen.\n\n IMPRESSION:\n 1. Multiple dilated small bowel loops within the abdomen displaying\n peristaltic activity. Findings worrisome for small bowel obstruction versus\n ileus. Recommend CT scan for further evaluation.\n\n 2. Mild echogenic appearance of the liver consistent with fatty liver.\n However, other forms of liver disease and more advanced liver disease,\n including significant hepatic fibrosis/cirrhosis cannot be fully excluded on\n this study.\n\n Findings were discussed with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 950692, "text": " 10:03 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? pneumo\n Admitting Diagnosis: EXPLORATORY LAPAROTOMY FOR SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with RIJ\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST TO ASSESS LINE PLACEMENT.\n\n COMPARISON: None.\n\n FINDINGS: Right internal jugular vein catheter tip is at cavoatrial junction.\n There is no pneumothorax or pleural effusion. There are low lung volumes with\n bibasilar discoid atelectasis. There are no sizable pleural effusions. NG\n tube tip is in the stomach.\n\n" }, { "category": "ECG", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 115890, "text": "Sinus rhythm\nNonspecific T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , T wave changes slightly less prominent\n\n" }, { "category": "ECG", "chartdate": "2174-03-22 00:00:00.000", "description": "Report", "row_id": 115891, "text": "Sinus rhythm\nDiffuse nonspecific T wave abnormalities - cannot exclude in part ischemia -\nclinical correlation is suggested\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2174-03-24 00:00:00.000", "description": "Report", "row_id": 115841, "text": "Sinus arrhythmia. Otherwise, normal. Compared to the previous tracing\nof no change.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262971, "text": "focus hemodymics\nneuro: admitted to the sicu from the or. intubated and on iv propofol gtt. pupils #3 and reacts briskly. moves all extremities on the bed. mouthing words but difficult to understand. attempting to write in the air. expressing he has abd pain and fentanyl gtt started and very comfortable.\n\nresp breath sounds clear. intubated with 7.5 et tube. goal is to extubate today. suctioned for thick yellow sputum. o2sats 99-100%.\n\ncardiac: in nsr. no ectopy seen. bp 110-130's. when coughing bp elevates to the 150's. hct 43.6, k 3.3 and repleted with 40meq kcl iv.\nmagnesium 2.2. iv d5lr with 40meq kcl iv at 125cc/hr.\n\ngu : foley patent and draiing yellow cloudy urine. creat 1.7 and bun 49.\n\ngI abd softly distended. ngt to lcws and draining bilius drainage. no bowel sounds. protonix as ordered. ast 44 and alt 95.\n\naction: post op q15min-q1hr vital signs. fentanyl gtt infusing and propofol gtt. neuro signs q2hrs. iv flagyl and iv cefazolin given. ngt to lcws. vented and attempt to extubate today. k repleted. venodynes.\n\nrespnse: monitor closely post op.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262972, "text": "Resp Care,\nPt. admitted from OR intubated #7.5 ET taped at 22@lip. Placed on A/C overnoc. More awake this am, placed on IPS10/5. RSBI 66 this am. Plan to cont. to wean and extubated this am when more awake.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262973, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nCV: BP stable, systolic 130-150s. Episode of SBP >160 for about an hour, Dr. aware and started pt on 5mg Lopressor IV, given with effect. EKGx2 done today, cards in to see pt, will correct all electrolytes and monitor EKGs. K 4.0. Recieving Sodium Phos for Phos of 2.4. NSR HR 70-90s. No ectopy noted.\n\nRESP: Pt extubated well today with no problems, maintaining sat's 98-100%. Currently on 1L NC sat'ing 97-99%. LCTAB, slightly coarse at times. Productive cough.\n\nNEURO: A&Ox3. Pleasant and cooperative. PEERLA 3mm. Follows commands, lifts and holds all extremities. Pt c/o cramping abdominal pain (), fentanyl drip discontinued and started on Dilaudid PCA, dose 0.12mg with hour total 1.2mg. Pt using pump appropriately and cough pillow as needed.\n\nGI/ENDO: Abdomen soft, slightly distended. + BS. No BM. Pt remains NPO. Right nare NGT to lcws putting out small amount light brown liquid drainage. No insulin coverage required, no blood sugar checks.\n\nGU: Foley patent draining adequate amount of clear/cloudy dark yellow urine.\n\nSKIN: Intact. No breakdown on backside noted. Original dressing from OR intact on midline abdomen, clean and dry, no drainage.\n\nSOCIAL: Pts wife and friend into visit.\n\nPLAN OF CARE: Continue to check and replace electrolytes as needed. Monitor pain, temp, skin integrity. Pt called out, will transfer to floor with tele when bed available. HO aware of above, will call with any changes.\n" } ]
30,855	179,092	19 yo female with hx of question of asthma with many exacerbations, vocal cord dysfunction, depression, and conversion disorder presents with stridor and tachypnea. . # dyspnea and stridor: this is typical of her previous ? asthma exacerbations, for which she does not appear to have a definitive diagnosis. She received ativan, heliox, and nebs in the ED with some resolution of symptoms. Although she has a question of airway disease and a diagnosis of vocal cord dysfuction, this is most likely a manifestation of her conversion disorder. CXR appears normal and unchanged. Most recent admission reported good response to ativan. She continues to sat well in the upper 90s. She will likely benefit most from consistent social and outpatient medical support to help her more effectively deal with anxieties and avoid the ED/ICU where iatrogenic harm may come to her. She has seen ENT before. She was given ativan prn, reassurance, and her inhalers were continued. A coordinated attempt improve her support structure was already in development, but further impetus was placed by emails and phone calls to her major sources of health care support - her PCP, and . Will discuss with PCP, , and : coordination of care. Follow up appointments are set up health services on at 9 am. They agreed to set up support services necessary to her after the visit tomorrow. Will encourage her to follow up with speech/swallow/behavioral therapy as outpatient . # conversion disorder: previously diagnosed at . As above, this is likely the root cause of her exacerbations and would benefit from greater outpatient and social support. . # depression: previously treated with lamotrigine, though not currently treated. Possible or psychiatric referal after appointments at and/or PCP. . # FEN: regular diet, replete lytes prn . # PPx: ambulation, cont outpatient PPI . # Code: full	CXR CLEAR. RESPONDED WELL TO ATIVAN. ARRIVED WITH NOTABLE STRIDOR. PT. PT. PT. BREATH SOUNDS CTA. BREATH SOUNDS CTA. IN PT. BS+. HEMODYNAMICALLY STABLE.GI: ABD. MEDICATE WITH ATIVAN PRN. Lungs clear. AFEBRILE. + PULSES. EMOTIONAL SUPPORT TO PT. COMPARISON: . MAE. The cardiomediastinal silhouette is normal. ALERT AND ORIENTED X3. NO C/O PAIN. PUPILS EQUAL AND REACTIVE. FINDINGS: AP view of the chest in upright position. PROBABLE C/O TO FLOOR THIS AM. Sats 100%. THE THIRD ADMISSION, PT. The lungs are clear. WHEN WE LEFT ROOM, STRIDOR RETURNED. SOFT. VERY PLEASANT AND COOPERATIVE.RESP: PT. HER SATS REMAINED 98-100%. NO ECTOPY NOTED. NO BM. The pulmonary vasculature is normal. INHALERS ORDERED.CV: NSR/ST WITH HR 90'S TO LOW 110'S. NO EDEMA. AM LABS PENDING. IMPRESSION: No acute cardiopulmonary process. WHEN TALKING TO THIS RN AND MD'S THE STRIDOR WENT AWAY. ORDERED FOR REGULAR DIET.GU: PT. TRANSFERRED HERE TO MSICU FOR CLSER MONITORING.NEURO: PT. There is no pneumothorax or pleural effusion. NO STRIDOR WITH SLEEPING. The osseous structures are unremarkable. FELL ASLEEP SHORTLY AFTER TRANSFER. REASON FOR THIS EXAMINATION: please eval for acute cardiopulmonary process FINAL REPORT INDICATION: Vocal cord dysfunction with stridor and feeling of tightness status post exercise. VOIDING IN COMMODE CLEAR YELLOW URINESKIN: INTACTACCESS: R FA 20G PIV - INTACTPLAN: CONTINUE WITH CONTINUOUS PULSE OX MONITORING. 11:16 PM CHEST (PORTABLE AP) Clip # Reason: please eval for acute cardiopulmonary process MEDICAL CONDITION: F w/known vocal cord dysfunction presents w/stridor and feeling of tightness s/p exercise. GIVEN 3 MG OF ATIVAN AND PUT ON HELIOX. NPN 7P-7ATHIS IS A 19YO FEMALE WITH PMH: MULTIPLE ADMISSIONS WITH INTUBATION FOR PRESUMED ASTHMA EXACERBATIONS, PAROXYSMAL VOCAL CHORD DYSFUNCTION, DEPRESSION AND CONVERSION D/O WHO PRESENTED TO EW WITH DYSPNEA AND STRIDOR. ON 40% AEROSOL FACE MASK WITH SATS 98-100%.	2	[ { "category": "Radiology", "chartdate": "2150-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986602, "text": " 11:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F w/known vocal cord dysfunction presents w/stridor and feeling of tightness\n s/p exercise. Sats 100%. Lungs clear.\n REASON FOR THIS EXAMINATION:\n please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Vocal cord dysfunction with stridor and feeling of tightness\n status post exercise.\n\n COMPARISON: .\n\n FINDINGS: AP view of the chest in upright position. The cardiomediastinal\n silhouette is normal. The lungs are clear. There is no pneumothorax or\n pleural effusion. The pulmonary vasculature is normal. The osseous\n structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-12-30 00:00:00.000", "description": "Report", "row_id": 1658219, "text": "NPN 7P-7A\nTHIS IS A 19YO FEMALE WITH PMH: MULTIPLE ADMISSIONS WITH INTUBATION FOR PRESUMED ASTHMA EXACERBATIONS, PAROXYSMAL VOCAL CHORD DYSFUNCTION, DEPRESSION AND CONVERSION D/O WHO PRESENTED TO EW WITH DYSPNEA AND STRIDOR. OF NOTE, SHE HAS HAD 3 RECENT ADMISSIONS (, AND ) FOR HER VOCAL CHORD D/O VS. ASTHMA FLARE REQUIRING 2 INTUBATIONS. THE THIRD ADMISSION, PT. RESPONDED WELL TO ATIVAN. IN PT. GIVEN 3 MG OF ATIVAN AND PUT ON HELIOX. CXR CLEAR. BREATH SOUNDS CTA. HER SATS REMAINED 98-100%. TRANSFERRED HERE TO MSICU FOR CLSER MONITORING.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. PUPILS EQUAL AND REACTIVE. NO C/O PAIN. VERY PLEASANT AND COOPERATIVE.\n\nRESP: PT. ON 40% AEROSOL FACE MASK WITH SATS 98-100%. BREATH SOUNDS CTA. PT. ARRIVED WITH NOTABLE STRIDOR. WHEN TALKING TO THIS RN AND MD'S THE STRIDOR WENT AWAY. WHEN WE LEFT ROOM, STRIDOR RETURNED. PT. FELL ASLEEP SHORTLY AFTER TRANSFER. NO STRIDOR WITH SLEEPING. INHALERS ORDERED.\n\nCV: NSR/ST WITH HR 90'S TO LOW 110'S. NO ECTOPY NOTED. + PULSES. NO EDEMA. AFEBRILE. HEMODYNAMICALLY STABLE.\n\nGI: ABD. SOFT. BS+. NO BM. PT. ORDERED FOR REGULAR DIET.\n\nGU: PT. VOIDING IN COMMODE CLEAR YELLOW URINE\n\nSKIN: INTACT\n\nACCESS: R FA 20G PIV - INTACT\n\nPLAN: CONTINUE WITH CONTINUOUS PULSE OX MONITORING. MEDICATE WITH ATIVAN PRN. EMOTIONAL SUPPORT TO PT. AM LABS PENDING. PROBABLE C/O TO FLOOR THIS AM.\n" } ]
24,963	126,722	Pt is a 82 yo female R CHF, Afib on coumadin, DM, non-healing vascular ulcers, and CRI who is transferred to MICU for sepsis. She was intubated in the ED. It was felt that the hypotension was secondary to sepsis based on exam, with a possible cellulitis as a source. Blood cultures grew out GNR on HD #1. She was convered broadly with zosyn and vancomycin as well as flagyl for potential gut sources. We continued levophed. Given her low SVO2s, dobutamine was tried with resultant decrease in blood pressure; dopamine was then added. Over the course of the day, pt was anuric despite many fluid boluses. It was thought that her severe right sided heart failure and 4+ TR were leading to a cardiac component to the shock. Given her extremely grave prognosis, several family meetings were held. It was decided on the night of to make patient CMO. She passed away at 11:26 pm on with her entire family present.	Diffuse osteopenia is noted. The aorta is diffusely atherosclerotic and calcified. Mild (1+) aortic regurgitation is seen. EXHIBITS GROSS JVD, AND HISTORY OF SEVERE TRICUSPID REGURG.PT. DOBUTAMINE WAS DC'D. PT'S LACTATE 6.9, INR 6.0. Again noted is diverticulosis of the sigmoid colon. TTE DONE SHOWING LARG RIGHT SIDE OF HEART. WAS HYPOTENSIVE UPON ARRIVAL TO THE E.D. HAS BEEN SUCTIONED FOR SCANT CLEAR SECRETIONS. There is atrivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , the estimatedpulmonary arterty systolic pressure and severity of tricuspoid regurgitationare lower. SHOWS COMPRESSION OF LEFT SIDE OF HEART BY RIGHT.GI- ABD SOFT DISTENDED WITH ABSENT BS. B/P REMAINS SUPPORTED BY LEVOPHED PRESENTLY AT 0.1MCG/KG/MIN. IS INTUBATED WITH A 7.5/21 RIGHT LIP LINE. The common iliac arteries are noted to be diffusely calcified. RIGHT SIDE 75/40, AND LEFT 86/46. Aside from a probable right adrenal hematoma, the abdominal and pelvic organs appear grossly within normal limits. Mildaortic valve stenosis is present. REMAINS NPO, WITH OGT PLACED IN E.D. THIS IS A RE OCCURING WOUND THAT PT. LACTATE 6.9. Abnormal diastolic septalmotion/position consistent with RV volume overload.AORTA: Normal aortic diameter at the sinus level. DRESSING REMAINS D&I. THIS IS SLIGHTLY INPROVED WITH FLUID BOLUSES. GRIMACED TO CARE. Right ventricular function.Height: (in) 61Weight (lb): 159BSA (m2): 1.72 m2BP (mm Hg): 94/45HR (bpm): 65Status: InpatientDate/Time: at 12:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. CONTINUES ON FLAGYL, AND UNASYN. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. VAP PROTOCOL FOLLOWED.PT. PRECEPT CATHETER HAS BEEN REPOSITIONED, STILL WAVEFORM IS QUESTIONABLE, BUT PT. IS DRAINING APPROX. Moderate PA systolichypertension.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left and right atria are moderately dilatedThe estimated right atrialpressure is >20 mmHg. CONT ON FLAGYL. The ascending aorta ismildly dilated. There is abnormal diastolic septal motion/positionconsistent with right ventricular volume overload. WAS INTUBATED AND PLACED ON SEPSIS PROTOCOL. ABG WAS 7.29/20/92/10. There is trivial mitralregurgitaiton. The origins of the celiac and SMA are noted to be calcified as well. REMAINS SEDATED ON BOTH FENTANYL 12.5MCG, AND VERSED 1.5MG/HR. Mild AS (AoVA1.2-1.9cm2). The tip of this catheter is in the expected location of the cavoatrial junction or possibly just inside the right atrium. The right ventricular cavity is moderately dilated withgood free wall motion. WILL RESPOND AFTER GTT IS SHUT OFF FOR APPROX. Degenerative changes of the hips bilaterally, right greater than left, are relatively unchanged compared to the CT from . There is diffuse anasarca of the subcutaneous tissues. Good oxygenation when FiO2 1.0. REMAINS ON SEPSIS PROTOCOL AT THIS TIME. There is a small left pleural effusion. STARTED ON LEVO. Focal calcifications inaortic root. 5:24 PM FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT Clip # Reason: Subcutaneous air. DR AWARE. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. Normal regional LV systolic function.RIGHT VENTRICLE: Moderately dilated RV cavity. Dilated IVC (>2.5cm) with nochange with respiration (estimated RAP >20 mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). MONITOR UO. Thereis moderate pulmonary artery systolic hypertension. IMPRESSION: Diffuse ascites and the presence of anasarca suggest so-called "third-spacing" of fluid. TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases to the feet. Trivial MR.TRICUSPID VALVE: Moderate to severe [3+] TR. IS NOTED PRIOR TO THIS ADMISSION TO HAVE +MRSA CULTURE TO THIS WOUND SITE. A comparison was made to prior radiographs dated . Heart size remains enlarged and there is a stable position to endotracheal tube which now appears approximately 4 cm from the carina, orogastric tube, and a single lead left-sided pacemaker device. Mildly dilated ascending aorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. she was sx'd for minimal secretions. SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: A right-sided internal jugular central venous catheter has been pulled back with tip now within the distal SVC. CT OF THE LOWER EXTREMITIES WITHOUT CONTRAST: There is diffuse stranding within the subcutaneous tissues. Moderate to severe [3+] tricuspid regurgitation is seen. Right ventricular cavity size and free wall motioin are similar.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. IMPRESSION: Findings consistent with mild congestive heart failure. Compared to the previous tracing of no change.TRACING #1 PRESENTLY THIS IS TO LOW INTERMITTENT WALL SUCTION FOR SCANT AMT'S OF TAN/CLEAR DRAINAGE. Just superior to the right kidney, there is a 4.1 x 3.9 cm collection with multiple punctate foci (series 2, image 28), which could represent an adrenal hemorrhage. Tip of a right-sided central venous catheter within distal SVC. SVO2 IN THE MID TO UPPER 60'S. BOWEL SOUNDS ARE ABSENT AT PRESENT.FOLEY CATHETER REMAINS IN PLACE WITH URINARY OUTPUT NIL. There is minimal associated atelectasis secondary to pleural effusions. The femoral artery, popliteal arteries, and their respective branches are noted to be calcified bilaterally. IMPRESSION: 1. IMPRESSION: 1. Additionally, a mild interstitial edema appears improved. A single AP view of the chest was obtained on at 1759 hours but is presented on for interpretation. Themitral valve leaflets are mildly thickened. THIS DRESSING HAS BEEN CLEANSED WITH N/S AND DSD APPLIED. The abdominal organs, including the bowel, appear grossly within normal limits otherwise on this noncontrast, limited evaluation. Ventricular pacemaker. Ventricular pacemaker. COMPARISONS: CT pelvis from . Regional systolicfunction is normal. PRESENTLY PT. SON IN WHO IS HER HCP. There is bilateral perinephric stranding and diffuse mesenteric stranding which could be related to the ascites. WITH THIS HER HR WENT UP INTO THE 70'S AFIB WITH RARE PVC. There are multilevel degenerative changes of the lumbar and lower thoracic spine. Improvement to mild interstitial pulmonary edema. COMPARISONS: . UO SINCE HAS BEEN 2-12CC/HR. ON THIS SHE WITHDREW TO PAIN.	17	[ { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 960572, "text": " 5:42 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new R IJ line\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Line placement.\n\n A single AP view of the chest was obtained on at 1759 hours but is\n presented on for interpretation. It is compared with a radiograph\n performed approximately one hour previously and shows insertion of a\n right-sided IJ line. The tip of this catheter is in the expected location of\n the cavoatrial junction or possibly just inside the right atrium. No other\n acute change is noted from the prior radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960596, "text": " 9:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tlc line placement\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p intubation\n\n REASON FOR THIS EXAMINATION:\n tlc line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Reevaluation of line.\n\n Comparison is made to multiple prior films dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n A right-sided internal jugular central venous catheter has been pulled back\n with tip now within the distal SVC. Additionally, a mild interstitial edema\n appears improved. Heart size remains enlarged and there is a stable position\n to endotracheal tube which now appears approximately 4 cm from the carina,\n orogastric tube, and a single lead left-sided pacemaker device.\n\n The lungs are otherwise clear.\n\n IMPRESSION:\n\n 1. Tip of a right-sided central venous catheter within distal SVC. No\n evidence of pneumothorax.\n\n 2. Improvement to mild interstitial pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "LP FEMUR (AP & LAT) LEFT PORT", "row_id": 960570, "text": " 5:24 PM\n FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT Clip # \n Reason: Subcutaneous air. Please do the whole left leg. Thanks.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with non-healing ulcers concern for nec fas\n REASON FOR THIS EXAMINATION:\n Subcutaneous air. Please do the whole left leg. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with non-healing ulcers concerning for\n necrotizing fasciitis.\n\n COMPARISON: .\n\n FINDINGS: Four views of the left thigh and lower extremity. There is a large\n soft tissue defect in the posterior aspect of the mid left lower extremity.\n There is a 1.6 cm density in the superior and medial aspect of the soft tissue\n defect which could represent foreign body or overlying bandage material.\n Bandage material is seen overlying the soft tissue defect. Hardware from\n previous bimalleolar fracture is again noted, not completely assessed in this\n lateral view. Diffuse osteopenia is noted. No evidence of gas within the soft\n tissues. No evidence of acute fracture. No evidence of knee joint effusion.\n The left femoral head is obscured by overlying soft tissues.\n Vascular calcifications.\n\n IMPRESSION:\n 1. Large soft tissue defect in the posterior aspect of the mid left lower\n extremity with a 1.6 cm density in the superior and medial aspect which could\n represent foreign body or overlying bandage material.\n 2. No evidence of gas within the soft tissues.\n 3. Limited evaluation of the left femoral head due to overlying soft tissues.\n 4. Vascular calcifications.\n\n Findings discussed with Dr. at 10:30 PM on .\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960578, "text": " 6:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n assess ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female status post intubation.\n\n A comparison was made to prior radiographs dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS\n\n Endotracheal tube terminates approximately 3 cm from the carina and orogastric\n tube projects below the diaphragm, however distal tip is not visualized but\n likely terminates within the stomach. Appearance of radiograph is otherwise\n unchanged from film taken approximately one hour prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 960583, "text": " 7:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT LOW EXT W/O C BILAT\n Reason: evalaute for source of infection, sepsis\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with renal failure, sepsis\n REASON FOR THIS EXAMINATION:\n evalaute for source of infection, sepsis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen to the feet.\n\n INDICATION: 82-year-old female with renal failure, sepsis. Assess for source\n of infection.\n\n COMPARISONS: CT pelvis from .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases\n to the feet.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral pleural effusions,\n right greater than left. Limited views of the lung bases are unremarkable.\n There is minimal associated atelectasis secondary to pleural effusions. There\n is a significant amount of perihepatic and perisplenic fluid, which extends\n throughout the abdomen and into the pelvis. Just superior to the right\n kidney, there is a 4.1 x 3.9 cm collection with multiple punctate foci (series\n 2, image 28), which could represent an adrenal hemorrhage. This area measures\n approximately 35 Hounsfield units. There is bilateral perinephric stranding\n and diffuse mesenteric stranding which could be related to the ascites. The\n abdominal organs, including the bowel, appear grossly within normal limits\n otherwise on this noncontrast, limited evaluation. The aorta is diffusely\n atherosclerotic and calcified. The origins of the celiac and SMA are noted to\n be calcified as well. There is diffuse anasarca of the subcutaneous tissues.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Extensive diverticulosis of the sigmoid\n and distal descending colon is present and high-density material is seen\n within multiple diverticula, which could be residual barium, but there are no\n reports of recent studies at this institution. There is pelvic fluid\n surrounding the uterus and bladder. A Foley balloon is present within the\n bladder. The common iliac arteries are noted to be diffusely calcified.\n\n CT OF THE LOWER EXTREMITIES WITHOUT CONTRAST: There is diffuse stranding\n within the subcutaneous tissues. At the level of the mid tibia, there is a\n prominent defect within the subcutaneous tissues extending to the deep tissue\n planes along the posterior medial surface of the left lower extremity which\n correlates to a known nonhealing ulcer. There is no associated subcutaneous\n air in this area. The femoral artery, popliteal arteries, and their respective\n branches are noted to be calcified bilaterally.\n\n (Over)\n\n 7:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT LOW EXT W/O C BILAT\n Reason: evalaute for source of infection, sepsis\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n Degenerative changes of the hips bilaterally, right greater than left, are\n relatively unchanged compared to the CT from . There are multilevel\n degenerative changes of the lumbar and lower thoracic spine.\n\n IMPRESSION: Diffuse ascites and the presence of anasarca suggest so-called\n \"third-spacing\" of fluid. Without IV or oral contrast, this examination is\n limited. Aside from a probable right adrenal hematoma, the abdominal and\n pelvic organs appear grossly within normal limits. A left lower extremity\n subcutaneous defect is present but there is no evidence of subcutaneous air in\n the soft tissues. Again noted is diverticulosis of the sigmoid colon.\n\n Findings were discussed with Vascular Surgery service and Dr. from\n General Surgery at 10:00 p.m. on by Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 960562, "text": " 4:45 PM\n CHEST (PA & LAT) Clip # \n Reason: evalaute for volume overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with h/o CHF now with SOB, wt gain\n REASON FOR THIS EXAMINATION:\n evalaute for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray with AP and lateral views.\n\n INDICATION: 82-year-old female with history of CHF, now presenting with\n shortness of breath and weight gain. Assess volume overload.\n\n COMPARISONS: .\n\n FINDINGS: A single-lead pacemaker projects over the left chest. The cardiac\n silhouette is enlarged and the pulmonary vascular markings are prominent. The\n interstitial markings are prominent as well. There is a small left pleural\n effusion. The aorta remains calcified and tortuous without focal dilatation.\n No focal infiltrate within the lungs is present. The soft tissues and osseous\n structures are unremarkable aside from mild degenerative changes of the\n thoracic spine.\n\n IMPRESSION: Findings consistent with mild congestive heart failure.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587772, "text": "PT. BROUGHT FROM HOME WITH C/O WORSENING SOB, AND LEG SWELLING. PT'S MED REGIME WAS CHANGED TWO WEEKS AGO, DUE TO RISING CREATININE. PT. EXPERIENCED A 17 POUND WEIGHT GAIN, ALONG WITH SOB, AND WORSENING LEG EDEMA. PT. WAS HYPOTENSIVE UPON ARRIVAL TO THE E.D. RIGHT SIDE 75/40, AND LEFT 86/46. PT. IS KNOWN TO HAVE RIGHT SIDED HEART FAILURE AND SEVERE TRICUSPID VALVE REGURG . SOB, AND WORSENING LABS PREEMPTED INTUBATION. PT'S LACTATE 6.9, INR 6.0. PT. TAKEN TO CAT SCAN WITH SURGICAL CONSULT ORDERED FOR POSSIBLE ISCHEMIC BOWEL. PT. PLACED ON LEVOPHED, GIVEN 2 LITERS OF N/S AND 2 UNITS OF FFP, AND VITAMIN K.\n\nALLERGIES: ZAROXOLYN\n\nPT. IS A FULL CODE, AND REMAINS ON CONTACT PRECAUTIONS FOR MRSA IN HER WOUND.\n\nPT. REMAINS SEDATED ON BOTH FENTANYL 12.5MCG, AND VERSED 1.5MG/HR. PT. WILL RESPOND AFTER GTT IS SHUT OFF FOR APPROX. 15-20MINS, AND WILL OPEN EYES SPONTANEOUSLY, AND MAE'S. PT. DOES NOT FOLLOW COMMANDS, OR TRACK. PUPILS ARE BILAT EQUAL AND REACTIVE. PT. REMAINS ON BAIR HUGGER DUE TO LOW TEMPS. PRESENTLY PT. IS 95.7 DOWN FROM 96.2 AFTER BEING ON BAIR HUGGER FOR PAST FEW HOURS.\n\nPT. HAS REMAINED 100% V PACED AT RATE OF 65. NO NOTED ECTOPY THROUGHOUT THIS SHIFT. B/P REMAINS SUPPORTED BY LEVOPHED PRESENTLY AT 0.1MCG/KG/MIN. REFER TO CAREVUE FOR LATEST SETTINGS. PT. HAS ALSO RECEIVED OVER 4LITERS OF N/S BOLUSES. PULSES REMAIN DOPPLED AND LOWER LEGS HAVE DARKENED DURING THIS SHIFT. VASCULAR TEAM HAS BEEN AROUND AND, IS AWARE OF THIS. B/P HAS BEEN 88-115/50-60'S. SVO2 MONITORED AND RANGES 64-66. CVP MONITORED AT 30-36. PRECEPT CATHETER HAS BEEN REPOSITIONED, STILL WAVEFORM IS QUESTIONABLE, BUT PT. EXHIBITS GROSS JVD, AND HISTORY OF SEVERE TRICUSPID REGURG.\n\nPT. IS INTUBATED WITH A 7.5/21 RIGHT LIP LINE. VENT SETTINGS ARE CMV TV 500, 60%, RATE 24, AND 5 OF PEEP. PT. HAS BEEN SUCTIONED FOR SCANT CLEAR SECRETIONS. PT. CONTINUES TO BREATH ABOVE VENT, BY 2-4BPM. THIS IS DUE TO HER METABLIC ACIDOSID. VAP PROTOCOL FOLLOWED.\n\nPT. REMAINS NPO, WITH OGT PLACED IN E.D. THIS WAS TRAUMATIC WITH ORALL BLEEDING NOTED FOR 2HRS POST PLACEMENT OG THIS TUBE. PRESENTLY THIS IS TO LOW INTERMITTENT WALL SUCTION FOR SCANT AMT'S OF TAN/CLEAR DRAINAGE. ABD. IS LARGE AND ROUND WITH DOCUMENTED ASCITIES FOUND ON CT SCAN. BOWEL SOUNDS ARE ABSENT AT PRESENT.\nFOLEY CATHETER REMAINS IN PLACE WITH URINARY OUTPUT NIL. PT. IS DRAINING APPROX. 4CC/HR OS CLEAR AMBER URINE. THIS IS SLIGHTLY INPROVED WITH FLUID BOLUSES. CREATININE HAS ALSO RESPONED TO FLUID BOLUSES. 2.7 DOWN FROM 3.2.\n\nSKIN EXHIBITS FIST SIZE ULCER TO LEFT LOWER CALF. THIS IS A RE OCCURING WOUND THAT PT. HAD PLANS FOR A SURGICAL DEBRIDEMENT SCHEDULED FOR NEXT WEEK. THIS DRESSING HAS BEEN CLEANSED WITH N/S AND DSD APPLIED. PT. IS NOTED PRIOR TO THIS ADMISSION TO HAVE +MRSA CULTURE TO THIS WOUND SITE. BOTH LOWER EXT'S REMAIN DUSKY AND DARK, LEFT WORSE THAN RIGHT. LEFT LEG ALSO HAS A REDDENED CELLULITIS WHICH WAS MARKED AT THE BEGINNING OF THIS SHIFT. THIS HAS NOT EXTENDED AT ALL. ALL TEAMS, SURGICAL, VASCULAR, AND MI\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587773, "text": "Respiratory Care\nPt admitted to unit from ED intubated on ventilatory support. Initial ABG demonstrates significant respiratory compensated metabolic acidosis with high minute ventilation requirements. Good oxygenation when FiO2 1.0. No AM RSBI due to FiO2 requirements. BS clear anteriorly and equal. Xray reports satisfactory placement of ETT. No plans for vent wean at this time.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587774, "text": "(Continued)\nCU ARE AWARE. RIGHT I.J PRECEPT CATHETER REMAINS INTACT, AND AFTER BLEEDING AT THIS SITE FOR FIRST FEW HOURS AFTER INSERTION. DRESSING REMAINS D&I. RIGHT PIV TO HAND REMAINS INTACT AND PATENT.\n\nPLAN: PT. REMAINS A FULL CODE. PT. CONTINUES ON FLAGYL, AND UNASYN. PT. WILL RECEIVE AN ALINE, AND WILL WEAN PRESSORS TO SUPPORT B/P. PT. REMAINS ON SEPSIS PROTOCOL AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587775, "text": "FOCUS; NURING PROGRESS NOTE\n82 YEAR OLD FEMALE ADMITTED TO ED LAST PM WITH SOB, INCREASED LEG SWELLING AND HYPOTENSION. WAS INTUBATED AND PLACED ON SEPSIS PROTOCOL. LACTATE 6.9. STARTED ON LEVO. RECEIVED A TOTAL OF 1L IVF OVERNIGHT.\nREVEIW OF SYSTEMS-\nNEURO- SHE WAS SEDATED ON 1.5MG/HR OF VERSED AND 12.5MCG/HR OF OF FENTANYL. ON THIS SHE WITHDREW TO PAIN. PEARL 2MM. GRIMACED TO CARE. THESE WERE SHUT OFF FOR DAILY WAKEUP. SHE IS SLIGHTLY LIGHTER AS SHE WITHDRAWS ALL EXT TO PAIN. AND GRIMACES MORE FREQUENTLY TO CARE. IS CALM WHEN NO CARE BEING DONE. SHE HAS MAE WITH TURNING. HAS COUGH AND GAG.\nRESP- SHE REMAINS INTUBATED AND VENTED. WAS ON 60% FIO2 TV OF 500CC AND A/C RATE OF 24 OVERBREATHING BY UP TO 4 BREATHS. PEEP 5. ABG WAS 7.29/20/92/10. SHE HAD INCREASED WOB AND WAS SWITCHED TO PS OF 15 &0% FIO2 AS SATS WERE ONLY 92% AND 5 PEEP. ON THIS RESP HAVE BEEN IN THE MID 20'S AND SATS HAVE BEEN 93-96%. BS CLEAR. SUCTIONED FOR ALMOST NOTHING THIS SHIFT Q 4 HOURS.\nCARDIAC- HR THIS AM WAS 65 V PACED. MAP WAS MAINTAINED AT 60 WITH LEVOPHED AT UP TO .322MCGS/KG/MIN. ON ROUNDS TEAM DECIDED TO SLOWLY ADD DOBUTAMINE DUE TO HER HX OF RIGHT SIDED HEART FAILURE WITH SVO2 IN HIGH 50'S TO LOW 60'S. DOBUTAMINE WAS STARTED AT .5MCGS/KG/MIN AND TITRATED UP TO 2.5 MCGS/KG/MIN. ON 2.5 MCGS/KG/MIN SHE DROPPED HER SBP TO THE MID 80'S AND HER SVO2 TO 40'S. DOBUTAMINE WAS DC'D. DECISION WAS MADE TO START DOPA AND SHE HAS BEEN ON 5-7MCGS/KG/MIN TO MAINTAIN MAP OF 60 OR GREATER. SVO2 IN THE MID TO UPPER 60'S. CVP 25-35. WITH THIS HER HR WENT UP INTO THE 70'S AFIB WITH RARE PVC. K THIS AM 5.2. REPEAT PENDING FROM 1500. TTE DONE SHOWING LARG RIGHT SIDE OF HEART. SHOWS COMPRESSION OF LEFT SIDE OF HEART BY RIGHT.\nGI- ABD SOFT DISTENDED WITH ABSENT BS. OGT TO LIS DRAINING SMALL AMOUNTS BROWN GASTRO POS DRAINAGE. NO STOOL TODAY. TEAM WANTED TO KEEP HER NPO AS ? OF BOWEL ISHCEMIA BUT UNABLE TO DO CONTRAST CT TO R/O THIS AS SHE CANNOT GET DYE WITH INCREASED CREAT SHE HAS. ALSO GENERAL SURGERY STATES SHE IS NOT A SURGICAL CANIDATE SHOULD SHE HAVE ISCHEMIC BOWEL.\nGU/RENAL- UO 60CC FOR 2 HOURS THIS AM. UO SINCE HAS BEEN 2-12CC/HR. DR AWARE. WILL CONT TO WATCH. FEEL THIS IS DUE TO HER HEART FAILURE AND THAT WE CAN DO NO MORE THAN WE ALREADY ARE. CREAT 2.7 THIS AM WHICH IS WORSE THAN HER BASELINE BUT SLIGHTLY BETTER THAN LAST PM.\nHEME- HCT 41.1. INR UP TO 4.4.\nENDO- BS AT NOON 127. NO NEED FOR SS INSULIN.\nID- TEMP 96.5-98.8. DOSED WITH VANCO FOR LEVEL OF 12.9 TODAY. CONT ON FLAGYL. AMPICILLIN CHANGED TO ZOSYN AS HAD ONE BC FROM YESTERDAY WITH GRAM NEG RODS. PUT IN FOR BC IN AM.\n SON IN WHO IS HER HCP. PULM FELLOW AND DR AND THIS NURSE MET WITH HIM. HE WAS UPDATED ON THE GRIM PROGNOSIS. HE SEEMS TO UNDERSTAND HOW ILL HIS MOTHER IS BUT HAS HOPE THINGS COULD CHANGE. OF NOTE TODAY IS THE ANNIVERSARY OF THE HUSBANDS DEATH FROM RENAL CELL CA. PATIENT REMAINS A FULL CODE.\nPLAN- DOPA 5-10MCGS/KG/MIN TO MAINTAIN MAP >60.\n MONITOR UO.\n MONITOR SVO2.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587776, "text": "FOCUS; NURING PROGRESS NOTE\n(Continued)\n CALL SON IF CONDITION DETERIORATES.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587777, "text": "focus; addendum\nCARDIAC- SPOKE WITH DR AT 1720. AT THIS TIME PATIENT IS ON 10MCGS/KG/MIN OF DOPA AND HAS MAPS OF 59 WITH SVO2 OF HIGH 50'S. NOT ANYMORE TO DO AS SHE WILL NOT TOLERATE PRESSORS WITH HER RIGHT HEART FAILURE. FLUIDS WILL ALSO NOT DO WELL FOR HER AND DOBUTAMINE HAS FAILED. IF HER CONDITION WORSENS WILL INFORM SON.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587778, "text": "pt weaned to PSV successfully early in shift which improved pt's BP. she was sx'd for minimal secretions. plan uncertain at this time.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587779, "text": "focus; addendum\ncardiac- patient on 20mcgs/kg/min of dopa and not responding . svo2 in the mid 40's. hr 65 and paced and map 64. spoke with son and told him that things were looking poorly. Dr paged to discuss code status with family. Priest paged and will be up to give the patient the last rights.\n" }, { "category": "Echo", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 69195, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Congestive heart failure. Right ventricular function.\nHeight: (in) 61\nWeight (lb): 159\nBSA (m2): 1.72 m2\nBP (mm Hg): 94/45\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 12:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Dilated IVC (>2.5cm) with no\nchange with respiration (estimated RAP >20 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Abnormal diastolic septal\nmotion/position consistent with RV volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA systolic\nhypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left and right atria are moderately dilatedThe estimated right atrial\npressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy\nwith normal cavity size and systolic function (LVEF>55%). Regional systolic\nfunction is normal. The right ventricular cavity is moderately dilated with\ngood free wall motion. There is abnormal diastolic septal motion/position\nconsistent with right ventricular volume overload. The ascending aorta is\nmildly dilated. The aortic valve leaflets are moderately thickened. Mild\naortic valve stenosis is present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is trivial mitral\nregurgitaiton. Moderate to severe [3+] tricuspid regurgitation is seen. There\nis moderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the estimated\npulmonary arterty systolic pressure and severity of tricuspoid regurgitation\nare lower. Right ventricular cavity size and free wall motioin are similar.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 154789, "text": "Ventricular pacemaker. No change from the previous tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2121-05-29 00:00:00.000", "description": "Report", "row_id": 154790, "text": "Ventricular pacemaker. Compared to the previous tracing of no change.\nTRACING #1\n\n" } ]
11,492	195,784	Patient was taken to the operating room and underwent an orthotopic liver transplant; the patient only required 1 unit of packed cells, 2 units of platelets, 500-cc of albumin, and 1 unit of cryo intraop. He was taken to the APCU intubated and in stable condition. Patient did extremely well and was therefore extubated later that day (ahead of the pathway). He stayed in the ICU for monitoring for another 24hours, and was then transferred to the floor late on POD1. From here he made a remarkabel recovery. He continued to make good urine and LFTs went downward for the first few days. He ambulated with assitance and tolerated good po pretty early. Some hampering to his recovery was the fact that he is blind and somewhat deaf - he was continually claiming to be depressed because of boredom and lonliness. Duplex on POD1 was normal, and CXRs continued to be normal. His CVL was removed before he left the ICU. On POD5 his LFTs bumped up slightly, so he recieved 2 boluses of steroids as a precautionary measure and a repeat US was performed which showed a mural thrombus in the donor IVC. Biopsy was done which was normal and without signs of rejection. After that, LFTs started to decline again and patient continued to do extremely well.	A new 2.9 x 1.1 x 1.4 cm echogenic nodule is seen within the region of the excluded donor IVC most consistent with thrombus. The main, right, and left hepatic arteries demonstrate normal systolic upstroke with resistive indices measuring 0.83, 0.72, and 0.83, respectively. UO 40-180cc/hr.Integ: Abdominal "" incision w/ primary dsg intact; small amount of serosang drainage noted on dsg. IMPRESSION: PA and lateral chest compared to : Normal heart, lungs, hila, mediastinum and pleural surfaces. Abdominal dsg w/ small amount serosang drainage; dsg changed by transplant team. acute process / baseline FINAL REPORT PA AND LATERAL CHEST . Normal liver Doppler study. vs remain stable.resp: intubated ac at 28%fio2x 650x 10x peep5, ls clear, sats 98%, overbreathing 1 to 2 breaths. FINDINGS: The previously seen Swan-Ganz catheter has been exchanged for a right internal jugular central venous line with the tip appearing to terminate high within the right atrium. Pt w/ trace generalized edema. IMPRESSION: Normal liver transplant ultrasound. pt has oral thrushgi: ogt to ilws, +bs, abd drsg d&I, tolerated transplant surgery well md's. With the patient in end-expiration, the skin was marked over the right lobe of the liver. 2:52 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: please do duplex? UpdateSee careview for details....Neuro: Pt off propofol for extubation, post extubation pt 3, MAE, calm and cooperative, denies pain, MAE, very HOH and legally blindCV: Hemodynamics stable, PA line d/c'd and changed to TLC, NSR 80's, + periph pulses, post op EKG done this AM as orderedResp: Pt extubated this afternoon, tol 35% OFM, sats 97-98%, denies SOB, encouraging to C&DB, lungs clear after extubationGI: Abd soft, hypoactive BS, no BM, NGT d/c'd per transplant team, tol sips, no N/VGU: fair UO via foley, transplant team awareSkin: Abd dsg D&I with sm amt serosang dng to dsg, JP x2 with min dng, #1 straw colored dng, #2 serosang dngEndocrine: BS's elevated this AM, Spoke with Dr , MD prfers that insulin gtt not exceed 10 units/hr, ordered to bolus instead, blood sugars remain high, IVF's changed from D5 .45NS to .45 NS, BS's decreased to 90's, insulin gtt down to 4units/hrPlan: Monitor labs, UO, pain Incentive spirometry teaching performed; inspiratory volume 250-750mL.GI: Abdomen softly distended w/ hypoactive BS. The right, middle, and left hepatic veins demonstrate normal direction of flow and respiratory variation. LIVER TRANSPLANT ULTRASOUND: FINDINGS: The portal vein is patent and has normal direction of flow. NPO except meds. Labs drawn q8hr; stable. 3rd (last) dose of Unasyn given. LFTs decreasing.Pulm: Lungs clear, diminished at bases. New thrombus within excluded donor IVC. 4:08 AM CHEST (PORTABLE AP) Clip # Reason: ? Right internal jugular central venous catheter tip remains within the proximal right atrium. The right jugular Swan-Ganz catheter terminates in the right main PA. A nasogastric tube terminates in the gastric fundus. COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and compared with previous study of yesterday. Sinus rhythm.Rightward axis - is nonspecific and may be within normal limitsSince previous tracing of , no significant change The tip of the endotracheal tube is identified at the thoracic inlet. SUPINE AP VIEW OF THE CHEST: Patient has been extubated and the nasogastric tube removed. FINAL REPORT INDICATION: Status post liver transplantation and extubation. No BM this shift.Endo: Insulin gtt titrated per CSRU protocol. Continue 0.45% NS @ 100cc/hr and D5W @ 10cc/hr. CT scan showed 2x1.8sm enhancing mass in r lobe of live, biopsy demonstrated HCC and cirrhosis, pt denies and extrahepatic manifestations of his HCV. Start methylprednisolone on POD#1. Continue ICU care and treatment. underwent RFA of lesion , currently prior to surgery pt states he is feeeling well and has no complaints. The hepatic veins are patent. Superior extension to the recipient IVC anastomosis is not clearly identified, and follow-up imaging is recommended. The main, posterior right, anterior right, and left portal veins are patent, with appropriate direction of flow. BS checked q1hr.GU: Foley intact w/ clear, yellow urine. HR 70-90s (NSR). LIVER ULTRASOUND WITH DOPPLER EXAMINATION: The liver parenchyma is normal in echogenicity, without focal nodules or masses. The endotracheal tube and NG tube are in stable position. Diet changed to clear liquid. The hepatic artery and its branches are patent. JP#1 w/ small amount serous drainage and JP#2 w/ small amount serosang drainage. Addendum to NPN:Hct 27.1; WBC elevated 16.9 (Dr. and transplant team aware; see CareVue for all labs). source of hep c)he has been tx with pegIFN/RBV x3 without SVR, summer pt had noted rise in AFP on screening. HISTORY: Preop liver transplant. 10:06 AM CHEST PORT. DP/PT pulses palpable. COMPARISON: Chest x-ray obtained earlier on the same day. Pt w/ nonproductive cough. Insulin gtt d/c'd at 0600; continue to monitor BS. 2:11 PM CHEST PORT. Sinus rhythmRightward axis - is nonspecific and may be within normal limitsSince previous tracing of , no significant change ABP 120-140/50-60s. Monitor JP output and empty frequently. O2 sat >/= 97% on 3LNC. JPX2 to bulb suction. Patchy atelectasis is seen at the lung bases. Offer pain med as needed. Please mark spot for liver biopsy. Update pt and family w/ plan of care. No c/o nausea. IMPRESSION: 1. FINDINGS: Limited study of the liver was performed for localization.	14	[ { "category": "ECG", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 204563, "text": "Sinus rhythm\nRightward axis - is nonspecific and may be within normal limits\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2175-07-11 00:00:00.000", "description": "Report", "row_id": 204564, "text": "Sinus rhythm.\nRightward axis - is nonspecific and may be within normal limits\nSince previous tracing of , no significant change\n\n" }, { "category": "Radiology", "chartdate": "2175-07-11 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 915761, "text": " 12:15 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE LIVER DISEASE\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with HCV/HCC pre-op for liver transplant\n REASON FOR THIS EXAMINATION:\n ? acute process / baseline\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST .\n\n HISTORY: Preop liver transplant.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Normal heart, lungs, hila, mediastinum and pleural surfaces.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915926, "text": " 2:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PA line change over wire to CVL, check placement\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n PA line change over wire to CVL, check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, PA line changed over wire.\n\n COMPARISON: Chest x-ray obtained earlier on the same day.\n\n FINDINGS: The previously seen Swan-Ganz catheter has been exchanged for a\n right internal jugular central venous line with the tip appearing to terminate\n high within the right atrium. Note is made of relatively low lung volumes.\n There is increased atelectatic changes in the left retrocardiac region. The\n endotracheal tube and NG tube are in stable position. The remainder of the\n lungs are clear. No pneumothorax or effusions are identified. Surgical\n changes in the upper abdomen are also noted.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-17 00:00:00.000", "description": "P GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT", "row_id": 916516, "text": " 7:57 AM\n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT Clip # \n Reason: ONLY NEED BEDSIDE US MARKING FOR LIVER BIOSPY BY HEPATOLOGYP\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man S/P LIVER TRANSPLANT\n REASON FOR THIS EXAMINATION:\n ONLY NEED BEDSIDE US MARKING FOR LIVER BIOSPY BY HEPATOLOGYPLEASE DO IN AM\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY\n\n HISTORY: 66-year-old man S/P liver transplant. Please mark spot for liver\n biopsy.\n\n FINDINGS: Limited study of the liver was performed for localization. With\n the patient in end-expiration, the skin was marked over the right lobe of the\n liver. Biopsy to be performed by the clinical staff.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 915897, "text": " 10:27 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: S/P LIVER TRANSPLANT ,EVAL FOR VASCULATURE FLOW AND PATENCY\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant day 0\n REASON FOR THIS EXAMINATION:\n DUPLEX - please evaluate vasculature flow and patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male status post liver transplant.\n\n TECHNIQUE: The liver transplant was performed.\n\n LIVER TRANSPLANT ULTRASOUND:\n\n FINDINGS: The portal vein is patent and has normal direction of flow. The\n hepatic artery and its branches are patent. The hepatic veins are patent. No\n obvious fluid collections or free fluid is seen.\n\n IMPRESSION: Normal liver transplant ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915893, "text": " 10:06 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line position\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess line position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE\n\n INDICATION: 66-year-old man status post liver transplant.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with previous study of yesterday.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right jugular Swan-Ganz catheter terminates in the right main PA. A\n nasogastric tube terminates in the gastric fundus. No pneumothorax is\n identified.\n\n Patchy atelectasis is seen at the lung bases. The lungs are clear otherwise.\n The heart is normal in size.\n\n IMPRESSION: No pneumothorax. No active lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-16 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 916432, "text": " 2:52 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: please do duplex? rejection ?thrombus/clot\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant with increasing lfts\n REASON FOR THIS EXAMINATION:\n please do duplex? rejection ?thrombus/clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man status post liver transplant with increasing\n liver function tests. Evaluate.\n\n COMPARISON: .\n\n LIVER ULTRASOUND WITH DOPPLER EXAMINATION: The liver parenchyma is normal in\n echogenicity, without focal nodules or masses. A new 2.9 x 1.1 x 1.4 cm\n echogenic nodule is seen within the region of the excluded donor IVC most\n consistent with thrombus. Superior extension to the recipient IVC anastomosis\n is not clearly identified, and follow-up imaging is recommended. The adjacent\n recipient IVC is patent. The right, middle, and left hepatic veins\n demonstrate normal direction of flow and respiratory variation. The main,\n posterior right, anterior right, and left portal veins are patent, with\n appropriate direction of flow. The main, right, and left hepatic arteries\n demonstrate normal systolic upstroke with resistive indices measuring 0.83,\n 0.72, and 0.83, respectively.\n\n IMPRESSION:\n 1. Normal liver Doppler study.\n\n 2. New thrombus within excluded donor IVC. Proximal extension into the\n recipient IVC is not clearly defined, and follow-up imaging is recommended for\n further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915992, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant and extubation\n\n REASON FOR THIS EXAMINATION:\n ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplantation and extubation.\n\n COMPARISON: and .\n\n SUPINE AP VIEW OF THE CHEST: Patient has been extubated and the nasogastric\n tube removed. Right internal jugular central venous catheter tip remains\n within the proximal right atrium. Two drains project over the upper abdomen.\n Heart is normal size. Slight widening of the mediastinum and new mild\n pulmonary edema may be secondary to the patient's recent extubation or\n reflect volume overload. Heterogeneous opacity in left lower lobe is likely\n atelectasis. No effusions or pneumothorax are present.\n DFDdp\n\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413131, "text": "admission note\npt is 65 yo male with hx of testicular CA tx with l orchiectomy and chemo( received blood products ? source of hep c)he has been tx with pegIFN/RBV x3 without SVR, summer pt had noted rise in AFP on screening. CT scan showed 2x1.8sm enhancing mass in r lobe of live, biopsy demonstrated HCC and cirrhosis, pt denies and extrahepatic manifestations of his HCV. underwent RFA of lesion , currently prior to surgery pt states he is feeeling well and has no complaints. please see hx for extensive animal and plant ownership by pt\n** pt is functionally blind and ahs neurological deafness ( can hear using bilat hearing aids)\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413132, "text": "admission note\npt admitted from OR at 5am,\nneuro: sedated on propofol at 40mcg, perrla at 2mm, pt's wife took home his hearing aid.\n\npain: none sedated.\n\ncad hr 94 to no ectopy noted, abp 97/58 to 130/51 neo off shortly after admission. vs remain stable.\n\nresp: intubated ac at 28%fio2x 650x 10x peep5, ls clear, sats 98%, overbreathing 1 to 2 breaths. pt has oral thrush\n\ngi: ogt to ilws, +bs, abd drsg d&I, tolerated transplant surgery well md's. no bm, no flatus noted. jp's patent, draining ss fluid #1 3.2 cc #2 17.5cc total since admission\n\ngu: foley patent draining clear yellow urine 130 to 200cc/hr.\n\nid: temp 99.2, next dose of unasyn due at 10am,\n\nendo: insulin gtt started at 630am at 10u/hr\n\nplan: continue transplant clinical pathway, monitor vs, i&o, resp status as ordered. unasyn at 10am, labs due at 1300.\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413133, "text": "Update\nSee careview for details....\nNeuro: Pt off propofol for extubation, post extubation pt 3, MAE, calm and cooperative, denies pain, MAE, very HOH and legally blind\n\nCV: Hemodynamics stable, PA line d/c'd and changed to TLC, NSR 80's, + periph pulses, post op EKG done this AM as ordered\n\nResp: Pt extubated this afternoon, tol 35% OFM, sats 97-98%, denies SOB, encouraging to C&DB, lungs clear after extubation\n\nGI: Abd soft, hypoactive BS, no BM, NGT d/c'd per transplant team, tol sips, no N/V\n\nGU: fair UO via foley, transplant team aware\n\nSkin: Abd dsg D&I with sm amt serosang dng to dsg, JP x2 with min dng, #1 straw colored dng, #2 serosang dng\n\nEndocrine: BS's elevated this AM, Spoke with Dr , MD prfers that insulin gtt not exceed 10 units/hr, ordered to bolus instead, blood sugars remain high, IVF's changed from D5 .45NS to .45 NS, BS's decreased to 90's, insulin gtt down to 4units/hr\n\nPlan: Monitor labs, UO, pain\n" }, { "category": "Nursing/other", "chartdate": "2175-07-13 00:00:00.000", "description": "Report", "row_id": 1413134, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Pt slept most of the night. Easily arousable to voice. Pupils not equal; left is 4mm and right pupil is 3mm (Dr. and Dr. aware). Bilat pupils are sluggish. Pt is blind. Pt moves all extremities; follows commands. Very hard of hearing; pt's wife took home his hearing aids, but will bring them in tomorrow. Clear speech. Aks appropriate questions. Morphine 2mg IV given for back pain w/ +effect.\nCV: Afebrile. HR 70-90s (NSR). ABP 120-140/50-60s. MAP 83-90. CVP 2-8. Pt w/ trace generalized edema. DP/PT pulses palpable. 24hr net I&O balance was approx +6,355cc. Pt's weight is up 3kg from yesterday (weight today: 69.7kg). Start methylprednisolone on POD#1. 3rd (last) dose of Unasyn given. Continue 0.45% NS @ 100cc/hr and D5W @ 10cc/hr. Labs drawn q8hr; stable. LFTs decreasing.\nPulm: Lungs clear, diminished at bases. O2 sat >/= 97% on 3LNC. RR 18-24. Cough/deep breathing encouraged. Pt w/ nonproductive cough. Incentive spirometry teaching performed; inspiratory volume 250-750mL.\nGI: Abdomen softly distended w/ hypoactive BS. NPO except meds. Pt swallowed pills without difficulty. No c/o nausea. No BM this shift.\nEndo: Insulin gtt titrated per CSRU protocol. BS checked q1hr.\nGU: Foley intact w/ clear, yellow urine. UO 40-180cc/hr.\nInteg: Abdominal \"\" incision w/ primary dsg intact; small amount of serosang drainage noted on dsg. JPX2 to bulb suction. JP#1 w/ small amount serous drainage and JP#2 w/ small amount serosang drainage. Both JPs stripped and emptied q2hr. Pt turned and repositioned frequently to maintain skin integrity. No pressure ulcers noted. T&R also helps relieve back pain.\nSocial: wife called x1; updated by RN on plan of care and on pt's condition. Wife will visit in the afternoon.\nPlan: Monitor VS, I's and O's, labs. Check tacrolimus trough in the morning at 0700. Monitor JP output and empty frequently. Titrate insulin gtt per CSRU protocol; check BS q1hr while on insulin gtt. Offer pain med as needed. ?transfer to 10 today. Update pt and family w/ plan of care. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2175-07-13 00:00:00.000", "description": "Report", "row_id": 1413135, "text": "Addendum to NPN:\nHct 27.1; WBC elevated 16.9 (Dr. and transplant team aware; see CareVue for all labs). Abdominal dsg w/ small amount serosang drainage; dsg changed by transplant team. Insulin gtt d/c'd at 0600; continue to monitor BS. Diet changed to clear liquid. OOB to chair today. ?transfer to 10 later today.\n" } ]
3,224	193,246	1. Respiratory: This baby required oxygen for the first few hours after admission to the Neonatal Intensive Care Unit. He then weaned to room air and remained in room air through the remainder of his course. He has had no episodes of spontaneous apnea or bradycardia. 2. Cardiovascular: maintained normal heart rates and blood pressures. No murmurs have been noted. 3. Fluids, electrolytes and nutrition: Enteral feeds were started on day of life one and gradually advanced to full volume. He required some gavage feeds during the first two days of admission but then has been all bottle since that time. He has been taking between 150 and 200 cc per kg per day of breast milk or Enfamil 20. His weight on the day of discharge is 2.58 kg. 4. Infectious disease: Due to his prematurity and oxygen requirement, this baby was evaluated for sepsis. A white blood cell count was 9,700, 30% polys, 0% bands. Blood culture was obtained and was no growth in 48 hours. He was not treated with antibiotics. 5. Hematology: Hematocrit at birth was 52.5%. This baby has not required any transfusions of blood products. His bllod type and ccombs was O+, coombs negative. 6. Gastrointestinal: required treatment for unconjugated hyperbilirubinemia with phototherapy. His peak serum bilirubin occurred on day of life five with a total of 14.5/0.3 mg per dL direct. He was treated with phototherapy for three days. His rebound bilirubin on was 10/0.3 direct for an indirect of 9.7 mg per dL. 7. Neurology: has maintained a normal neurological examination during admission and there are no concerns at the time of discharge. 8. Orthopedic: Polydactyly of the hands and feet were discussed with Dr. , orthopedic surgeon from . He will follow up with the patient after discharge. He has an appointment on . 9. Sensory/audiology: Hearing screening was performed with automated auditory brainstem responses. passed in both ears.	Was d/ctoday. Neonatology-NNP Physical ExamInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. Dev remains in OAC, Temp stable, swaddled with hat.Active with cares. Vigorousnon-nutritive suck. Rebound biliobtained and values in careview. Abd benign. BMZ given on and . Continue tomonitor.4. c/=. AFOSF, PFOSF, MAE, AGA. RRR, without murmur, pulses 2+ and symmetrical. Extra digits PWWP. Mild S/Cretractions noted. Resp remains in RA. Will cont to educateand prepare for discharge.REVISIONS TO PATHWAY: 1 RESP; resolved Cl and = BS. V/S.Continueto monitor and support FN. Circ healing. NPN 7p7a#2 Wt 2580 (+60). Active BS. Neonatology Attending NoteDay 1RA. RESP: Pt remains in RA with RR 30-60's. Girth stable.Continue to encourage PO feeds.3. Will cont to keep informed andsupported. Vigorous non-nutritivesuck. Signed consent s for PKU and Hep B. Pedi choosenbut no appointment yet. Continue tomonitor.2. Made aware of possible DCtomorrow. Lites DC . Neonatology Attending NoteDay 2CGA 33 RA. Nospells or desats noted.2. AGA. Given BBO2 only. PO/PG. Continue tomonitor and support developmental mile stones.4. A/A with cares. Returned to floor. Refer to RR inflowsheet. MAES. FOS&F. Active and alert with cares.#4 No parental contact thus far this shift. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. All POs, BM/E20. Needed some direction re BF andbottling and when to burp. Monitor DS, start IVF with D10W. NPNI have examined this infant. Lungs clear, equal and well aerated.#2 Weight down 45gms to 2395 on full enteral feeds of PE20at 80cc/k/d po/pg. Abd soft,round. TF 80 cc/k/day PE20. TF 80 cc/k/day all pg. Nl voiding and stooling. PE 20. d/s 84.Under radiant warmer.A/P: - Monitor for the development of PDA - Maintain current TF - Transition to isolette Polydactyly noted onboth hands and on right foot. Continue to encourage PO's.3. Baby remains in RA, color pink, BBS equal, clear,very mild sc retractions, RR40-50, no spells A: stable in RA P: continue to monitor.2. Continue to monitor.2. Abd soft,nt/nd, no loops. Tolerates well with nospits. Nobleeding. Active, alert in an open warmer, AFOF, sutures split, good tone. If increased WOB or increasing O2 req may need CXR, ABG. Active bowel sounds, without loops, without HSM, tolerating feeds well. Refer toflowsheet for temps. No murmur, pulses +2, pink, RRR. No murmur, pulses +2, pink, RRR. No murmur,pulses +2, pink, RRR. TF 80cc/k PE20 33cc q4h, all pg except took 18cc po atlast feeding, abd soft, active bowel sounds, no loops, nospits, minimal aspirates, voiding, no stool A: toleratingfeedings P: continue present care, check bili at 24h.3. Temps remain stable in open cribdressed, hatted and swaddled. Neonatology Attending NoteDay 3CGA 34RA. 1. FN TF 120cc/kg/d of PE/BM 20 q4h. TF min 100cc/k/day. Refer to flowsheet for RR. Sleepy duringPO's however able to surpass min. Without rashes. Feeding well. Belly is soft with active bowelsounds, stable girths, no spits and no residuals. HR 130-150s. Tolerates wellwith no spits, and surpasses min. Obtinradiographic studies of extra digits. Remains in RA sats >95%, no drifts, spells, desats. P. Check bili this am. P: CHECK BILIIN AM. P: CHECK BILI IN AM. Nursed well then PC 60cc Bm. Check bili in am, TEMP STABLE. Reviewed d/cteaching. Hep B given and PKUdone. BFWx30minutes. P: A.M. bili pending. Voiding qs, Passing lgstools.A: Adequate intake for wt gainP: Cont per plan.#3 Dev: O: Temps stable in heated isolette. Neonatology-NNP Physical ExamInfant remains in RA. Fontanelssoft/flat. NPN:RECEIVED INFANT @ 0100:2. O: Infant remains on min TF's of 120cc/k/d of BM20. BABY IS NOWNESTED IN HIS ISOLETTE. Cl and = BS. A: AGA. Mom in at .. (TFI: 178). (TFI: 178). Infant sl. INFANT SL. Abd soft and round with active bowelsounds. This R,N. 0700- NPN AddendumHYPERBILI: Bili drawn this AM was 9.4-0.2-9.2. Pt is currentlydressed/swaddled. MAEW. Cl and =. Cl and =. Bottles well. Tol well. EYESCLEAN AND COVERED. A: IMPROVING BILI. Am bilisent-pending. continue with current plan.#4 S. O. Nl voiding and stooling.Under single phototherapy. Neonatology Attending NoteDay 6CGA 34 3RA. Min 80 cc/k/day PO ad lib BM20 (TFI: 171). Both Mom and baby did verywell. Active, in an isolette, AFOF, sutures opposed, good tone. Neonatology Attending NoteDay 7RA. Nospits. CONT TO MONITOR. CONT TOMONITOR.3. A: Tolerating po feeds. O: Infant remains under single phototherapy. TF 120 cc/k/day BM/E20. Discharge teaching.#5 Hyperbili:O: under single phototx. NPN#2 S. O. belly benign. A. A. BABY FEEDSWITH BM20. ABDOMEN BENIGN,VOIDING AND STOOLING. MAE, /active with cares, wakesindependently for feeds. INFANT WOKE @ 0300 AND BOTTLED100CCS OF BM20. TF 120 cc/k/day BM20 all po. A. Jaundiced. A: FEEDING WELL. Neonatology Attending NoteDay 8CGA 34 5RA. Infant continues on adlib demand feeding schedule. Bili mask in place.Color jaundiced.A/P; Cont. Nursing Progress Note#2. TF REMAIN @ MIN 80CC/KG/D. A: Involved Mom. P: CONTINUE TO KEEP INFORMED.#5 O: CHANGED FROM BILIBLANKET TO PHOTOTHERAPY AS BILIINCREASED SLIGHTLY TODAY. A: APPROPRIATE FOR AGE. A: APPROPRIATE FOR AGE. A: APPROPRIATE FOR AGE. A:APPROPRIATE FOR AGE. TF 145 +BF-BM/E20 all po. Sweetand active with cares. HR 130-160s. A:WAKING TO DEMAND FEED. Appropriate activity for age. Nl voiding and stooling.In open crib.A/P: - Progressing well. Eye shieldsin place. To home today. RR30-60s. RR40-70s. Invested mom.P.Support and keep updated.#5 S. O. Singlephototherapy was d/c'd at 1030 as ordered. CONT TO DEV NEEDS.4. A: feeding wellP: Follow weight#3 Temps stable in air isolette under phototherapy. Abdomen benign. AFOF, and activewith feeds , MAE. with phototx. Infant doing wellwith feeds.P. Askinglots of appropriate questions. Mom needing assistance with positioning.Otherwise po fed well. Neonatology Attending NoteDOL 5CGA 34 RA. BABY MOVED TO ISOLETTEFOR CHANGE TO PHOTOTHERAPY FROM BILIBLANKET. jaundiced. benign, soft, active BS, noloops. Nursing Discharge NoteF&N: TF min 120cc/kg/day BM/E20. Pt is voiding, trace stool x 1.G&D: Received pt in air-controlled isolette that was turnedoff at 1030, temps have remained stable. Infant received145cc/k/d +BFW x1 yesterday. WAKING FOR FEEDS, SUCKINGVIOGURSLY ON PACIFIER. Rebound bili tobe checked tomorrow AM. Voiding and stooling. Voiding and stooling. Voiding and stooling. Bottling/ Nursing well.A: AGAP: Cont to support dev.#4 :o: Mom in to visit, Handling infant well.A/P: Cont to suuport and inform.	36	[ { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725557, "text": "NPN 1900-0730\n\n\n#1 Stable in RA, no drifts or spells, problem resolved.\n\n#2 Weight up 25gms to 2420 on full enteral feeds of BM/PE20\nat 100cc/k/d po. Taking po feeds well except for \nfeeding after long afternoon of visitors. Ngt dropped after\ninfant bottled 10cc. Now awake and acting interested. Belly\nis soft with no spits or loops, voiding and stooling well.\nWill cont to offer all po's and d/c feeding tube if able.\n\n#3 Waking for feeds every four hours. Temps remain stable in\nopen crib dressed, hatted and swaddled. Vigorous\nnon-nutritive suck. Sleeps quietly when undisturbed.\n\n#4 Mom up at to visit, bringing breast milk. No new\nquestions or concerns voiced. States feeling much better\nthan this afternoon. Will cont to keep informed and\nsupported.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725558, "text": "Neonatology Attending Note\nDay 3\nCGA 34\n\nRA. RR40s. No murmur.\n\nWt 2420, up 25 gms. TF min 100cc/k/day. all PO.\n\nIn open crib.\n\nA/P:\n - TF to 120 cc/k/day\n - If continues to feed well, with no CVR issues, will be ready to go home soon\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725559, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOf, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur,pulses +2, pink, RRR. Abdomen soft,non-distended with active bowel sounds, no HSM, tolerating feeds. Extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725548, "text": "Nursing Admission Note\n\n\nPt admitted to NICU at from L&D. Please see Attending\nMD/NNP note for maternal history and pt's physical exam.\n\n1. RESP: Pt remains in RA with RR 30-60's. Mild S/C\nretractions noted. Sats >93%. Lung sounds are clear. No\nspells or desats noted.\n\n2. F&N: Pt is workign up on feeds. Pt initiall received\n20cc/k of PE20 and was then advanced by 20cc/k/d Q 4 hours.\nGoal TF is 80cc/k/d. Initial D/S 84. Feeds gavaged in via\nNG tube. BS were initially hypoactive, but increasing\nactive during this shift. No spits and no aspirates noted\nso far this shift. Voiding small amounts. No stool noted.\n\n3. DEV: Pt was placed upon sheepskin on radiant warmer.\nTemp stable. Baby meds were given. Polydactyly noted on\nboth hands and on right foot. Mongolian spot noted.\nFontanels are soft and flat.\n\n4. PAR: Maternal grandmother in to visit. Mom has not\nbeen in to visit because she is still in L&D.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725549, "text": "Neonatology Attending Note\nDay 1\n\nRA. RR30-60s. Cl and = BS. No A&Bs. No murmur. HR 120-150. Mean BPs 41-57.\n\nWt 2440. TF 80 cc/k/day all pg. PE 20. d/s 84.\n\nUnder radiant warmer.\n\nA/P:\n - Monitor for the development of PDA\n - Maintain current TF\n - Transition to isolette\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725550, "text": "1. Baby remains in RA, color pink, BBS equal, clear,\nvery mild sc retractions, RR40-50, no spells A: stable in RA\n P: continue to monitor.\n2. TF 80cc/k PE20 33cc q4h, all pg except took 18cc po at\nlast feeding, abd soft, active bowel sounds, no loops, no\nspits, minimal aspirates, voiding, no stool A: tolerating\nfeedings P: continue present care, check bili at 24h.\n3. temps stable on servo warmer, now swaddled on off warmer,\non sheepskin with boundaries, quiet alert and active with\ncares, brings hands to mouth and sucks well on pacifier P:\ncontinue to support needs for growth and development.\n4. Mom in briefly on her way to floor, continue to update\nand offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725551, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open warmer, AFOF, sutures split, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725552, "text": "NPN 1900-0730\n\n\n#1 No resp issues this shift, minimal to absent WOB with\nsats >96% in RA. Lungs clear, equal and well aerated.\n\n#2 Weight down 45gms to 2395 on full enteral feeds of PE20\nat 80cc/k/d po/pg. Able to take all feeds po thus far\ntonight with little effort. Belly is soft with active bowel\nsounds, stable girths, no spits and no residuals. Voiding\nwell, no stool thus far, but infant noted to be passing\nflatus. Will cont to monitor and advance feeds. TBili wnl\nat this time.\n\n#3 Temps remain stable in open crib with infant dressed,\nhatted and swaddled. Waking for feeds every four hours and\nsleeping quietly when undisturbed. Vigorous non-nutritive\nsuck. Active and alert with cares.\n\n#4 No parental contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-26 00:00:00.000", "description": "Report", "row_id": 1725547, "text": "Newborn Med Attending Admit\n\n2440g, 33 4/7 weeks EGA male infant born by pit augmented vaginal delivery to a 27 yo G4 p1->2. Unremarkable preganancy until mother seen in clinic on and noted to have high BP. BMZ given on and . Induction today for worsening PIH.\n\nDR: Infant emerged with good cry. Given BBO2 only. APgars .\n\nPNS: O-/AB-/HBSAg-/RPRNR/GBS?\n\nexam: intial exam only notable for extra digits (see newborn exam sheet). Subsequently developed mild supplemental O2 req with mild G/F/Ring, still good air entry.\n\nA: Preterm male infant presents with mild resp distress. Most likley retained fetal lung fluid but can't r/o RDS at this time. No sepsis risk factors except prematurity and possibly GBS (mother's status unknown).\n\nP: Place in BBO2. Monitor sats and WOB. If increased WOB or increasing O2 req may need CXR, ABG. Obtain CBC and blood cx. Hold abx uness clinical exam worsens or supplemental O2 req persisits beyond a few hours. Monitor DS, start IVF with D10W. Obtinradiographic studies of extra digits. If no structures will tie off at base of pedicle. Keep family informed of plans and progress.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725560, "text": "CoWorker Progress Note\n\n\n1. Remains in RA sats >95%, no drifts, spells, desats. C/=\nno worker breathing. Refer to flowsheet for RR. Continue to\nmonitor.\n\n2. FN TF 120cc/kg/d of PE/BM 20 q4h. Tolerates well with no\nspits. PO/PG. Refer to flowsheet for volumes. Abd soft,\nnt/nd, no loops. V/ no stool as of yet. Girth stable.\nContinue to encourage PO feeds.\n\n3. GD Temp stable in OAC, swaddled with hat. Refer to\nflowsheet for temps. A/A with cares. Wakes for feeeds.\nSleeps well between. AFOSF, PFOSF, MAE, AGA. Continue to\nmonitor and support developmental mile stones.\n\n4. Parent Mom in this afternoon with grandmother. Asking\nappropriate questions. Will return possibly tonight. Was d/c\ntoday. Excited to go home. Anxious for d/c of baby. \ncontinue to update, educate, and support mom.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725561, "text": "NPN 1900-0730\n\n1 RESP\n\n#2 Cont to grow and gain weight well on full enteral feeds\nof BM20 po ad lib with a min of 120cc/k/d. Weight up 35gms\nto 2455, surpassing birth weight. Po feeding very well, ngt\npulled. Waking every 3-3.5hrs to eat. Belly is soft with\nactive bowel sounds, voiding and stooling very well. No\nspits.\n\n#3 As above, waking for feeds. Active and alert with cares,\nMAEW. Extra digits PWWP. Vigorous non-nutritive suck,\nenjoys snug boundaries. Temps remain stable in open crib\ndressed, hatted and swaddled. Hearing screen completed.\nCirc is red with some bloody staining on gauze with diaper\nchanges. Sat monitor d/c'd.\n\n#4 Mom in with MGM, discharge teaching completed except CPR\nand car seat training. Mom to bring in seat tonight for\ntesting. Is aware of infants impending discharge and is\nexcited to take him home. No new questions or concerns.\nShe does have a pediatrician lined up. Will cont to educate\nand prepare for discharge.\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725562, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Circed male, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725563, "text": "Neonatology Attending\n\nDOL 4 CGA 34 1/7 weeks\n\nStable in RA. No A/B\n\nBP 70/50 mean 57\n\nOn min of 120 cc/kg/d BM/E 20. Taking 55-60 cc q 3, took 124 cc/kg yest. Voiding. Stooling. Wt 2455 grams (up 35)\n\nBili 14.4/0.3\n\nCircumcision done.\n\nDr. following re polydactyly.\n\nTemp stable in crib.\n\nFamily visiting and up to date.\n\nA: Doing very well. Never had A/B. Feeding well. Hyperbili requires treatment.\n\nP: Monitor\n Feed ad lib\n Start wallaby\n Follow bili\n Car seat test, hearing screen and PKU before discharge\n If he continues to do well, can go home early next week once off phototherapy\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725553, "text": "Neonatology Attending Note\nDay 2\nCGA 33 \n\nRA. RR40-50s. No rtxns. No murmur. HR 130-150s. BP 83/53, 71.\n\nBili 6.1/0.2.\n\nWt 2395, down 45 gms. TF 80 cc/k/day PE20. All po. Nl voiding and stooling. d/s 90.\n\nIn open crib.\n\nA/P:\n - Adv TF to 100c/k/day\n - Dr. consulted for polydactyly. He would like to meet the family 1 week post discharge.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725554, "text": "NICU CoWorker Note\n\n\n1. Resp remains in RA. Sats > 93%. c/=. Refer to RR in\nflowsheet. no drifts, no spells. Continue to monitor.\n\n2. FN TF increased to 100cc/kg/d of PE/BM20. Tolerates well\nwith no spits, and surpasses min. Abd benign. V/S.Continue\nto monitor and support FN. Continue to encourage PO's.\n\n3. Dev remains in OAC, Temp stable, swaddled with hat.\nActive with cares. does not wake for feeds. Sleepy during\nPO's however able to surpass min. MAE, AFOSF, PFOSF, AGA.\n6th digit on both hands and one lower extremity. Continue to\nmonitor.\n\n4. Mom in for 12 feed. Unable to stay because of\nN/V. Returned to floor. Unable to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725555, "text": "NPN\nI have examined this infant. I agree with this co-worker's note for this shift.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725556, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feed. Extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725580, "text": "NPN 7p7a\n\n\n#2 Wt 2580 (+60). All POs, BM/E20. Active BS. Abd soft,\nround. Voiding and stooling. No spits. Tolerating TF PO.\nMonitor weight and exam.\n#3 In OAC since evening . Stable temps. A/A with cares.\nWakes on own q 3-4 hrs for feeding. FOS&F. MAES. Appointment\nset with Dr. for consult re extra digits on hands and\nfoot. Circ healing. Some swelling and red glans. No\nbleeding. Covered with gauze and petrolium. AGA. Support\nG/D.\n#4 Mother in this evening. Participated in cares.\nEnthusiastic to participate. Needed some direction re BF and\nbottling and when to burp. Made aware of possible DC\ntomorrow. Signed consent s for PKU and Hep B. Pedi choosen\nbut no appointment yet. Involved and caring mother. Support\nand educate.\n#5 Infant slightly jaundice. Lites DC . Rebound bili\nobtained and values in careview. Active, feeding and\nstooling. Infant with hyperbilirubinemia. Monitor activity\nand labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725581, "text": "Neonatology Attending Note\nDay 8\nCGA 34 5\n\nRA. RR30-50s. No A&Bs. Cl and = BS. No murmur. HR 130-160s. BP 86/56, 62.\n\nRebound bili 10/0.3 (9.4 yest).\n\nWt 2580, up 60 gms. TF 120 cc/k/day BM/E20. (TFI: 178). Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\n - Progressing well. To home today. Please see dictated summary and bedside chart for further details\n\nd/c t>30'.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725582, "text": "Nursing Discharge Note\n\n\nF&N: TF min 120cc/kg/day BM/E20. Baby taking over minimum.\nHas bottled 75cc, 55cc, and 45cc so far this shift. No\nspits. belly benign. Stool heme -.\nDev: Temp stable in open crib. Awake and with cares.\nWaking q3-4hrs to eat. Appropriate activity for age.\n: Mom and grandma in to d/c baby. Reviewed d/c\nteaching. Pedi appt made for Friday. Hep B given and PKU\ndone. Will have Caregroup VNA visit within the next couple\nof days.\nHyperbili: Resolved.\nBaby dc'd home with mom.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725574, "text": "NPN\n\n\n#2 FEN:\n O: Wt 2.520 (+ 55 gms) Abd. benign, soft, active BS, no\nloops. Nursed well then PC 60cc Bm. Voiding qs, Passing lg\nstools.\nA: Adequate intake for wt gain\nP: Cont per plan.\n\n#3 Dev:\n O: Temps stable in heated isolette. AFOF, and active\nwith feeds , MAE. Bottling/ Nursing well.\nA: AGA\nP: Cont to support dev.\n\n#4 :\no: Mom in to visit, Handling infant well.\nA/P: Cont to suuport and inform. Discharge teaching.\n\n#5 Hyperbili:\nO: under single phototx. Bili mask in place.Color jaundiced.\nA/P; Cont. with phototx. Check bili in am,\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725575, "text": "#2 TF min 120cc/k=50cc of BM20 q 4hrs. Took in 178cc/k yest.\nBottled 70cc each feed overnight easily. Abdominal exam\nbenign. Voiding and stooling. Weight ^ 55g. A: feeding well\nP: Follow weight\n\n#3 Temps stable in air isolette under phototherapy. Sweet\nand active with cares. Bottles well. A: AGA P: Support\ndevelopment\n\n#4 No contact overnight.\n\n#% Beneath single spotlight phototherapy. Am bili\nsent-pending. Eye shields in place. A: ^ bili P: Follow labs\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725576, "text": "Neonatology Attending Note\nDay 7\n\nRA. RR30-60s. No rtxns. No A&Bs. HR 130-160s.\n\nUnder single photo --> 9.4/0.2\n\nWt 2520, up 55 gms. TF 120 cc/k/day BM20 all po. (TFI: 178). Tol well. Nl voiding and stooling.\n\nIn isolette (for photo).\n\nA/P:\n - Approaching d/c readiness\n - d/c photo - check bili in am\n - Transition to open crib\n - If rebound bili ok and temps ok in open crib will d/c to home tomorrow\n - d/c planning including car seat, hepatitis\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725577, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725578, "text": "0700- NPN\n\n\nFEN: TF= min 140cc/kg/d of BM20 (50cc Q4hr). Pt currently\ntaking all feeds PO, and took 80cc at each feed this shift.\nNo spits. Abdomen benign. Pt is voiding, trace stool x 1.\n\n\nG&D: Received pt in air-controlled isolette that was turned\noff at 1030, temps have remained stable. Pt is currently\ndressed/swaddled. MAE, /active with cares, wakes\nindependently for feeds. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. Pt passed car seat test this shift. AGA.\n\nPARENTING: Mom called x 1 for update, asking appropriate\nquestions. Mom plans to visit sometime this afternoon or\nevening.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725579, "text": "0700- NPN Addendum\n\n\nHYPERBILI: Bili drawn this AM was 9.4-0.2-9.2. Single\nphototherapy was d/c'd at 1030 as ordered. Rebound bili to\nbe checked tomorrow AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725570, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY CONTINUES TO FEED AD LIB DEMAND. BABY WOKE\nEVERY 4 HOURS TODAY AND FED WELL. ABDOMEN BENIGN, VOIDING\nAND STOOLING, NO SPITS. DESITIN APPLIED TO DIAPER RASH\nWHICH WAS BLEEDING THIS MORNING, IMPROVED THIS AFTERNOON.\nCIRC IMPROVING. VASELINE APPLIED. A: FEEDING WELL TODAY.\nP: CONTINUE TO FEED AD LIB DEMAND WITH BREASTFEEDING WHEN\nMOM VISITS.\n#3 O:TEMP WAS STABLE IN AN OPEN CRIB. BABY MOVED TO ISOLETTE\nFOR CHANGE TO PHOTOTHERAPY FROM BILIBLANKET. BABY IS NOW\nNESTED IN HIS ISOLETTE. TEMP STABLE. BABY WAKES TO DEMAND\nFEEDS AND FEEDS WELL. BABY SLEEPS WELL BETWEEN FEEDS. A:\nAPPROPRIATE FOR AGE. P: CONTINUE TO SUPPORT DEVELOPMENT.\n#4 O: MOTHER CALLED FOR AN UPDATE THIS AFTERNOON AND PLANS\nTO VISIT THIS EVENING. P: CONTINUE TO KEEP INFORMED.\n#5 O: CHANGED FROM BILIBLANKET TO PHOTOTHERAPY AS BILI\nINCREASED SLIGHTLY TODAY. BABY REMAINS JAUNDICED. EYES\nCLEAN AND COVERED. A: APPROPRIATE FOR AGE. P: CHECK BILI\nIN AM.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725564, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY IS WAKING TO FEED EVERY 3 TO 4 HOURS TODAY.\n55 TO 90CC TAKEN. LAST FEEDING GIVEN AT 1800. BABY FEEDS\nWITH BM20. MOTHER WAS ENCOURAGED TO BREASTFEED AT HER NEXT\nVISIT. ABDOMEN BENIGN, VOIDING AND STOOLING, NO SPITS. A:\nWAKING TO DEMAND FEED. P: CONTINUE AD LIB FEEDS AND\nBREASTFEEDING.\n#3 O: TEMP STABLE IN OPEN CRIB. BABY IS AND ACTIVE\nWITH CARES AND WAKES TO DEMAND FEED. BABY SLEEPS WELL\nBETWEEN FEEDS. A: APPROPRIATE FOR AGE. P: CONTINUE TO\nSUPPORT DEVELOPMENT.\n#4 O: MOTHER CALLED AND PLANS TO VISIT LATER THIS EVENING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725571, "text": "Nursing Progress Note\n\n\n#2. O: Infant remains on min TF's of 120cc/k/d of BM20. Mom\nin to BF this evening for first time. Infant latched. BFW\nx30minutes. Mom needing assistance with positioning.\nOtherwise po fed well. Abd soft and round with active bowel\nsounds. No loops. Voiding and stooling. Infant received\n145cc/k/d +BFW x1 yesterday. Wgt is down 15gms tonight to\n2465gms. A: Tolerating po feeds. P: Encourage Mom to BF\nwhile visiting.\n\n#3. O: Infant remains in low heat isolette with stable temp.\nHe is and active with cares. MAEW. A: AGA. P: Continue\nto assess and support developmental needs.\n\n#4. O: Mom in this evening. First time breastfeeding. Asking\nlots of appropriate questions. Both Mom and baby did very\nwell. A: Involved Mom. P: Continue to inform and support.\n\n#5. O: Infant remains under single phototherapy. Eye shields\nin place. A: Hyperbilirubinemia. P: A.M. bili pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725572, "text": "Neonatology Attending Note\nDay 6\nCGA 34 3\n\nRA. RR 40-50s. Cl and =. HR 140-150s. No murmur. Mean BP 51. No A&Bs.\n\nWt 2465, down 15 gms. TF 145 +BF-BM/E20 all po. Nl voiding and stooling.\n\nUnder single phototherapy. Bili 13/0.3.\n\nReceiving nystatin for dipaer rash.\n\nNeeds hep B vaccine.\n\nA/P:\n - Mature feeding skills and cardioresp control\n - Still being treated for hyperbilirubinemia\n - Appraoching discharge readiness once increased bili resolves\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725573, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: TOTAL FLUID MIN 120CC/KG/DAY OF BM20. FEEDS OFFERED\nON DEMAND AND WERE TAKEN WELL. NO SPITS. ABDOMEN BENIGN,\nVOIDING AND STOOLING. A: FEEDING WELL. P: CONTINUE AD LIB\nFEEDS AND BREASTFEEDING WHEN MOM VISITS.\n#3 O: TEMP STABLE IN ISOLETTE ON AIR MODE. BABY WAKES FOR\nFEEDS AND SLEEPS WELL NESTED IN ISOLETTE AND UNDER\nPHOTOTHERAPY. A: APPROPRIATE FOR AGE. P: CONTINUE TO\nSUPPORT DEVELOPMENT.\n#4 O: NO CONTACT FROM TO TIME OF REPORT.\n#5 O: BABY REMAINS UNDER SINGLE PHOTOTERAPY. EYES CLEAN AND\nCOVERED. A: IMPROVING BILI. P: CHECK BILI IN AM.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725565, "text": "NPN\n\n#2 S. O. Weight up 25 grams. Voiding and stooling. Circ\nsite red. Vaseline applied to area. Infant continues on ad\nlib demand feeding schedule. Infant woke at 5 hours and\ntook 80cc po of breast milk 20 cal. A. Infant doing well\nwith feeds.P. continue with current plan.\n\n#4 S. O. Mom in at .. This R,N. explained to mom about\ninfant requiring bili blanket. (Infant ate at 1800 and was\nsleeping. ) Mom pumped and will return tomorrow. Mom aware\nthat we should have car seat tomorrow. A. Invested mom.P.\nSupport and keep updated.\n\n#5 S. O. Infant sl. jaundiced. Infant on bili blanket. A.\n Jaundiced. P. Check bili this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725566, "text": "5 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 5 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725567, "text": "NPN:\n\n\nRECEIVED INFANT @ 0100:\n\n2. TF REMAIN @ MIN 80CC/KG/D. INFANT WOKE @ 0300 AND BOTTLED\n100CCS OF BM20. INFANT WAKING Q4-5HRS TO BOTTLE. VDG AND\nSTOOLING ADAQUATE AMTS, ABD BENIGN, NO SPITS. CONT TO\nMONITOR.\n\n3. INFANT REMAINS SWADDLED IN AN OAC, TEMPS REMAIN STABLE.\n AND ACTIVE WITH CARES. WAKING FOR FEEDS, SUCKING\nVIOGURSLY ON PACIFIER. FONTANELS REMAIN SOFT AND FLAT. CIRC\nRED, NO OZZING AT SITE. APPLIED VASELINE WITH EACH DIAPER\nCHANGE. CONT TO DEV NEEDS.\n\n4. NO CONTACT FROM THUS FAR, UNABLE TO ASSESS FAMILY\nDYNAMICS AT THE PRESENT TIME.\n\n5. INFANT SL. JAUNDICE, REMAINS UNDER PHOTOTHERAPY BLANKET.\nBILI DRAWN THIS AM WAS GROSSLY HEMOLYZED, PLAN TO REDRAW\nBILI @ NEXT CARE. CONT TO MONITOR.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725568, "text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOf, breath sounds clear/equal with easy WOB, no murmur, abd soft, + bowel sounds, circ clean/equal no drainage, perianal red slighlty excoriated diaper rash, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725569, "text": "Neonatology Attending Note\nDOL 5\nCGA 34 \n\nRA. RR40-70s. Cl and =. No A&Bs. No murmur. HR 140-150s.\n\nBili 14.5/.0.3 --> bili blanket\n\nWt 2480, up 25 gms. Min 80 cc/k/day PO ad lib BM20 (TFI: 171). Nl voiding and stooling.\n\ns/p circ.\n\nDesitin to diaper dermaitis.\n\nIn open crib.\n\nA/P:\n - Will change to photo light to facilitate reduction in bili\n - Good po intakes\n - Approaching discharge readiness\n" } ]
30,984	138,822	Patient came into the ED and midline shift had increased from 5mm to 2cm since prior CT obtained at the OSH. Attempts were made to reverse anticoagulation in the patient, but due to the extent of the lesion and evidence early transtentorial and tonsillar herniation with entrapment the ventricle, a poor prognosis was discussed with her husband . explained that prior discussions with his wife led him to believe that she would not want any heroic interventions, and this surgical intervention was deferred. He did leave his wife intubated so that other family members could come by to see her and say their good-byes. On PM, she was extubated and subsequently expired shortly thereafter.	Nsurg HO and SICU HO notified. Afebrile.+ BS x4 abd soft nt/nd. Foley draining adeq amounts cyu. Stable on vent. Pboots on. BP stable. Skin wdi. BLBS clear. LSCTA. +bs. IVFs. Pt in afib with occasional PVCs. Leftward subfalcine, uncal, early downward transtentorial and tonsillar herniation, and entrapment of the contralateral lateral ventricle. See careview for further details. See Careview for further details. NPNPlease see carevue for further details.Family at bedside. We are sxtn for scant secretions. Bs are bil clear. Bs are bil clear. Continues on A/C w/ PIP/Pplat = 22/18; not initiating over set vent rate of 16. Plan: keep confortable. IMPRESSION: 1. Effacement of basal cistern, suggestive of uncal herniation. We asxtn for scant amt of thick yel secretions from ETT. Abd soft/nd. RSBI done ~77. See resp flowsheet for specific vent settings/data.Plan: maintain support LS clear throughout. SpO2 90s. Respiratory TherapyPt remains orally intubated on full mechanical support. Dilatation of contralateral ventricle. Afib 90s. Morphine titrated for pt comfort. Respiratory Care:Pt remain orally intubated on full ventilatory support. NPnPlease see carevue for further details.Extubated on day shift. Respiratory Care:Pt rremain orally intubated on full ventilatory support. There is significant mass effect with obliteration of the right frontal , entrapment of the contralateral lateral ventricular temporal , leftward subfalcine herniation of 2 cm, and uncal, early downward transtentorial and tonsillar herniation. Pt withdraws to nailbed pressure, at times posturing in BUE. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. Made comfort measures only. SBP 130-140s. Nursing NotePlease see carevue for detailsPt admitted from ED with large IPH. Continue to provide comfort and support. Visualized paranasal sinuses and mastoid air cells are clear. Family at bedside. Family at bedside. Family at bedside. 2. sats 98-100. transfer to morgue. pt appears comfortable. Consult SW. Continue to provide comfort and support to pt and family. addendumPt passed at 0520. Hypodensity within the left basal ganglia may reflect a prior lacunar infarct. This may be secondary to anticoagulation (of which there is reportedly, a history), amyloid angiopathy - though ventricular extension is rare, or an underlying mass. STATUSD: NEURO STATUS UNCHANGED..AWAITING FAMILY(HUSBAND) TO EXTUBATE PTA: FAMILY HERE PT ..STARTED ON MSO4 GTT & EXTUBATED @ 1700 WITH FAMILY & HUSBAND AT BEDSIDER: P: COMFORT MEASURES (Over) 5:53 PM CT HEAD W/O CONTRAST Clip # Reason: eval ICH FINAL REPORT (Cont) Unresponsive, not opening eyes, + corneal reflexes, PERRL, UE posturing to painful stimuli bilat, LE withdraw to nail bed pressure bilat. No vent changes. No vent changes. Plan: awaiting husband & priest in AM and will elective extuabted, maded . Intraventricular hemorrhage in lateral ventricles bilaterally, and in 4th ventricle. Continue to closely monitor and provide comfort and support to the family. PERRL 2- 3 mm brisk. No vent changes made this shift. FINDINGS: There is a large right frontal lobar parenchymal hemorrhage, with associated vasogenic edema. No gag or cough. Intubated on AC 50%/16/500. Osseous structures are unremarkable. Large right frontal lobar parenchymal hemorrhage with transependymal dissection and intraventricular extension. The hemorrhage extends into the ventricular system, with hemorrhage seen within the lateral, third, and fourth ventricles, and also into the foramen of Luschka. Awaiting husband and priest in the morning. No prior studies for comparison. Findings were entered into the ED dashboard at the time of interpretation, and reviewed with Dr. (Neurology) in-person. FOCUS: CONDITION UPDATED: SEE CAREVUE FOR DETAILS.81 Y/O WOMEN S/P LARGE HEAD BLEED.FAMILY VERY SUPPORTIVE OF PATIENT'S WISHES, AND WAITING FOR ALL FAMILY TO BE HERE BEFORE EXTUBATING PATIENT AND PROVIDING COMFORT MEASURES ONLY.ON A/C NOW ON VENT, BUT WILL BREATH WHEN PLACED ON CPAP.WILL PROVIDE SUPPORT TO FAMILY/PATIENT.EXTUBATE AND STARTS MSO4 GTT FOR COMFORT WHEN ALL FAMILY HERE.SOCIAL SERVICES CONSULTED--SUPPORT GIVEN. suctioning mod amounts of thick yellow sputum. Family meeting with , NP - pt made DNR, end of life decisions discussed, but not finalized - waiting for pt's brother and sister today.Plan: Monitor neuro status. Per husband, awaiting to speak to pt's priest in the a.m and then will proceed making pt and extubate in the morning. FINAL REPORT HISTORY: 81-year-old female with large intracranial hemorrhage, evaluate intracranial hemorrhage. Morphine gtt at 20 mg/hr.	10	[ { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659154, "text": "Nursing Note\nPlease see carevue for details\n\nPt admitted from ED with large IPH. Unresponsive, not opening eyes, + corneal reflexes, PERRL, UE posturing to painful stimuli bilat, LE withdraw to nail bed pressure bilat. Pt in afib with occasional PVCs. BP stable. Stable on vent. LSCTA. Abd soft/nd. +bs. Foley draining adeq amounts cyu. Skin wdi. Family meeting with , NP - pt made DNR, end of life decisions discussed, but not finalized - waiting for pt's brother and sister today.\n\nPlan: Monitor neuro status. Consult SW. Continue to provide comfort and support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659155, "text": "Respiratory Care:\n\nPt rremain orally intubated on full ventilatory support. No vent changes. Bs are bil clear. We are sxtn for scant secretions. Plan: keep confortable. See careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659156, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on A/C w/ PIP/Pplat = 22/18; not initiating over set vent rate of 16. SpO2 90s. BLBS clear. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659157, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR DETAILS.\n81 Y/O WOMEN S/P LARGE HEAD BLEED.\nFAMILY VERY SUPPORTIVE OF PATIENT'S WISHES, AND WAITING FOR ALL FAMILY TO BE HERE BEFORE EXTUBATING PATIENT AND PROVIDING COMFORT MEASURES ONLY.\nON A/C NOW ON VENT, BUT WILL BREATH WHEN PLACED ON CPAP.\nWILL PROVIDE SUPPORT TO FAMILY/PATIENT.\nEXTUBATE AND STARTS MSO4 GTT FOR COMFORT WHEN ALL FAMILY HERE.\nSOCIAL SERVICES CONSULTED--SUPPORT GIVEN.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659158, "text": "NPN\nPlease see carevue for further details.\nFamily at bedside. Per husband, awaiting to speak to pt's priest in the a.m and then will proceed making pt and extubate in the morning. Pt withdraws to nailbed pressure, at times posturing in BUE. PERRL 2- 3 mm brisk. Intubated on AC 50%/16/500. No gag or cough. suctioning mod amounts of thick yellow sputum. LS clear throughout. sats 98-100. Afib 90s. SBP 130-140s. Pboots on. Afebrile.\n+ BS x4 abd soft nt/nd. IVFs. Family at bedside. Awaiting husband and priest in the morning. Continue to provide comfort and support.\n" }, { "category": "Radiology", "chartdate": "2133-04-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1014209, "text": " 5:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with large ICH, transfer\n REASON FOR THIS EXAMINATION:\n eval ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 7:10 PM\n Right large intraparenchymal hemorrhage with edema, significant mass effect\n with subfalcine herniation of 2.3 cm. Effacement of basal cistern,\n suggestive of uncal herniation. Dilatation of contralateral ventricle.\n Intraventricular hemorrhage in lateral ventricles bilaterally, and in 4th\n ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with large intracranial hemorrhage, evaluate\n intracranial hemorrhage.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is a large right frontal lobar parenchymal hemorrhage, with\n associated vasogenic edema. There is significant mass effect with\n obliteration of the right frontal , entrapment of the contralateral\n lateral ventricular temporal , leftward subfalcine herniation of 2 cm,\n and uncal, early downward transtentorial and tonsillar herniation. The\n hemorrhage extends into the ventricular system, with hemorrhage seen within\n the lateral, third, and fourth ventricles, and also into the foramen of\n Luschka. Hypodensity within the left basal ganglia may reflect a prior lacunar\n infarct. Visualized paranasal sinuses and mastoid air cells are clear. Osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1. Large right frontal lobar parenchymal hemorrhage with\n transependymal dissection and intraventricular extension. This may be\n secondary to anticoagulation (of which there is reportedly, a history),\n amyloid angiopathy - though ventricular extension is rare, or an underlying\n mass.\n 2. Leftward subfalcine, uncal, early downward transtentorial and\n tonsillar herniation, and entrapment of the contralateral lateral ventricle.\n\n Findings were entered into the ED dashboard at the time of interpretation,\n and reviewed with Dr. (Neurology) in-person.\n (Over)\n\n 5:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659159, "text": "Respiratory Care:\n\nPt remain orally intubated on full ventilatory support. No vent changes. RSBI done ~77. Bs are bil clear. We asxtn for scant amt of thick yel secretions from ETT. Plan: awaiting husband & priest in AM and will elective extuabted, maded . See Careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659160, "text": "STATUS\nD: NEURO STATUS UNCHANGED..AWAITING FAMILY(HUSBAND) TO EXTUBATE PT\nA: FAMILY HERE PT ..STARTED ON MSO4 GTT & EXTUBATED @ 1700 WITH FAMILY & HUSBAND AT BEDSIDE\nR: \nP: COMFORT MEASURES\n" }, { "category": "Nursing/other", "chartdate": "2133-04-24 00:00:00.000", "description": "Report", "row_id": 1659161, "text": "NPn\nPlease see carevue for further details.\nExtubated on day shift. Made comfort measures only. Morphine gtt at 20 mg/hr. pt appears comfortable. Family at bedside. Morphine titrated for pt comfort. Continue to closely monitor and provide comfort and support to the family.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-24 00:00:00.000", "description": "Report", "row_id": 1659162, "text": "addendum\nPt passed at 0520. Nsurg HO and SICU HO notified. Family at bedside. transfer to morgue.\n" } ]
1,620	122,881	A/P 30 year old woman with AML s/p allo with relapse, GVHD, hematochezia p/w progressing gait impairment and sensory deficit . 1.) Gait impairment: The patient's symptoms and exam were concerning for cord compression from either an infectious or neoplastic process in the L5 region. High dose steroids were started with dexamethasone 10 mg iv x1 and 4mg q6 hours thereafter. An emergent MRI was attempted. A neurology consult was obtained. However, due to patient pain and involuntary movement despite mild sedation, initial imaging was inadequate. The patient was electively intubated with general anesthesia to allow for adequate imaging. An epidural mass in the L4-L5 region was identified. A neurosurgical consult was obtained who recommended CT guided biopsy. A CT guided biopsy was not performed as it was thought that the lesion was not safely approachable. She was empirically treated for a chloroma with radiation therapy. She underwent XRT treatment planning to receive 10 fractions treating to a total of 20 Gy. She tolerated the XRT well except for some mild nausea. She received 4 treatments while inpatient. Her leg strength did not appreciably improve during her hospital course. She was able to walk adequately with a walker. She was evaluated by physical therapy and was witnessed walking stairs safely prior to discharge. She will receive PT services as an outpatient. . 2.) AML with GVHD: There was no evidence of peripheral blood relapse. She continued to receive her home regimen of cellcept. While she received dexamethasone for her neurologic condition, her home prednisone for GVHD was held. A bone marrow biopsy was not not performed while an inpatient, however, this could be considered as an outpatient. . 3.) Hx of GIB: The patient was recently admitted for a upper GI bleed with subsequent clipping of a visible vessel. She had trace guaiac positive stools, but there was no evidence of significant bleeding. She continued to receive her home PPI, sucralfate . 4.) Bradycardia: Following transfer back to the BMT service from the ICU, the patient developed transient asymptomatic bradycardia with heart rate in the upper 30's. Her blood pressure was normal. The rhythm was sinus. She underwent a TTE which revealed normal LV function and estimated filling pressures. By time of discharge, her heart rate had normalized. The most likely causes of the bradycardia was sedating medications, high dose steroids, or physiologic causes for a young patient. . 5.) UTI: The patient developed dysuria without vaginal symptoms. She had a UA that was remarkable for elevated WBC. She received 3 days of ciprofloxacin. A urine culture was pending at the time of discharge. . 6.) CMV viremia: On the patient had surveillance CMV viral load drawn. The result was less than 600 copies, but not "non-detected." She was started on empiric treatment with valganciclovir with concern for rapid viral replication while on high dose steroids. A repeat CMV viral load was ~800. She will complete a 21 day course of valganciclovir. 7.) Prophy: fluc, acyclovir, bactrim, PPI . 8.) CODE: FULL . 9.) Dispo: home to have outpatient PT and to return to to complete XRT course. f/u appointment with hematology clinic scheduled prior to discharge. Medications on Admission: Mycophenolate Mofetil 500 mg PO TID Acyclovir 400 mg PO Q8H Pantoprazole 40 mg PO Q12H Fluconazole 400 mg PO Q24H Prednisone 25 mg PO DAILY Sucralfate 1 gm PO QID Hydromorphone 2 mg PO ONCE Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:56 Tablet(s) Refills:0 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Line Care Midline line care per protocol 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:21 Tablet(s) Refills:0 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. Disp:2 Tablet(s) Refills:0 9. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:30 Tablet(s) Refills:0 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Primary: Epidural mass Leukemia . Secondary: Chronic graft versus host disease Cytomegalovirus viremia Discharge Condition: good. ambulating with walker. climbing stairs without incident. tolerating oral nutrition and medications. Discharge Instructions: You have been evaluated and treated for your leg weakness and difficulty walking. These symptoms were attributed to a mass in your low back that was pressing on your nerves. You received steroids and radiation therapy to treat this mass. Your radiation therapy will continue after you leave the hospital as was discussed while you were here. . While you were in the hospital you were found to have a urinary tract infection. Please take the antibiotic (ciprofloxacin) as directed and contact your doctor if the pain returns. . Please attend your physical therapy and radiation treatments. . Please take your medications as prescribed. . If you develop any concerning symptoms particularly worsening leg strength, inability to urinate, fevers to greater than 100.3F, or shortness of breath, please seek medical attention. Followup Instructions: You have your next radiation treatment on Monday . The radiation therapists will give you the appointment time. . Please arrange for physical therapy near your home to start on Monday. . You have an appointment to see Dr. on next Thursday at 12:30pm	Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting bradycardic (HR<60bpm).Conclusions:The left atrium is elongated. Normal ascending aorta diameter. IMPRESSION: Left PICC catheter positioned as described, unchanged from . The estimated pulmonary artery systolic pressure is normal.There is no pericardial effusion.Compared with the report of the prior study (images unavailable for review) of, tricuspid regurgitation is now less prominent. PATIENT/TEST INFORMATION:Indication: bradycardiaHeight: (in) 63Weight (lb): 182BSA (m2): 1.86 m2BP (mm Hg): 110/83HR (bpm): 48Status: OutpatientDate/Time: at 09:28Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. IMPRESSION: No abnormal enhancement identified in the cervical or thoracic region. REASON FOR THIS EXAMINATION: evidence of cord compression No contraindications for IV contrast FINAL REPORT EXAM: MRI of the cervical and thoracic spine. Supraventricular bradycardiaShort P-R intervalNormal ECG except for rateSince previous tracing, no significant change No resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Pt in NARD on current vent settings; no vent changes required overnoc. Taken to MRI x 2 without incident for seperate scans. FINDINGS: No abnormal intraspinal enhancement is seen in the cervical or thoracic region. CHEST, SINGLE AP VIEW CENTERED AT THE LEVEL OF THE DIAPHRAGMS: An NG tube is present. TECHNIQUE: T1 sagittal and axial images of the lumbar spine were obtained following gadolinium administration. The indication states confirm right PICC placement, though discussion with the ordering physician, . THORACIC SPINE: TECHNIQUE: T1 and T2 sagittal images acquired. FINAL REPORT EXAM: Thoracic spine. Mildlydilated aortic arch.AORTIC VALVE: Normal aortic valve leaflets (3). THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic spine were acquired. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation. ADEQUATE U/O'S.CV: HEMODYNAMICALLY STABLE.ENDOC: K+ 3.4-REPLETED WITH 40MEQ KCL.HEM: HCT AND PLTS STABLE. TECHNIQUE: T1 sagittal images of the cervical and thoracic spine were obtained following gadolinium administration. The mediastinal and hilar contours are normal. FINDINGS: The previously noted mass at the anterior epidural space at L4 and L5 level does not demonstrate enhancement. There is mild symmetric left ventricularhypertrophy. IMPRESSION: No significant abnormalities on the MRI of the cervical spine. The mass appears to be epidural in location with compression of the thecal sac and cauda equina. The distal spinal cord shows normal signal intensities. The distal spinal cord shows normal signal intensities. MED X1 FOR PAIN IN THE RIGHT LOWER LEG, OTHERWISE NO DISCOMFORT NOTED. Tissue velocity imagingdemonstrates an E/e' <8 suggesting a normal left ventricular filling pressure(<12mmHg). FINDINGS: No cord compression or intrinsic spinal cord signal abnormalities. REASON FOR THIS EXAMINATION: evidence of brain lesions No contraindications for IV contrast FINAL REPORT EXAM: MRI of the brain. Neuro: patient off propofol sedation @ 1100, alert and oriented, denies pain in lower extremeties, slightly weak but was able to move them without difficulty. FINDINGS: The ventricles and extra-axial spaces are normal in size. still on MRSA and VRE precaution. Following gadolinium, no evidence of abnormal parenchymal, vascular, or meningeal enhancement seen. IMPRESSION: No significant abnormalities detected on the MRI of the brain with and without gadolinium. The left ventricular cavity size is normal. IMPRESSION: The previously noted epidural mass does not demonstrate enhancement and is less likely due to a neoplastic lesion. The sideport lies at the level of the lower esophagus and has not passed beyond the GE junction. Respiratory CarePt remains on full ventilatory support as noted in Carevue. REMAINS INTUBATED. Resp care Note:Pt cont intub with OETT and on mech vent as per Carevue. Right ventricular chamber size and free wall motion are normal. It is most likely due to hematoma. Correlation was made with the earlier lumbar spine MRI examination of . IMPRESSION: No cord compression or intraspinal mass in thoracic region. Comparison was made with the previous thoracic spine MRI of the same day of . 12:01 PM MR SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST Clip # -52 REDUCED SERVICES Reason: PLEASE USE GADO. Vascular flow voids are maintained. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were acquired. OF HEMATOMA. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal images of the lumbar spine were obtained. CLINICAL INFORMATION: Patient with AML status post allograft with gait impairment and sensory deficit evidence of cord compression. A left-sided PICC line is present, the tip appears to lie in the left brachiocephalic vessel, immediately proximal to its junction with the SVC. O2 SATS 99-100%.NEURO: REMAINS ON PROPOFOL. There is a left-sided PICC catheter in place, with the tip overlying the distal left brachiocephalic vein. Please evaluate epidural mass. Please evaluate epidural mass. Normal LV cavity size. There is enhancement at the superior aspect which appears to be secondary to venous enhancement. Theaortic arch is mildly dilated. The mass appears to be extending bilaterally into the neural foramina but no enhancement is seen. Gadolinium-enhanced MRI recommended for further evaluation. SUCTIONED FOR SCANT AMT OF TAN SECRETIOS.	20	[ { "category": "Echo", "chartdate": "2106-09-23 00:00:00.000", "description": "Report", "row_id": 78320, "text": "PATIENT/TEST INFORMATION:\nIndication: bradycardia\nHeight: (in) 63\nWeight (lb): 182\nBSA (m2): 1.86 m2\nBP (mm Hg): 110/83\nHR (bpm): 48\nStatus: Outpatient\nDate/Time: at 09:28\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). TVI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardic (HR<60bpm).\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue velocity imaging\ndemonstrates an E/e' <8 suggesting a normal left ventricular filling pressure\n(<12mmHg). Right ventricular chamber size and free wall motion are normal. The\naortic arch is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, tricuspid regurgitation is now less prominent.\n\n\n" }, { "category": "ECG", "chartdate": "2106-09-22 00:00:00.000", "description": "Report", "row_id": 191482, "text": "Supraventricular bradycardia\nShort P-R interval\nNormal ECG except for rate\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283038, "text": "RESP: BS'S CLEAR. REMAINS INTUBATED. SUCTIONED FOR SCANT AMT OF TAN SECRETIOS. NO VENT CHANGES. O2 SATS 99-100%.\nNEURO: REMAINS ON PROPOFOL. GIVEN FREQUENT BOLUSES WHILE IN MRI. PT. REQUIRED 2ND MRI WITH CONTRAST. EPIDURAL MASS SEEN. ? OF HEMATOMA. CT SCAN WITH BIOPSY SCHEDULED FOR TOMORROW AM ON THE ? .. PT CRYING WHEN PROPOFOL HALVED FOR NEURO CONSULT. I ASSURED HER THAT THE TUBE WOULD BE REMOVED AFTER HER PROCEDURES.\nGI: OGT PLACED FOR ORAL MEDS. PASSING FLATUS.\nRENAL: IVF'S AT 100CC/HR. ADEQUATE U/O'S.\nCV: HEMODYNAMICALLY STABLE.\nENDOC: K+ 3.4-REPLETED WITH 40MEQ KCL.\nHEM: HCT AND PLTS STABLE. ELEVATED LFT'S.\nID: + for MRSA, VRE, C-DIFF.\nsocial: HUSBAND INTO BY THE RESIDENT.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283039, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\n30 yo, married, w/ 21 months child, hx AML s/p allo BMT from sister; relaps then tx MEC and DLI ; has chronic GVHD skin and liver--bili stable; UGIB;\n\nc/c: 2 weeks hx bilat motor, sensory, and urinary symptoms, progressive gait instability (though symptoms (numbness) in Rt leg started one month ago); found to have L3-4 to L5-S1 mass; CT guided bx recommended; XRT likely recommended if mass is tumor, possibly chemo;\n\nthis night;\npt remains intubated on same settings, with hope of CT Sun. ;\ntan return when suctioned;\n\nno new findings neuro exam; remains on propofol without change; pt able to awaken and respond w/ nods, also writes on tablet;\n\nvss; remains on IVF of D5 at 100 ml/hr; urine output adequate, amber;\n\nreceiving prn oxycodone for pain, as had been taking at home for leg pain d/t develping recent LE symptoms;\n\nteam did not desire serum K+ or lytes in the eve, stated to wait for morning labs and to maybe send abit early;\n\n2 sisters, pt's mother, and another relative in to visit last eve;\n\nPLAN:\n1) ?CT Sun \n2) a.m. labs sent at 02:15, check results\n3) oxycodone prn for pain, avoid over sedation\n4) emotional support to pt and family\n5) pt wrote on tablet last eve \"no students\"\n" }, { "category": "Nursing/other", "chartdate": "2106-09-20 00:00:00.000", "description": "Report", "row_id": 1283044, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 109/65-162/98. SB/SR WITH HR RANGING FROM 50-88, NO ECTOPY NOTED. PPP BILAT.\n\nNEURO: A&OX3. MED X1 FOR PAIN IN THE RIGHT LOWER LEG, OTHERWISE NO DISCOMFORT NOTED. FOLLOWS COMMANDS. NO DEFICTS NOTED.\n\nRESP: PT WAS EXTUBATED YESTERDAY AT 1100 WITH NO DIFFICULTY. LUNGS HAVE REMAINED CLEAR THROUGHOUT. SAO2 HAS RANGED FROM96-100% ON RA. RR 10-21.\n\nGU: FOLEY CATH PATENT AND DRAINING ADEQUATE AMTS OF CLEAR YELLOW URINE.\n\nGI: ABD SOFT WITH +BS, PASSING FLATUS. WAS EATING SM AMTS FROM WHICH FAMILY BROUGHT IN.\n\nPLAN: NO BX TO THE MASS FOUND IN LOWER SPINE. PLAN IS FOR PT TO HAVE XRT ON MASS. PT DOES NOT WANT STUDENTS TO DO PROCEEDURES ON HER. PT IS A CALL OUT WAITING FOR HER BED ON 7F.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283036, "text": "MICU ADMISSION NOTE\nPATIENT IS A 30 Y/O WITH H/O GASTRIC BYPASS, MRSA BACTEREMIA, GIB WITH ULCER, HTN. H/O AML WITH ALLOGENIC TRANSPLANT , RELAPSED IN , RECEIVED CHEMO THEN A DONOR LYMPHOCYTE INFUSION FROM HER SISTER.\n\nPRESENTED FROM CLINIC YESTERDAY WITH BILATERAL LE PAJN AND NUMBNESS WITH UNSTABLE GAIT. ALSO EXPERIENCING URINARY HESITENTANCY. ? CORD COMPRESSION. HAD MRI YESTERDAY IN WHICH SHE RECEIVED ATIVAN AND DILAUDID BUT WAS UNABLE TO TOLERATE MRI FOR MORE THAH 1/2 HOUR AND IMAGING WAS UNINTERPRETABLE. BEING ADMITTED TO INTUBATION AND MRI.\n\nARRIVED @0430. HD STABLE. UNDERSTOOD THAT SHE WAS TO BE INTUBATED. TUBED BY ANESTHESIA AND SEDATED ON PROPOFOL. FOLEY PLACED. TRANSPORTED TO MRI FOR SCAN OF NECK AND SPINE WITH CONTRAST TO R/O CORD CMPRESSION.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283037, "text": "Respiratory Care\nPt remains on full ventilatory support as noted in Carevue. Taken to MRI x 2 without incident for seperate scans. All vent settings noted in Carevue as well.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283040, "text": "Resp care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283041, "text": "npn 7a addendum:\n\nre a.m. labs:\nsome LFT's slightly higher than yesterday morning, ?change from Propofol for sedation to another sedative?\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283042, "text": "Neuro: patient off propofol sedation @ 1100, alert and oriented, denies pain in lower extremeties, slightly weak but was able to move them without difficulty. pupils 2mm reactive to light, patient stated \"I don't want any students\" Patient was crying most of the time while intubated, post extubation, in a happy mood, conversing with family members and staff.\n\nRespi: extubated @ 1100, no shortness of breath or respiratory distress, lung sounds clear, diminished @ bases. sats >95% @ room air.\n\nCV: episodes of asymptomatic SB, BP 130-140's; PICC line within normal limits, denies any chest pain.\n\nGI/GU: on regular diet, ate lunch with good appetite. OGT pulled out 1100, no BM today. passing out gas.Bowel sounds present, soft and non-tender. adequate amount of amber urine.\n\nEndo: on RISS, FS 1200 = 190, 2 units coverage given\n\nSocial: family in and stayed @ bedside, takled with team on plan of care.\n\nPlan:\n\npossible transfer out to floor, possible radiation therapy in the morning, monitor patient for weakness of extremeties, support to patient and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283043, "text": "addendum:\n\npatient called out of ICU, waiting for availability of room. still on MRSA and VRE precaution.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR L SPINE WITH CONTRAST", "row_id": 928104, "text": " 12:01 PM\n MR L SPINE WITH CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: r/o cord compression by mass or abscess\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p alloBMT with chronic GVDH, now with left leg\n pain, urinary retention, unsteady gait\n REASON FOR THIS EXAMINATION:\n r/o cord compression by mass or abscess\n ______________________________________________________________________________\n FINAL REPORT\n MRI LUMBAR SPINE\n\n CLINICAL INFORMATION: Patient with AML and left leg pain and urinary\n retention and unsteady gait. Rule out cord compression.\n\n TECHNIQUE: T1 sagittal and axial images of the lumbar spine were obtained\n following gadolinium administration. Fat suppression was utilized to detect\n enhancement. Comparison was made with the previous lumbar spine MRI obtained\n on the same day earlier on .\n\n FINDINGS: The previously noted mass at the anterior epidural space at L4 and\n L5 level does not demonstrate enhancement. There is enhancement at the\n superior aspect which appears to be secondary to venous enhancement. The mass\n appears to be extending bilaterally into the neural foramina but no\n enhancement is seen. There are no paraspinal abnormalities seen.\n\n IMPRESSION: The previously noted epidural mass does not demonstrate\n enhancement and is less likely due to a neoplastic lesion. It is most likely\n due to hematoma. Clinical correlation with patient's laboratory bleeding\n functions is recommended. In absence of an involvement of the vertebral\n bodies or disc infection or abscess is not considered likely.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR T SPINE SCAN WITH CONTRAST", "row_id": 928105, "text": " 12:01 PM\n MR SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: PLEASE USE GADO. Please evaluate epidural mass.\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p BMT, with gait instability.\n REASON FOR THIS EXAMINATION:\n PLEASE USE GADO. Please evaluate epidural mass.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Thoracic spine.\n\n CLINICAL INFORMATION: Patient with leukemia and mass in the lumbar spine, for\n further evaluation of thoracic spine for abnormal enhancement.\n\n TECHNIQUE: T1 sagittal images of the cervical and thoracic spine were\n obtained following gadolinium administration. Comparison was made with the\n previous thoracic spine MRI of the same day of .\n\n FINDINGS: No abnormal intraspinal enhancement is seen in the cervical or\n thoracic region. There is no evidence of discitis or osteomyelitis in the\n lumbar or thoracic region.\n\n IMPRESSION: No abnormal enhancement identified in the cervical or thoracic\n region.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 928065, "text": " 5:37 AM\n MR L SPINE W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evidence of cord compression\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of cord compression\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI lumbar spine.\n\n CLINICAL INFORMATION: Patient with AML status post allograft with gait\n impairment and sensory deficit evidence of cord compression.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were acquired. Correlation was made with the earlier lumbar\n spine MRI examination of .\n\n FINDINGS: As seen on the previous study, there is an epidural mass identified\n extending from L3-4 to L5-S1 level within the anterior epidural space with\n high-grade compression of the thecal sac and cauda equina. The mass also\n extends to both neural foramina at L4-5 level. No paraspinal mass is\n identified. There is no evidence of abnormal signal seen within the vertebral\n bodies or discs in the lumbar region. The distal spinal cord shows normal\n signal intensities.\n\n IMPRESSION: Epidural mass from L3-4 to L5-S1 level with high-grade thecal sac\n compression. The mass extends to both neural foramina at L4-5 level. This\n finding could be secondary to an epidural hematoma or due to leukemic\n infiltrates. Gadolinium-enhanced images would help for further assessment.\n Findings were discussed with BMT attending at the time of interpretation of\n this study on .\n\n" }, { "category": "Radiology", "chartdate": "2106-09-17 00:00:00.000", "description": "MR THORACIC SPINE W/O CONTRAST", "row_id": 928041, "text": " 8:29 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/n\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with\n REASON FOR THIS EXAMINATION:\n 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/numbness/weakness to\n right leg x 1 week\n ______________________________________________________________________________\n WET READ: DDH SAT 3:01 AM\n very limited exams secondary to motion artifact; no obvious cord\n compression seen. may consider repeating with appropriate sedation\n if indicated.\n\n\n , MD\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic and lumbar spine.\n\n CLINICAL INFORMATION: Patient with AML, status post ablation and bone marrow\n transplant with back pain and numbness in the lower extremities one week, for\n further evaluation.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1 and T2 sagittal images acquired.\n\n FINDINGS: The examination is somewhat limited by motion. There is no\n evidence of spinal cord compression or intraspinal mass identified. There is\n no abnormal signal seen within the spinal cord. There is no evidence of\n abnormal signal seen within the vertebral bodies on limited evaluation.\n\n IMPRESSION: Limited study due to motion. No evidence of cord compression.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal images of the lumbar spine\n were obtained.\n\n FINDINGS: There is a mass identified within the spinal canal extending from\n L3-4 disc to L5-S1 disc level. The mass appears to be epidural in location\n with compression of the thecal sac and cauda equina. On T1-weighted images,\n the mass is isointense to the distal spinal cord and on T2 images it is low\n signal. The differential diagnosis includes an epidural hematoma versus\n leukemic infiltrates in the epidural space.\n\n There is no evidence of other abnormality in the lumbar spine. The distal\n spinal cord shows normal signal intensities.\n\n (Over)\n\n 8:29 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/n\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Epidural mass extending from L3-4 to L5-S1 level with low T2 and\n isointense T1 signal could be due to an epidural hematoma or due to leukemic\n infiltrates. Gadolinium-enhanced MRI recommended for further evaluation.\n Findings discussed with BMT attending on-call at the time of interpretation of\n this study on at 9 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928123, "text": " 4:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG placement\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC, s/p elective intubation now\n with ng tube.\n REASON FOR THIS EXAMINATION:\n NG placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AML status post BMT, assess NG tube placement.\n\n CHEST, SINGLE AP VIEW CENTERED AT THE LEVEL OF THE DIAPHRAGMS:\n\n An NG tube is present. The tip overlies the expected site of the GE junction.\n The sideport lies at the level of the lower esophagus and has not passed\n beyond the GE junction. As a result, the NG tube should be advanced prior to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 928063, "text": " 5:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evidence of brain lesions\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of brain lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with AML and status post allograft with gait\n impairment and sensory deficit, to rule out evidence for brain lesions.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were obtained. Following gadolinium, T1 axial and\n coronal images of the brain were acquired. There are no prior similar\n examinations for comparison.\n\n FINDINGS: The ventricles and extra-axial spaces are normal in size. No\n evidence of midline shift, mass effect, or hydrocephalus seen. There are no\n focal signal abnormalities seen within the brain. Vascular flow voids are\n maintained. Following gadolinium, no evidence of abnormal parenchymal,\n vascular, or meningeal enhancement seen.\n\n IMPRESSION: No significant abnormalities detected on the MRI of the brain\n with and without gadolinium.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928062, "text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of ETT\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC, s/p elective intubation\n\n REASON FOR THIS EXAMINATION:\n eval placement of ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate ET tube.\n\n CHEST, SINGLE AP PORTABLE SUPINE VIEW\n\n There are low inspiratory volumes. An ET tube is present, tip approximately\n 2.2 cm above the carina, in satisfactory position. A left-sided PICC line is\n present, the tip appears to lie in the left brachiocephalic vessel,\n immediately proximal to its junction with the SVC. No pneumothorax is\n identified. Prominence of vascular markings is likely accentuated by low\n inspiratory volumes. No focal infiltrate or effusion is identified. No\n pneumothorax is seen.\n\n IMPRESSION:\n\n ET tube satisfactory position 2.2 cm above the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-17 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 928031, "text": " 6:32 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: confirm R PICC placement\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC\n REASON FOR THIS EXAMINATION:\n confirm R PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with AML status post bone marrow transplant with PICC.\n The indication states confirm right PICC placement, though discussion with the\n ordering physician, . , the patient's PICC is on the left side.\n No right-sided PICC was placed.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The heart size is normal. The mediastinal and hilar\n contours are normal. There is a left-sided PICC catheter in place, with the\n tip overlying the distal left brachiocephalic vein. It is unchanged compared\n to . There is no consolidation or vascular congestion within\n the lungs. A tiny (sub 3-mm) rounded opacities in the lower portions of the\n lungs likely represent vessels on end. No pleural effusion or pneumothorax.\n\n IMPRESSION: Left PICC catheter positioned as described, unchanged from \n .\n\n Findings were discussed with Dr. at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 928064, "text": " 5:35 AM\n MR CERVICAL SPINE; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MR THORACIC SPINE W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: evidence of cord compression\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of cord compression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical and thoracic spine.\n\n CLINICAL INFORMATION: Patient with bone marrow transplant and lower extremity\n weakness and sensory deficit and gait impairment for further evaluation.\n\n CERVICAL SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient echo and T2\n axial images of the cervical spine were obtained.\n\n FINDINGS: From the skull base to T3 level, there is no evidence of cord\n compression or abnormal signal within the cord. There is no significant disc\n bulge, disc herniation or spinal stenosis seen. There is increased signal\n seen in the nasopharynx and oropharynx which could be related to retained\n fluid.\n\n IMPRESSION: No significant abnormalities on the MRI of the cervical spine. No\n evidence of cord compression seen. No abnormal signal within the cord.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were acquired.\n\n\n FINDINGS: No cord compression or intrinsic spinal cord signal abnormalities.\n No evidence of discitis or osteomyelitis. No intraspinal mass.\n\n IMPRESSION: No cord compression or intraspinal mass in thoracic region.\n\n" } ]
10,247	168,051	64 yo male with a PMH significant for morbid obesity, DMII, GERD, HTN, yperlipidemia, and prior ventilatory dependency (felt to be multifactorial in the setting of obesity, OSA, and ?COPD) s/p trach removal for plugged trach, presents with hypotension and hypercarbic respiratory failure, now resolved and extubated. . # Hypercarbic Respiratory Failure: Quickly weaned from , have been caused by infection, ie UTI, with poor pulmonary reserve, or mucus plugging, given quick recovery. Now extubated and sats in mid 90s on room air. Continue with alb/atro, chest PT, to prevent future mucus plugging. . # Genital abnormality: divided ventral surface of penis, congenital hypospadias vs possibly secondary to chronic indwelling foley catheter, appears chronic with well-healed skin and no signs of infection. Recommend outpatient follow-up with urology if patient desires reconstructive surgery. . # Acute renal failure: Pts BL Cr is 0.9 to 1.1, with Cr peak 1.6, now 1.0. Peripheral diff shows 10% eos, down from 12, likely resolving AIN. Recent new medications have included bactrim, imipenem, and levofloxacin. Possible causes of AIN include the bactrim and levofloxacin. - received vanc and cefepime for UA with mod leuk est, neg nitr, + WBCs, but culture negative, so will D/C abx . # Eosinophilia: Suspect AIN given ARF. --trend diff now that off abx and Cr normalized . # Diastolic dysfunction: From TTE in , the pt had a nl EF with hyperdynamic function. Restart lasix on discharge. . # HTN: Restarted lisinopril 20, metoprolol 75 tid, amlodipine 10mg since BP stable after extubation. . # CAD risk equivalent: on , home statin . # DM: continue SSI and NPH; had been on NPH 35 , reduced to 14 qam and 10 qpm with good control of FSBS. need to increase again if diet changes. . # Psych: Continue on Wellbutrin and Effexor; restarted remeron after it had been on hold for concern of contributing to decreased MS. . # PPX: SC Heparin, colace, reglan, PPI # FEN: Diabetic diet. # Access: R IJ placed in ICU; D/C'd RIJ since has working peripherals # FULL CODE	Generalized + edema. +PP, mild peripheral edema. Note is made of stable appearance of elevated left hemidiaphragm. Left atrial abnormality. Foley patent drng minimal u/o HO aware pt started on Maint IVF.Endo: RISSID: On Vanco/cepPlan: cont to monitor resp status. BS remain slightly coarse bilaterally with increased aeration. Bs initially with expiratory wheezes bilaterally. SVO2 monitoring d/c'd.GI - Abd obese, +BS. Unchanged appearance of elevated left hemidiaphragm and atelectatic changes of left lung. Antibx. Pt tolerating extubation well. Wean to MDI's as tolerated. + Obese abd soft NT. Nebs. Lungs clear to coarse diminished at the bases.GI/GU: Currently NPO except meds. Afebrile. Afebrile. There is a small rounded hypodensity of the left basal ganglia, which is consistent with a small lacune or enlarged perivascular space. 1 suture visible, MICU team unable to d/c. Sinus rhythm. FINAL REPORT INDICATION: Altered mental status. IMPRESSION: 1. Pt. Pt. Pt. Wheezes clearing over course of shift. The endotracheal tube has been removed. Respiratory Care:Patient given Albuterol/Atrovent nebs Q4hr. SR w/occ PVCs. Vanco and cefapime for UTI, ? RLL PNA.Skin - W->D dsg on coccyx, positioned side->side. + BS +BM today. Cont to monitor resp status. +BS, abdomen soft, obese. Left lower lobe atelectasis, elevation of the left hemidiaphragm and distention of the splenic flexure of the colon are unchanged. Stage II to coccyx reddened, serosang drainage. Crit stable. There is mild-to-moderate mucosal thickening within the ethmoid air cells. The heart, mediastinal and hilar contours are otherwise unremarkable. SBP 130s. The right IJ line with tip in the right atrium is unchanged. FINDINGS: There is bilateral lower lobe volume loss. AM CXR pending. Atelectatic changes of the left lung base is unchanged. ET tube tip terminates 2.4 cm above the carina. ABP 113-140/48-55. Ill-defined opacity in the right lower lung field is consistent with right middle lobe atelectasis. cont with current Plan of care Denies pian. HR 80-110's with occ PVC's. Lung sounds clear, healing old trach site w/DSD to cover, no drainage. Lacune vs. enlarged perivascular space of the left basal ganglia. CVP 5-10. FINAL REPORT REASON FOR EXAM: Shortness of breath, altered mental status, assess ET tube placement. ETT tip terminates 2 cm above the carina. Denies pain. CVP 6-8 Pre-cep cath SV02 70-73. MAE and follows commands.CV: Pt currently off levo. Lacune versus enlarged perivascular space of the left basal ganglia. Deconditioned d/t prolonged illness. Comparison is made to the recent CT of the trachea on . W-D applied this am, wound care RN to assess. ? ? ? Pt given 2 1Liter fluid bolus's early in am for hypotension. The remainder of the lungs are unremarkable. Otherwise, no diagnostic interim change. Good cuff leak present prior to extubation with difficult airway cart on standby. Will cont to monitor for s/s fatigue. Pt enc to cough and deep breathe. Tolerated well with mask. Urine is tea colored.UD - Afebrile. FSBS covered by HISS, to restart NPH today-? 2. SINGLE AP PORTABLE VIEW OF THE CHEST. Alert and oriented X3. Otherwise, the osseous and soft tissue structures are unremarkable. ABG 7.31/48/113/26.CV - ABP 170s/60s, HR 100s ST last night, restarted on lopressor with HR decreasing NSR 80s, occ PACs, PVCs. Atrialectopy is no longer recorded. SINGLE AP PORTABLE VIEW CHEST. Pt able to clear secretions and protect airway. Glucose stable on NPH/SSRI. No resp distress. NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by patient movement. 2:55 AM CHEST (PORTABLE AP) Clip # Reason: ett placement? Lungs are essentially clear throughout, RR teens. There is a small osteoma the left maxillary antrum. 8:52 PM CT HEAD W/O CONTRAST Clip # Reason: MS CHANGES. Nursing Progress NOTePlease see carvue for specifics:Neuro: Pt very pleasant. Pt maintaining MAP >65 w/o medical intervention. c/o to floor tomorrow if remains stable. HR 80's with RR mid teens. able to easily assist w/turning and repositioning. O2 sats 99%.Improved with bronchodilators. restart diet today. The ventricles and cisterns are normal. 3:56 AM CHEST PORT. Otherwise, the density values of the brain parenchyma are normal, with preservation of the -white matter differentiation. extubated yesterday and continues to do well.Plan: Will continue to follow with Nebs Q4hr. able to clear secretions without difficulty. Meds crushed in custard. BLOOD / MASS. There are no other acute interval changes. Other visualized paranasal sinuses and mastoid air cells are clear. Nursing note: A/Ox2-3, at times forgets he isn't in NH. Skin care consult to be done.Plan - Monitor resp care, Nebs, O2. Very pleasant and cooperative w/care. Tolerating diabetic diet, good appetite, no dysphagia. Foley patent amber urine in adequate amounts, >30cc/hr. Now normotensiveResp: Extubated this PM around 1700. Foley irrigated, balloon deflated, advanced, with large UOP. Family in to visit.A/P:Stable for c/o to floor. Intraventricular conduction delay.Compared to the previous tracing of the rate has increased. IMPRESSION: No evidence of acute intracranial hemorrhage. Productive cough of thick yellow secretions. No evidence of acute cardiopulmonary process. 40% cool mist in use via face tent. There is no pneumothorax. Note is also made of tortuous course of the trachea. Sats 97-100%, desatted to 85% when asleep. No stool. Comparison is made with prior study performed 1 hour before. MAE on bed, assists with turns. There are no prior studies for comparison. Resp CarePt extubated this afternoon to 40% cool aerosol well with spo2 100% RR 18-20.	11	[ { "category": "Radiology", "chartdate": "2110-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954842, "text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusion\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB, COPD\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Altered mental status.\n\n FINDINGS: There is bilateral lower lobe volume loss. It is unclear if any of\n the opacity represents an underlying infectious infiltrate. The endotracheal\n tube has been removed. The right IJ line with tip in the right atrium is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 954700, "text": " 3:56 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for line placement\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB s/p intubation\n\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Evaluate ETT placement.\n\n Comparison is made with prior study performed 1 hour before.\n\n SINGLE AP PORTABLE VIEW CHEST. ETT tip terminates 2 cm above the carina. There\n are no other acute interval changes.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954671, "text": " 7:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with altered mental status and shortness of\n breath.\n\n Comparison is made to the recent CT of the trachea on .\n\n Note is made of stable appearance of elevated left hemidiaphragm. The heart,\n mediastinal and hilar contours are otherwise unremarkable. Note is also made\n of tortuous course of the trachea. Atelectatic changes of the left lung base\n is unchanged. The remainder of the lungs are unremarkable.\n\n IMPRESSION:\n\n 1. Unchanged appearance of elevated left hemidiaphragm and atelectatic\n changes of left lung.\n\n 2. No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 954679, "text": " 8:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS CHANGES. ? BLOOD / MASS.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for bleed, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:14 PM\n No evidence of acute hemorrhage. Lacune vs. enlarged perivascular space of the\n left basal ganglia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n There are no prior studies for comparison.\n\n NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by patient\n movement. There is no evidence of acute intracranial hemorrhage or shift of\n normally midline structures. The ventricles and cisterns are normal. There\n is a small rounded hypodensity of the left basal ganglia, which is consistent\n with a small lacune or enlarged perivascular space. Otherwise, the density\n values of the brain parenchyma are normal, with preservation of the -white\n matter differentiation. There is mild-to-moderate mucosal thickening within\n the ethmoid air cells. Other visualized paranasal sinuses and mastoid air\n cells are clear. There is a small osteoma the left maxillary antrum.\n Otherwise, the osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. Lacune versus\n enlarged perivascular space of the left basal ganglia.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954697, "text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement?\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ett placement?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Shortness of breath, altered mental status, assess ET tube\n placement.\n\n Comparison is made with prior study performed seven hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST. ET tube tip terminates 2.4 cm above the\n carina. Ill-defined opacity in the right lower lung field is consistent with\n right middle lobe atelectasis. Left lower lobe atelectasis, elevation of the\n left hemidiaphragm and distention of the splenic flexure of the colon are\n unchanged. There is no pneumothorax.\n\n" }, { "category": "Nursing/other", "chartdate": "2110-04-25 00:00:00.000", "description": "Report", "row_id": 1397645, "text": "Resp Care\n\nPt extubated this afternoon to 40% cool aerosol well with spo2 100% RR 18-20. Good cuff leak present prior to extubation with difficult airway cart on standby. Will cont to monitor for s/s fatigue.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-25 00:00:00.000", "description": "Report", "row_id": 1397646, "text": "Nursing Progress NOTe\nPlease see carvue for specifics:\nNeuro: Pt very pleasant. Alert and oriented X3. MAE and follows commands.\nCV: Pt currently off levo. Pt maintaining MAP >65 w/o medical intervention. CVP 6-8 Pre-cep cath SV02 70-73. HR 80-110's with occ PVC's. Crit stable. Afebrile. Pt given 2 1Liter fluid bolus's early in am for hypotension. Now normotensive\nResp: Extubated this PM around 1700. Pt tolerating extubation well. Pt enc to cough and deep breathe. Pt able to clear secretions and protect airway. Lungs clear to coarse diminished at the bases.\nGI/GU: Currently NPO except meds. + Obese abd soft NT. + BS +BM today. Foley patent drng minimal u/o HO aware pt started on Maint IVF.\nEndo: RISS\nID: On Vanco/cep\nPlan: cont to monitor resp status. Cont to monitor resp status. ? c/o to floor tomorrow if remains stable. cont with current Plan of care\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397647, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs Q4hr. Tolerated well with mask. Bs initially with expiratory wheezes bilaterally. HR 80's with RR mid teens. Productive cough of thick yellow secretions. Pt. able to clear secretions without difficulty. 40% cool mist in use via face tent. O2 sats 99%.\nImproved with bronchodilators. Wheezes clearing over course of shift. BS remain slightly coarse bilaterally with increased aeration. No resp distress. Pt. extubated yesterday and continues to do well.\nPlan: Will continue to follow with Nebs Q4hr. Wean to MDI's as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397648, "text": "MICU nursing progress note 7P-7A\nNeuro - A&O x 3, awake most of night, watching TV. Slept in naps. MAE on bed, assists with turns. Deconditioned d/t prolonged illness. Denies pain. Takes pills crushed in custard, drinking PO fluids without difficulty.\n\nResp - No resp distress, doing well on 40& cool neb via face tent. Nebs. + strong cough, expectorating thick yellow secretions, using yankeur. Lungs are essentially clear throughout, RR teens. Sats 97-100%, desatted to 85% when asleep. AM CXR pending. ABG 7.31/48/113/26.\n\nCV - ABP 170s/60s, HR 100s ST last night, restarted on lopressor with HR decreasing NSR 80s, occ PACs, PVCs. ABP 113-140/48-55. Generalized + edema. CVP 5-10. SVO2 monitoring d/c'd.\n\nGI - Abd obese, +BS. No stool. FSBS covered by HISS, to restart NPH today-? restart diet.\n\nGU - UOP increased 90-200cc/hr after fluid bolus last night then tapered off again. Foley irrigated, balloon deflated, advanced, with large UOP. Urine is tea colored.\n\nUD - Afebrile. Vanco and cefapime for UTI, ? RLL PNA.\n\nSkin - W->D dsg on coccyx, positioned side->side. Skin care consult to be done.\n\nPlan - Monitor resp care, Nebs, O2. ? restart diet today. Meds crushed in custard. Antibx.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397649, "text": "Nursing note:\n A/Ox2-3, at times forgets he isn't in NH. Very pleasant and cooperative w/care. Denies pian. Afebrile. SR w/occ PVCs. SBP 130s. +PP, mild peripheral edema. Lung sounds clear, healing old trach site w/DSD to cover, no drainage. 1 suture visible, MICU team unable to d/c. +BS, abdomen soft, obese. Tolerating diabetic diet, good appetite, no dysphagia. Foley patent amber urine in adequate amounts, >30cc/hr. Glucose stable on NPH/SSRI. Stage II to coccyx reddened, serosang drainage. W-D applied this am, wound care RN to assess. Pt. able to easily assist w/turning and repositioning. Family in to visit.\nA/P:Stable for c/o to floor.\n\n" }, { "category": "ECG", "chartdate": "2110-04-24 00:00:00.000", "description": "Report", "row_id": 209252, "text": "Sinus rhythm. Left atrial abnormality. Intraventricular conduction delay.\nCompared to the previous tracing of the rate has increased. Atrial\nectopy is no longer recorded. Otherwise, no diagnostic interim change.\n\n" } ]
15,929	171,608	Post catheterization Integrilin was held secondary to the recent surgery, but aspirin and Plavix was continued. He remained chest pain free in the hospital and had no more events on telemetry. His episode of ventricular fibrillation in the catheterization laboratory was likely due to the ventricular irritation. His cardiac enzymes trended downward in the hospital with a peak CK of 1301. His echocardiogram showed an ejection fraction of 50% with 2+ MR was evaluated by physical therapy on the day of discharge and deemed stable to go home.	Site wnl, no hematoma, dopplerable pulses.GI: NPO except for sips clears with meds in anticipation of sheath removals. Theleft ventricular inflow pattern suggests impaired relaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. Discussed anti-hypertensives/rate control drug dose changes -> maintained doses at current level as HR decreases to 60-70's when asleep and is 80's when awake and OOB, and captopril was held at mid-night dose.Pulses strong, HRR, NSR.RESP: LS clear, no issues, no distress.GI: BS present. Moderate (2+) mitral regurgitation is seen. PT DENIES SOB, LS CLEAR.CV: HR NSR 70-90'S, NO ECTOPY. Overall leftventricular systolic function is mildly depressed.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Bedrest maintained with RLE flat MD order. RIGHT FEM ANGIO SITE D&I. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 70Weight (lb): 200BSA (m2): 2.09 m2BP (mm Hg): 99/49Status: InpatientDate/Time: at 13:56Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. BS clear bilat.CV: HR 60's-80's SR with occasional unifocal PVC's. There is mildmitral annular calcification. Frequent v/s per order, stable. NSR without ectopics, blood pressure stable. Tolerating Metoprolol, Captopril doses. Moderate (2+) mitralregurgitation is seen. +BIL PULSES.GI/GU: ABD SOFT, +BS, NO BM. R groin arterial and venous cath sheath and pacing wires dc'd by Dr. , no swelling, hematoma, + distal pulses. Sinus rhythm- borderline first degree A-V blockLong QTc intervalLeft axis deviationInferior infarct - probably acute/recentAnterolateral ST-T changes are nonspecific but consider posterolateral wallinvolvementNo previous tracing for comparison Passed hard stool and lg amt of flatus. PT TOLERATING . Neurologically intact, prn-mild disorientation, easily redirects, anxious to move out of unit. Slept in short naps.Resp: Stable, sats > 97% on 3l NP. GU: diuresing well.GI: abd soft, no stools today. Rt fem art sheath capped off, venous sheath with NS @ KVO. Nursing Progress Note-0700-Generally good day. NURSING MICU NOTE 7P-7ANEURO: PT 2, MAE, FOLLOWS COMMANDS. Tolerating po's. The left ventricular cavity size is normal. Pt agreed to tx.SKIN: Intact. BP stable. PT WANTED TO SPEAK W/ MD. Inferior hypokinesis is present.3. Stool guaiac negative.GU: Voiding qs, urine has strong malaodorous scent.HAEM: Spoke with intern re: risks/benefits of Plavix and aspirin s/p stents and with history of macular degeneration. Overall left ventricularsystolic function is mildly depressed. CVstable. CCU INTER AWARE.RESP: PT ON RA, O2 SATS 97-99%. PT DENIES ANY PAIN. ATIVAN PRN WAS ORDERED, NONE GIVEN AT THIS TIME. Received Percocet 1 PO for c/o back discomfort, Ambien 5mg PO at 2300 for sleep. Nursing Progress Note-1900S/ONEURO: Alert, oriented. The left atrium is moderately dilated.2. PT WAS THEN PLACED BACK IN BED AND GIVEN TIME TO COOL DOWN. No stool overnight, + bowel sounds.GU: Voiding qs clear yellow urine.Social: Full code. Irregular sinus tachycardia - premature ventricular contractionsInferior infarct - age undetermined - may be acute/recentAnterolateral ST-T changes may be due to myocardial ischemia - in part toposterolateral wall involvementClinical correlation is suggestedSince previous tracing of : spresentinus tachycardia SBP 90-110;S. PT DID HAVE SBP 140 THIS AM WHEN AGITATED. Resp: lung fields clear to auscultation, all fields, 02 weaned to off, spo2>95%. Had stent placed in lab, episode VT/VF shocked x1 w/200j, episode of symptomatic bradycardia Rx w/ 0.5mg Atropine IV, transvenous pacing wire left in overnight.Neuro: Awake, alert, oriented x3. At 1800, sat up, dangled for 10min, weak, mildly shaky, tol x10min, became tired. VOIDING IN URINAL CLEAR AMBER URINE.DISPO: PT HAS BEEN CALLED OUT TO MEDICAL BED, AWAITING A TELE BED. Nursing Progress Note85 yr old gentleman with PMH per FHP/Adm History sheet is admitted to MICU-B from CCL as CCU boarder. PT . PT IS A FULL CODE. Transfers self from chair to bed and bed to chair with supervision due to ARMD and inability to see wires.CV: HR increased with activity. Vent pacing wire in place, attached to pacer box mA2/sens2, rate 50, no pacing overnight. The aortic valve leaflets (3) are mildly thickened.4. PT STATED HE WANT TO LEAVE THE HOSPITAL NOW AND THAT WE WERE KEEPING HIM HERE PRISIONER. Bleeds at puncture sites, stops with pressure held x 5 minutes and pressure dressing applied.O/P:Continue current care.Support pt through his frustration during hospitalization by explaining all care options. The mitral valve leaflets are mildly thickened. Quiet day, awaiting bed on step-down . PT DENIES ANY CP. Pleasant and cooperative with care. PT WAS PLACED IN CHAIR, CCU INTERN UP TO SPEAK W/ PT. AT 0430 PT AWAKE, ANGRY AND AGITATED. PT REFUSING TO HAAVE BP CUFF ON AND LABS DRAWN THIS AM. Social: wife called in and spoke w/ twice. A FEW TIMES OVERNIGHT PT HAD ATTEMPTED TO GET OOB, NOT KNOWING WHERE HE WAS.	7	[ { "category": "Echo", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 73809, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 99/49\nStatus: Inpatient\nDate/Time: at 13:56\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate (2+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed. Inferior hypokinesis is present.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 172019, "text": "Irregular sinus tachycardia\n - premature ventricular contractions\nInferior infarct - age undetermined - may be acute/recent\nAnterolateral ST-T changes may be due to myocardial ischemia - in part to\nposterolateral wall involvement\nClinical correlation is suggested\nSince previous tracing of : spresentinus tachycardia\n\n" }, { "category": "ECG", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 172020, "text": "Sinus rhythm\n- borderline first degree A-V block\nLong QTc interval\nLeft axis deviation\nInferior infarct - probably acute/recent\nAnterolateral ST-T changes are nonspecific but consider posterolateral wall\ninvolvement\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 1469781, "text": "Nursing Progress Note\n85 yr old gentleman with PMH per FHP/Adm History sheet is admitted to MICU-B from CCL as CCU boarder. Had stent placed in lab, episode VT/VF shocked x1 w/200j, episode of symptomatic bradycardia Rx w/ 0.5mg Atropine IV, transvenous pacing wire left in overnight.\nNeuro: Awake, alert, oriented x3. Pleasant and cooperative with care. Received Percocet 1 PO for c/o back discomfort, Ambien 5mg PO at 2300 for sleep. Slept in short naps.\nResp: Stable, sats > 97% on 3l NP. BS clear bilat.\nCV: HR 60's-80's SR with occasional unifocal PVC's. BP stable. Tolerating Metoprolol, Captopril doses. Vent pacing wire in place, attached to pacer box mA2/sens2, rate 50, no pacing overnight. Rt fem art sheath capped off, venous sheath with NS @ KVO. Site wnl, no hematoma, dopplerable pulses.\nGI: NPO except for sips clears with meds in anticipation of sheath removals. No stool overnight, + bowel sounds.\nGU: Voiding qs clear yellow urine.\nSocial: Full code. Pt's family in to visit during evening, updated by Nursing and CCU resident.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 1469784, "text": "Nursing Progress Note\n-1900\n\nS/O\nNEURO: Alert, oriented. Transfers self from chair to bed and bed to chair with supervision due to ARMD and inability to see wires.\n\nCV: HR increased with activity. Discussed anti-hypertensives/rate control drug dose changes -> maintained doses at current level as HR decreases to 60-70's when asleep and is 80's when awake and OOB, and captopril was held at mid-night dose.\n\nPulses strong, HRR, NSR.\n\nRESP: LS clear, no issues, no distress.\n\nGI: BS present. Tolerating po's. Passed hard stool and lg amt of flatus. Stool guaiac negative.\n\nGU: Voiding qs, urine has strong malaodorous scent.\n\nHAEM: Spoke with intern re: risks/benefits of Plavix and aspirin s/p stents and with history of macular degeneration. Pt agreed to tx.\n\nSKIN: Intact. Bleeds at puncture sites, stops with pressure held x 5 minutes and pressure dressing applied.\n\nO/P:\nContinue current care.\nSupport pt through his frustration during hospitalization by explaining all care options.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 1469782, "text": "Nursing Progress Note-0700-\nGenerally good day. Neurologically intact, prn-mild disorientation, easily redirects, anxious to move out of unit. CV_stable. NSR without ectopics, blood pressure stable. R groin arterial and venous cath sheath and pacing wires dc'd by Dr. , no swelling, hematoma, + distal pulses. Bedrest maintained with RLE flat MD order. Frequent v/s per order, stable. Resp: lung fields clear to auscultation, all fields, 02 weaned to off, spo2>95%. GU: diuresing well.GI: abd soft, no stools today. Social: wife called in and spoke w/ twice. At 1800, sat up, dangled for 10min, weak, mildly shaky, tol x10min, became tired. Quiet day, awaiting bed on step-down . \n" }, { "category": "Nursing/other", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 1469783, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT 2, MAE, FOLLOWS COMMANDS. PT DENIES ANY PAIN. A FEW TIMES OVERNIGHT PT HAD ATTEMPTED TO GET OOB, NOT KNOWING WHERE HE WAS. PT . AT 0430 PT AWAKE, ANGRY AND AGITATED. PT STATED HE WANT TO LEAVE THE HOSPITAL NOW AND THAT WE WERE KEEPING HIM HERE PRISIONER. PT WANTED TO SPEAK W/ MD. PT WAS PLACED IN CHAIR, CCU INTERN UP TO SPEAK W/ PT. PT WAS THEN PLACED BACK IN BED AND GIVEN TIME TO COOL DOWN. ATIVAN PRN WAS ORDERED, NONE GIVEN AT THIS TIME. PT REFUSING TO HAAVE BP CUFF ON AND LABS DRAWN THIS AM. CCU INTER AWARE.\n\nRESP: PT ON RA, O2 SATS 97-99%. PT DENIES SOB, LS CLEAR.\n\nCV: HR NSR 70-90'S, NO ECTOPY. SBP 90-110;S. PT DID HAVE SBP 140 THIS AM WHEN AGITATED. PT DENIES ANY CP. RIGHT FEM ANGIO SITE D&I. +BIL PULSES.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT TOLERATING . VOIDING IN URINAL CLEAR AMBER URINE.\n\nDISPO: PT HAS BEEN CALLED OUT TO MEDICAL BED, AWAITING A TELE BED. PT IS A FULL CODE.\n" } ]
89,936	136,208	# CORONARIES: The patient had an inferior STEMI with occlusion of left circumflex. The patient received two bare metal stents in the left circumflex. She was then medically managed initially with ASA 325 mg daily, Clopidogrel 75 mg daily, Metoprolol 12.5 mg , Atorvastatin 80 mg daily. Her lipid panel showed a total cholesterol of 157, triglycerides of 65, HDL of 56, and LDL of 88. Her echocardiogram showed mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function (LVEF > 55%). Mild mitral regurgitation. Increased PCWP. Lisinopril was also added to help control her hypertension. She was returned to her home dose of atenolol. . # PUMP: Patient's PCWP was 28. JVD was . Patient denied symptoms of right-sided heart failure. On the morning of , the patient awoke to a coughing fit and some dyspnea. Due to the hydration given and concerns for heart failure, she was administered Lasix 10mg IV. Her dyspnea improved, but given the lack of other symptoms of heart failure, her cough may have been the result of a chronic post-nasal drip, as the patient reports cough for many months. . # HYPERTENSION: Given the STEMI, the patient's anti-hypertensive regimen was changed. She was kept on atenolol, since she was already on and toerated that beta-blocker. The patient's HCTZ was stopped, adn lisinopril started at a low dose. . # COUGH, LIKELY SECONDARY TO POST-NASAL DRIP: During the patient's hospitalization, she demonstrated a regular cough. The patient ascribed the cough to post-nasal drip. She was prescribed Flonase.	Mild symmetric left ventricularhypertrophy with preserved global biventricular systolic function. Left pleuraleffusion.Conclusions:The left atrium is mildly dilated. Moderate mitral annularcalcification. Mild (1+) mitral regurgitation is seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Consider lateral myocardialinfarction. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Inferior wall myocardial infarction, age undetermined.Q waves in the lateral precordial leads. Since the previous tracing of ventricular ectopy is nowpresent. Mild mitralregurgitation. Inferior Q waves suggestive of old inferior myocardialinfarction. Sinus rhythm with ventricular premature beat. Coronary artery disease.Height: (in) 60Weight (lb): 170BSA (m2): 1.74 m2BP (mm Hg): 133/55HR (bpm): 58Status: InpatientDate/Time: at 15:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). Since the previous tracing of ST segment elevationin lead V6 is less prominent. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are mildly thickened (?#). Inferoposterolateral myocardial infarction. There is no pericardial effusion.IMPRESSION: Suboptimal image quality. Estimated cardiac index is normal(>=2.5L/min/m2). No resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Increased PCWP.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Compared to the previous tracing of ST segment elevations haveresolved.TRACING #2 There is mild symmetric left ventricularhypertrophy with normal cavity size and global systolic function (LVEF>55%).Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Inferior Q waves persist compared to the previous tracing.TRACING #3 Inferolateral myocardialinfarction with ST-T wave configuration suggesting acute/recent/in evolutionprocess. TissueDoppler imaging suggests an increased left ventricular filling pressure(PCWP>18mmHg). No AS. There is no aortic valvestenosis. The pulmonary arterysystolic pressure could not be determined. No previous tracingavailable for comparison.TRACING #1 No aortic regurgitation is seen. TDI E/e' >15, suggesting PCWP>18mmHg. The mitral valve leaflets aremildly thickened.	6	[ { "category": "Echo", "chartdate": "2126-11-04 00:00:00.000", "description": "Report", "row_id": 77207, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Coronary artery disease.\nHeight: (in) 60\nWeight (lb): 170\nBSA (m2): 1.74 m2\nBP (mm Hg): 133/55\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 15:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Estimated cardiac index is normal\n(>=2.5L/min/m2). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global biventricular systolic function. Mild mitral\nregurgitation. Increased PCWP.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2126-11-02 00:00:00.000", "description": "Report", "row_id": 182178, "text": "Sinus rhythm. Inferior Q waves suggestive of old inferior myocardial\ninfarction. Compared to the previous tracing of ST segment elevations have\nresolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-11-02 00:00:00.000", "description": "Report", "row_id": 182179, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2126-11-05 00:00:00.000", "description": "Report", "row_id": 182175, "text": "Sinus rhythm. Inferior wall myocardial infarction, age undetermined.\nQ waves in the lateral precordial leads. Consider lateral myocardial\ninfarction. Since the previous tracing of ST segment elevation\nin lead V6 is less prominent.\n\n" }, { "category": "ECG", "chartdate": "2126-11-04 00:00:00.000", "description": "Report", "row_id": 182176, "text": "Sinus rhythm with ventricular premature beat. Inferolateral myocardial\ninfarction with ST-T wave configuration suggesting acute/recent/in evolution\nprocess. Since the previous tracing of ventricular ectopy is now\npresent.\n\n" }, { "category": "ECG", "chartdate": "2126-11-03 00:00:00.000", "description": "Report", "row_id": 182177, "text": "Sinus rhythm. Inferior Q waves persist compared to the previous tracing.\nTRACING #3\n\n" } ]
3,023	106,157	He was referred to Dr. of cardiac surgery and was seen and evaluated. The plan was discussed with CMI attending, and it was determined that his benefits would be far greater with bypass grafting. The following morning, on , he underwent coronary artery bypass grafting x 3 with a LIMA to the LAD, a vein graft to the PDA, and a left radial artery to the OM. He was transferred to the cardiothoracic ICU in stable condition on a propofol drip at 40 mcg/kg/min, and Neo-Synephrine drip at 0.5 mcg/kg/min, and a nitroglycerin drip at 0.5 mcg/kg/min for coverage of is radial artery. On postoperative day 1, the patient removed on a Neo- Synephrine drip at 1.5 and nitroglycerin drip at 0.8. He was started on aspirin therapy. He was hemodynamically stable with a postoperative hematocrit of 31.2 and a creatinine of 0.8. He had some sinus tachycardia and some ectopy, but these both normalized by the end of the day. The patient was successfully extubated. He had been started briefly on Levophed, and this was weaned off on postoperative day 2. He began beta blockade with Lopressor and Lasix diuresis. On postoperative day 2, he was transferred out to the floor. He had some sinus tachycardia to 114 with a stable blood pressure. He continued on Lasix diuresis. His beta blockade was increased to 75 p.o. twice a day and then switched over to Toprol XL 100 later that day. His creatinine remained stable. He was saturating 94 percent on room air. He began to work with the nurses and physical therapist. His chest tubes were removed later on postoperative day 3. On postoperative day 4, he had a low-grade temperature overnight. It was 101.2 in the morning. His Toprol was increased to 125 p.o. once a day. He continued to ambulate. Percocet was switched over to Dilaudid, and repeat labs were drawn. He did complain of some pain with movement, and he was instructed on splinting and continued to receive p.o. pain medications. He was alert and oriented, and he was strongly encouraged to use in incentive spirometer and work on pulmonary toilet. His incisions were clean, dry, and intact. On postoperative day 5, he was restarted on his Lipitor. He continued to progress very well and did a level 5 later in the day and was discharged to home with VNA services. He was also seen and evaluated by case management prior to his discharge to VNA services.	MAE SPONT AND TO COMMAND.ID--FEBRILE TO 101. BY THIS AM NOTED W/ EXERTIONAL EXP WHEEZES. PA LINE D/CED.GI--NGT D/CED WITH REMOVAL OF ETT. NTG WEANED OFF AFTER RECEIVING PO IMDUR. REMAINS TACHY AT 110'S. WEANED OFF. PERCOCET GIVEN W/ EFFECT. GIVEN 4U SQ AND GTT OFF. WBC FLAT THIS AM.ASSESS: SEDATE. TITRATE . REMAINS SINUS TACHY TO LOW 100'S (PT FEBRILE EARLY IN SHIFT).RESP: LUNGS INITIALLY CLEAR W/ DIM BASES BILAT. RECEIVED VANCO. PCT/TORADOL/PUL HYGIENE W/ GOOD EFFECT.WBC FLAT.ASSESS: STABLE PM. TO RECHECK BS AT 1600.NEURO--WEANED OFF VENT WITH . TOL PO LIQUIDS THUS FAR. FEBRILE . USING IS TO 1L. LOW DOSE RESUMED FOR BP. SINUS TACH LOW 100'S MUCH OF PM. PERL. TORADOL ADDED TO MED REGIME W/ EFFECT.ID: T MAX 102.3. DENIES NAUSEA. RELIEF OBTAINED.SKIN--CONSTANTLY DIAPHORETIC WITH DECREASE IN BODY TEMP. CTGI/GU: ABD SOFT. CARAFATE/PROTONIX CONT.ID: T MAX TO 38.5->TYLENOL GIVEN, REMAINS 38.1. DID NOT FOLLOW.CV: VS/HEMOS AS PER FLOWSHEET. MUCH PULM TOILET GIVEN WITH USE OF IS. PRESENTLY ON .08MCG/KG/MIN. ALSO C/O OF MOD BACK PAIN, NO RELIEF DESPITE REPOSITION, OOB TO CH. FEBRILE.PLAN: WEAN , DELINE, PULM TOILET, ?TRANSFER 2. PATIENT 'S U/O DRIFITNG DOWN NEED VOLUME VS. ATIVAN 1MG IV AS WELL. CRACKLES RT BASE. WILL LET SERVICE MADE AWARE ON PM ROUNDS. NO DEFICITS.CV: VS AS PER FLOWSHEET. LUE CSM INTACT. Non-specific inferolateral repolarization changes.Non-diagnostic inferior Q waves. PT IS X3. ?D/C SWAN. ABD SOFT. UP FOR BP. NO ISSUES W/ CO. A/V WIRES FUNCTIONING, CHECKED LATE IN SHIFT R/T TACHY.RESP: GOOD ABG THIS. Resp Care: pt continues intubated overnoc and on ventilatory support with simv to abg; bs clear, sxn small amts tan secretions, will wean when awake. DECREASE IN TEMP, MUCH PULM TOILET NEEDED.P--CON'T PULM TOILET. LASIX BEGAN W/ GOOD RESULTS. PULSES INTACT. ATTEMPTING TO WEAN . TEMP DOWN TO 99.0 WITH PULM TOILET.PAIN--MEDICATED X2 WITH 4MG MSO4 SC. SBP 84-120/50'S. USING IS TO 1000CC INDEPENDENTLY. UOP QS W/ GOOD RESPONCE FROM LASIX.PAIN: C/O INCISIONAL PAIN. PATIENT SHAVED/NEW DSD TO CL PLACED.. PT STATES HE IS NOT HUNGRY. DENIES HUNGER. CON'T WITH POST OP PLAN. O2 4L N/C W/ O2 SATS HIGH 90'S. Sinus tachycardia, rate 104. CSRU NURSING PROGRESS NOTE 0700-1500RESP--WEANED AND EXTUBATED. .PLAN: WEAN TO EXTUBATION AS QUICKLY AS POSSIBLE IN AM. csru upadteNEURO: ALERT, ORIENTED. CSRU UPDATENEURO: PT HAS REMAINED SEDATED ON PROPOFOL THROUGHOUT SHHIFT. NTG CONT FOR RAD ART GRAFT. SX FOR MOD THICK TAN SECRETIONS, OCCAS SM, OLD BLD NOTED. SOME COFFEE GRND DNG EARLIER THOUGH APPEARS TO BE CLEARING TO CLEARISH DNG. INTACT. CT TO SX FOR MOD (~40CC/H)SANG DNG, NO AIR LEAKGI/GU: UOP QS VIA FOLEY. BETA BLOCKER. BS WNL NO TREATMENT. MAP >65. O2 SATS 95-99%. WEARING O2 VIA FACE TENT AND ITITIALLY SAO2 90-91%. BILATERAL BREATH SOUNDS ARE COARSE IN ALL FIELDS.CARDIAC-- WEANED OFF. TEAM AWARE. BP UP/DOWN DOES NOT APPEAR TO CORRELATE W/ LEVEL OF SEDATION. PT DOES REMAIN ON FULL VENT SETTINGS AS NOTED, NO CHANGES THIS SHIFT AS OF YET. NO SIGNS OF ETOH WITHDRAWEL. SAO2 NOW 96-97%.PT HAS PRODUCTIVE STRONG COUGH OF TAN/BROWN SPUTUM. ALL INCISIONS WITH DSD INTACT.COPING--FAMILY MEMBERS HAVE PHONED AND HAVE BEEN UPDATED REGARDING CONDITION.A--TOL WEAN. PATIENT EASILY WEANED OFF , ST IN THE 120'S GIVEN TOTAL OF 15MG IV GIVEN WITH TEMPORARILY RESPONSETO 108 -110, TOTAL OF 25MG LOPRESSOR PO GIVEN OVER 2HRS. OFFER SUPPORT TO PT AND FAMILY. TOL SIPS WATER. 500CC LR MD. CHECK RESULT OF LABS. No previous tracing available for comparison. NEURO CONTINUES TO WAKE WITH EXTREME AGITATION THRASHING IN BED PULLING AT LINE MOVING ALL EXTREMETIES DOES FOLLOW SOME COMMANDS BUT REMAINS AGITATED DESPITE AT .6MCGS AND PROPOFOL AT 30MCGS MS FOR POSSIBLE PAIN AS SOURCE OF AGITATION WITH NO EFFECTC/V SR TO ST WITH NO FURTHER ECT HR DROP FOR 90S TO 60S WITH MD OFF PROPOFOL MAINTAINED FOR SEDATION B/P STABLE LOW DOSE NEO NITRO MAINTAINEDRESP VENT UNCHANGED SATS 97% 40% FIO2 LUNGS CLEAR CHEST TUBES SMALL AMTS SANG DRAINAGEGU/GI ABD SOFT CARAFATE AND PROTONIX FOR COFFEE GROUND MATERIAL VIA O/G ADEQUATE URINES VOLUMES REPLACEDPLAN MAINTAIN SEDATION TONOC WITH VERY GRADUAL DECREASE TO EXTUBATE IN AM PLEASANT, COOPERATIVE,INQUISITIVE AND ASKING QUESTIONS. HYPOACTIVE BS.GU--FOLEY CATH PATENT DRAINING >50 CC HR OF CLEAR YELLOW URINE.ENDO--INSULIN GTT WEANED OFF FROM 2U HR. DID BECOME RESTLESS ON 60MCQ/K OF PROPOFOL, NOTED TO MAE IN BED. STRONG COUGH PRODUCTIVE OF THICK YELLOW SECRETIONS. HE STATES THAT HE HAD BROWN PHLEGM BEFORE THE SURGERY AND TOLD INTAKE RN HE HAD THIS.	8	[ { "category": "ECG", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 193257, "text": "Sinus tachycardia, rate 104. Non-specific inferolateral repolarization changes.\nNon-diagnostic inferior Q waves. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 1301203, "text": "47 Y/O PMH HTN HIGH CHOLESTEROL ETOH/SMOKES 6/DAY ADMITTED FROM OR POST CABG X3 WITH L RADIAL ARTERY HARVEST PATIENT ALLERGIC TO SHELLFISH\n\nNEURO SEDATED ON PROPOFOL WEANED TO SEDATION ATTEMPTS TO WEAN OFF PROPOFOL WITH DIFFICULTY PATIENT WAKES THRASHING IN BED MOVES ALL EXTREMETIES BUT NOT TO COMMANDS PULLING ON LINES AND TUBES LIFTING SELF UP OFF BED MS FOR PAIN WITH LITTLE EFFECT PRECEDEX STARTED AT .4MCG AND PROPOFOL DECREASED TO 40MCGS WITH WAKING WITH CONTINUED AGITATION LIFTING UP OFF BED PRECEDEX INCREASED TO .5MCG WITH NO EFFECT PRECEDEX CURRENTLY AT .6MCGS WITH PROPOFOL DOWN TO 25MCGS TOL WELL\n\nC/V ST WITH FREQ PVCS COUPLETS SOME 3 BEAT RUNS ON ARRIVAL TO CSRU MAG INFUSING K REPLACED INCREASED VOLUME GIVEN WITH GOOD RESULTS HR DECREASED TO 92-106 NO FURTHER ECT CVP 12-15 B/P MAINTAINED WITH NEO TITRATED AS NEEDED NITRO MAINTAINED AT .5MCGS FOR RADIAL ARTERY GRAFT\nEPI WIRES INTACT FUNCTIONAL AWIRES CI > 2 PALP PULSES\n\nRESP VENT MAINTAINED ABG WITH PH 7.33 TO REASSESS RESP INCREASED RR TO 10 SUCTIONED FOR SMALL AMT THICK LUNGS SOME COARSE SOUNDS UPPER CHEST TUBES WITH MOD AMTS SANG DRAINAGE INCREASED WITH AGITATION SATS 98-100%\n\nGU/GI ABD SOFT UNABLE TO HEAR BOWEL SOUNDS OG DRAINAGE MOD AMTS COFFEE GROUND MATERIAL CARAFATE GIVEN PROTONIX STARTED LARGE AMTS URINE OUT REPLACED WITH VOLUME\n\nPLAN ATTEMPT TO ACHIEVE CONTROL OF AGITATION WITH PRECEDEX AND WEAN TO EXTUBATE\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301207, "text": "CSRU NURSING PROGRESS NOTE 0700-1500\nRESP--WEANED AND EXTUBATED. WEARING O2 VIA FACE TENT AND ITITIALLY SAO2 90-91%. MUCH PULM TOILET GIVEN WITH USE OF IS. SAO2 NOW 96-97%.PT HAS PRODUCTIVE STRONG COUGH OF TAN/BROWN SPUTUM. HE STATES THAT HE HAD BROWN PHLEGM BEFORE THE SURGERY AND TOLD INTAKE RN HE HAD THIS. USING IS TO 1L. BILATERAL BREATH SOUNDS ARE COARSE IN ALL FIELDS.\n\nCARDIAC-- WEANED OFF. NTG WEANED OFF AFTER RECEIVING PO IMDUR. REMAINS TACHY AT 110'S. SBP 84-120/50'S. ATTEMPTING TO WEAN . PRESENTLY ON .08MCG/KG/MIN. MAP >65. PA LINE D/CED.\n\nGI--NGT D/CED WITH REMOVAL OF ETT. TOL SIPS WATER. PT STATES HE IS NOT HUNGRY. HYPOACTIVE BS.\n\nGU--FOLEY CATH PATENT DRAINING >50 CC HR OF CLEAR YELLOW URINE.\n\nENDO--INSULIN GTT WEANED OFF FROM 2U HR. GIVEN 4U SQ AND GTT OFF. TO RECHECK BS AT 1600.\n\nNEURO--WEANED OFF VENT WITH . WEANED OFF. PT IS X3. PLEASANT, COOPERATIVE,INQUISITIVE AND ASKING QUESTIONS. NO SIGNS OF ETOH WITHDRAWEL. MAE SPONT AND TO COMMAND.\n\nID--FEBRILE TO 101. RECEIVED VANCO. TEMP DOWN TO 99.0 WITH PULM TOILET.\n\nPAIN--MEDICATED X2 WITH 4MG MSO4 SC. RELIEF OBTAINED.\n\nSKIN--CONSTANTLY DIAPHORETIC WITH DECREASE IN BODY TEMP. INTACT. PULSES INTACT. ALL INCISIONS WITH DSD INTACT.\n\nCOPING--FAMILY MEMBERS HAVE PHONED AND HAVE BEEN UPDATED REGARDING CONDITION.\n\nA--TOL WEAN. DECREASE IN TEMP, MUCH PULM TOILET NEEDED.\n\nP--CON'T PULM TOILET. CHECK RESULT OF LABS. OFFER SUPPORT TO PT AND FAMILY. CON'T WITH POST OP PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301208, "text": "PATIENT EASILY WEANED OFF , ST IN THE 120'S GIVEN TOTAL OF 15MG IV GIVEN WITH TEMPORARILY RESPONSETO 108 -110, TOTAL OF 25MG LOPRESSOR PO GIVEN OVER 2HRS. ATIVAN 1MG IV AS WELL. PATIENT 'S U/O DRIFITNG DOWN NEED VOLUME VS. BETA BLOCKER. WILL LET SERVICE MADE AWARE ON PM ROUNDS. BS WNL NO TREATMENT. PATIENT SHAVED/NEW DSD TO CL PLACED..\n" }, { "category": "Nursing/other", "chartdate": "2132-02-16 00:00:00.000", "description": "Report", "row_id": 1301209, "text": "csru upadte\nNEURO: ALERT, ORIENTED. NO DEFICITS.\n\nCV: VS AS PER FLOWSHEET. LOW DOSE RESUMED FOR BP. LASIX BEGAN W/ GOOD RESULTS. REMAINS SINUS TACHY TO LOW 100'S (PT FEBRILE EARLY IN SHIFT).\n\nRESP: LUNGS INITIALLY CLEAR W/ DIM BASES BILAT. BY THIS AM NOTED W/ EXERTIONAL EXP WHEEZES. CRACKLES RT BASE. STRONG COUGH PRODUCTIVE OF THICK YELLOW SECRETIONS. USING IS TO 1000CC INDEPENDENTLY. O2 4L N/C W/ O2 SATS HIGH 90'S. CT\n\nGI/GU: ABD SOFT. DENIES NAUSEA. TOL PO LIQUIDS THUS FAR. DENIES HUNGER. UOP QS W/ GOOD RESPONCE FROM LASIX.\n\nPAIN: C/O INCISIONAL PAIN. PERCOCET GIVEN W/ EFFECT. ALSO C/O OF MOD BACK PAIN, NO RELIEF DESPITE REPOSITION, OOB TO CH. TORADOL ADDED TO MED REGIME W/ EFFECT.\n\nID: T MAX 102.3. TEAM AWARE. PCT/TORADOL/PUL HYGIENE W/ GOOD EFFECT.\nWBC FLAT.\n\nASSESS: STABLE PM. FEBRILE.\n\nPLAN: WEAN , DELINE, PULM TOILET, ?TRANSFER 2.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 1301204, "text": "NEURO CONTINUES TO WAKE WITH EXTREME AGITATION THRASHING IN BED PULLING AT LINE MOVING ALL EXTREMETIES DOES FOLLOW SOME COMMANDS BUT REMAINS AGITATED DESPITE AT .6MCGS AND PROPOFOL AT 30MCGS MS FOR POSSIBLE PAIN AS SOURCE OF AGITATION WITH NO EFFECT\n\nC/V SR TO ST WITH NO FURTHER ECT HR DROP FOR 90S TO 60S WITH MD OFF PROPOFOL MAINTAINED FOR SEDATION B/P STABLE LOW DOSE NEO NITRO MAINTAINED\n\nRESP VENT UNCHANGED SATS 97% 40% FIO2 LUNGS CLEAR CHEST TUBES SMALL AMTS SANG DRAINAGE\n\nGU/GI ABD SOFT CARAFATE AND PROTONIX FOR COFFEE GROUND MATERIAL VIA O/G ADEQUATE URINES VOLUMES REPLACED\n\nPLAN MAINTAIN SEDATION TONOC WITH VERY GRADUAL DECREASE TO EXTUBATE IN AM\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301205, "text": "CSRU UPDATE\nNEURO: PT HAS REMAINED SEDATED ON PROPOFOL THROUGHOUT SHHIFT. PERL. DID BECOME RESTLESS ON 60MCQ/K OF PROPOFOL, NOTED TO MAE IN BED. DID NOT FOLLOW.\n\nCV: VS/HEMOS AS PER FLOWSHEET. SINUS TACH LOW 100'S MUCH OF PM. 500CC LR MD. UP FOR BP. BP UP/DOWN DOES NOT APPEAR TO CORRELATE W/ LEVEL OF SEDATION. NTG CONT FOR RAD ART GRAFT. LUE CSM INTACT. NO ISSUES W/ CO. A/V WIRES FUNCTIONING, CHECKED LATE IN SHIFT R/T TACHY.\n\nRESP: GOOD ABG THIS. PT DOES REMAIN ON FULL VENT SETTINGS AS NOTED, NO CHANGES THIS SHIFT AS OF YET. O2 SATS 95-99%. SX FOR MOD THICK TAN SECRETIONS, OCCAS SM, OLD BLD NOTED. CT TO SX FOR MOD (~40CC/H)SANG DNG, NO AIR LEAK\n\nGI/GU: UOP QS VIA FOLEY. ABD SOFT. SOME COFFEE GRND DNG EARLIER THOUGH APPEARS TO BE CLEARING TO CLEARISH DNG. CARAFATE/PROTONIX CONT.\n\nID: T MAX TO 38.5->TYLENOL GIVEN, REMAINS 38.1. WBC FLAT THIS AM.\n\nASSESS: SEDATE. FEBRILE . .\n\nPLAN: WEAN TO EXTUBATION AS QUICKLY AS POSSIBLE IN AM. TITRATE . ?D/C SWAN.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301206, "text": "Resp Care: pt continues intubated overnoc and on ventilatory support with simv to abg; bs clear, sxn small amts tan secretions, will wean when awake.\n" } ]
26,702	125,308	While on floor, pt experienced hypercarbic respiratory failure of unknown etiology, was intubated and transferred to the -ICU on . hospital course: 1.) Respiratory Failure: Initially thought to flash pulmonary edema of ?etiology (no hx of CHF) and pt was treated initially for ?CHF with diuresis with ethacrynic acid (distant hx of sulfa allergy - therefore intially lasix was not used), also treated for ?COPD with steroids. Immediate complications included excessive bloody secretions, thought likely traumatic intubation, which was managed with holding anticoagulation and frequent suctioning. During this time CXR was showing improvement and differential diagnosis included 1.) flash pulmonary edema norpace for AFib (therefore norpace d/ced) or MR (ECHO had demonstrated 1+ MR) - attempted treatment of pulmonary edema included diuresis without improvement 2.) Chemical pneumonitis 2/2 blood from traumatic intubation, although did not clear with time 3.) Viral pneumonia 4.) Pulmonary/Renal process - thought of as a possibility bloody secretions (although more likely contributed bloody secretions to traumatic intubation) - r/o w/ negative ANCA, negative U/A for blood. Pulmonary embolism was ruled out on with negative CTA. Respiratory status complicated by worseing lung exam/CXR/oxygenation/fever spike on with sputum cultures sent that grew MRSA - therefore patient experience VAP +MRSA. Was treated with 14 day course of Vancomycin. Subsequent sputum culture was + for pseudomonas and patient was treated w/ Genatmicin x 2 days, switched to Merapenem after sensitivities returned. Further complication of patients respiratory status was fluid overload, as patient remained >10L positive throughout length of stay. Fluid removal with diuresis (ethacrynic acid and later lasix) was not effective due to patient's developed ARF during hospital stay. CVVH was started with gentle fluid removal as patient's blood pressure tolerated (as patient was on levophed pressors for BP support). Attempts made at vent weaning were met with decrease paO2 or respiratory acidosis on ABG - therefore, patient was maintained with as low FiO2 and PEEP as ABG would tolerate. Patient's breathing became completely ventilator-dependent, and decision was made by family to not withdraw care but to keep patient comfortable. 2.) ID: As mentioned above, patient suffered from VAP +MRSA from sputum cx and treated with 14 day course of Vancomycin. Also with subsequent sputum cx +pseudomonas and treated with gentamicin->merapenem. Other infections include repeatedly +urine cx for yeast = albicans, treated with 7 day course fluconizole. Also C. Diff+ and treated with flagyl. Blood cxs remained negative throughout hospital course. Maintnance LFTs sent in ICU to r/o obstruction and were negative. Sacral Decub ulcer was checked daily without signs of infection. Patient defervesced and antibiotics were withdrawn when course was completed. Once patient became completely ventilator-dependent and it was realized that all medical efforts would be futile, no further antibiotics were administered, and patient was kept comfortable on ventilator per wish of family. 3.) Hypotension: Pt with hypotension on initial presentation to ICU, initially responsive to fluid boluses. With fever spike/septic picture on hypotension returned requiring pressor support. Initially started on dopamine (as patient was bradycardic), but then became tachycardic w/ afib/flutter - therefore pressor was changed to levophed with good HR control. Wean was attempted, but was not successful, especially after starting CVVH with fluid removal, and patient remained on levophed pressor for BP support. Due to hypotension, patient received significant amount of fluids. Pressors were discontinued along with all non-essential medications once family decision was made to keep patient comfortable but not withdraw mechanical ventilation. 4.) AFlutter: Pt with history of AFlutter s/p ablation - returned to Aflutter on floor w/ HR into 90's. Initially placed on Procainimide gtt then to standing dose Procainimide - however, pt experienced hypotension, and among other interventions, procainimide d/ced and amiodarone started. During this time, pt became bradycardic and was becoming septic - therefore, all anti-arrythmics were held throughout rest of hospital course, and pt remained in AFib/Flutter, but with good HR control (80's-100). 5.) Acute Renal Failure: Pt developed acute renal failure, likely contrast induced ATN after CTA/Abd CT on . Creatinine increased (max=2.4) and she became oliguric. CVVH was eventually started fluid overload and unresponsiveness to lasix, and levophed was titrated up to allow more fluid removal from CVVH. Creatinine and urine output slightly improved on CVVH. After 3-5 days on CVVH, machine clotted and Lasix gtt was tried instead for fluid removal - successful in increasing UOP to 30-110cc/hr, but pt w/ net positive fluid balance over 24 hours, and after 24 hours on Lasix gtt, experienced increased Cr (0.9->->1.4) and decreased response to lasix even w/ titrating up drip (UOP=30-40cc/hr) - therefore switched back to CVVH. CVVH was discontinued, and patient continued to remain hypotensive. Within this time period, decision was made to remove all non-essential and non-comfrot medications/procedures, CVVH being one of them. 6.) Anemia: Pt with repeatedly decreased HCt requiring blood transfusions (average units pRBC/week) throughout hospital course. Thought to be acute illness + blood loss from traumatic intubation w/ continued bloody secretions + frequent blood draws for labs. More acute bleed (such as abd/retroperitoneal bleed) r/0 with negative Abdominal CT . No other signs of blood collection/hemorrhage noted (no gross GI bleed, no large hematomas, etc.). HCt monitored throughout stay until patient's status was changed to comfort care with mechanical ventilation. 7.) Abdominal distension: Pt with stable abdominal distension throughout stay. Likely constipation from the sedation medication (fentanyl and versed) - treated with Lactulose PRN. Subsequently likely C. Diff treated with flagyl. Abd hemorrhage r/o w/ negative abd CT . Exam monitored without significant change, though patient was heavily sedated and comatose during the last several weeks of her hospital course. 8.) DM: Patient maintained on Insulin gtt throughout initial ICU stay for goal BS control 80-110 in setting of acute illness. Changed to ISS and standing dose long insulin with poor BS control - therefore changed back to Insulin gtt along w/ standing dose of long-acting insulin with good BS control. Once decision was made to withdraw non-essential medications and keep patient comfortable, insulin gtt was discontinued. 9.) FEN: Pt maintained on tube feeds per NG tube -> changed to OG tube per nutrition recommendations. Patient was having high residuals once comfort measures were instituted, tube feeds were then discontinued. 10.) Prophylaxis: Pt maintained on PPI, SC heparin until comfort only with mechanical ventilation measures instituted. 11.) Communication: With husband and 2 sons throughout hospital course. 12.) Numerous conversations concerning prognosis, code status were discussed throughout stay, and family was updated on patient's condition daily. Family discussion w/ husband and rabbi to explain medical condition of patient. Family decision = full intervention. Ethics involved as medical condition without change and still with poor prognosis per ICU team x past 3-4wks. At family meeting on Monday, with Dr. , pt's husband, 2 sons on phone, the futility of further intervention was discussed. Patient's family had extensive discussions with home rabbi and hospital rabbi, and eventually decision was reached to not withdraw care (i.e. ventilator) but to only institute measures that would keep patient comfortable. Patient was maintained on mechanical ventilation and sedation for several more weeks, with further discussions with the family and ethics. It was felt by the ICU team that maintaining patient on ventilator without any improvement, and rather, decline, was harming the patient. Ethics was re-consulted, and a family meeting had been planned. However, prior to the meeting, patient's BP began to decline further and oxygen saturation dropped, and patient expired on .	ABGS CONSISTENT WITH SLIGHT RESP. pt tolerating CVVHD. with A-fib with HR 70-120. Resp CarePt. softly distended with hypoactive BS.GU: Foley cath in place. Latest ABG's pH 7.42, PCO2 33, PaO2 91. on Levophed gtt at 0.015mcg/kr/min maintaining ABP 100-130/50-60. resp. Administering Albuterol and Atrovent MDI's in line with vent ~Q2hrs. NPNNEURO: Pt. Abd soft distended, BS hypoactive. remains DNR. sacral decub still with duoderm in place. made DNR this PM. Generalized edema and weaping.GU: Lasix gtt at 7cc/hr. Followup abg 7.34/47/140/26. remains on IV sedation Versed 9mg/hr and Fentanyl 300mcg/hr. BUN 52, creat 1.5 this AM.GI: Abd distended and firm. will continue with present vent settings.gi: pt still not receiving tube fdgs b/cause of high residuals. slight weeping from upper extremities.resp: remains on same vent settings- see events. T-Max 99-100.Resp: Remains intubated. Resp Care Note:Pt intub with OETT and on vent as per Carevue. abd remains distended with absent bowel sounds on asucultation.gu: foley cath in place with minimal up throughout the day- <30cc's this shift. remains DNR/DNI. BS hypoactive and TF on hold after Pt. Settles out when left alone.UO 0-10 cc hr. Remains on CVVHD,vent changed order so Ric can PM it.Poor prognosis,hypoxemic,sensitive to FI02 changes.BS coarse withR>L,on MDI Albuterol/Atrovent. Sons & also phoned & were updatedPt remains CPR not indicatedA/P: Stable on above vent settings. Smicu nsg progress noteS/O- essentually unresponsive on fent/versed gtt. No VEA noted.Cont on CVVH. Smicu nsg progress noteS/O- to be unresponsive on fent/versed gtts. (Do not increase levo to maintain hrly neg balance)Apears adequately sedated on fent & versed.Support to family distended and soft, BS hypoactive.GU: Pt. last glu 199 at 1230 and covered.ID: afebrile with fluconozole added to regimen. course bs with exp wheezes throughout. RESPIRATORY CARE: PT W/ A 7.0 ORAL ETT IN PLACE.REMAINS ON PCV AS PER CV. No spontaneous movement noted.CV: Tmax 100.0 axillary. ABD FIRMLY DISTENDED WITH ABSENT BS. Cardiac: HR 90-100's afib, rare PVC's cont on levo, titrated to keep SBP>90/ range tonight has been 0.808mcg/kg/min to 0.55. presently on 0.55mcg/kg/min. progress note:Neuro: remains sedated on fent 75 mcg and midaz 2 mg with PERL sluggish. Albuterol/Atrovent MDI's given Q4hr. MD aware.Gi/GU: PT remains oliguric. ALBUTEROL AND ATROVENT MDI'S GIVEN.WILL C/W VENTILATORY SUPPORT. Tolerating PO2 of >60.ID: Hypothermic at 96 axillary. sacral decub with douderm in place. sacral decub with douderm . mdi's given q4h and prn. repeat ABG pnd. remains edeamtous, LOS is still + ll liters. anascara, oozing from prevous puctures. Resp CarePt. Respiratory CarePt weaned today changed mode to A/C 450/22/peep14/40% last abg734/34/96/19/-6 pt bld. Administering Albuterol and Atrovent MDI's in line w/ vent, see flowsheet for rx times. 7cc urine output noted.Skin: Duoderm remains on . sedated on Versed 1mg/hr and fentanyl 50,cg/hr. LS COURSE AND DIMINSHED BILAT.GI/GU: TF ON HOLD SECONDARY GROSS AMOUNTS OF RESIDUAL. Douderm over sacral decub. FOLEY CATH WITH NO OUT-PUT.SKIN: DUODERM CHANGED TODAY. BS ansent. remains NPO d/t increased residuals. RESP CARE:Pt remains intubated with 7.0ETT/on vent on settings per carevue. Albuterol and Atrovent MDI given Q vent check. Changed .Access: R IJ Dialysis cath / L IJ TL Central line.Plan: Pt. NPNNeuro: Pt. GU: foley in place and draining. Albuterol/Atrovent MDI's given Q4hr. BS insp/expri wheezes on the right. Hypoactive bowels sds. Albuterol/ Atrovent MDI Q vent check. r/t fluid status. LEFT BRISK.GU: FOLEY CATH PATENT, HAD BEEN REPLACED DURING SHIFT, THE FOLEY PT ARRIVED WITH WAS NOTED TO BE OUT. Sacral decub with duoderm dsg c/d/i. Cardiac: remains on Levophed to maintain SBP>90 attempted to wean to off and SBP dropped to low of 82/ back on levophed at the original dose...0.03mcg/kg/min. HSV vs trauma.Continues on Levophed. Able to wean levo from .07mcg/kg to .03mcg/kg. GI: abd distended. MSICU NPN 0700-1900Please see flowsheet for further details...Remains sedated on Fentanyl and versed gtt. 1 interruption in therapy d/t clotted filter. remains DNR/. Otherwise .Access: R IJ Dialysis cath, L IJ central line.Plan: Pt. remains sedated with versed/fentanyl. ABG=7.39/28/94/-. Foley cath w/ << u/o - 0-30cc/hr. Miscellaneous (not measured) output of mod-lg amt of PO secretions as well as mod-lg amt of serosanguinous drainage from around L SC. Is now being ultrafiltrated only. Hypoactive bowel sds. remains NPO.GU: Pt. A-line dc'd..following with NBP More tachycardic..?d/t fever.. ID: Febrile..given tylenol GI: TF continue..no stool.. GU: Poor u/o..<10cc hr. opens eyes to suctioning and repositioning, otherwise no movement noted.cv: hr ranging 70s-low 100s afib with occas pvcs in pm. Levophed gtt weaned off. Will hold on gtt and cover with s/s and fixed dose glargine in pm. Smicu nsg progress noteNeuro- Well sedated on 170mcg/hr fent and 5mg/hr versed. Pt has become hypotensive in past when levo d/c'd.Resp- Intub/vented. Weaned off Levophed.ROS:NEURO: Pt remains sedated on Fentanyl and Versed gtts; rates increased d/t pt appearing uncomfortable. Remains in afib with occasional PVC's. secreations minimal this shift.abgs:ess. wheezes tx'd with mdis as ordered. GI: abd distend, +BS sounds, stool x 1 mod amount. Remains on .03mcg/kg/min levofed with BP 110's-120's/40's. Suctioned for minimal clear secretions.GI: Abd firm with edema, +BS's. remains NPO d/t absent BS and increased residuals. Responds fairly to some supplemental bolusing.CV: HR 70's-90's, Afib with occassional PAC. is now CPRNI. settings titrated per abgs, again with worsened oxygenation although stable on vent today d/t incr.sedation level. Resp CarePt. Resp CarePt. Turned and repositioned as tolerated. Stable left groin bowel containing hernia. There is a minimally increased gradient consistentwith minimal aortic valve stenosis. Normal ascending aorta diameter.AORTIC VALVE: Aortic valve not well seen. Trivial MR.TRICUSPID VALVE: Mild [1+] TR. Bilateral patchy infiltration involving both lungs and left pleural effusion are again noted, unchanged. Extremities stiff.Cont on CVVH. Trivial mitral regurgitationis seen. Stable mild intrahepatic biliary ductal prominence. Cont with very little uo 0-10cc/hr. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. There is aminimally increased gradient consistent with minimal aortic valve stenosis.Mild (1+) aortic regurgitation is seen. Mild mitral annularcalcification. There is mild pulmonary artery systolichypertension. Mild pulmonary hypertension is now detected. IMPRESSION: 1) Endotracheal tube and nasogastric tube in stable position. Right ventricular chamber size and free wall motion arenormal. Sinus bradycardiaBorderline first degree A-V blockPoor R wave progression - probable normal variantSince previous tracing of , no significant change MildPA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated.	237	[ { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611730, "text": "NPN 0700-1900\n\nNeuro: Remains on same dose of sedation: fent/versed 50/1. Opens eyes spontaneously, moving L arm up to face, other extremities are stiff; ocassionally answers yes or no questions by nodding or shaking head; denies having pain; PERRL.\nCV: ABP 111-155/43-57 with maps 57-82, no pressors required, BP increases with any stimulation; HR 69-95, NSR, no ectopy; CVP 10-14; 3+ generalized body edema, L leg is bigger than R.\nResp: Vent settings unchanged, 500X20X.5X8; suctioned q 1-2hrs for large amts brownish red sputum; has a good cough; lung sounds are coarse throughout; O2sats 97-100%.\nGI/FEN: Abdomen obese, slightly firm; TF thru NGT nepro at 40/hr tolerated well with no residuals; no stools during the night.\nGU: Foley catheter draining 20-35cc/hr yellow urine with sediment; fluid status is presently +68.5, LOS +8816.\nEndo: FSBG 102-135; insulin gtt has been at 2.5 units/hr continuously.\nID: Tmax 99.3; wbc 15.4; remains on aztreonam.\nAccess: A-line L radial; multi-lumen L subclavian; R subclavian dialysis catheter.\nSkin: Duoderm on remains ; no other breakdown.\nPlan: Continue to monitor resp status, wean vent and sedation as tolerated, aggressive pulmonary toilet; monitor hemodynamic status, administer pressors as needed; monitor fluid/electrolyte status, replete prn; skin care as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611731, "text": "Respiratory Care Note:\n Patient remains intubated and ventilated. Suctioned for moderate amounts of thick blood tinged, tan sputum. BS are coarse t/o. WBC >15. She remains >+9Kg up in volume. See Carevue flowsheet for specifics. FIO2 weaned with SaO2>97%. Patient has #7.0 ET tube with cuff pressure 28cm for minimal occlussive pressure. Mouth with lots of ulcerations and patient does not like to have her mouth suctioned. Plan to maintain supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611732, "text": "MSICU NPN 0700-1900\n\n\nplease see flowsheet for further details...\n\nNo change in sedation. Easily arousable. Does not follow commands.Grimaces with turning and becomes hypertensive which resolves with cessation of activity.\n\nFiO2 decreased to 40%. No other changes. Sputum less bloody today. ABG unchanged.\n\nAfebrile. UO remains ~20cc/hr. Foley changed d/t yeast in urine. Currently leaking mod amt and balloon filled more.\n\n dsd changed by skin care RN.\n\nTol TFs at goal of 35cc/hr. No stool.\n\nHusband in most of day. Both sons called.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611789, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnoc. Sxing thick pale yellow secretions. BS's diminished, no wheezing heard. Administering Albuterol and Atrovent MDI's in line with vent. See flowsheet for data and rx times. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611790, "text": "Respiratory Care Note\nPt received on AC as noted. BS diminished throughout; Pt suctioned for mod amts thick secretions; MDI's given; BS increased aeration with expiratory wheezes bilat. IMV weaned and PEEP increased according to ABG's. Pt vomited and aspirated RN who suctioned tube feeding from ETT. Plan to remain on current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611747, "text": "RESP CARE: PT REMAINS INTUBATED WITH 7.0ETT/ON VENT ON SETTINGS PER CAREVUE. NO CHANGES OVERNIGHT. LUNGS COARSE BILAT. SXD THICK BLD TINGED SPUTUM. PT BITING ON TUBE AT TIMES. MDIS GIVEN WITH GOOD EFFECT. NO RSBI DUE TO HEMODYNAMIC STATUS. ABGS CONSISTENT WITH SLIGHT RESP. ACIDOSIS. CONTINUE FULL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611748, "text": "Reps Care\n\nPt remains intubated but mode ov ventilation was changed to CPAP/PSV. Pt settings 20/8/50%. Followup abg 7.34/47/140/26. BS remain coarse and suctioning thick blood tinged sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611749, "text": "MICU/SICU NPN ICU day #15\nNo events\nFull code\n\nS/O:\n\nNeuro: pt remains sedated with fentanyl/midazolam, no independednt movement of extremities noted, pupil fixed and nonreactive\n\nPulm: pt remains intubated in PSV 13+5/0.5, last ABG 7.34/47/140, SpO2 100%, LS coarse, dim at bases, Vt 470's, Ve 6.7-9.5\n\nCV: 77-102 AF without notable ectopy, BP 92-131/42-55, CVP 14-15, please see flowsheet for data\n\nInteg: remains anasarcic most notably in extremities, sacral decub dressed with Duoderm, dsg change next due on Tues., old healed venous stasis ulcer on RLE, multiple areas of eccymosis on abdomen and thorax\n\nGI/GU: and is firm and distended, BS present, tolerating Nepro with Promod at goa rate of 35cc/h, LBM , Foley is patent for small amts clear yellow urine\n\nLines: left SC QLCL day #11, left radial art line day #15, right IJ Quenin cath day #9\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT and indwelling catheter\naltered breathing r/t volume overload\nhigh risk for injury cebro/cardiovascular r/t hypotension, pressor requirement\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contniue to wean resp support as tolerated, contninue to wean hemodynamic support as tolerated, schedule family meeting at earliest convenience\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611750, "text": "RESPIRATORY CARE:\n\nPt remains intubated, switched back to AC at 10pm this shift, for worsening acidosis. Pt has been significantly bronchospastic, I:E wheezing noted throughout all lung fields. Administering Albuterol and Atrovent MDI's in line with vent ~Q2hrs. Continue to sx thick brown/bloody secretions. See flowsheet for rx times, further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-25 00:00:00.000", "description": "Report", "row_id": 1611809, "text": "NPN\n\nNeuro: Pt remains on fent and versed, she is very sedated today and rarely opens her eyes to stimulation.Her versed was decrease to 9 mg/hr and her fent to 300 mcg/hr and she remains somulent.\n\nCV: Remains in afib 70s-120s, SBP started to drop this afternoon to to 70s and 80s though she conts to urinate.\n\nResp: Remains on A/C, no changes were made on the vent, sx for thick tan secreations.\n\nGI: Tolerating her TF, no stool today, conts on bowel meds.\n\nGU: U/O 10-20cc/hr\n\nSoc: Husband was in today as was their rabbi, though two along with their son discussed where to head with her care - they will discuss this with us tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611761, "text": "S/MICU Nursing Progress Note\n Respiratory: difficult night sedating pt, biting on ETT, PIP of 40-50's with dropping TV, requiring increasing her sedation... a number of bolused throughout the night. presently is on 170mcg/hr of fentanyl and 5mg/hr of versed. still will bite and PIP's up t50's with any type of stimulation. Have had difficulty with vent, rising CO2 and droping pH. have adjusted her vent accordingly. settings are 500cc/30/60%/12 .... only showing TV of 380cc during the night. suctioning for thick tan to yellow sputum.\n Cardiac: HR 80-90's Afib, rare PVC's, rare couplet. BP 140-170/'s on levo at 0.06mcg/kg/min. have not try to titrate as pt is on CVVHD\n Renal: BUN 96 creat 1.9 restarted CVVHD last evening at 1845. goal is to be -100cc/hr. have slowly increased PFR. pt tolerating CVVHD. temp low was 96 ax. blanket placed on temp now up to 98. have had a number of problems with access pressures. reversed the ports. Pt will still stop the machine with coughing,\n ID: temp max 99 ax. cont on vanco( will need levels before tonight's dose) D7, aztreonam D11( increased the dose last night from 500mg to 1000mg) and po flaygly for +c-diff. WBC this am 18.7\n Skin: oozing from everywhere esp arms. elevated on pillows, bleeding from dialysis cath site and now from triple site. numberous eccymotic areas. hepatic lesions on lips and inner lips, bleeding from those sites. with biting on ETT ...bite block was neccessary. causing more bleeding. sacral decub still with duoderm in place.\n GI: cont on TF of deliver with promod, rate 35cc/hr at goal rate. mushroom catheter in place min stool output.\n Plan: sedation requirements increased but may also be related to dialysis. cont CVVHD with goal to be -100/hr. monitor VS closely.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611829, "text": "NPN:\nNeuro: Pt. remains on IV sedation with Fentanyl and versed. No dose increase this shift.\n\nCV: BP remains low at 50-60's systolic with MAP 30-40's.\n\nResp: LS coarse. Suctioned x2 this shift for moderate amount of thick tan sputum. Unable to do mouth care, Pt. clamping down her teeth. Pt. vented with A/C 450x16 peep of 5 and FiO2 50%.\n\nGI: Tube feeding held again for high residual of bile liquid. MD aware of high residuals and decision made to keep tube feedings off. Residuals greater than amount fed for the past 24 hr. Abd. softly distended with hypoactive BS.\n\nGU: Foley cath in place. Urine output remains low at 5-10cc every 2 hr. Positive for anasarca.\n\nSocial: Pt. remains DNR. Awaiting visit from son who is ariving from in AM. Plan to make Pt. .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611830, "text": "Resp Care\nPt. remains intubated/sedated with no changes overnight.\nBS: coarse bilat. 'd for mod. amts. of thick tan.\nPlan: family meeting once son arrives, to make pt. >\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611831, "text": "Resp Care\n\nP tremains intubated and on full vent support. NO changes made during the shift. BS coarse and suctioning thick tan sputum. Spo2 100%\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611791, "text": "NPN\n\nNeuro: Pt remains on fent and versed, the rates have not been increased but I have given her versed boluses (5-10 mg) for aggitation. She is lighter than she was yesterday but mostly appears comfortable.\n\nCV: Remains on levo, SBP has been 110-130s, HR 70s-80s afib\n\nResp: LS coarse, she vomited TF this morning and TF appearing material was suctioned from her ETT. A CXR showed that her pedi tube is at the GE junction - to be replaced by the team. ABG was 7.50/32/66, the alkolosis is felt to be due to the lasix gtt, her rate was decreased to 16 and PEEP was increased to 12.\n\nGI: Vomited TF as above, pedi tube to be replaced because it is in the GE junction. Her ABD remains firm and distended, reglan and lactulose are now q6hrs, to start on PO narcan to decrease the GI effects of the fent - this should not effect her systemically.\n\nGU: U/O 30-80cc/hr, her lasix rate is now 7mg/hr, K to be checked this afternoon, CVVHD is on hold because of we are able to get fluid off with the lasix.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611792, "text": "NPN\nNeuro; Pt. sedated on Fentanyl 300mcg/hr and Versed 10 mg/hr. Pt. cont. to reuired additional sedation boluses when being turned.\n\nResp: Pt. remains on a Vent A/C 450x16 with FiO2 of 50 and PEEP of 12. Latest ABG's pH 7.42, PCO2 33, PaO2 91. Ls remain coarse but unable to suction any secretions.\n\nCV: Pt. cont. on Levophed gtt at 0.015mcg/kr/min maintaining ABP 100-130/50-60. Cont. with A-fib with HR 70-120. Pt. also on Lasix gtt at 7cc/hr. H/H this AM 9.7/28.8 and stable. MD aware and no new orders at this time. Generalized edema and weaping.\n\nGU: Lasix gtt at 7cc/hr. Urine output anywhere from 27-85cc/hr of clear yellow urine. BUN 67, creat 1.4 this AM and MD aware. Cont. with Lasix gtt. Fluid balance +0.23L for 24hr and +13.7L LOS.\n\nGI: OGT insterted on day shift . Placement checked with CXR and by ascultation. Probalance tube feed restarted at at 10cc/hr. Rate slowely titrated up to 30cc/hr with last increase in dose at 0400. Residual 10cc each time. Goal to increase tube feeding to 35cc/hr. Pt. on insulin gtt at 5units/hr. BS at 97. Insulin rate decreased and then stoppped for BS 84. Lantus insuline held on for BS of 80-90's. Insulin gtt restarted and infusing at 4 units/hr. Cont. to monitor BS q 1 hr. Mushroom cath in placce with no significant BM noted. Pt. on Lactulose q 6 hr till BM.\n\nSocial: Pt. remins full code. Spoke with son who called from . Will update family on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611894, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 40%, and Peep 5. Bs decreased and slightly coarse bilaterally. Sx'd for sm amounts of thick yellow secretions. O2 sats 97-100%. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611895, "text": "resp. care\npt. remains intubated/vented. no vent changes today.\nplan continue support. family meeting tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611896, "text": " ICU nursing progress note:\n Remains intubated and vented.no changes mad. Pt was turned with left side down to clean backside..noted decreased sat and hr..pt was cyanotic..placed on back..hr and sat slowly returned to baseline.\n BP running 50-60/..remains in af.\nTo have family meeting tomorrow at 1400 with ICU team,sons,husband,rabbi,ethics and social service.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611810, "text": "NPN\nNEURO: Pt. remains on IV sedation Versed 9mg/hr and Fentanyl 300mcg/hr. Pt. sedated and does not seem to be in pain.\n\nCV: Pt. remains off levophed gtt. ABP 80's-115/60-80. HR 80's-100's. Pt. remains with anasarca with weeping skin. No labs this AM.\n\nResp: Pt. intubated on vent with A/C 450x16 peep 10 and FIO2 50%. O2 sat 100%. LS coars. Pt. suctioned x2 this shift for moderate amount of thick yellow secretions.\n\nGI: Pt. remains on tube feeding at 35cc/hr. Residuals 10-20cc. Abd soft distended, BS hypoactive. No BM this shift. Mushroom cath in place.\n\nGU; Foley cath in place and draining clear yellow urine 10-15cc/hr. Fluid balance +13.8L LOS and 0.389L 24 hr.\n\nSocial: Pt. made DNR this PM. Will update family on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611811, "text": " 4icu npn 0700-1900\nAt present pt's husband wants to continue vent support and continue \"hydration\". Cont on TF\nNo labs drawn\nCont on fent and versed gtts. All other medications except tylenol d/c'd.\nOpens eyes when turned. otherwise no spont movement. extrem stiff.\nNo vent changes. Scant to small amts white to ligh yellow secretions.\nSBP >90's most of the day with transient drops to low of 76. Bp improves with stimulation\noliguric.\nHusband in to visit most of the shift\nA/P; No sig change in status.\nAppears comfortable on fentanyl & versed gtts.\nCont vent support and TF at present with comfort proirity.\nSupport to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611812, "text": "Respiratory Care:\nPt remains fully ventilated but occasionally adds 1 or 2 extra breaths. The respiratory Meds have all been D/C'd. Still significantly fluid overloaded. The meds that are continuing are for BP support.\nPlease see CareVue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611832, "text": "S/MICU Nursing Progress Note\n Neuro: sedated on fentanyl and versed. not moving still at times biting on ETT unable to do mouth care.... drooling creamy like substance similar to tube feeding( though has not been fed for over 24hours)\n Respiratory: vented, no changes in settings 450/16/50/5. O2 sat 100% suctioning q3-4 hr for thick creamy tan/green sputum\n Cardiac: HR 80-110 afib BP had been 50-60's/ during most of day... after trying to do mouth care, BP up to 100/ and HR up to 115's received bolus of fentanyl 200mcg and 3mg of versed.... then able to do mouth care.\n GI no stool. no BS, abd still distended. aspirates remain high.\n Social: husband and two sons at bedside most of the day... aware of poor hemodynamic. are with DNR/DNI. to the family means still provide hydration/feeding(unable to fed due to high gastric residuals.)\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611833, "text": "Progress Note 7p-7a\nEvents: No change from previous shift.\n\nNeuro: Pt remains sedated with versed and fentanyl. Pupils equal and reactive.\n\nCVS: Pt remained A-Fib throughout shift with HR 80's to low 100's. SBP 60's to 80's. 4+ pitting edema noted. Weeping from extremities. Pulses difficult to palpate. T-Max 99-100.\n\nResp: Remains intubated. Vent settings unchanged at: 450/16/50/5. Coarse breath sounds bilat. Thick tan secretions from mouth. Thick yellow/green secretions from lungs.\n\nGI: OGT in place. Feedings remain on hold d/t absent BS. No BM last night.\n\nGU: Foley cath in place. Minimal urine output.\n\nSkin: decub. ulcer on covered with duoderm. R IJ dialysis cath. L ij TL central line.\n\nPlan: Pt. remains DNR/DNI. Pt.'s family did not agree to . They want nothing withdrawn. Pt. is an Orthodox Jew, therefore if possible the family would like her fed and hydrated as well. Pt. is not having any more blood draws (including blood sugar checks).\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611834, "text": "RESP CARE\nPt. remains intubated on AC mode with no changes made.\nBs: coarse bilat.'d thick yellow x2.\nPlan: DNR/I . to support as is.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611835, "text": "multisystem failure\nd: pt sedated on fentanyl gtt at 375 mcg/hr and versed gtt at 14 mg/hr. pupilsequally reactive to light but sluggish in response. no spontaneous movements to her extremities.\n\ncardiac: hr has been in the 90's without ectopy and sbp 50-60's pt is a dnr but because of the families' religious beliefs they do not want to withdraw care. both pt's husband and 2 sons were at the bedsdie this afternoon and were updated on pt's condition. no labs are being drawn.\n\nresp: pt orally intubated with vent settings of 50%/450/ac 16 with 5 peep and pt not overbreathing the vent. coarse bs bil on auscultation. suctioned orally for thick tan secretions and via ett for sm to mod amts of thick yellow sputum. will continue with present vent settings.\n\ngi: pt still not receiving tube fdgs b/cause of high residuals. abd remains distended with absent bowel sounds on asucultation.\n\ngu: foley cath in place with minimal up throughout the day- <30cc's this shift. pt with 4 + pitting edema and leaking serous fluid from upper extremities. pt not receiving maintenance ivf b/cause of her total body fluid overload and kidney failure. fluid balance pos 17.2 liters fpr los.\n\nid: max temp=99 and not on any antibiotics.\n\nintegumentary: pt turned form side to side throughout htis shift. pt on kinair air mattress. duoderm to decub at site and q 3 day drsg for tomorrow. pt with r ij quintan cath and l ij triple lumen in place.\n\nsocial: pt is dnr/dni but family would like pt to receive nutrition and iv hydration but aware that this is not being done at present time because of high residuals form tube fdg and total boly fluid overload. pt's son and his wife have returned to this afternoon but voiced that they would like to be called if his mother was passing. they were informed that we would place a call to them that they may not make it back to the hospital in time. will continue with present level of care and keep family well informed on pt's status. will offer emotional support to family .\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611726, "text": "MICU/SICU NURSING NOTE 7p-7a:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNEURO: PT remains sedated on Fentanyl/versed. Pt opens eyes to painful stimuli. non-purposeful movement of upper ext. NOt following commands. PT with decreased cough/gag.\n\nCV: PT weaned off Dopamine. BP 105-160/40-70. (Goal MAP > 60). HR 50-80 SB-SR no ectopy. afebrile. Repeat HCT 29.0 after 2 unit PRBC on dayshift for HCt 23.4. + 3 anasarca + pedal pulses bilat. L sub TLC WNL. WHIte port clotted off and tpa administered. Currently infusing without difficulty with good blood return. L rad A-line WNL + waveforem/+blood return. R IJ dialysis cath dsg c/d/i.\n\nPULM: Pt's vent weaned aggressively yesterday. Peep increased from 5 to 8 secondary to paO2 = 65. Pt currently on AC-20 50% TV 500 Peep 8 last abg 7.42/40/107/27. Sats 96-100% lungs reamin coarse t/o suctioning mod amount thick bloody/clots from ETT. MD aware. PT= 13.3 INR= 1.2 ptt= 32.4 Fibrinogen = 351.\n\nGI/GU: Abd soft, NT + BS X 4. no BM overnight. NGT placement confirmed via air bolus. TF increased this morning to 30 cc/hour (GOAL = 40 cc/hour). PT tolerating feedings, minimal residuals noted. Foley draining yellow/cloudy urine with sediment. UO decreased ~ 10-15 cc/hour overnight. Md aware. NO talks of restarting CVVHD. Last creat 1.7.\n\nENDOCRINE: Insulin gtt @ 2.5 units/hour. glucose stable, will cont to follow insulin protocol as ordered.\n\nSKIN: Sacral stage III decub with duoderm c/d/i. Groin/thigh rash red, no open areas noted, miconazole powder applied. R leg ulcer healing/OTA no drainage observed.\nPT bathed. Turned side-to-side as tolerated.\n\nPLAN: Wean vent as tolerated, ANtibiotics, Keep MAPS > 60, Cont TF advance as tolerated to goal rate 40cc/hour, cont to check BS q 2 hours titrate insulin as needed, wound care, monitor labs replete as needed. Will cont to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611727, "text": "Respiratory Care\nPt's 1100 and 1400 data recorded on careview after system became up and running. Paper flow sheet kept unti that time.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-18 00:00:00.000", "description": "Report", "row_id": 1611897, "text": "micu/sicu nsg note: 19:00-7:00\nevents: remains intubated and vented with no change in vent settings. appears comfortable on fent. and versed gtts. desats to the high 80s on fi02 40%, tidal volume 450, rr 16, peep 5 with audible cuff leak and ? hole in tubing of cuff. tegaderm noted to be on part of the tubing of the cuff- ? there was a hole with air leaking. air replaced into cuff by resp but pt continues with intermittent air leaks. continues to have moderate green thick secretions suctioned from her ett. sp02 up to 93% after air inserted into the cuff by resp.\n\nneuro: remains unresponsive with no grimacing noted. appears comfortable on 500mg/hr fentanyl and 15mg/hr versed. no movement noted.\n\ncv: hr ranging 90s-100s afib, bp 30s-60s/20s-40s. generalized anasarca. slight weeping from upper extremities.\n\nresp: remains on same vent settings- see events. 'd moderate amts green thick sputum. mouth care given.\n\ngi/gu: abd obese, remains npo, no bowel sounds. rectal tube remains in with lbm . no bm overnight. foley patent with minimal urine- only 5cc the whole shift of brown thick colored urine.\n\nskin: stage 2 5x4cm unchanged. area cleansed with soap and water. left ota as all dsgs do not stay on area. aloe vesta applied to site.\n\nsocial: has 2 sons and husband involved in care. pt's husband is \"not ready to let go\" per sw note. family meeting is planned for today with and ethics team involved.\n\nlines: l ij patent- dsg changed as the other dsg was peeling off. r ij dialysis catheter .\n\nplan: continue vent settings as ordered. maintain comfort for pt with fent and versed gtt. family meeting today to discuss pt's plan.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-18 00:00:00.000", "description": "Report", "row_id": 1611898, "text": "micu/sicu nsg note: 19:00-6:15am addendum\npt having runs of vtach progressing in length and having low minute ventilations with low tidal volumes with audible cuff leak despite air inserted. md aware. comfort maintained with 5cc fentanyl bolus given x2 when pt appeared to have a slight grimace. at 6:05am pt found pulseless and breathless with no obtainable 02 sat. md notified and pronounced pt at 6:15am. md notified pt's 2 sons and sons to notify pt's husband. rn remained and remains at bedside with pt. family to come in to see pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611728, "text": "MSICU NPN 0700-1900\n\nplease see flowsheet (careview and paper flowsheet) for further details....\n\n\nRemains on Fentanyl and Versed gtts. No changes made. Opens eyes to stimuli. Does not follow commands. Grimaces when mouth care attempted (will not open mouth). Sleeps when undisturbed.\n\nDopamine gtt at 2mcg/kg/hr. Weaned to 1mcg but MAP dropped to 50s and UO dropped (from ~35-20). Increased to 2mcg for most of day with no improvement in UO. Weaned off at 1730. HR 60-70s NSR. CVP 13.\n\nSame vent settings. PEEP decreased to 5cm from 8cm but PaO2 dropped to 66 and PEEP inc to 8cm. Suctioned q 2h-3hrs for tenacious bloody sputum. Sputum appears more brown this afternoon. Min spont RR.\n\nAfebrile.\n\n dsd dry and . Skin RN to come back tomorrow. Plan to change dsd then. Supplies ordered. Mouth w/multiple sores. Frequent lip care given including area above ETT. Scabs beginning to fall off.\n\nCreat up to 1.9. Renal team in. CRRT remains on hold for now.\n\nHusband in. Spoke with Dr. and Social Worker.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611729, "text": "Resp Care\nPt. remains intubated/sedated overnight with no vent changes or abgs.\nBs: coarse bilat. with scattered exp. wheezes. Sxn'd for copious amts. of thick blood q4.\nPlan:continue current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611785, "text": "NPN\n\nNeuro: Conts on 300mcg/hr of fent and 10 mg/hr of versed, she is less sedated than Sun when I last took care of her on Sunday. She opens her eyes with turning, suctioning, moving the ETT, she requires ~ 10 mg of versed and sometimes 150-300 mcg of fent to resedate her. She does not move any of her extremities, her body conts to be very stiff.\n\nCV: She conts of levo at .03 mcg/kg/min, her BP droped to the 90s-100s this morning after the CVVHDF clotted off - this has not been restarted do to her lower BP. Given K this morning for a K of 3.6.\n\nResp: Remains on A/C 450x18/ .5/10 PEEP with an 7.45/37/66, sx for min amount of yellow/tan colored sputum, LS diminished, conts to bleed from her mouth/lips.\n\nGI: ABD remains firm and distended, she was given lactulose, no stool out today, conts on TF at her goal rate of 35cc/hr.\n\nGU: Her CVVHDF clotted off this morning, her BP has since been 90s-100s and she has not been restarted, the team would like to try a lasix gtt before putting her back on CVVHD. Her u/o has increased since the CVVHD stopped but she conts to be positive by.\n\nEndo: She is back on an insulin gtt to maintain a blood sugar of 80-120 - she conts to receive lantus in the evening.\n\nHeme: HCT was 27 this morning - she is receiving a unit of PRBC.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611786, "text": "Patient transfered from to today.Transfused due to low Hct.Hypokalemia treated,ABG shown hypoxemia with acceptable PH and paco2.BP fluctuated during CVVHD. Mild temp,BS coarse,treated with Albuterol/Atrovent with vent check.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611787, "text": "NPN Addendum\n\nPt vomited tube feeding like material, her TF are no on hold, ABD remains firm and distended, she does not have any residuals from her pedi tube, I can oscultate her fedding tube in her ABD, I did not suction out TF from her ETT. She was given half of her lantus dose (17 units), she conts on an insulin gtt. The lasix gtt remains on hold until her BP increases.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611788, "text": "Neuro: Pt. intubated and sadeted with Fentanyl 300mcg/hr and Versed 10mg/hr. Pt. aroused to painful stimuli.\n\nResp: Pt. intubated on vent A/C 450x18 with 50% FiO2 and 10 of PEEP. LS coarse, requiering to be suctioned x2 for thick tan secretions.\n\nCardiovascular: Pt.on Levophed 0.03mcg/kg/min for low BP. ABP 120-140/70's and Levophed gtt off. ABP down to 90's systolic when off the gtt. Levophed gtt restarted at 0.015 mcg/kg/min and BP remain stableat SBP 130-140's. Pt. also started on Lasix gtt at 5mg/hr. H/H 10.2/30.3 after transfusion. Pt. cont with anasarca, skin weaping. electrolytes WNL as per careview.\n\nGU: Pt. with foley cath in place and draining clear yellow urine, small amount of sediment noted. Urine output 30-100cc/hr after lasix gtt initiated. BUN 52, creat 1.5 this AM.\n\nGI: Abd distended and firm. BS hypoactive and TF on hold after Pt. vomited. Lactulose given to promote BM. Mashroom cath in place. Pt. was incontinent of large amount of liquid stool this AM. Tube feeding on hold. Abd. remains firm, BS positive. Mashroom cath remains in place.\n\nSkin: Pt. with large decube ulcer to . wound cleansed and new duoderm applied.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611883, "text": "MICU/SICU NPN\nPt remains sedated with fentanyl & midazolam, unresponsive to all stimuli. Remains intubated on AC 16x450x0.50/+5, please see flowsheet for assessment data. Plan to continue comfort focus of care without initiating new therapies, DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611884, "text": "ADDENDUM NPN:\nPT IS STILL SAME CONDITION, SEDATED NOT RESPONDING, ON SAME MECHANICAL VENTILATOR SETTING, SUCTIONED WITH MODERATE THICK YELLOWISH SECRETIONS. B.P 50-55/15-16, T 32.5 AX. ANURIC, DR. INFORMED, SUGGESTED NOTHING TO BE DONE.\nPLAN: CONTINUE SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611885, "text": "Respiratory Care\nPt remains on current vent settings, suctioning moderate amounts of thick green/yellow secreations. No spontaneous inspiratory efforts noted.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611886, "text": "Resp Care Note:\n\nPt intub with OETT and on vent as per Carevue. Lung sounds coarse rhonchi improve somewhat with suct sm=>mod th yellow sput. Pt in NARD on current settings; no vent changes required overnoc. vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611887, "text": "NPN 0700-1500\nPt remains sedated on fentanyl 500mcg/hr and midazolam 15mg/hr. Pupils unreactive bilaterally and is unresponsive to all stimuli. Remains intubated on CMV at 17x 450-560x.40x5, SPo2 89-93. Lungs course bilaterally. HR 93-105, AFib, no ectopy, MAPs 27-35. Bowel sounds absent. Rabbi in to speak with Attending, patient's husband and nursing staff regarding current treatment status and will be in Thursday, 25th to speak with team and patient's husband again. Please page him then. Continue comfort care, DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611888, "text": "Respiratory Care\nPt remains on current vent settings as per carevue. Suction for moderate amounts of thick green/yellow secreations. No chnages made in current settings.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611889, "text": "Smicu nsg progress note\nS/O- to be unresponsive on fent/versed gtts. Bp marginal 40-60s with no urine output. on vent. No changes made. Suctioned for copious amts thick yellow foul smelling secretions.\nA- Unchanged\nP- . Family Support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611723, "text": "NPN\n\nNeuro: Remains on fent and versed, her fent was increased to 50 mcg/hr from 25 because she was easily arrousible and often coughing and fighting with the vent. SHe appears to be more comfortable with the increased sedation.\n\nCV: Hypotensive to the 60s this morning, CVP was 8, she was given 1000cc NS which brought her SBP up to the 70s, CVP to 10. She was started on levophed and has needed a max of .05 and is now .02 mcg.kg.min, we are still unable to wean her off of this even after 2 units of PRBC - she dropped her BP to 90/40s and a MAP in the low 50s. Her Sputum has MRSA in it, to continue on vanco and aztreonam.\n\nResp: Remains on A/C 500x20/.5, able to wean the PEEP down to 8 with an ABG of 7.42/38/100, to go down to 5 of PEEP. She has MRSA in her sputum, she conts to have bloody secreationes from her ETT and from her mouth, she conts on vanco and aztreonam.\n\nGI: ABD is now soft, tolerating her TF, had a formed BM today.\n\nGU: Her U/O is low 5-13cc/hr, there are no plans to restart to the CVVHDF due to her sepsis - this will be readdressed in the furture.\n\nEndo: Able to keep her BS under fairly good control with the insulin gtt\n\nSoc: Her husband was in for most of the day, told that she was not doing well, he spoke with his sons and the attending about the choices of care, her husband and sons want to talk with their rabbi.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611724, "text": "Addendum\n\nLevo changed to dopa due to bradycardia - she now has a HR in the 60s\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611725, "text": "Respiratory Care\nPt. remains intubated/sedated on ventilator. PEEP was weaned aggressively yesterday, resulting in moderate hypoxia via abg. PEEP increased back to 8CMh20.\nBs: coarse bilat with scattered rhonchi, and diffuse exp. wheezes. Sxn'd q3-4 for mod-copious thick bloody clots.\nPlan: continue current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611782, "text": " 4 ICU NPN 0700-1900\nWeaned to 50% X 400 X 24, PEEP 15. ABG 7.47/35/75/26/1. BS coarse. Small amts thick, yellow secretions.\nBP/MAP maintained on levophed 0.031.HR 70-8's AF. No VEA noted.\nCont on CVVH. Negative fld balance 1.5L since MN. Goal 100 cc(-) hr. Prisma filter clotted. System changed. treatment resumed.\nFent 300 mcg hr & versed 10 mg hr. Occas opens eyes when she is turned in bed with transient htpertension. Settles out when left alone.\nUO 0-10 cc hr. BUN 51, creat 1.0\nAfeb. Cont on meropenum & flagyl. Fluconazole d/c'd.\nTf at goal. Mod amt brown diarrhea. Abd firm with good BS.\nDuoderm on sacral skin break down\nReceived glargine 35u at 1800\n husband in to visit throughout the day. He was updated on pt's condition. Husband also spoke with dr. & Social worker . Sons & also phoned & were updated\nPt remains CPR not indicated\n\nA/P: Stable on above vent settings. Cont CVVH for fld removal. Wean as tol. ? trach if PEEP can be weaned.\nTOL CVVH with good effect on small amt levo. Cont to remove fld with goal 100 cc negative Q hr. Decrease hrly negative goal if MAP falls <60. (Do not increase levo to maintain hrly neg balance)\nApears adequately sedated on fent & versed.\nSupport to family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611890, "text": "Resp Care Note:\n\nPt intub with OETT and on vent as per Carevue. Lung sounds coarse rhonchi improve somewhat with suct for sm=>mod th yellow sput. Pt in NARD on present vent settings; no vent changes made overnoc. vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611891, "text": "MICU NPN\nNO CHANGES IN PT'S CONDITION, NO VENT CHANGES, HUSBAND AT BEDSIDE THIS AFTERNOON, FAMILY MEETING PLANNED FOR THIS COMING FRIDAY WITH HUSBAND AND CHILDREN AND RABBI AND TEAM TO DISCUSS A DECISION THAT NEEDS TO MADE RE: CARE FOR PT. FENT/VERSED GTTS. UNCHANGED.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611892, "text": "resp care\nremains intub/full vent support in ac mode,.no changes made today. cuff appears to be sealed adequately. scant to small dk yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611893, "text": "Smicu nsg progress note\nS/O- essentually unresponsive on fent/versed gtt. Marginal bp with no uo. No changes made in ventilation.\nA- No change\nP- . Family meeting for friday.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611693, "text": "Micu Nursing Progress Notes\nEvents: Sent for CTA scan of chest and abd, continuing to suction blood from ETT, disimpacted for a large amount of very hard stool.\n\nResp: Vent settings unchanged, PCV driving pressure 25, Peep 10, FIO2 50%. Suctioning large amounts of very thick bloody secretions that require lavage to remove. Pt went for CTA of chest and abd. Results pending.\n\nCardiac: B/P 130-140/50's, HR 60's, When she had any ADL's or suctioning her B/P increases to 160-170/'s. Procainamide stopped at 1700 as ordered.\n\nGI: She remains NPO due to a distended firm abd. A dulcolax supp was given at 11 am with no results by 1600. She placing the supp it was felt that the rectal vault was filled with hard stool. So when no results were obtained from the supp, she was dis-impacted for a very large amount of hard stool. She did have some bleeding following the dis-impaction.\n\nEndo: Insulin gtt at 0.5u/hr with blood sugars 148-147. However at 1100 her BS increased to 161 so the insulin gtt was increased to 1u/hr and her BS hav e dropped to 114-127.\n\nGU: Her foley was drainiing clear yellow urine. U/O 30-50cc/hr. No leakage seen from her foley.\n\nNeuro: Fentanyl maintained at 100mcg/hr and the versed was 4mg/hr. She did require several boluses of versed 1mg, to help with routine care. Her BP would increase to 160-170/ and then fall following the boluses back to 130-140/.\n\nSkin: Sacral decub cleaned and deodurm. Decub is through dermis layer, clean and without digns of infection.\n\nSocial: Her husband in to visit most of the day and both of her sons called to inquire. Husband asked many questions and they were answered was well as possible.\n\nPlan: suciton PRN, monitor resp status, monitor cardiac status for possiblilty of arrhythmias, support husband and family\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611694, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient continues on PCV with Pinsp. 35 Peep 10, RR: 26 with I:E 1:1.9. Breathsounds are coarse. Suctioned multiple times for bloody secretions and one bloody plug. Albuterol/atrovent given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611783, "text": "Remains on CVVHD,vent changed order so Ric can PM it.Poor prognosis,hypoxemic,sensitive to FI02 changes.BS coarse withR>L,on MDI Albuterol/Atrovent.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611784, "text": "Smicu nsg progress note\nNeuro- Remains sedated on 300mcg fent and 10mg midaz. Does open eyes and grimise with turning/suctioning but easily settles. Not requiring additional boluses. No spontaneous movement of extremities noted.\nResp- Intub/sedated initially on ac 450x24 50% 15peep. Resp rate decreased to 22 and then 20. Cont with good abg's 121/36/7.48. Ventilation and oxygenation appear to be improving with fluid removal. ?decrease peep to 10 as pt will need decrease peep before ?trach.\nCardiac/fluids- Pt cont on chhv initially able to maintain goal of 100cc neg/hr with stable bp/hr on .03 mcg levo. Pt 2000cc neg at 12m. Then becoming more tacycardiac with hr 110-120af Bp down to 88-94s. Removal rate initially decreased to keep pt even and then decreased to removal rate of 0 (see flow sheet). Bp and hr improving. Cont on levo at .03 mcg.\nGi- Cont on goal tube feeds. Bs/fs more elevated today. ? need to add ss insulin.\nId- Remains afebrile on current antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611870, "text": "Resp: Pt remains intubated and vented on a/c 16/450/+5/50%. Bs are coarse bilaterally. Suctioning for moderate amounts of thick yellow/greenish secretions. Slight leak noted, but maintaining adequate Vt's. Pt remains unresponsive. No vent changes noc. No abg's. Pt is dnr.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611871, "text": "Respiratory Care\nPt remains on same A/c settings without change, continues to have balloon leak, suctioning thick green secrections from et tube.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611872, "text": "S/MICU Nursing Progress NOte\n Pt remains the same, no changes in the vent. on fentanyl 400mcg/hr and versed at 14mg/hr. husband and son at bedside during the afternoon. with comfort care\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611873, "text": "PT WITHOUT CHANGE. NO CHANGE IN VENT SETTINGS.PT ON FENTANYL 400MG/HR & VERSED 14MG/HR. SHE REMAINS ON .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611874, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nUnable to measure RSBI due to lack of spontaneous respiration.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611875, "text": "S/MICU Nursing Progress Note\n Pt remains unchanged on the same vent settings 450/16/.50/5 suctioning q3-4hr for thick yellow sputum. BS remain coarse throughout. remains no urine output. +++ pitting edema, oozing from arms. saturating the pads. Fentanyl increased to 500mcg/hr and versed increased to 15mg/hr as pt out of phase with the vent... comfort care remains a priority. Son in contact via phone.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611876, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no changes made to any parameters throughout the night. SX'd for moderate amounts of green, thick sputum.\n\nNo RSBI determined due to lack of spontaneous respiration.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611877, "text": "NPN 7P-7A:\n\nPT WITHOUT CHANGE NOTED. NO CHANGE IN VENT SETTINGS. SHE ON FENT/VERSED.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-12 00:00:00.000", "description": "Report", "row_id": 1611758, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains vented with settings of A/C 500cc/20/. suctioning q2-3 for thick tan sputum BS cont to be insp/expir wheezes throughout all fields. BS diminished on the right. cont to maintain O2 sat 98-100%.\n Cardiac: HR 90-100's afib, rare PVC's cont on levo, titrated to keep SBP>90/ range tonight has been 0.808mcg/kg/min to 0.55. presently on 0.55mcg/kg/min. given lasix 40mg x2 with only sm response. pt is presently 17 liters LOS +, very edematous .... weeping from the arms.\n ID: presently on vanco(day 7) aztreonam (day 10) po flaygl(day 2) pt has MSRA in sputum, c-diff+, yeast in urine(did receive po fluconzole), rash in groin area improved. less reddened. still with ulcers/lesions on lips and inner lip region. new culture to be sent this am.\n SKin: still with a number of eccymotic ares, though nothing new... still eccymotic around right shoulder,chin,near dialysis line, under right breast, right calf, and right lower abd. duoderm over the sacral area due to be changed in three days..(22)\n GI: cont on TF of nepro with promod at 35cc/hr. at goal rate. mushroom catheter in place. sm amt of output. abd soft. BS+ Pt had received 2 units of RBC overnight and post transfusion hct was 34.\n GU: foley in place and draining. urine yellow, less sedimented from prevous. BUN 89 with creat 1.9\n Social: no contact tonight.\n : goal to get fluid off pt .... will not be able to wean given her BS ... really wheezy. monitor I&O's closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-12 00:00:00.000", "description": "Report", "row_id": 1611759, "text": "progress note:\nNeuro: remains sedated on fent 75 mcg and midaz 2 mg with PERL sluggish. pt alert to noxious stim during mouth care but doesn\"t follow commsnds.\n\ncard: afib rate 70-80's, sys bp >100 on .08 mcg/kg /min levophed. decreased levo at 1500 and sys in 90-100 range.\n\nresp: current vent settings CMV at 8 peep rate 20 02=50% with set tv 500 and actula 370. no changes made in vent. course bs with exp wheezes throughout. CXR this am indicates inc in fluid and will start CVVH this evening. per team suggestion pt needs freq lavage and suction to mobilize secretions. thick tan green speciman sent for cult.\n\nrenal: will start cvvh this eve. solutions ordered and requested from pharmacy. hope to remaove fluid and decision made with son and husband to cont to offer all support available to pt.\n\ngi: approx 25 cc in fecal bag and no inc in output noted. gave lactulose at 0800. pos bs and cont tf at 35 cc/hr\n\nendo: swithched pt to SSI and eve dose glargine. last glu 199 at 1230 and covered.\n\nID: afebrile with fluconozole added to regimen. herpes cult of mouth lesion sent.\n\nplan: start cvvh and remove fluid as tolerated, per family meeting, will head toward peg and trach asap, cont to wean levo if poss\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611878, "text": "NPN 7P-7A:\n\nPT WITHOUT CHANGE NOTED. VENT SETTINGS UNCHANGED. SX FOR THICK YELLOW SPUTUM ON LARGE AMOUNTS. FENTANYL 500MCG/HR & VERSED 15MG/HR.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611879, "text": "S/MICU Nursing Progress Note\n condition remains unchanged... on the vent with setting of A/C 450/16/.50/5 suctioned q3-4 hr for thick yellow sputum. afebrile. no urine output. remains anasarca grossly weeping from arms. frequently changing pads under arms. Husband and in to visit. Continue with DNR.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611880, "text": "Respiratory Care\nPt remains on a/c vent without changes, suctioning thick green secrections from airway, stopcock at pilot holding vol.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611881, "text": "Respiratory care:\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. No morning abg results and no RSBI determined at this time due to lack of spontaneous respirations.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611882, "text": "pt.is unchanged. unresponsive and sedated on fentanyl and versed gtts.\nNo vent changes. sbp in the 50's most all night. remains in afib in the 80's.Frequently suctioned for thick copious yellow sputum.\nSkin continues to weep/ full body edema noted.\nno uop or stool.\ndnr/ status\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611745, "text": "MICU/SICU NPN ICU Day #14\nNo events\nFull code\n\nS/O:\n\n\nNeuro: pt remains sedated with fentanyl/midazolam, no independent movement of extremities noted, pupils fixed and non-reactive\n\nPulm: pt remains intubated on AC 20/500x0.5/+8, SpO2 96-100%, LS coarse, occasional I/E wheezes on left, dim at bases, Vt 430-507, Ve 8.8-9.9. PIP 37-41, RR 20-24\n\nCV: HR 82-105 AF/Aflutter, BP 96-132/38-60 on Levophed, CVP 14-15, please see flowsheet for data\n\nInteg: total body anasacra particularly n extremities, sacral decub healing, Aquacel dsg changed today next due on tuesday, right lower leg venous stasis ulcer has nearly healed, pt has multiple areas of eccymosis over abdomen and thorax\n\nGI/GU: abd is firm and distended, BS are present, pt is tolerating Nepro with Promod at goal rate of 35cc/h, pt was incontinent of large amts OB neg loose brown stool, a mushroom catheter is in place and draining small amts loose stool, Foley in place and patent for small amts clear yellow urine\n\nLines: left SC TLCL day #10, left radial art line day #14, right IJ Quentin cath day #8\n\nFEN: remains on insulin gtt at 1.5U/h and FSBS have been 124-164\n\nA:\n\naltered breathing r/t volume overload\nhigh risk for infection r/t invasive lines, ETT indwelling catheter\nhigh risk for injury, cerebro/cardiovascular r/t hypotension and pressor requirement\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contniue to wean respiratory support as tolerated, contniue to wean hemodynamic support as tolerated, consider gentle diuresis while on pressors, resume HD when appropriate, attempt to schedule family meeting with sons and husband at earliest conveneince\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611746, "text": "NURSING NOTE 7P-7A:\n\nSEE CAREVUE FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS SEDATED ON FENTANYL/VERSED. PUPILS PINPOINT/NONREACTIVE BILAT. PT OPENS EYES TO PAINFUL STIMULI. DECREASED COUGH/GAG + CORNEALS. NO PURPOSEFUL MOVEMENT.\n\nCV: PT TMAX 98.9 (AX). HR 80-100 AFIB/FLUTTER. PT RESTARTED ON LEVOPHED GTT @ 0.06 MCG/KG/MIN TO KEEP MAPS> 60. CVP 9-20. +4 ANASARCA + PULSES.\n\nPULM: PT REMAINS INTUBATED ON AC-20 50% TV 500 PEEP 8. SATS 97-100%. ABG THIS AM 7.33/46/113/25. PIP 30-40 MINUTE VENT= 8.5-9.3 LUNGS COARSE T/O DECREASED @ BASES. SMALL AMOUNT THICK/TAN BLOOD TINGED SECRETIONS SUCTIONED FROM ETT.\n\nGI/GU: ABD LARGE/FIRM + BS X 4. TUBE FEEDS @ 35CC/HOUR (GOAL) INFUSING WITHOUT DIFFICULTY VIA ORAL PEDITUBE. PLACEMENT CONFIRMED WITH AIR BOLUS. NO RESIDUALS NOTED. FOLEY DRAINING AMBER/CLEAR URINE\n~25-35 CC/HOUR. LAST CREAT 1.9 MUSHROOM CATHETER IN PLACE NO STOOL OVERNIGHT.\n\nENDOCRINE: PT REMAINS ON INSULIN GTT @ 1.5 UNIT/HOUR. CONT TO CHECK FINGERSTICKS Q 2 HOURS AND ADJUST GTT PER PROTOCOL.\n\nPLAN: WEAN VENT AS TOLERATED, FOLLOW LABS REPLETE AS NEEDED, ANTIBIOTICS, WOUND CARE, LEVOPHED TO MAINTAIN MAPS > 60, INSULIN GTT PROTOCOL, CONT SEDATION, CONT WITH CURRENT , CONT TO MONITOR.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611690, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 114/48-165/70. SB/SR WITH H/R RANGING FROM 55-71 WITH OCC BLOCKS TO THE 40'S WHEN PT COUGHS AND MIN VOL DECREASES. PPP BIL. PT HAS 3+ EDEMA IN HANDS AND FEET. ON PROCANIMIDE AT 2MG/MIN X24 HOURS, (UNTIL 1700). QTC WAS 368 BY EKG. CVP 19-24 WITH 10 OF PEEP. PT 1 UNIT OF PRBC FOR HCT 28.3. ( 2 UNITS ON PREVIOUS SHIFT FOR HCT OF 23.8 FOR TOTAL OF 3 UNITS).\n\nRESP: ON PCV WITH50% FIO2, RR 26,PEEP 10, INS PRESSURE 35TV 400-460 RANGE. LUNGS COARSE THROUGHOUT WITH SX SEVERAL X FOR MOD AMT OF OLD BLOODY SECRETIONS. AT BEGINING OF SHIFT SX RED SECRETIONS.\n\nNEURO: SEDATED ON VERSED 4MG AND FENTANYL 100MIC/HR. DOES WITHDRAW WHEN TURNED AND GRIMMACES TO PAIN. OPENED EYES ONCE WHEN BEING TURNED. PUPILS EQUAL BUT SLUGGISH. DOES NOT FOLLOW COMMANDS AND NO PURPOSEFUL MOVEMENTS.\n\nENDO: PT HAD BEEN ON INSULIN GTT YESTERDAY AT 0.5UNITS HOUR HAS NOT BEEN RESTARTED BUT WILL BE IF FSBS INCREASES TO > 150.\n\nSKIN: DECUBIDUS ULCER NO COCCYX WITH DUODERM INTACT. PT IS ON CONTACT PRECAUTIONS FOR POSSIBLE MRSA IN WOUND.\n\nGU/GI: FOLEY CATH PATENT. FOLEY DID LEAK A LG AMT OF URINE. ON FOLEY SLIPPED OUT ENTIRELY AND A LARGER FOLEY WAS INSERTED. U/O MINIMAL UNTIL SHE ETHNACRYNIC ACID 100MG AND UNABLE TO MEASURE AS THE URINE LEAKED FOR AN HOUR. URINE LYTES WERE SENT YESTERDAY TO R/O POSSIBLE ATN. ABD FIRMLY DISTENDED WITH ABSENT BS. NGT PLACEMENT VERIFIED. YESTERDAY PT HAD OLD COFFEE GROUND DRAINAGE.\n\nPLAN: CONT TO DIURESE PT FOLLOW CVP. WEAN PT FROM VENT AS APPROPRIATE. MONITOR SECRETIONS TO ENSURE NO FURTHER BLEEDING. STOP PROCANIMIDE AT 1700. PROVIDE UPDATES FOR FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611691, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick bld tinged secretions. MDI'S given. HR occ SB. Sedated with fentanyl and versed.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611692, "text": "RESPIRATORY CARE: PT W/ A 7.0 ORAL ETT IN PLACE.\nREMAINS ON PCV AS PER CV. VT ABOUT 400 CC W/ A\nDP OF 25 CM H2O. CT SCAN OF CHEST/ABDOMEN TODAY\nW/OUT INCIDENT. SX FOR BLOOD-TINGED SPUTUM.\nALBUTEROL/ATROVENT MDI'S GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611824, "text": "NPN\nNeuro: Pt. . on IV sedation with Versed 14mg/hr and Fentanyl 350mcg/hr. Pt. remains comfortable did not require extra boluses this shift.\n\nCV: NBP 60-80 systolic with HR 70-90 in A-fib. Pt. afebrale this shift.\n\nResp: LS coarse. Pt. suctioned x2 this shift for moderatr amount of thick tan sputum. Pt. remains intubated on vent A/C 450x16 peep of 5 and FiO2 of 50.\n\nGI: Pt. restarted on tube feedings after gastric contents residual 40cc at 2200. Tube feedings at 10cc/hr. Unable to increase rate due to residual of 90cc 4 hr after tube feedings restarted. Will check residual later this shift and increase rate if Pt. tolerates. Abd. distended and soft, BS hypoactive.\n\nGU: Pt. with no urine output since about midnight today. Pt. has general anasarca and skin weeping.\n\nSocial: Pt. is a DNR/DNI. Will keep family informed on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611825, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 98%; bs coarse, thick tan secretions, will full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611826, "text": "S/MICU NURSING PROGRESS NOTE\n Neuro: on sedation of fentanyl 350mcg/hr and versed 14mg/hr. no grimacing with turning at times will still bite down on ETT/NGt unable to do mouth care. requiring a bolus of meds to get suction in the mouth.\n Respiratory: vent without any changes... A/C 450/16/0.5/5 O2 sat of 98-100% suctioning for thick creamy sputum(very much like TF coloring) BS coarse throughout.\n GI: was on Deliver with promod at 10cc/hr found to have drooling out mouth...same as TF, residuals 60cc. stopped TF at 9am recheck still 50cc remain off. BS hypoactive no stool\n GU: foley in place and no urine output.\n Social: husband and son in today and updated by Dr. .\n Plan: Continued with support. focusing on comfort... family and rabbi believe, feeding, antibx are part of comfort care.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611827, "text": "Resp Care\n\nPt remains intubated and on full vent support. BS coarse and suctioning thick tan sputum. Spo2 in the high 90's\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611828, "text": "MICU NPN:\nNEURO: Sedated on 350mcg/hr of fentanyl and 14mg/hr of versed. Appears comfortable but biting down on tube. No spontaneous movement noted.\nCV: Tmax 100.0 axillary. HR 70s-100s AF, with occasional pacs. SBP 50s-70s. Pt. with anasarca.\nRESP: No vent changes made- continues on ACV 450x16 +5peep and 50% O2 with O2 Sat >95%. LS coarse throughout. Sx'd for moderate amts of thick tan secretions via ETT and mouth.\nGI/GU: Abd. distended with hypoactive bowel sounds. TF restarted but shut off again for high residuals. No BM. Foley with small amts of amber yellow urine.\nSKIN: Duoderm to . Repositioned side to side and on air mattress.\nOTHER: Husband into visit this evening. Son , from , due in tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611707, "text": "MICU/SICU NPN ICU Day #7\nEvents: started on furosemide gtt yesterday, remains oliguric\n\nS/O:\n\nNeuro: remains sedated with fentanyl/midazolam, eyes open to painful stimulation, no independent movement of extremities, pupils pinpoint\n\nPulm: remains intubated on PCV 38+18/0.4/24, last ABG 7.36/31/87, SpO2 98-100%, LS coarse, Ve 10.5-12.1, Vt 405-530, PIP 40\n\nCV: HR 59-77 SR with occasional PVC's and rare PAC's, BP 83-143/35-57, PA 43-74/25-37, PCWP 21-24 (corrects to for PEEP), CVP 14-25 (corrects to for PEEP), CI 3.40-4.17, please see flowsheet for data\n\nInteg: global anasarca particularly in extremities, pt has a healing venous stasis ulcer on right lower leg, 1cm x 1cm, pt has Duoderm over sacral decub due for change today, pt has a rash between thighs, in groin and in flod beneath abd pannus\n\nGI/GU: abd is obese, firm and distended, BS are present, pt tolerating Nepro at goal rate of 35cc/h via NGT in left nare, FOley in place draining scant amts clear yellow urine dispite furosemide gtt, furosemide on hold for now\n\nAccess: left SC intorducer with PAC day #3, left radial art line day #3\n\nFEN: pt remains hyperkalemic, hyperphosphatemic, creatinine continues to rise, daily weight 105 kg\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT, indwelling catheter\naltered breathing r/t acute inflammatory process vs. acure on chronic cardiac process\nimpaired skin integrity r/t chronic altered nutrition, chronic immobility\nhigh risk for injury, cardiopulmonary r/t acute on chronic pulmonary HTN\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contninue to wean resp supports as tolerated, contnieu skin/wound care as reccomended, consider HD vs CVVHDF as pt not responding to diuresis\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611708, "text": "RESP CARE NOTE\n\nPT REMAINS ON PCV 38/18 0N 40%, RR 24. THERE IS AN INCREase IN THE AMT OF SECRETIONS SINCE WEDNESDAY. There has been an improvement in lung dynamics and oxygenation however. Last ABG 7.36, 31,87 showing continued metabolic acidosis with significant respiratory compensation. Pt appears to have peripheral edema but also is still hypotensive at times. CVVH is being considered\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611709, "text": "MICU NURSING NOTE 10:30-1900:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNeuro: PT remains sedated on Fentanyl/Versed. PT opens eyes to painful stimuli. PUpils pinpoint bilat. MD aware. NO spontaneous movement of extremities. Decreased cough/gag.\n\nCV: PT hypotensive this am, Fentanyl gtt decreased and pt received 1 unit PRBCs for HCt 26.9. PT BP responded. BP currently 105-140/40-60. HR 50-80 SR with rare PACs and PVCs. Afebrile. + 4 anasarca + pulses. L subclavian Swanganz catheter d/c this afternoon and triple lumen placed over guide wire. Pt oozing blood from site. MD aware. INR 1.3 and plts = 109. Pt to receive vit K 5 mg sq when returns to floor. CVP 16-20.\n\nPULM: PT switched from PCV to Volume control ventilation and Peep weaned. Current vent settings rate 24 FIO2 40% TV 450 Peep 14 Pt tolerating vent changes Last ABG on current settings was 7.36/31/87/18/96 sats 96-100%. Minute volumes 8.5-10.0. PIP=30-40. SUctioning mod amount of thick bloody secretions. MD aware.\n\nGi/GU: PT remains oliguric. Foley draining 5-15 cc urine/hour. LAsix gtt off since @ 0100. Renal saw patient today and CVVHD to be started this evening. Pt currently in IR for dialysis catheter placement. Creat 2.3, K= 4.9 Abd large, firm distended + BS X 4 quad. PT has not stooled since . Lactulose dose given this am, will repeat as ordered until pt stools. pt also receiving reglan to promote BM. NGT placement confirmed by air bolus Pt tolerating Nepro @35cc/hour (goal). Minimal residuals noted.\n\nSKin: R leg with healing ulcer OTA no drainage noted. Sacral decub Stage III. Wound base yellow small serosang drainage. Duoderm dsg changed today. Cont to turn pt side to side as tolerated. Groin, bilat thighs with yeast/rash, Mitrazol powder applied.\n\nEndocrine: Pt remains on Insulin gtt @ 4 units/ hour. WIll titrate gtt per insulin gtt protocol. BS Q1 hour.\n\nSocial: Family visited and updated on pt status and POC by attending physician. given emotional support.\n\nPLAN: Wean vent as tolerated, Wound care, start CVVHD this evening, INsulin gtt per protocol, cont sedation, monitor labs replete as needed. Will cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611710, "text": "Respiratory Care\nPt weaned today changed mode to A/C 450/22/peep14/40% last abg\n734/34/96/19/-6 pt bld. Pt traveled to IR without incident for cath placement will start cvvhd tonight. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611711, "text": "NURSING NOTE ADDENDUM:\n\nPT HAD DIALYSIS CATHETER PLACED R IJ SITE WNL. WILL BEGIN CVVHD THIS PM. L SUBCLAVIAN TRIPLE LUMEN SITE CONTINUED TO OOZE BLOOD, SUTURE PLACED BY MD WITH GOOD RESULTS. PT LAST ABG 7.30/40/69/- ON VOLUME CONTROLLED VENT RR= 22 TV 450 FIO2 40% PEEP= 14. VENT CHANGES MADE BY RT, RR INCREASED TO 25, TV INC TO 500 AND FIO2 INCREASED TO 50%. WILL SEND REPEAT ABG @ 1900.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611712, "text": "S/MICU Nursing Progress Note\n Events: weaned sedation on days, dialysis catheter placed in RIJ, multilumen catheter in the left subclavian, CVVHDF started at tonight.\n Neuro: on sedation of fentanyl at 50mcg/hr and versed at 1mg/hr, will open eyes to pain, grimaces with turning and movement. extermites extremely edematous. difficult for spontaneous movement. +gag,+cough.\n Respiratory: cont to suction thick bloody sputum. occasional plugs. BS coarse throughout. able to wean the vent down to a rate of 23. Current settings are A/C 500x 23, spontaneous RR of 4 over the vent. FIO2 50% PEEP of 14cm. repeat ABG pnd.\n Renal: CVVHDF started at last night. slowly increasing PFR up to goal of -100cc. intially tolerating then dropping her SBP to lowest of 80/ decreased flow rate. BP back up to SBP>100. will slowly increase rate. goal is to be -100cc/hr. Did have difficult with access pressures. able to flush catheter and only draw back 3cc with resistance, better flow from venous side. reversed ports. warming blanket placed on the pt. temp now 97-98ax.\n Cardaic: Hr 60-70's NSR , no VEA, BP mostly 90-120/60's as noted above. off pronestyl. hourly intake 50cc/hr.\n GI: TF infusing at 35cc/hr. tolerating well. residuals only 20cc, have not advance rate as needed to turn off TF to lie pt flat with hypotensive episode. Abd remains firm, BS thoughout all quads. +flautus with turning. no stool cont with lactolose.\n SKin: rashes in the folds of abd, placed on nystatin powder. extremely edematous, eccymotic areas on the right calf,right armpit. areas. sacral decub with douderm in place. due to be changed on . +mouth sores.\n Endocrine: was on IVF insulin at a rate of 5units/hr. FS came back at 49,,insulin stopped and amp D50 given, FS onl yup to 69 second amp was given. insulin restrated at 3am for fS 178. now on 3uints/hr.\n Social: spoke with son this evening updated.\n Plan: will cont to try to get goal rate on CVVHDF cont to monitor labs q6hro and q12.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611713, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported on AC overnoc. BS's coarse throughout. Sxing moderate amts thick bloody secretions from ETT. Administering Albuterol and Atrovent MDI's in line w/ vent, see flowsheet for rx times. Pt airway pressures borderline, plateau=30-40 overnoc. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611805, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt cont on the vent with settings of 450/16/.50/10 spont RR 0-5, suctioned Q4hr for thick scant amts of tan sputum. BS coarse upper and diminished at the bases. no wheezes, cont on steroids 40mg Q8hr. Remains sedated on fentanyl 350mcg/hr and versed at 12mg/hr.\n Neuro: as noted above pt is sedated on fentanyl and versed. will open eyes when turning. biting down on ETT and NGT, ocluding both. requiring bolus of meds. no spont movement from pt. impaired gag and cough.\n Cardiac: Hr 80-100's afib with occasional PVC, cont on levophed at 0.03mcg/kg/min BP ranging 100-130/70's unable to titrate. remains edeamtous, LOS is still + ll liters.\n Renal: on CVVHD, was averaging over 100cc neg with an ending balance of -883 cc at midnight. As per Renal fellow CVVHD was stopped at 2300. over the past few hours pt is now +350cc. anascara, oozing from prevous puctures. Restarting will depend on family meeting today..\n ID: cont on antibx, po flaygl and IV merepenum. rash in groin improved, oral ulcer improved. still on internal lips.\n Skin: cont on the air bed. turing frequently. sacral decub with douderm . eccymotic areas on the right calf, upper right neck,\n Plan: family meeting plan for today with the sons being at the meeting via phone. plan is to discuss comfort care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611806, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 50% and Peep 10. Abg's within normal limits with PaO2 103. Bs coarse R lung, decreased L lung. Albuterol/Atrovent MDI's given Q4hr. CVVHD in use. No further changes made. Continue with mechanical support and wean peep as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611807, "text": "NPN\n\nNeuro: Remains sedated, no changes were made in the rate, she was given a 10mg vent and a 200mcg fent bolus for HTN and tachycardia - good effect with a lowering of both HR and BP.\n\nCV: She is off levo with no plans to restart it, her SBP has been 100-130.\n\nResp: LS coarse, no changes were made on the vent, sx for thick tan secreations.\n\nGI: Her residuals were 210 this morning, they were off until the residuals were <150 - 5 hrs. She has been having liquid stool, conts on bowel meds.\n\nGU: U/O 15-20cc/hr, she remains off of CVVHD with no plans to restart.\n\nEndo: BS have been 80-100s, glargine has been reduced to 25 units.\n\nSoc: There was a family meeting today with the husband, her rabbi, both of her sons were on conferance call. She is CPRNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-25 00:00:00.000", "description": "Report", "row_id": 1611808, "text": "NPN\nNeuro: Pt. remains sedated on Versed 12mg/hr and Fentanyl 350mch/hr. Did not require extra boluses this shift.\n\nCV: Pt. remains off Levophed at this time. ABP 100-120's HR 80-100. Cont. with A-fib. Pt. remains with anasarca and weeping through her skin. Labs pending.\n\nResp: Pt. remains intubated on vent A/C 450x16 with peep of 10 and FiO2 50%. LS remain coarse did not require to be suctioned this shift.\n\nGI: Pt. on tube feeding at 35cc/hr tolerating well with less than 15cc residual. Abd. softly distended, BS+. Pt. cont. with liquid brown stool contained with mushroom cath. Pt. cont. on bowel meds. Lactulose held for liquid stool this shift.\n\nGU: Pt. off CVVH at this time. Foley cath in place draining 8-25cc/hr. MD aware.\n\nSocial: Pt. remains full code with CPR not indicated MD order. Ethics involved in case. Will cont. to update family on plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611754, "text": "NPN 1900-0700\n\nEvents: Levophed gtt weaned off at 0400.\n\nNeuro: Sedation unchanged. Opens eyes slightly to verbal and physical stimuli; grimaces when turned or extremities moved; pupils pinpoint; no spontaneous movement noted.\nCV: ABP 106-134/48-60; levo weaned as above with maps staying above 60; HR 81-100, a-fib with ocassional PVC; gross body edema unchanged.\nResp: Remains on vent in AC mode 500X20X50%X5; repeat ABG's 7.32/44/114/24/-3; RR 20-28, ocassional spontaneous breath; suctioned ET tube 4-5 times for moderate amounts reddish brown sputum; frequent suctioning of mouth required also; sores on lips are healing slowly; O2 sats 99-100%; lung sounds coarse throughout.\nGI/FEN: Abdomen obese; TF at goal of 35/hr tolerated fair; rectal tube in place, drained 200cc golden brown stool, C. diff spec sent; no electrolyte repletion during the night, am labs pendingl\nGU: Foley drained 15-30cc/hr plus leaking moderate amount every 2-3 hrs.\nID: Tmax 99.1 ax; remains on aztreonam and vanco.\nSkin: Duoderm on buttucks , due to be changed today; sores on lips are healing slowly; abdomen is very ecchymotic from heparin shots\nEndo: FSBG 83-107; insulin gtt decreased to 1.5units/hr.\nPlan: Trach/PEG if unable to wean vent; continue antibiotics, monitor temp, wbc's, follow cultures; replete lytes prn; TF, insulin gtt per protocol; maintain good skin care, turn frequently.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611755, "text": "Pt on AC x 20 x 500, 50%, + 5. Pips increased since last evening. Sx for mod amts tk blood streaked. Last ABG better than previous but still a conbined resp and met. acidosis.Continue to support and monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611756, "text": "NPN\n\nNeuro: Pt conts on 75 mcg/hr of fent and 2 mg/hr of versed for sedation, she has been gimicing with some of her care - turning, rotation of the ETT, she does not follow any commands.\n\nCV: She became hypotensive to the upper 70s this morning and was started back on levo, she has been maintaining a SBP of90-100s on .04-.1 mcg.kg/min, her HR has been in the 70s-80s (down from 90s-100s) while on the levo - she has dropped her HR by 20-30 beats/min in the past to levo.\n\nResp: Remains on the vent, she was placed on PS for a very short period of time but dropped her MV to far due to a decrease in her VTs. SATs have been in the upper 90s, suctioning dark blood, LS with exp wheezes.\n\nGI: ABD is firm and distended, positive BS, conts on TF at 35cc/hr. given lactulose - no stool today so far.\n\nGU: U/O 10-20cc/hr, creat 1.8, k 4.4\n\nEndo: Remains on an insulin gtt, she has required increase doses today due to rising BS, she will be started on glargine this evening but cont on the insulin gtt to maintain a BS of 80-120.\n\nSoc: There was a family meeding today with the patients husband and their rabbi, the team went through her case and their questions were answered, no decisions were made.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611757, "text": "RESPIRATORY CARE: PT W/7.0 ORAL ETT IN PLACE.\nREMAINS ON AC MODE AS PER CV. UNABLE TO STAY\nON PSV DUE COMBINATION OF UNDERLYING METABOLIC\nACIDOSIS AND APNEIC PERIODS. SX FOR YELLOW\nSPUTUM. ALBUTEROL AND ATROVENT MDI'S GIVEN.\nWILL C/W VENTILATORY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611770, "text": "resp care\nremains oett/vented in ac mode. multiple changes today d/t worsening oxygenation, dysynchrony on vent. in a.m. had line change in trendelenburg position...during which above complications started. ?water in exhalation valve...changed with good results. in p.m again with dysynchrony with poor oxygenation...responded to increased sedation. does not tolerate any spont resp efforts...pips incr, desats,etc. mdi's given q4h and prn. sxning brownish to green sputum. c/w passive ventilation, on increased peep level again.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611771, "text": "NPN\n\nDiffucult day; cont need for pressors, worsening oxygenation and venilatory, increased sedation requirements.\n\nNeuro: She has needed increased doses of both fent and versed, more alert this morning, periods of opening her eyes, this afternoon she was fighting the vent causing increased PIPs, decreased VTs and MVs. I have given her doses of 300-500mcg of fent and 10-15 mg of versed in a bolus, her fent is now 300mcg/hr and her versed is 10 mg/hr - she is still requiring boluses with these increased doses.\n\nCV: Remains on the levo, her rate has increase to as high as .2mcg/kg/min and as low as off but mainly she has been ~ .03 mcg/kg/min. She remains in afib, her HR was as high as 120s and her SBP 170s while alert, she presently has a BP of 100-120s/40s, with a mean ~ 60-70s, her CVP is , HR 60s, she conts on levo and CVVHDF. The CVVHDF was restarted this afternoon, the levo will most likely continue to be needed to maintain a MAP of >60 - the goal is to keep the levo at a low level, if her BP drops than decrease the PFR on the CVVHDF.\n\nResp: LS diminished, she needed to have her SC line replaced necessitating that she be in trandelanberg, during the proceedure her PIPs increased to the 40s, her MV dropped to 4-5L/min, VTs were cut in half due to the pressure, her ABG was 7.39/42/58; the PEEP was increased to 15, rate to 26, FI02 to 100%, the MV decreased to 400, and her sedation was increased. A pressure valve was replaced and this initially helped but she again had low MVs, VTs and high PIPs, her present ABG on the 400x26/15/100% was 7.43/37/174; her FI02 was dropped to 80%. Sx for sm to mod amounts of tan/brown secreations.\n\nGI: Her ABD conts to be distended and firm, TF cont, I am not able to pull back any residuals from her pedi tube, she has pos BS, she was given lactulose x2 today.\n\nGU: Poor u/o 0-20cc/hr, she was restarted on CVVHDF and is tolerating it so far, she does cont on the levophed at a low dose of .03 mcg/kg/min.\n\nEndo: She has been hyperglycemic all day - she was restarted on an insulin gtt and is presently at 4 units/hr - the goal of her FS is 80-120.\n\nAccess: Her L SC was leaking and only 2 ports would withdraw blood, when I flushed to the white port with NS it leaked - the other ports did not do this; she now has a new L IJ which is not leaking, her SC was removed.\n\nID: She has been afebrile today ~ 96 ax, her gent and aztreonam were d/ced. meropenum was added.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611772, "text": "M/SICU Nursing Progress Note (1900-0700)\n\nPlease see carevue for all objective data, including q1hr fingersicks and subsequent adjustments in insulin gtt, hemodynamic monitoring and subsequent titration of levophed, q1hr CVVHD documentation and hourly fluid removal.\n\nCNS: Pt. well sedated on fentanyl and versed gtts. They have both been titrated down slightly due to hypotension and are currently running at fentanyl 250mcg/hr, versed at 8mg/hr. Occasional boluses of fentanyl (250-300mcg) given with turning and bathing. Pt. also requires additional boluses when overbreathing due to drop in MV. Pt. does grimace with noxious stim, but settles down when left to rest.\n\nCVS: Heart rate variable at 60-100, AFib, no VEA noted. Levophed weaned off by 0400 and B/P stable at 100-120/syst with MAP>60.\n\nF and E/CVVHD: Unable to remove any fluid (due to hypotension) as of midnight. Pt. ended past 24hr 500cc+. PFR gradually increased and is now at goal of -100cc hourly. -116cc as of 0400 and will continue to ultrafiltrate as tolerated. CVP initially 8, increased to 15 (?accuracy). Electrolytes WNL. Of note, both filter pressure and effulent pressure have increased significantly. No clotting visible in filter.\n\nRESP: Lungs with coarse, diminished breath sounds. Suctioned infrequently for small brown plugs. FIO2 decreased from 80% to 60% with ABG of 7.36 42 63 25 -1. Tolerating PO2 of >60.\n\nID: Hypothermic at 96 axillary. Bair hugger on with only mild improvement.\n\nENDO: Insulin gtt adjusted per hourly fingersticks. Currently at 5U/hr with blood sugars in the 120's.\n\nSKIN: Anasarca. Oral ulcers oozing BRB. Duoderm over , not removed.\n\nGI: Tolerating tube feedings at goal rate. Mushroom catheter, no additional stool overnight.\n\nSOCIAL: Son, , called and was updated on his mother's condition. He seems appropriately concerned and aware of the severity of her condition.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611773, "text": "Resp Care\nPt. remains intubated/sedated on ventilator. Fio2 weaned overnight, otherwise no changes.\nBS:coarse bilat. sxn'd x2 for thick brown plugs.\nabgs:moderately hypoxic, tolerating PaO2>60. Other parameters within acceptable range.\nPlan: cont. to support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611850, "text": "Resp: pt on a/c 16/450/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs auscultated reveal bilateral wheezing noted with coarse sounds. Suctioned for moderate amounts of thick yellow/greenish secretions. Pt biting on ett at times. No changes noc. Will continue with full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611851, "text": "Respiratory Care Note\nPt remains on AC as noted. No vent changes. BS coarse throughout. Pt suctioned for moderate amts thick yellow-green secretions. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611818, "text": "S/MICU Nursing Progress Note\n Pt remains intubated, no vent changes on settings of A/C 450/16/50/5 suctioned for thick sputum. on sedation of versed at 12mg/hr and fentanyl 350mcg/hr. pt comfortable, no grimacing with turning will elevate her HR and BP with activity but then quickly returns to previous level.\n Cardiac: HR 70-100 afib. rare to occasional PVC, BP lowest 68 during the night. now up to 93/33\n GI: on TF at 35cc/hr. sm amt of stool\n Social: son phoned and updated on mother's status. family is planning to come on Sunday ( son should arrive from on Sunday)\n Plan: with present plan, comfort care is the priority.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611819, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 100%; bs coarse, thick tan secretions, rsbi not indicated: , full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611820, "text": "NPN\n\nPt remains sedated, the versed was increased to 14 mg/hr due to biting on the ETT, she appears comfortable, SBP 60s-90s, HR 70s-80s, her HR will increase to the low 100s with turning or care. Son to visit tomorrow, to come early this coming week.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611821, "text": "NPN\nNeuro: Pt. sedated on IV Fentanyl 350mcg/hr and Versed 14mg/hr. Pt. remains comfortable with no grimace.\n\nCardiovascular: NBP systolic 70-80's over 30's. HR 80-100's . in A-fib.\n\nResp: LS coarse. Pt. suctioned for moderate amount of thick tan secretions. O2 sat 100%. Pt. . on vent A/C 450x16 with PEEP of 5 and FiO2 50%.\n\nGI: Tube feeding on hold for large amounts of brown liquid residual from OG tube.\n\nGU: Foley cath in place draining small amounts of dark yellow urine 5-10cc/hr. Pt. . with anasarca and weeping skin.\n\nSocial: Pt. DNR/DNI. Pt.'s son called about Pt.'s condition. Family awaiting visit from Pt.'s son from possibly sunday. ? comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611822, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 100%; bs coarse, thick tan secretions with lavage, will full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611823, "text": "NPN\n\nNeuro: Pt remains sedated on versed and fent, she was given boluses of each for biting on the ETT and increased HR to the low 100s, she presently appears comfortable.\n\nCV: Her BP has been 70s-80s for most of the day, her HR has been decreasing through the day, this morning it was in the 90s-100s and now in the 70s-80s.\n\nResp: LS coarse, sx for thick tan secreations, no changes were made on the vent.\n\nGI: She conts to have residuals from her OGT and her TF remain off because of them. ABD firm and distended, hypoactive bowel sounds.\n\nGU: U/O 5-10cc/hr, conts to have anasarca.\n\nID: She had a temp today to 100.8, she was started on levoquin.\n\nSoc: Her husband was in today, he conts to state as he has throughout her hospitalization that he \"doesn't know what he will do without her\", that \"she is all he has\". Her son came today, is making plans to be here on Tuesday.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611701, "text": "S/MICU Nursing Progress Note\n Events: swan ganz placed,ultrasound of right calf/leg,\n Respiratory: cont on the vent with settings of PCV driving pressures of 26 able to decrease to 22cm, PEEP of 18cm, TV ranged from 480cc-600cc suctioning for thick blood tinge sputum, occasional plugs.\n BS coarse throughout. sedated on fentanyl 100mcg/hr and versed 3mg/hr.\n Cardiac: HR 50-60NSR, cont on Pronestyl 250mg po, BP stable today 90-130/70's Swan-ganz catheter place this afternoon. Readings showed a PA 68/38, CVP 20, PCW 28 with fick CO 9.1, will cont to monitor overnight but will consider CCVHD tomorrow.\n GU: foley in place and draining. U/O poor for the day. BUN up to 71 with creat 1.7\n GI: NGt in place, on LCS with output 300cc of coffee grounds abd still firm, +BS, +flatus, no stool today. lactolose given x1.\n Neuro: sedated, will grimace to painful stimuli, no spont movement.\n +gag,+cough.\n Skin: hematoma on the right leg, seen by surgery ? if pt had a lipoma on the calf and has brusing around the area. ultrasound ordered and done, results pnd. Pulses good, foot warm to touch. Douderm over sacral decub. (dsg is aquacel in the wound,douderm overwound and to be changed every 3days....due on the 8th)\n Social: husband in to visit, updated by Dr. , on phone and updated by Dr. . Son calls from .\n Plan:MOnitor swan ganz readings, I&O's ? CVVHD tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611702, "text": "MICU/SICU NPN ICU DAY #6\nEvents: PAC placed last PM, FiO2 weaned to 0.40\n\n\nS/O:\n\nNeruo: pt remains well sedated on fentanyl/midazolam gtt, fentany and midazolam reduced, no independent movement of extremities, pupils pinpoint, initially no response to noxious stimuli, pt now opens eyes to painful stim\n\nPulm: remains intubated on PCV 40+18/0.4/26, last ABG 7.42/27/157, SpO2 97-100%, LS coarse, suctioned x2 for small amts clear thick secretions, it can be difficult to pass suction catheter into ETT at times, Ve 12.3-13.1, Vt 470-510, PIP 41-42, Pplat 36-38\n\nCV: HR 66-86 SR with rare to occasional PVC's, BP 92-141/44-56, MAP 55-83, PAP 43-67/25-37, PCWP 17-22 (corrects to for 18cm H2O of PEEP), CVP 14-25 (corrects to for PEEP), CI 2.9-3.94, episodes of hypotension appear to occur in relation to bradycardic episodes, please see flowsheet for data\n\nInteg: pt has anasarca, particularly in extremities, pt has a healing venous stasis ulcer, 1cm x 1cm, on anterior RLE, it is C/D/I, pt has a Duoderm over a sacral decub that is reported to be dressed with Aquacel\n\nGI/GU: abd is obese, firm and distended, BS are present, pt has a clamped NGT in left nare for meds, it can be difficult to aspirate gastric content at times, last PM ~30cc \"coffee grounds\" were aspirated and found to be OB negative with a pH of 2, Pt has a Foley in place which is draining scant amts of clear yellow urine, pt had no reponse to 60mg IV furosemide\n\nAccess: left radial art line day #2, left SC introducer with VIP+ PAC at 55cm day #2, #20 angio right hand\n\nFEN: pt remains mildly hyperkalemic, daily weight unchanged from 104.0 Kg, nutritional support on hold at this time\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT, indwelling catheter\nrisk for altered nutrition, LBR r/t >72h poor caloric intake\naltered breathing r/t acute inflammatory process vs. acute on chronic cardiac process\nimpaired skin integrity r/t chronic altered nutrition, chronic immobility\nhigh risk for injury, cardiopulmonary r/t acute on chronic pulmonary hypertension\n\nP:\n\ncointinue to monitor hemodynamic/respiratory status, contniue to wean respiratory support as tolerated, consider judicious reduction in PEEP, aggressive pulmonary toilet, gentle diuresis, consider adding small amts free water throughout the day to replete intravascular volume without worsening edema and improve hydration, consider dietitian's reccomendation to start TF even if only at trophic rate, continue skin/wound care as reccomended, consider reanal consult to evaluate need for HD vs. CRRT\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611703, "text": "Resp Care Note\n\nPt is vented on PCV Pi 40, + 18, weaned to 40%, RR 26. Last ABG showing compensated ( severe metabolic ) acidosis presumably due to renal failure. Pt is getting combi vent MDI Q 4-6 hrs. BS are course and diminished, there are few if any wheezes. Due to rebounded pO2, oxygen has been weaned to 40% from 55% @ start of shift. Driving pressure still @ 22, may consider decresing peep later on\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611704, "text": "NPN 0700-1900\n\nNeuro: Remains on fentanyl 75mcg/midazolam 2mg/hr; Opens eyes when turned, suctioned, sometimes to voice; no movement of extremities noted; pupils pinpoint.\n\nCV: HR 60-79, NSR with ocassional PVC; po pronestyl reordered for 500mg tid, 250mg ; ABP 83-134/41-60 with maps 58-120, SBP decreases to 80's when asleep but goes right up with stimulation; PAP 37-69/22-37 with mean 27-48; CVP 14-24; PAWP 20-22; C.O. 6.10-8.83; lasix gtt started at 7mg/hr and titrated to keep uo >30cc/hr, presently gtt is at 15mg with uo only 15cc/hr; ABP stable in low 100's, high 90's; transfused 1U PRBC's for crit 25.1; no active signs of bleeding noted.\n\nResp: Intubated on vent in PSV mode 40x18x.4x26, no changes made on vent; O2sats 96-100%; suctioned 3-4 times for moderate amounts thick dark tan sputum; lung sounds are coarse throughout; solumedrol decreased to 40mg; esophageal balloon d/c'd when tube retaped per Dr. ; oral airway removed due to sores on pt's lips.\n\nGI/FEN: Abdomen firmly distended, slightly less than yesterday per team, +BS, small amt loose brown stool X2; TF of Nepro w/additives started at 10cc/hr thru NGT, goal is 35/hr.\n\nGU: Foley draining 5-22cc/hr; lasix gtt started as above; fluid status is +1L X24hrs, +2351 for LOS. Renal U/S done per renal consult, results pending; plan is likely for ultrafiltration with CVVH\n\nSkin: Sacral decub remains covered with duoderm, due to be changed tomorrow; peri area is red and peeling, ?fungal, mycostatin powder ordered; RLE ecchymosis remains unchanged; pt has sores on L upper lip from ?oral airway vs intubation process.\n\nEndo: FSBG 49-122; insulin gtt off X 2hrs for hypoglycemia and resumed at 2units/hr with BS wnl; pt given 1 amp D50 X1 for BS of 49.\n\nID: Tmax 98.6 core temp. Remains on MRSA precautions; not antibiotics; sputum darker and thicker today.\n\nPlan: Monitor hemodynamic status, diurese with lasix gtt as tolerated, titrate to u.o. > 30cc/hr, continue cardiac meds; monitor resp status, wean sedation and vent as tolerated, suction prn; monitor crit and s/s of bleeding, goal crit >25; monitor fluid/electrolytes, ultrafiltration to decrease anasarca; monitor temp, sputum, cultures; FSBG q 1hr, titrate insulin gtt accordingly; drsg as ordered for sacral decub, turn q 2hrs, ?A& to sores on lips.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611705, "text": "Resp. Care Note\nPt remains intubated and vented on PCV settings as charted on resp flowsheet. With driving pressure of 22, TV's mid 400's with minute vent. of 11-12L. Sats 97-98% and last PaO2 157 this morning. esophageal balloon measurements this morning showed trans. pulm end exp pressure was -5. Esophageal balloon DC'd in afternoon as threaded through oral airway and 2 deep cuts noted on pt's lips from the airway. Sxn for thick tan secretions. Albuterol and Atrovent MDI given Q vent check. Plan to recheck ABG and adjust vent.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611706, "text": "Addendum to NPN 0700-1900\n\nRepeat labs K 5.0, Mg 2.1, ABG's 7.45/29/100; vent changes made as follows PSV 38/40%/24/18; will repeat abg's at 1900; FSBG at 1800 76, insulin gtt off.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611852, "text": "NPN 7A-7P:\n\nNEURO: PT INTUBATED AND SEDATED ON FENTANYL 375MCG/HR AND MIDAZOLAM 14MG/HR, WITH GOOD EFFECT NOTED. SHE RAMAINS UNRESPONSIVE WITHOUT PURPOSEFUL MOVEMENT NOTED. PUPILS 2MM AND REACTIVE. SHE DOES BITES DOWN ON THE ET TUBE WITH SX AT TIMES.\n\nRESP: VENT SETTINGS 50%X450/ PEEP5/RR 16. O2 SAT 90-98%. SX FOR THICK WHITE/BROWN PLUGS X2-3 HOURS IN MOD AMOUNTS. LS COURSE AND DIMINSHED BILAT.\n\nGI/GU: TF ON HOLD SECONDARY GROSS AMOUNTS OF RESIDUAL. NO BS. NO BM. FOLEY CATH WITH NO OUT-PUT.\n\nSKIN: DUODERM CHANGED TODAY. WOUND PINK AT BASE. MILD ORDOR NOTED. SCANT YELLOW DRAINAGE. ANASARCA NOTED. 6+ ON RIGHT FOOT.\n\nAXCESS: RIGHT DIALYSIS CATH, AND LEFT IF CENTRAL LINE.\n\nSOCIAL: HUSBAND IN TODAY. TALK TO ICU TEAM. PT REMAINS .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611853, "text": "Progress Note 7p-7a\nEvents: Pt. unchanged. No significant events throughout shift\n\nNeuro: Pt. remains sedated on fentanyl and versed. Pupils 2mm and brisk bilat. No purposeful movement noted. Gag and cough reflex impaired at this time. Pt. occassionally bites ETT with suctioning.\n\nResp: Pt. remains intubated/on ventilator. No change in settings: 50/450/5/16. Thick yellow/green sputum with suctioning.\n\nCVS: Pt. remains in AFib with rate controlled in 70's-80's. BP 40's to 60's systolic. Pitting/weeping edema in all extremities and trunk. Pulses difficult to palpate. T-max 95.6\n\nGI: Pt. remains NPO d/t increased residuals. BS ansent. OGT remains in place.\n\nGU: Foley cath in place. 7cc urine output noted.\n\nSkin: Duoderm remains on . Changed .\n\nAccess: R IJ Dialysis cath / L IJ TL Central line.\n\nPlan: Pt. remains DNR/ with no meds/lab draws. Family in to visit pt. yesterday and continue to refuse to withdraw life support d/t religious beliefs (Orthodox ). Continue to offer support to family members. pt. comfortable.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611854, "text": "Resp: Rec'd on ac 16/450/+5/40%. Bs are coarse thoughout bilaterally. Suctioned for moderate amounts of thick yellow/green secretions. Ett re-taped and secured. No vent changes noc. Will continue full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611855, "text": "Patient remains on mechanical ventilation with no vent changes.Bit on pilot balloon line during bronchial hygien. One clamp is used to stop the leak until ETT is replaced.Suctioned for minimal to small amount of secretion.Patient vot responding to commands,but visually loks better.Maintaning good saturation,BP labile with good HR;will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611738, "text": "S/MICU Nursing Progress Note\n Respiratory: cont on the vent with settings 500/20/8/.50 suctioned q2-3 hr for thick blood tinged sputum. coarse BS throughout. occasionally biting on ETT, difficult to do mouth care as pt clamping down. sedated on Versed 1mg/hr and fentanyl 50,cg/hr.\n ID: temp max 101.2 rectally, pan cultured Blood cultures x 2 one from triple lumen and one from arterial line. urine and sputum sent. cont on vanco(+MRSA in sputum, and yeast in urine from previous cutures) aztreonam. tyenol given x1\n Cardaic: HR 90-100's afib, BP 94-130/60 cont on levo at 0.05mcg/kg/min attempted to wean to 0.03 however dropped BP to low of 68/ presently levo at 0.109 mcg/kg/min\n GI: cont on TF of 3.4 str nepro with promod, rate at 35cc/hr residuals high 65cc. have not advanced rate.sm oozing of stool, +++flatus, lactolose given at 12am.\n GU: foley in place and urine yellow with sediment.output only averaging 20-30cc/hr.\n Skin: sacral decub with duoderm, numerous eccymotic areas.... increasing in size and location.. right arm pit, lower abd, right calf and left arm.\n Social: no contact tonight with family\n Plan: Pt cont to slowly have a downward course. Will not be able to wean vent. Con discussions of code status. ? need to encourage sons to travel to .\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611739, "text": "RESP CARE:Pt remains intubated with 7.0ETT/on vent on settings per carevue. No changes this shift. Lungs coarse rhonchi/wheezes bilat.Sxd thick bld tinged sputum. MDIs given Q$ with good effect. No RSBI at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611740, "text": "Resp Care\n\nPt remains intubated with a # 7 OETT and is on full vent support. Receiving bronchodilators and BS remain coarse and suctioning thick bloody tinged sputum\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611741, "text": "MSICU NPN 0700-1900\n\n\nRemains on Fentanyl and Versed gtts. No changes made. Grimaces w/turning and suctioning. Very edematous. Minimal spontaneous mvmt. Sluggish cough and gag. Fights mouth care w/ down.\n\nNo vent changes. Suct ~q4hrs for sm-mod amt thick brown,occ bld-tinged sputum. O2sats gd on 50% FiO2.\n\nT max 99.4 ax. NGT changes to OGT d/t presumed sinusitis. Nasal sprays started. Gentamycin started. Lips remain excoriated. ? HSV vs trauma.\n\nContinues on Levophed. MAPS drop below 60 gtt weaned. Currently on 0.1 mcgs/kg. Remains in Afib.\n\nUO ~ 20cc/hr. No Lasix given d/t hypotention. Renal team following.\n\nNo stool. No change in TFs. Asp 15-120cc. Plan to give Lactulose q2hr until she stools. Send stool for C-diff.\n\nHusband in most of afternoon. Updated by MD.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611742, "text": "S/MICU Nursing Progress Note\n Pt is a 80y/o woman admitted from rehab with abnormal labs,increasingly agitated and poor po intake, intially admitted to medical floor found to be in Aflutter converted to NSR chemically, over 24hrs developed SOB, and respiratory arrested.. intubated and transfer to S/MICU on . course in the ICU has been renal failure, worsening edema now +10liters for LOS, increasely infected,,, yeast in urine, gram +and neg in sputum currently on vanco,aztreonam, renal dose of gent and fluconozole.\n Pmh: see FHPA\n Allergies: Sulfa, Keflex, clindamycin and PCN\n System Review:\n Respiratory: remains intubated on settings of 500/20/. spont rate 0-4 over the vent. sedated on fentanyl 50mcg/hr and versed 1mg/hr. only bolused x2 during the night as pt biting on ETT. suctioning creamy thick bloody to blood tinged sputum. Q2-3 hr. BS insp/expri wheezes on the right. coarse on the left. right BS more diminished.\n Cardiac: HR 80-100\"s afib, BP ranged for low 70(after bolused with meds) to 120's cont on levo at 0.103 unable to titrate.\n GI: on TF on nepro with promod at goal rate of 35cc/hr. was having high residuals, giving lactolose yesterday now having loose stool mushroom catheter in place. c-diff spec sent this am.\n GU: foley in place urine output only 30-40cc/hr was on CVVHD stopped as pt was hypotensive during treatment and unable to get much fluid off. did receive lasix on Wednesday with fair response but need pressors after 8hr.\n ID: spiked sputum gram +, gram - on vanco, aztreonam, yeast in urine , fluconozole, gent x1. groin rash.\n Skin: decub on sacral aquacel and covered with duoderm. numberous areas of eccymotic areas..... right shoulder, right lower abd and right calf.\n Neuro: grimaces with turning and movement, +coughing, biting on ETT, occasionally moves her left arm.\n Social: no contact with family during the night.\n Plan: cont to monitor. unable to wean vent, unable to wean pressors.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611743, "text": "RESP CARE: PT REMAINS INTUBATED/ON VENT PER CAREVUE. NO VENT CHANGES THIS SHIFT. LUNGS COARSE WITH WHEEZES BILAT. SXD THICK BLD TINGED SPUTUM. PT BITING ON TUBE AT TIMES. NO RSBI THIS AM DUE TO HEMODYNAMIC INSTABILITY.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611744, "text": "Resp Care\n\nPt remains intubated and on full vent support. BS remain coarse and suctioning thick blood tinged sputum. Receiving bronchodilators\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611687, "text": "NARRATIVE NOTE:\n\nRESP: PT ARRIVED FROM FLOOR PRIOR TO SHIFT. INTUBABED. PLEASE SEE CARE VUE FOR VENT CHANGES AND ABGS DRAWN THROUGHOUT SHIFT. PRESENT VENT SETTINGS ARE PCV 50%,RATE 26, PEEP 10, AND ISP PRESSURE 35.LUNGS VERY COARSE THROUGHOUT WITH SX Q 2-3 HR FOR MOD TO LG AMTS OF BRIGHT RED BLOOD. SAO2 HIGH 90'S.\n\nCV: B/P HAS RANGED FROM 116/31-171/74. SB SR WITH HR RANGING 56-84, NO ECTOPY NOTED. PPP. PT HAS + EDEMA IN EXTREMITIES. HCT AT 2100 26.5 DOWN TO 23.8 THIS AM. INTERN NOTIFIED. PT WILL A UNIT OF BLOOD. PT HAS ONE SMALL IV ACCESS AND INTERN AND RESIDENT WILL REPEAT ATTEMPT TO START A TRIPLE LUMEN. K HAS BEEN HIGH, PT 30GM OF EX AND A DOSE OF LACTULOSE THIS AM AS PT HAS HAD NO RESULTS AS OF YET.\n\nNEURO: PT ON VERSED AT 4MG/HR WHICH WAS TITRATED UP FROM 2MG. ALSO ON FENTANYL AT 75MIC/HR. PT NOT FOLLOWING COMMANDS. WITHDRAWS TO PAIN. OPENS EYES TO PAINFUL STIMULI. + GAG AND COUGH. R PUPIL SLUGGISH. LEFT BRISK.\n\nGU: FOLEY CATH PATENT, HAD BEEN REPLACED DURING SHIFT, THE FOLEY PT ARRIVED WITH WAS NOTED TO BE OUT. U/O MARGINAL. PT DID ETHACRYNIC 50MG. UNSURE HOW EFFECTIVE AS FOLEY DISLODGED. BALLOON ONLY SLIGHTLY INFLATED ON OLD FOLEY. NG TUBE PLACED WITHOUT DIFFICULTY. PLACEMENT VERIFIED BY XRAY., AND BY AIR BOLUS AND ASPIRATION. ABD SOFTLY DISTENDED. BS+ X4 QUADS.\n\nSKIN PT HAS STAGE III PRESSURE ULCER ON COCCYX. DUODERM PLACED.\n\nPLAN: PLACE A CENTRAL LINE AND PROVIDE BLOOD PRODUCTS AS NEEDED. PROVIDE RESP SUPPORT AS NEEDED, WITH ABG'S. MONITOR HEMODYNAMICS . PROVIDE SUPPORT TO FAMILY WITH UPDATES AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611688, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated on the vent with settings of PCV driving pressure 26, PEEP 10cm, inspir Pressures 36, maintaining TV 440-500cc with minute ventilations of liters/minute. When pt coughing,or appears to be bearing down will drop her TV 100-200cc and then will block to a HR 38-40SB, slight drop in BP however will resolve with boluses of sedation. Have suctioned to evaluate possible plug, secretions are bloody to old blood no plugging. Secretions are thick not really frothy or thin (as CHFvs pul edema are part of differatal dx.) FIO2 at 50%(tried to wean to 40% and pAO2 down to 69)BS coarse througout. on alb and atrovent\n Cardiac: Hr 60-70 NSR(P waves sometimes difficult to see however confirmed on EKG) will block to 34-40's with drop in her TV/minute ventilation. BP stable 110-130/60's this am after multiple boluses of sedation pt did drop her BP to 84/ due to 2 Units of RBC's transfused each over 2hr, CVP ranged 10-14 this morning after 2uints of RBC then up to 15-16(on 10cm of PEEP) did give 100mg ethnacrynic acid. with good response. u/o 330cc after dose. Norpace dose D/C started on procaimide at 2mg/min over 24hours, levels to be checked in the am. QTC at start of IVF 368(by 12lead).Serum K 5.6 am no change all day. repeat level tonight.\n Renal: poor u/o all day slight improvement after dose of ethnacrynic acid. BUN 68 creat 1.2 urine lytes sent to evalutate possible ATN\n GI: NGT in place, aspirates coffee grounds, clears after 100cc flush ( ?trauma from insertion) hct had been 23 received two units of RBC post tx hct 27.5 will repeat at 1800. no stool today, +flatus, lactose given this am no results. serum K 5.6(no peaked T on EGK)\n Neuro: sedated on Versed 4mg/hr and Fentanyl 100mcg/hr. grimace with pain, slight tremor noted in the left arm. no spont movement. Pupils Pinpoint.\n endocrine: once IV access was obtained started on IV insulin at 12pm low dose 0.5 to 1unit/hr. titrated accordingly. FS qhr.\n IV: quad lumen place in the right IJ after multiple attempts in the subclavian. CXray done post procedures. Perpherial IV in the left hand. Art line left radial.\n Skin: sacral decub, open through epidermis, no drainage, douderm placed 3 & 4 + pitting edema on extremites. right foot skind cracked and started to ooze fluid.\n ID: low grade temp only 99.8 po blood cultures x2 today, sputum x1 sent for culture. urine had been sent yesterday. not on antibx.\n Plan: diursis, follow I&O's closely with CVP, monitor ABG and wean accordingly. still feel event that cause her respiratory arrest was sudden unclear etiology. differital DX, CHF, PE, pneumonia(?inflitrate in right upper lobe) or COPD. pt has hx crushing CP the evening before event. CPK presently flat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611689, "text": "Respiratory Care:\nPt remains on PCV. Bleeding on and off today via lung ??? Occasionally over breaths the vent. ABG @ 13:34 7.32 40 81 22 -5. Develops lo MV's that trigger lo sats but these episodes have spontainously resolved. Look at CareVue for detals.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611766, "text": "NPN\n\nNeuro: Conts on fent and versed, she woke suddenly - eyes open, appeared scared, SBP was in the 170s, I told her where she was and why she was here, she requred a total of 300mcg of fent and 15mg of versed before she was sedated again. She has woken periodically through the day, she again has required fent and versed bolus though not as large, when she cough or fight the vent then the CVVHD shuts off greatly increasing the risk of it clotting.\n\nCV: Pt became hypotensive this morning BP 60/30, CVP OF 6, levo was started. She is currently on .09mcg/kg/min of levo, she conts on CVVHDF with the goal of even for the day. She had one episode of bradycardia to the 30s when the levo was started, she has since had a HR in the 60s-80s, afib, occ PVCs.\n\nResp: Conts on A/C, new settings of 450x22/12/.5, sx for min amounts of reddish sputum. LS diminished.\n\nGI: ABD firm and distended though less this afternoon after she was given lactulose. No today so far. She conts on TF 3/4 strength Deliver with 55 gms Promod at the goal rate of 35cc/hr.\n\nGU: The CVVHDF conts, the pt removal rate was 0 this morning while she was hypotensive, after her BP came up with the levo fluid was again removed with a pt removal rate of 100cc/hr. She is presently ~ 100cc neg since MN, her goal is even for today, when she tolerates being off of the levo than we will again try to make her fluid balance neg each day.\n\nEndo: She conts to have high BS, her long acting insulin will be increased this evening.\n\nID: She has been afebrile, WBC 7, gent is now q24 hrs with peak and trough levels being followed, conts on aztreonam and vanco - she needs a peak vanco at 8 pm. Total body anasarca conts, she is weaping from any open areas including her IV sites.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611767, "text": "Resp. care note - Pt. remaines intubated and vented, fio2 rr and peep weaned pt. tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611768, "text": "Smicu nsg progress note\n Pt initially well sedated on 225mcg/kg fent and 7.5mg versed. Not requiring additional boluses even with turning. At 4am pt becoming suddenly more awake with eyes open increased hr/bp. Given additional boluses fent/versed and pt evenually settling down.\nCardiac- Bp relatively stable. Able to wean levo from .07mcg/kg to .03mcg/kg. Does have intermittent periods with bp down to 90's but increases to 110-120's without intervention. Remains in af with hr 70-110.\nResp- Remains intub/vented. Peep weaned to 10. Abg on ac 450x22 50% 86/41/7.39. Suctioned for mod amts thick tan secretions requiring saline instillation.\nRenal- Cvvhd on hold. Will readdress in am. Cont with minimal urine output(see flow sheet). Also with total body anacarcia- weeping from arms/legs/iv sites. Lytes/bun/creat have been stable.\nGi- Cont on goal tube feeds without problem. Passing sm amt brown stool via mushroom cath.\nId- Remains afebrile. No changes in antibiotics.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611769, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated this AM. Peep decreased to 10. Sxn for thick blood tinged secretions. BLBS are coarse.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611801, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains intubated with settings of 450/16/.50/10 spont RR 0-3 over the vent. suctioned Q3-4 hr for thick white sputum. BS coarse throughout, with diminished at the bases.\n Cardiac: remains on Levophed to maintain SBP>90 attempted to wean to off and SBP dropped to low of 82/ back on levophed at the original dose...0.03mcg/kg/min. urine output only averaging 10-30cc/hr. still is 12liter LOS + for fluid balance, anascara,\n Renal: off CVVHD during the night to be restarted in the am. ended yesterday -1600cc for 24 hr. urine output only 10-30cc/hr.\n GI: cont on TF of deliver with promod at 35cc/hr tolerating well. low aspirates, receiving lactolose and colace. stool output averaging 200cc for 12hr. period.mushroom catheter in place. NGT orally.\n Neuro: cont on sedation of fentanyl at 350mcg/hr and versed at 12mg/hr. will open eyes to stimuli, not moving exteremites....however they are very edematous and very difficult to move.\n Skin: sarcal decub dsg changed today area size remains unchanged. still 4cm length and 3cm in wideth. healing well.\n Social: no contact with family during the night.\n Plan: CVVHD this am, cont with goal to diuresis 1.6 liters off /day.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611802, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 10. Sx'd for sm amounts of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr. O2 sats 98-100%. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611803, "text": "SMICU NSG PROGRESS NOTE\nNeuro- Remains essentually unresponsive on 350mcg fent and 15mg midaz. Pt will bite down and grimise with turning but does not follow commands. No spontaneous movement noted. Cont with total body anacarca.\nCardiac- Bp stable on .03 mcg levo. More tachycardiac today with hr 98-112 af. ? r/t fluid status. Lytes stable.\nResp- Intub/vented. No changes made. Cont with minimal et secretions. Lg amts thick tan oral secretions. Cont to bite down with any stimulation. Will need to address need for trach if decision made to cont tx.\nRenal- Cvvh restarted. Able to maintain goal of 100cc neg/hr. Goal is to remove ~ 1-1.5l/day. Of note, filter pressures have been on high side even when cvvh first initiated. Renal notified. If Cvvh cont after discussion with family tommorrow ? consider heparin. Also ? need to change dialysis line. Cont with minimal uo.\nGi- On goal tube feeds. Abdominal appears firmer today. Still with good bowel sounds. Cont to pass mod amts liquid stool. Following fs Q6hrs on s/s and qpm glargine.\nId- Cont afebrile on current antibiotics.\n Pt's husband in to visit most of day. Updated on pt condition. Plans to attend family meeting on Monday to discuss further care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611804, "text": "Resp Care\n\nPt remains intubated and on full vent support. No changes in ventilation made. BS coarse. Spo3 96%\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611751, "text": "Nursing NOte 7p-7a:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNEURO: Pt remains sedated on fentanyl/versed. gtts increased secondary to biting of tube and not synchronizing with ventilator. Pupils fixed/nonreactive. eyes open to pain. no spontaneous movement of extremities. cough/gag decreased.\n\nCV: PT received 1 unit PRBCs on evening shift for hct 27.2 AM CBC pending. HR 70-90 Afib/no ectopy. Remains on levophed gtt @ 0.08 mcg/kg/min MAPs range from 60-70. Goal MAP > 60. +4 anasarca + pulses.\n\nPULM: Pt switched back to AC-20 50% TV 500 peep 5 after becoming increasingly acidotic. pt extremely bronchospastic, inhalers given by RT q 2hours. Suctioning mod amount thick/tan blood tinged secretions. sats 96-100% last abg 7.34/42/91/24\n\nGI/GU: Abd large, firm distended. + BS X 4. - BM overnight. PT tolerated TF @ 35 cc/hour (goal) infusing via oral peditube. Placement confirmed with air bolus no residuals noted. foley draining amber/clear urine, UO 30cc/hour.\n\nEndocrine: Pt remains on insulin gtt @ 1.5 units/hour. COnt to check glucose q 2 hours. Fingersticks range from 105-130 overnight.\n\nSKin: PT bathed. Sacral decub with duoderm dsg c/d/i. old healed ulcer on right leg OTA, multiple ecchymotic areas will cont to turn side to side as tolerated.\n\nPLAN: antibiotics, wean vent as tolerated and follow abgs, wound care, follow H&H transfuse as needed, titrate levophed to maintain MAP > 60, fingersticks q 2hours adjust insulin gtt per protocol, cont with current , cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611752, "text": "Resp Care\n\nPt remains intubated and in full vent support. Attempted to change mode to psv but abg after 1hr 15 minutes reveal a respiratory acidosis. (7.27/51/81/24) Mode was than returned to A/C. MV on PSV was approx. 6L. On A/C MV is 9L. Lung examine reveals inspired and expired wheezing. Pt receiving bronchodilators. Suctioning thick blood tinged sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611753, "text": "MSICU NPN 0700-1900\n\n\nPlease see flowsheet for further details...\n\nArousable to pain. Grimaces w/turning and suctioning. Very anasarcic. Appears comfortable when left alone. No changes made in Fentanyl and Versed gtts.\n\nAttempted PSV trial w/20cm PSV and 5cm PEEP. She dropped MV < 7L despite inc RR. ABG w/ Ph 7.27. Returned to A/C mode. Suctioned q3-4hrs for sm-mod amt brownish tan sputum.\n\nLevophed gtt weaned from 0.1 to 0.04. Current MAP 58. Remains in AF.\n\nUO ~ 25cc/hr. Wt continues to climb.\n\nAfebrile.\n\nTol TFs at goal rate. No stools. Hypoactive bowels sds. Lactulose given x2.\n\nHusband in all afternoon. Plan for conference call with sons and medical team this evening.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611697, "text": "Resp. Care Note\nPt received intubated and vented on PCV settings as charted on resp flowsheet. Pt with marginal oxygenation despite peep 10 and 60%. Esophageal balloon placed which showed pt was under-peeped. Peep increased from , with an end exp trans pulm pressure of -5. Peep later increased again to 18 with some improvement in oxygenation. Currently ventilated with a driving pressure of 25 and Tv 450-500 range. Albuterol/ Atrovent MDI Q vent check. Sxn for blood tinged secretions. Cont current support, follow ABG's, adjust vent.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611844, "text": "d: pt's condition unchanged. pt unresponsive on fentanyl and versed gtts at rates/doses documented in careview. no vent changes made. pt wiht rhoncherous bs bil and exp wheezes as well. suctioned ett for mod amts of thick yellow/green sputum. hr afib with rate of 80-100's without ectopy and sbp 40's to low 60's.foley in place with no uo this shift. pt is dnr/ but family will not withdraw ventilator support b/cause of religious beliefs. continue with present medical management. pt's husband and son in to visit at bedside for short period of time today. will continue to support family members,\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611845, "text": "Smicu nsg progress\nS/O- Remains unresponsive with minimal bp. Still with no urine output. Remains on ventilator without change.\nA- No change\nP- . family support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611846, "text": "Resp: Pt remains on intubated and vented on a/c 16/450/50%/+5. ETT #7, 22 lip. BS are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. No abg's or changes noc. Will continue full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611847, "text": "nursing progress note: pt is DNR comfort measures only\n\nneuro: pt remains unresponsive. only response was biting et tube upon suctioning and inc resp rate with bathing. pupils 1 mm unresponsive to light.\n\ncard: bp 40-60 sys rate 80-100 afib with rare pvcs\n\nresp: remains vented with 16 bpm, 50% o2, 5 peep tv 500 CMV\nsuctioned by resp care.\n\ngi: htpoactive bs, no bm this shift\n\ngu: renal failure, no output this shift. intake is only iv meds infusing\n\nskin: duoderm patch to in place, arms edematus and weeping serous fluid. otherwise no other breakdown areas\n\nmeds: ONLY CHANGE MADE WAS TO CONCENTRATE MIDAZOLAM TO 250 MG IN 125 CC.\n\nFAMILY SUPPORT: SON\n called and asked to be called if death seems immediatly eminent.\nhusband not in due to sabbath.\n\nplan> support to family and maintain measures for pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611848, "text": "Respiratory Care Note\nPt remains on AC as noted. BS coarse bilaterally. Pt suctioned for moderate amts thick yellow-green secretions. No vent changes. Plan to continue with current rx plan.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611849, "text": "Progress Note 7p-7a\nNeuro: Pt. remains sedated with versed/fentanyl. Pt. unresponsive. Pupils 1mm and brisk bilat. No purposeful mvmt. noted.\n\nCVS: SBP remains 40's to 60's. HR 70's to 90's - AFIB. 4+ pitting, weeping edema. Pulses difficult to palpate.\n\nResp: Remains intubated. On ventilator: 50%/5/500. Thick green/tan secretions with suctioning. Insp/Exp wheezes present with auscultation of breath sounds.\n\nGI: Bowel sounds remain hypoactive. OGT in place and clamped. No BM noted this shift. Pt. remains NPO.\n\nGU: Pt. in renal failure. No urine output this shift.\n\nSkin: Duoderm remains over . Otherwise .\n\nAccess: R IJ Dialysis cath, L IJ central line.\n\nPlan: Pt. remains DNR/. Family continues to refuse withdrawal from ventilator d/t religious beliefs. Continue with support to family and pt. comfort.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611813, "text": "npn 7p-7a (see also carevue for objective data)\n\nPt admitted to ICU ; pt remains seriously ill; family has been discussing pt's prognosis since and direction of care; consulting with family's religious guidance re end of life issues;\nPt made DNR yesterday, ; pt remains on fentanyl and versed for comfort;\n\nPt remains unresponsive except for opening of eyelids to noxious stimuli; no eye tracking observed; no spontaneous movements observed;\n\nRemains in a-fib with controlled ventricular response; b/p adequate, vasopressors remains off; b/p does trend down when not stiumlated for awhile; when turned or stimulated, sbp goes up to 110's, even 130's with noxious stimuli;\n\nVentilator support witout changes; O2 sats remain in 90's;\nContinues on tube feedings at this time;\n\nturned approx. q 3 hrs to prevent further skin breakdown; duoderm on ; skin remains with much interstitial fluid; no more SQ FS's or injections per plan;\n\nPLAN:\ncontinued plan of care MD team and Family\nDNR\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611814, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnoc. MDI's DC'd. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611815, "text": "NPN\n\nPt remains sedated, the fent was increased to 350mcg/hr and the versed to 12 mg/hr. She had been opening her eyes with any care and now she does not, she appears comfortable. Her husband has been in the room since 11 am. The PEEP was decreased to 5k, her 02 SATS have been 100%, overbreathing the vent by 1, she conts on comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-28 00:00:00.000", "description": "Report", "row_id": 1611816, "text": "S/MICU Nursing Progress Note\n Pt remains on the vent with settings of 450/16/50/5 sedated on fentanyl 350mcg/hr and versed 12mg/hr, BP and HR elevates with care, turning requiring some boluses of meds. Pt DNR\n Cardiac: HR 80-100's afib, with rare PVC, BP ranged from low of 90 to 130/'s\n GI: Tf of deliver with promod rate at 35cc/hr abd firm hypoactive BS, fair amount of oral drainage, creamy purlent, difficult to give mouth care as pt is still clenching her jaw. +loose stool.\n social: son called and updated on his mother. states her other son is trying to come home on Sunday.\n Plan: goal is comfort care. Per husband and rabbi with feeding and vent support.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-28 00:00:00.000", "description": "Report", "row_id": 1611817, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..no changes made today..\nSuctioned for large amts tan secretions. Large amt of oral secretions..often blood tinged. Sats in high 90's..rare spont rr.\n Cardiovascular: BP on lower side this am..in 80's..by late afternoon..in the 60's. A-line dc'd..following with NBP More tachycardic..?d/t fever..\n ID: Febrile..given tylenol\n GI: TF continue..no stool..\n GU: Poor u/o..<10cc hr.\n Pt remains comfort care..on 350 mic fentanyl and 12mgm versed..appears comfortable.\nHusband in and son from called..updated.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611698, "text": "Addendum to Nursing Progress Note\n Cardiac: Pt dropped her HR to 48 at 1500 with a drop in SBP to 88/ treated with suctioning and NS instill, slight improvement in hr up to 60's with BP up to 90-100/ started on hydralazine tonight to tx afterloading her.... unable to given 1800 dose. EKG done after episode of bradycardia.\n Plan: vagal response. cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611699, "text": "FULL CODE Contact precautions - MRSA in wound\nAllergies: PCNs, Sulfas, Clindamycin and keflex\n\n\nNeuro: Opens eyes/grimaces to stim w/ sucioning, turning, etc. Does not track or follow commands. Does not move extrems. Versed at 4mg/hr and fent at 100mcg/hr. Pupils pinpoint.\n\nCV: HR at beginning of shift was 40-50s, SB w/ no ectopy and SBP was 88-90s/. No intervention and BP came up to 140s/50s and HR to 60-70s. Started on hydralazine 10mg q6hr to reduce afterload. Procainamide stopped at midnight and started on po. Weak periph pulses, hands and feet cool bilat. +anasarca., scleral edema.\n\nResp: PVC 60%, RR=26, P=18 and Vt=500. ABG=7.39/28/94/-. Sx for thick bloody secretions. Lungs clear bilat earlier in the shift but coarse now and sx more freq for same bloody secretions - brown/tan oral secretions. At 0400, pt dropped SBP to 88/ for no apparent reason - pt stimulated, sx'd and BP up to 100-110s since.\n\nGI/GU: abd firm/distended, hypo BS. NPO. Pt stooled x2 small amt thick brown BM. NGT to LCWS, draining small amt dark brown bilious drainage - heme +. Foley cath w/ << u/o - 0-30cc/hr. HOs aware. No rx ordered at this time. BUN/Cr: 71/1.6 (sl ^ from yesterday's labs)\n\nPain: Fent and Versed gtts.\n\nSkin: Acquacell drsg , R leg calf still w/ large hematoma - seen by surgery tonight for calf.\n\nID: Tmax 99.3, not on antibx.\n\nEndo: FS range from 89-133 w/ insulin gtt at 1.0 unit/hr. HCT=27.7 (down from 28.9)\n\nPlan: Monitor resp/cardiac/neuro status. Drainage from NGT and ETT bloody.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611700, "text": "Resp. Care Note\nPt remains intubated and vented on PCV settings as charted on resp. flowsheet. Vent changed this shift included driving pressure reduction from 25-22 and FiO2 decreased from 60-55%. Acceptable ABG's with these changes. Cont to receive Albuterol and Atrovent Inhalers Q vent check, sxn for blood tinged secretions. Stable on present settings, follow ABG's, wean FiO2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611762, "text": "RESPIRATORY CARE\nPt remains on mechanical ventilation, oxygenation remaining a high priority issue. Increase in PEEP as well a decrease in Vt as a result of ABG results. Breath sounds diminished throughout.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611733, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated and vented on settings 500/20/0.5/8 suctioning for thick creamy blood tinged sputum q3-4hr. BS remain coarse throughout. O2 sat cont 98-100%.\n Cardiac: Hr 80-100's ST with frequent APC's received lasix at 2200 and output averaging 50-100cc/hr. still total body edema.\n GU: foley again leaking in large amounts. replaced foley again. only leaking in sm amts. urine clear.\n GI: abd distended. +BS, no stool. low residuals on TF only 20-30cc, cont on nepro with promed at 35cc/hr.\n SKIN: rash in groin area, improving. less reddened. cream and powder applied. numberous areas of eccymotic areas. right calf area, lower area of abd... ?from SC heparin, right chin area. and right shoulder area.\n Neuro; pt cont on sedation of versed 1mg/hr and fentanyl 50mcg/hr with fair response, pt will open eyes to name, moves left arm better than right but will move right arm... both very edeamtous. .. difficult to move. bolused once for replacing foley as pt grimacing during procedure.\n ID: afebrile. cont on vanco(dosed last night) and atroeznam. MRSA in sputum and yeast in urine. (yeast in groin on supporitories)\n SOcial: updated via phone tonight.\n Plan: ?cont to diuresis as long as pt tolerated, monitor I&O's closely. attempt to wean vent further.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611734, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes overnoc, though increased FiO2 this am for poor PaO2. BS's coarse, sxing bloody secretions. Administering Albuterol and Atrovent MDI's in line with vent ~q4hrs. See flowsheet for further data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611735, "text": "Respiratory Care Note:\n There are no vent changes to note. BS remain coarse and wheezy at times. She continues to be suctioned for moderate amounts of thick brownish-blood tinged sputum. ABGs maintained without increased support despite fever and need for dopamine at times. Plan to continue monitoring and maintain support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611736, "text": "NPN\n\nNeuro: Remains on fent 50 mcg/hr and versed 1 mg/hr, more sedate than when I saw her on Monday, she only required 1 fent bolus on 50 mcg for fighting the vent.\n\nCV: Her BP dropped this morning to the low 70s, temp 100.8, she was started on dopa but with in a few hours she started to have short runs of Afib and then went into a rapid (~ 150) SVT; she was changed to levo. Her SBP has since been 90s-120s, levo is on .08 mcg/kg/min. She remains in afib, her K was repleated, she was given 2 units of blood for a HCT of 25.\n\nResp: No changes were made on the vent, conts to have thick, old bloody secreations.\n\nGI: Her residuals were as high as 150 today, she was given lactulose - no results yet, she had 65cc on her last residual check. TF changed to 3/4 strength nepro with 40 gms of promod.\n\nGU: U/O ~ 20-45cc/hr, no plans for CVVHDF per renal due to her hypotention. A u/a was sent - it showed 53 WBC, mod bacteria, many yeast.\n\nHeme: HCT was 25, given 2 units of PRBC, she bled from her SC line - this stopped after 10 min of pressure.\n\nEndo: Conts on an insulin gtt, her BS have been high today, she is up to 4 units/hr.\n\nID: T max 100.8, u/a sent showed many yeast, mod bacteria, and 53 WBC, fungal clx were sent.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611737, "text": "Correction - Pt is on strength Deliver with 40gms of promod - goal rate of 35cc/hr\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611763, "text": "MSICU NPN 0700-1900\n\nPlease see flowsheet for further details...\n\n\nRemains sedated on Fentanyl and versed gtt. No changes made. Grimaces with stimuli. No spont mvmt. Anasarca continues.\n\nOn CVVHD. Tol well. Able to wean Levophed off without problem. UO has progressively decreased. Currently she is anuric but is 1228cc neg since midnight. 1 interruption in therapy d/t clotted filter. Resumed without problem. Is now being ultrafiltrated only. Labs pnd. Miscellaneous (not measured) output of mod-lg amt of PO secretions as well as mod-lg amt of serosanguinous drainage from around L SC. Dialysis cath oozing sm amt blood.\n\nAfebrile. On steroids. Previous sputum growing 3+ GNR. Given Gentamycin x1. Will need trough at 1100 tomorrow. No other antibiotic changes made.\n\nABG w/PaO2 56 despite O2sat via oximetry of 97-98%. PEEP increased to 15cm (from 12) with increased PaO2 to 60s. ABG pnd. Suctioned q4-6hrs for sm amt brown sputum. PIPs 50s. Overbreathing vent at times w/ spont RR 4-8.\n\nTFs at goal rate. Promod increased d/t improved renal function. No stool via mushroom catheter. Hypoactive bowel sds. Abd remains firm and distended. Lactulose given x1. Previous stool sample C-diff +.\n\nHusband in all day. Updated by MD. called.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611764, "text": "Smicu nsg progress note\nNeuro- Well sedated on 170mcg/hr fent and 5mg/hr versed. Requiring only one additional bolus of fent when turning pt. Does grimice with any stimulation. No spontaneous movement of extremities noted.\nResp- Remains intub/vented on ac 470x28 60% 15peep breathing above with 02 sats 99-100%. Abg 82/38/7.41. Suctioned for sm amts thick tan secretions via et bloody secretions from mouth. Oral ulcers noted. Et tube rotated and bite block applied.\nCardiac- Bp remains stable off levo (see flow sheet) Able to maintain cvvhd goal of -100cc/hr. Pt ~1700 cc neg at 12m. Cont with total body anacarcia weeping from iv sites/arms/legs. Lytes remain stable.\nRenal- Cont on cvvhd- hemofiltration only/no dialysate. Bun/creat stable at 68/1.2. Cont with minimal urine output. Lytes/cal stable.\nGi- On goal tube feeds. Passing sm amt liquid brown stool via mushroom cath.\nId- T-max 97 ax. Blankets appied. No changes in antibiotics. 1000mg vanco- level 13.5. Will need to check random gent level at 11am .\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611765, "text": "RESP CARE: Pt remains orally intubated/on vent on settings per carevue. PIPs high this shift 40-55. Dysynchronous breathing pattern noted,No auto-peep. ABGs acceptable but Pa02 only 75 on 15PEEP/.60FI02. Lungs coarse bilat. Sxd thick tan bld tinged sputum. ETT retaped/rotated and new bite block placed at lip line 22. Continue full support\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611836, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift, sats at 100%. for small amounts of thick tan secretions. current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611837, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 5. Bs coarse with few rhonchi bilaterally. Sx'd for sm amounts of thick yellow secretions. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611793, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift. Cont to receive MDI's as ordered, by RN for thick secretions. Cont current vent support, no weaning planned as peep level remains at 12.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611794, "text": "micu/sicu nsg note: 7:00-19:00\nthis is an 80 y.o. woman adm originally to 12 from epic rehab hospital for elevated bun of 80, dehydration with hx dm, recent uti. pt developed hypercarbic resp failure and was intubated for management of chf. pt has been difficult to wean from vent currently on same settings as previous shift per team plan (see resp). pt has received cvvh with last course from -am of until system clotted off and pt was trialed on lasix gtt. pt currently on lasix gtt until machine and supplies ready for restart of cvvh. pt remains full code with cpr not indicated.\n\nneuro: pt remains sedated on fentanyl 300mcg/hr and versed 10mg/hr appearing comfortable at rest but grimacing with repositioning and suctioning requiring boluses with good effect. perrla pinpoint and brisk. opens eyes to suctioning and repositioning, otherwise no movement noted.\n\ncv: hr ranging 70s-low 100s afib with occas pvcs in pm. awaiting pm k results. sbp ranging 80s-130s with levophed titrated up to .030mcg/kg/min. continues with generalized anasarca, weeping small amts serous fluid from l arm. + pp. remains on iv lasix gtt (see gu).\n\nresp: remains intubated on ac: fi02 50%, tidal volume 450, rr 16, 12 peep. lungs coarse t/o. suctioned via ett for small to moderate amts very thick white secretions requiring ns instillation q2-4hrs. also suctioned small amts whitish clear blood tinged secretions from mouth with small tip catheter as pt clenching teeth together making it hard to suction with yankauer. pt not biting down on tube, has some missing teeth. frequent mouth care given.\n\ngi/gu: abd firm, distended, +bs, tolerating tube feedings at goal rate of 35cc/hr with 10-50cc residuals via ogt that was replaced yesterday and reconfirmed via cxr. had lg brown liquid stool in am inc. on pad as mushroom cath found out. new mushroom cath reinserted with 400cc liquid brown ob negative stool. lactulose held but continues on reglan and narcan iv as pt remains on high dose narcotics and was recently having min bms and was off tube feedings when found to have asp when prior ogt was found in the esophagus. foley patent draining poor u.o. in am down to as low as 15cc/hr with iv lasix gtt increased to 8 units/hr. u.o. now remains > 30cc/hr but pt still remains positive with +470 last 24hrs and + los. awaiting cvvhd machine and supplies to restart cvvh per team. cr also starting to rise, currently at 1.4.\n\nskin: with duoderm with skin care rn up to see wound but not due to be changed today so per wound care rn, duoderm remained on. per skin care rn, wound was last seen to have pink stage 2 area with small amt serosanguinous drainage-cleansed with wound spray cleanser followed by aquacel over wound and covered with duoderm. abd with bruising from heparin sc injections noted. weeping from l arm with pad around l arm.\n\nid: t max 97.8 ax, remains on iv meropenem day #7 for pseudomonas, po flagyl day #11 for cdiff. pt was recently tx'd with vanco and aztreonam empir\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611795, "text": "micu/sicu nsg note: 7:00-19:00\n(Continued)\nically for likely vent associated pna. pt was also recently tx'd with fluconazole for yeast in urine. bld cx negative to date.\n\nlines: quad lumen l ij placed , l rad. aline placed , r ij quinton cath placed . all lines .\n\nsocial: husband in to see pt for a few hours early this afternoon and briefly spoke with ethics md dr. re: issue of continuing all care for pt. husband verbalized to myself and dr. that he doesn't know what his wife would have wanted for care/if she would have wanted to continue to live on vent, have cvvh and other invasive procedures despite not much improvement in pt's condition. husband also verbalized he wishes to continue with all care as he feels he cannot make the decision to stop this care. this rn gave update to pt's son in . no contact with son in . this rn encouraged husband to contact to come in to see his mother in this condition as it has bveen a few weeks since has last seen his mother per husband. Dr. is available by page this weekend if staff and or pt's family needs to speak with him for support.\n\nendo: fs down to 69 this am with insulin gtt off, restarted when >100 and currently infusing at 4 units/hr. received full dose lantus this pm as pt now at goal rate of tube feedings and tolerating well.\n\nplan: start cvvh this pm when machine/supplies available. continue iv lasix until cvvh started. monitor lytes. continue vent settings with no current changes and reassess in am, continue iv sedation and give boluses with repositioning to maintain comfort. continue to monitor bld glucose q1hr with insulin ss- ? change over to ssri in am if bld sugars remain stable overnight. continue iv/po abx, monitor temp, consult dr. prn for support. encourage son to see pt if he calls, pt remains full code with no cpr indicated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611796, "text": "NPN 1900-0700:\n\nEVENTS: CVVH intiated and Lasix gtt stopped. Weaned off Levophed.\n\nROS:\nNEURO: Pt remains sedated on Fentanyl and Versed gtts; rates increased d/t pt appearing uncomfortable. She has also required boluses for turning/bathing. No spontaneous movement; extremities very stiff (possibly at least in part d/t fluid overload). Pupils pinpoint and reactive.\nRESP: PEEP decreased to 10; no other vent changes made. Most recent ABG 7.39/43/100 on CMV .5/450/16/10. Minimal secretions despite NS lavage. LS slightly coarse at times, diminished at bases. CXR to be done this AM.\nC-V: HR and BP gradually increasing overnight, ? d/t undersedation. Fentanyl and Versed gtts increased; will monitor response. Levophed gtt weaned off. Remains in afib with occasional PVC's. Lytes WNL.\nID: Afebrile, WBC increased to 17.4 (10.4). Cont's on same abx.\nGU/RENAL: Lasix gtt stopped and CVVH initiated at 2130 with goal PFR of 100cc/hr (not being dialyzed). She has tolerated this very well and there have been no problems with the system thus far. U/O ~20cc/hr on Lasix, now <10cc/hr. BUN/creat down a bit to 63/1.4.\nGI: TF's at goal of 35cc/hr; continues to tolerate this well. OGT clogged a couple of times and was cleared with Coke. Remains on numerous bowel meds, passing liquid brown stool via mushroom catheter.\nHEME: no active issues\nENDO: Insulin gtt currently at 1u/hr; FSBS stable and within desired range.\nSKIN: Remains anasarcic; Duoderm remains on ; skin otherwise .\nSOCIAL: no calls or visits\nACCESS: RIJ Quinton, LIJ quad lumen, L radial a-line\n\nA: tolerating fluid removal; improved oxygenation; off pressors; increased sedation needs\n\nP: Ensure pt comfort; continue CVVH for goal PFR 100cc/hr as tolerated; follow lytes q6 hours, particularly Ca++; follow temps and use Bair Hugger prn; consider changing to SSRI given minimal insulin requirements; wean PEEP/FiO2 as able; continue bowel meds prn. Plan to revisit goals of care on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611797, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. Bs coarse bilaterally. Sx'd for sm amount of thick white secretions. Albuterol/Atrovent MDI given Q4hr. Peep weaned to 10. Abg's within limits with PaO2 100. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 10. ETT retaped 22cm/lip on L side. No further changes made. Continue with mechanical support and wean peep/A/c rate as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611798, "text": "ADDENDUM:\nCVVH system clotting; new system primed and started at 0700. A-line becoming very positional, NBP utilized. BP dropping, so Levophed restarted at previous rate of 0.030mcg/kg/min.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611695, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS VARIED WITH A RANGE FROM 122/54-161/68. CM PATTERN HAS REMAINED SB/SR WITH H/R RANGING IN THE 50-60 RANGE. NO ECTOPY NOTED NO AFIB/FLUTTER THROUGHOUT SHIFT. CVP 21-23 RANGE. PPP BILAT, PT HAS 3+ PERIPH EDEMA IN THE HANDS AND FEET. PT RESTARTED ON PRONESTYL GTT AT 2MG/MIN. ECHO ORDERED FOR TODAY.\n\nRESP: REMAINS ON PCV WITH FIO2 OF 50%, INS PRESSURE OF 35, RATE OF 26, SAO2 HAS BEEN 97-100% WITH VOLUMES OF 363-445. SX SEVERAL X FOR LG AMTS OF THICK REDDISH SECRETIONS. LUNGS COARSE THROUGHOUT BUT ARE CLEAR FOR SHORT PERIODS OF TIME AFTER SX.\n\nNEURO: SEDATED ON VERSED 4MG/HR AND FENTANYL 100MIC/HR. PUPILS 2MM BIL AND SLUGGISH. DOES NOT FOLLOW COMMANDS, WITHDRAWS TO PAIN.\n\nGI/GU: PT ACID 50 MG. U/O TENDS TO DWINDLE AND THE GOAL IS TO DIURESE PT. FOLEY IS PATENT AND NO LEAKING NOTED. ABD IS FIRMLY DISTENDED. PT WAS ON PREVIOUS SHIFT FOR LG AMT OF HARD STOOL. ABD STILL REMAINS FIRMLY DISTENDED. NPO WITH VERY HYPO BS.\n\nENDO: INSULIN GTT OFF, BS RANG FROM 82-117. GOAL IS TO KEEP BS BETWEEN 80-120.\n\nSOCIAL: HUSBAND DOES COME IN AND SPEND TIME WITH PT DURING THE DAY, VERY CONCERNED ABOUT THE HEALTH OF WIFE. SONS CALL IN FOR UPDATES.\n\nPLAN: CONT TO SUPPORT PT ON VENT UNTIL PT IS ABLE TO TOL WEAN. MONITOR LYES AND REPLENISH AS NEEDED. FOLLOW HCT AND PROVIDE BLOOD RPODUCTS AND NEEDED. PROVIDE EMOTIONAL SUPPORT TO FAMILY WITH UPDATES. CONT TO DIURESE PT.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611838, "text": "S/MICU Nursing Progress Note\n PT on same vent settings, suctioning thick tan/green sputum. BS remain coarse through out. settings 450/16/50/5\n Cardiac: HR 90-110's afib, BP hovering at 40-50/40's remains sedated on fentynl and versed. no urine output.\n GI: abd distended and with residuals. no feeding as now.\n Social: husband aware of low BP, son still with his father. went home pt conts DNR\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611839, "text": "d: pt'd status unchanged. fentanyl gtt at 375 mcg/hr and versed at 14 mg/hr. pt unresponsive to verbal or painful stimuli. vent settings unchanged: 50%/450/ac 16 and 5 peep with o2 sats of 100%. no weaning of the vent done per recommendations of pt's rabbi who states that pt experiencing air hunger is not comfort. suctioned ett for sm amts of thick tan/greenish sputum. coarse bs bil on auscultation. foley cath in place and pt anuric. pt's husband in today and his son has espressed concern that his father is depressed. have been ordering kosher meal at lunch for pt's husband and have kept him updated. hr in the 80's afib and sbp 44-60. pt is dnr/ . not drawing labs,giving tuube fdgs b/cause of high residuals in the past. pt also not receiving ivf because of total body fluid overload and renal failure. continue wiht present medical management.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611840, "text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. No vent changes made. for thick tan secretions, current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611841, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. O2 sats 100%. Vent settings unchanged. Vt 450, A/c 16, Fio2 50%, and Peep 5. Sx'd for sm amount of thick yellow secretions. ETT retaped 22cm/lip. Bs coarse with few rhonchi bilaterally.\nPlan: Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611842, "text": "Smicu nsg progress note\nS/O- Status remains unchanged. Unresponsive on fent/versed gtts with bp 40-50s. Remains ventilated with no changes made. Suctioned for thick yellow/tan secretions. Copious nasal/oral secretions. Still with essentually no urine output.\nA- Unchanged\nP- with . to support family.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611843, "text": "Respiratory Care Note\nPt remains on AC as noted with no changes. BS rhonchi with slight exp wheezes bilaterally. Pt suctioned for moderate amts thick yellow-green secretions. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611799, "text": "Smicu nsg progress note\nNeuro- Remains sedated on 350mcg fent and 12 mg midaz. Cont to grimise and bite down on tube with increasing bp when turned but easily settles. No spontaneous movement noted.\nCardiac- Bp stable on .03mcg levo. No attempt to wean levo at this time. Will cont while on crrt and wait for family meeting on Monday to discuss further tx. Pt has become hypotensive in past when levo d/c'd.\nResp- Intub/vented. No changes made in ventilation. Abg/02 sats stable. Suctioned for minimal secretions. Cont with oral ulcers. Very difficult to do mouth care or suction mouth as pt bites down cramping jaw. Unable to place oral airway at this time.\n Pt crrt thoughout day. Able to maintain goal of 100cc neg. Pt 1600 cc neg by 1600. By 5pm clots noted in system with increasing pressures. Will d/c cvvt for night and restart in am. Lytes remain stable.\nEndocrine/Gi- Insulin gtt d/c'd for fs 63. Will hold on gtt and cover with s/s and fixed dose glargine in pm. Cont on goal tube feeds. Passing mod amts liquid brown stool.\nId- remains afebrile. No changes in antibiotics\nSocial- No family in to visit today. No calls. Plan for family meeting on Monday to discuss further care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611800, "text": "Resp Care\n\nPt remains intubated and on full vent support. No changes made during the shift. BS are coarse with small white sputum being suctioned. receiving albuterol/atrovent as ordered\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611686, "text": "Resp Care Note, Pt placed on Pressure Control ventilation overnight due to ^ PIP'S. Bleedind from ETT lrg amts thick bldy secretions. Also ^ sedation.Sedated with fentanyl and versed. MDI'S given. ABG'S improving.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611696, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt remains intubated with settings of PCV driving pressure of 25cm, PEEP of 10 inserted esphogeal balloon and increased PEEP to 15cm ABG remained hypoxic with p02 57 increased PEEP to 18cm. O2 sat have been 93-95% now are presently at 98-99%. suctioning thick blood tinged sputum. plugs at times. Bs cont to be coarse throughout. with fine crackles at the bases.\n Cardiac: HR 60-70 NSR, with occasional APC, BP 110-130/60-70's erthynic acid 100mg given with fair diuresis, Output is -177cc for shift. Is LOS +660cc. serum K 4.8 Cardiac Echo done this morning. showing MR,(+), AR mild,\n GI: abd remains firm, +BS, milk & molass enema done at 11am, without much results, difficult to pass the emema, lactlose given x2, and placed on LIS to help decompress abd.\n GU: foley in place BUN68 Creat 1.4 unchanged in the past 24hr.\n Nuero: sedated on Versed, and fentanyl. bolused for activity, and care. will open eyes to pain, no spont movement of extremites.\n Skin: skin RN to evaluate sacral wound her recommendations are to use aquacel in the wound then douderm over the site... changing Q3days. skin anascara, noted hematoma on the right leg under the pnuemoboot sleeves. stopped the pnuemoboots and there is a 4x4 hard area mid calf. Md aware.\n Family: husband in visiting, in contact with sons and via phone today. updated.\n Plan:Cont to diuresis, monitoring I&O's need pt to stool. decompress abd. monitor ABG's adjust vent accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611760, "text": "Respiratory Care:\nVentilatory parameters manipulated to compensate for decreased PO2 and increased hypercarbia. Final settings at this time consists of A/C mode, 500 X 28 X 60%, 12 cm PEEP. Last abg results on 30 BPM, revealed a normal acid-base balance with moderate hypoxemia. Rate was brought down in an attempt to lower the PIP, while maintaining the acid-base balance.\n\nNo RSBI measured due to the level of PEEP and FIO2 currently required.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611719, "text": "NPN\n\nNeuro: Pt conts on 50 mcg of fent and 1 mg of versed, she was occationally arrousible, not following any commands, she was given boluses of 50 mcg fent and 2 mg versed for aggitation.\n\nCV: VSS stable, SBP 100-120/50s, HR 60s-70s, started on amiodorone today for hx of aflutter. She was tolerating the CVVHDF, though it clotted off x2 (within a half an hour after restarting it) and it is now off. K was repleated - repeat K is pending.\n\nResp: Remains on A/C, no changes were made, conts to have bloody secreations. She has a bloody secreations from her mouth most likey from her bloody lip. She was going to be bronched today but the machine was not working properally.\n\nGI: She was given lactulose - she had a BM today, loose, golden, slightly OB pos. Her ABD conts to be distended and somewhat firm though less firm than yesterday. Her TF were off for part of the day for the bronch - they are now back on.\n\nGU: U/O 0-15cc/hr, she was tolerating with the CVVHDF with a SBP of 100-120 though we were only able to keep her fluid status even. Her CVVHDF pressures were ok, when she suddenly clotted off, the machine was restarted but clotted off within 30 min - we will wait until tomorrow to talk with renal, they may want to use citrate.\n\nEndo: Conts on an insulin gtt to try and maintain a BS of 80-120.\n\nSoc: Her husband was in for much of the day.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611720, "text": "Respiratory \nPt remains on same a/c settings 500/20/12peep/50%. Pt continues to have mod to large amts of bloody secrections. Attempted bronch today, however cancelled due to poor visibility of bronchcart. IP notified.\nCVVHD stopped due to clotting of machine. Will continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611721, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains intubated with settings of A/C 500cc x 20 breaths spont RR 0-6 over the vent. PEEP 12cm, Fio2 50%. suctioned q3hr for thick bloody sputum. BS cont to be coarse throughout. sedation fentanyl at 25mcg/hr and versed at 2 mg/kg.\n Cardiac: Hr 60-80's NSR with frequent to rare APC, BP ranged from a low of 80/ to 120/ increased with stimulation. started on Arimorine 200mg po. with episode of Hypotension at midnight pt was due for antibx so did recievd a fluid bolus with fair response.\n GU: foley in place, urine cloudy yellow in color. ua and culture sent tonight. output averaging around 10-15cc/hr. cont off the CVVHD to be re-evaluated today.\n GI: abd distend, +BS sounds, stool x 1 mod amount.\n ID: temp max, 101.6 cultured, blood x2, and urine sent. started on aztroenam and vanco.\n Skin: remains on kinair bed. eccymontic areas note in the right upper arm, right calf, douderm over sacral decub.\n Ednocrine: cont on insulin infusion, titrated to FS level\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611722, "text": "Resp Care\nPt. remains intubated/sedated overnight with no vent changes overnight.\nBs: coarse rhonchi t/o, cleared with sxn. Scattered exp. wheezes tx'd with mdis as ordered. Sxn'd copious amts. of thick bloody.\nabgs:within acceptable parameters.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611864, "text": "Status quo! Patient remains on mechanical ventilation with good sat. No recent ABG drawn,DNR,DNI,BP labile @ 62/24.Pilot ilne has a hole was clamped for 2 days,self repaired clamp is removed.BS wheezy,some rhonchi,suctioned for small amount of secretion.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611865, "text": "Progress Note 7p-7a\nNo change from previous assessment. Pt. remains unresponsive. Sedated with fentanyl and versed. Intubated and on ventilator 50%/500/16/5. Thick yellow secretions noted with suctioning. Pt. remains in A-fib with rate 80's to low 100's. SBP 50's to 70's. Pitting/weeping edema throughout trunk and limbs. Pulses difficult to palpate. Abd. distended. BS absent. Pt. remains NPO d/t absent BS and increased residuals. OGT remains in place. Foley with no urine output. Pt had R IJ dialysis cath and L IJ triple lumen central line.\n\nPlan: continue with DNR/DNI status including no lab draws. Continue to provide support to family.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611866, "text": "Resp: Pt remains intubated on a/c 16/450/+5/50% with no changes. Bs are coarse bilaterally, suctioning for moderate to copious amounts of thick greenish/yellow secretions. Pilot ballon is presently patent with Vt's 500's, 02 sats 98%. No abg's. Will maintain support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611867, "text": "NPN 0700-1900\nNo change from previous assessment. Pt remains unresponsive, sedated with fentanyl and versed IV. Contiues on CMV see careview for settings, HR 80-105 Afiv. MAP 30-40's. Continues with general Anasarca. Remains NPO d/t absent Bowel Sounds. Foley with 7cc total UO for the day. DNR status.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611868, "text": "Respiratory Care\nPt remains on a/c vent without changes. BS coarse, suctioned for moderate amts of thick yellow. Code status remains dnr.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611869, "text": "Progress Note 7p-7a\nNot significant events this shift. DNR/DNI status . Pt. remains sedated with versed and fentanyl. No response noted. Pt. remains intubated and on ventilator. No ventilator changes noted. Pt AFib with rate 70s-90s, SBP 50's throughout night. Pitting/Weeping edema. NPO. OGT in place. Foley with no urine output. Skin at this time. redness on . L IJ TL central line patent. Continue offering support to pt. and family.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611714, "text": "NPN\n\nNeuro: Pt is arousible at times, able to have some purposful movements, other times she is very sedate. She conts on fent at 50 mcg/hr and versed at 1 mg/hr, I gave her one bolus of fent of 2 mg and fent of 50 mcg for coughing which set off the CVVDHF.\n\nCV: She dropped her SBP to a low of 79 today and a mean to 47, she seemed to do this when I was trying to take off some fluid (50cc/hr). At present her PFR is 0, renal and the team are aware and are in agreement since she does not appear to tolerate any fluid removal. She has not been hypotensive since we have stopped removing fluid with the CVVHDF, if she does become so than the plan it to give her blood (her HCT was 27). Her CVP has been 15-23, she conts to have anasarca.\n\nResp: Remains on A/C 500x23/.4/12 PEEP. Her secreations are old blood - a speck was sent. If her Pa02 tolerates it than we can continue to decrease her PEEP.\n\nGI: ABD firm, pos BS, her TF has been off all day because her BP has not tolerated her being at 30 degrees semifowlers. No stool today.\n\nGU: Poor u/o, some hours she did not make any urine, her u/o has picked up a very little with the PFR at 0.\n\nEndo: Her BS has been 133-73, insulin gtt was titrated to keep her BS 80-120\n\nSkin: Her wound is covered in a duoderm, a kinair was ordered and she will be put on it today. She has been turned and she tolerates this.\n\nSoc: Her son called for an update.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611715, "text": "Respiratory Care\nPt remains on A/C vent cont on cvvhd. Pt increased to 50% decreased rate to 20 abg pending. Pt continues to have bloody secrections after move to kinair bed, awaiting pt to settle down. Tube repositioned,MDI's as ordered will continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611716, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick bldy secretions.MDI'S given. Sedated with fentanyl.On CVVHD.HR-PAC'S.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611717, "text": "S/MICU Nursing Progress Note\n Events: CCVHDF cont filter changed x 2 for clotting\n Neuro: cont on the fentanyl 50mcg/kg/min and versed 1mg/hr requires bolus for turning in bed as pt is grimacing with all turns. will move her arms slightly on the bed. tryign to mouth words to staff.\n Respiratory: vented with settings of A/C 500cc tV rate of 20 PEEP of 12cm. FIO2 50% still suctioning blood sputum. coarse BS Right worse than left. (see carevue for ABG details)\n Cardiac: BP stable all night. range 110-130/60's HR 70-80 NSR rare APC or PVC,\n Renal: cont on CCVHDF have adjusted PRF to 70cc as BP has tolerated it. goal of neg 100cc/hr has not been reached. ended yesterday - 300cc and present is neg 200cc. system clotted x2 during the night. is making urine only about 10-15cc/hr. urine amber and cloudy. labs pnd this morning.\n Skin: sacral dsg changed today. still some moisture reapplied aquacel in the inner wound and duoderm over both. yeast rash noted in the groin and folds of skin.... nyastin powder applied. reddened area on the inner aspects of theighs... antifungal cream applied.\n Social: spoke with sons and both on mother's progress.\n Plan: cont to monitor. wean vent as tolerated. re-evaluate CVVHD follow labs as needed.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611774, "text": "NPN\n\nNeuro: Sedation was increased to 300mcg/hr fentand 10mg/hr versed due to her decreased VTs and worsening oxygenation (she was moving her mouth - this is one way to tell if she is under sedated). She has not been fighting the vent today as she did yesterday.\n\nCV: Levo was restarted, she has been on a low dose of .02-.04 for most of the day. She remains in afib in the 60s-70s.\n\nResp: Conts on A/C 400x28/PEEP 15, FI02 was increased to .7 from .6 for a Pa02 of 57 - last ABG was 7.42/36/65. LS diminished and coarse\n\nGI: ABD conts to be firm and distended, she conts on TF at her goal rate of 35cc/hr, no stool today, lactulose was given.\n\nGU: CVVHDF conts, she clotted off this afternoon, her replacement rate was increased to 1800cc/hr and can be further increased to 2000cc/hr if she conts to clot. We are trying to take off ~ 80cc/hr today and she has been tolerating this.\n\nEndo: FS were 70-120 this morning, this afternoon they started to increase, she is now back on an insulin gtt.\n\nSoc: Her husband was in today, we talked to him about why his wife is now CPR not indicated, also told him that the ethics team would be following this case to give another perspective to both him, his family and the team.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611775, "text": "resp care\nremains oett/vented in ac mode. settings titrated per abgs, again with worsened oxygenation although stable on vent today d/t incr.sedation level. no significant episodes of dysynchrony. mdi's given q4h.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611776, "text": "Resp Care\nPt. remains intubated/sedated on mechanical ventilation,CVVHD. No changes made overnight.\nBS: coarse bilat. secreations minimal this shift.\nabgs:ess. normal parameters with exception of oxygenation which is marginal (considering .7 fio2/15 PEEP.)\nPlan: cont. support, pt. is now CPRNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611777, "text": "MICU NPN 1900-0700\nNeuro: Pt remains sedated on fentanyl at 300mcg/hr and versed 10mg/hr. Pt with facial grimacing, attempting to open eyes and increased resp effort with stimulation. Responds fairly to some supplemental bolusing.\n\nCV: HR 70's-90's, Afib with occassional PAC. Remains on .03mcg/kg/min levofed with BP 110's-120's/40's. Pt with MAP <60 when levo off. Cont on CRRT, running approx -50cc/hour. Filter changed at 0300 because of clotting. Lytes remain WNL, no dialysate running.\n\nResp: LS diminished throughout. Remains vented on AC 400x28, PEEP 15, FiO2 70%. O2 sat 98-100%, ABG's WNL. Suctioned for minimal clear secretions.\n\nGI: Abd firm with edema, +BS's. Tolerating TF at goal rate 35cc/hour via oral dobhoff. Mushroom cath in place draining small amount of brown liquid stool.\n\nGU: Remains on CRRT. BUN/cr improved, am labs pending. Foley draining 0-15cc/hour clear, yellow urine.\n\nSkin: Pt on kinnair airbed. Generalized edema. Turned and repositioned as tolerated. Pressure sore to healing well, aquacel dressing chaned with duoderm .\n\nEndo: Pt off of insulin gtt at 2300 after receiving 35units glargine at 1800 yesterday. BS's 80's-90's overnight.\n\nSocial: No family contact overnight. Pt's code status changed to CPR not indicated.\n\nPlan: Continue with supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611856, "text": "NPN 0700-1900;\nPT APPEARS TO HAVE BITTEN PILOT LINE OF ETT CUFF, ABLE TO MAINTAIN INFLATION WITH CLAMP.\nHUSBAND SPOKE WITH RABBI , WHO HAD A CONVERSATION AROUND CHOICES HE COULD MAKE IN FUTURE, PLEASE SEE NOTE IN CHART FEELS THAT MR STILL HAS SOME FANCIFAL THOUGHTS AROUND MRS MAKING IT TO LABOUR DAY THEIR 51 ST WEDDING ANNIVERSARY.\n\nNEURO; SEDATED WITH VESED AND FENTANYL AT SAME RATE. REMAINS UNRESPONSIVE, NO MOVEMENTS SPONTANEOUSLY OR TO COMMAND. PERLA 1-2MM.\n\nRESP; SEE ABOVE, NO VENT CHANGES REQUIRED SATS R95-97 % SUCTIONED FOR SMALL AMOUNTS THICK YELLOW SECRETIONS.\n\nCVS; BP STILL 50-60/19-20. AFIB RATE CONTROLLED. PLEASE SEE CAREVUE FOR FURTHER DETAILS.\n\nGU; OLIGURIC. FOLEY REMAINS IN PLACE.\n\nGI; NO BS NO STOOL NO FLATUS. CONTINUES TO BE NPO.\n\nSKIN; WEEPING FROM ARMS LINEN CHANGED Q4 DUODERM ON .\n\nSOC; HUSBAND AT BEDSIDE DAY SONS AND COMING THIS EVENING.LISW STATED THAT IS AT HOME TRYING TO CLEAR UP AS HUSBAND DOES NOT APPEAR TO BE TAKING CARE OF THINGS AND LOOKING AT SOME FORM OF FOR FATHER.\n\nA/P CONTINUE WITH PRESENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611857, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 50% and Peep 5. Bs slightly coarse R lung, clear L lung. Sx'd for moderate amount of thick yellow secretions. 02 sats 96-100%. ETT secure and stable with clamp on pilot line. No volume loss. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611858, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated on the same vent settings... 450/16/50/5 with O2 sat ranging form 97-100%. suctioning for thick cream sputum. BS coarse throughout. sedated on fentanyl and versed. bolused once for grimacing as turning.\n Cardiac: HR 80-100's afib, no VEA, BP range from 50-70/30's higher levels of BP after turning or stimulatioin.\n Renal: no urine output, remains total body anascara. oozing from arms and legs.\n GI: no TF as no stool no BS, high residuals via OGT.\n\n Social: husband and two sons in most of evening. still aware of prognosis. with supportive measures as family will not withdraw any further supports.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611859, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..no changes made. I/E wheezes noted. Suctioned for mod amts tan secretions..Continues to bite down on ETT at times.\n Cardiac: BP in 70/s..hr 90's af..occassional PVC\n GU: No urine output\n Neuro: Continues on fentany @ 375mic and movement of extremites..no response to name calling or noxious stimuli\n Social: Husband and son in..updated by Dr .\nPt remains DNR/comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611860, "text": "Tracheostomy tube pilot line is still clamped.Patient bit the line yesterday during stimulation from bronchial hygien.Status quo,remains on same vent settings,labile BP,DNR,DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611718, "text": "addendum: Nursing Note\n Endocrine: wa on IVF insulin at 1.5unit/hr turned off for FS 57 at 5am. repeat in 30minutes was 78 .. insulin IVF still remains off.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611778, "text": " 4ICUNPN 0700-1900\n\nBecoming hypotensive to 80's. Levophed increased to 0.144. HR 70's 90's AF. No VEA noted. Able to wean levo to 0.021. (SBP drops to 80's when levo d/c'd)\n\nOn a/c 28 X 400 X60%, PEEP 15. ABG 7.51/33/69/27/3. No spont resp. Scant brown secretions. ETT not rotated because pt biting down on tube when attempting to suction mouth.\n\nCont on fent & versed gtts. Does not open eyes or follow commands. Extremities stiff.\n\nCont on CVVH. Goal 100 cc negative in AM. No fluid removed after pt becoming hypotensive. At 1800 when BP stable restarted slow fld removal (negative 30 CC hr)\n\nTF at goal. Large loose OB negative stool. Abd remains firm. Positive BS.\n\nGiven glargine 35U at 1800. BS 80's\n\nHusband in to visit throughout the day. He was updated by this nurse.\n\nA/P; Decrease rate to 24. Chack ABG.\n\nTitrate levo to MAP >60.\n\nCont fent, versed.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611779, "text": "REMAINS ON MECHANICAL VENTILATION WITH PERIODS OF HYPOTENSION.CVVHD CONTINUOUS,EDEMATOUS AT EXTREMITIES.SUCTIONED FOR MINIMAL AMOUNT OF BROWN SECRETION,WILL CONTINUE TO FOLLOW\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611780, "text": "Smicu nsg progress note\nNeuro- Well sedated on 300mcg fent and 10mg midaz. Not requiring additional boluses. Will grimice with suctioning/turning. No spontaneous movement noted. Cont with total body anacarcia.\nResp- Remain intub/vented intially on ac 400x24 60% 15peep with sats 99%. Abg back at 52/36/7.48. Fio2 increased to 70% with abg pending. Suctioned for mod amts thick yellow/tan secretions requiring saline instillation.\nCardiac- Bp 100-120s on .02mcg levo. As removal rate on cvvd increased bp down to 95-98s. Levo increased to .03mcg with stable bp. Slowly able to reach goal of 100cc neg/hr.\nRenal- Cont on cvvd. Pt~350cc neg at 12m. By 2am able to reach goal of 100cc neg/hr. Cont with very little uo 0-10cc/hr. Bun/creat pending.\nGi- Tolerating goal tube feeds. Cont to pass sm amts liquid brown stool. Fs stable off insulin gtt.\nId- Afebrile with bair hugger on. T-max 97.6ax. No changes in antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611781, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Few changes made overnoc. Administering Albuterol and Atrovent MDI's in line with vent. BS's coarse at times. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611861, "text": "Smicu nsg progress note\nS/O: Remains essentually unresponsive on fent/versed. intub/vented (of note pt with continuous air leak from broken pilot) Suctioned for mod amts thick yellow/green secretions. Still with minimal bp and no urine output.\nA: No change\nP: with . family support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611862, "text": "RESP CARE\nPT. REMAINS INTUBATED/SEDATED WITH NO CHANGES OVERNIGHT. PILOT CUFF NOT PATENT, CLAMPED, HOWEVER LEAK APPEARS TO BE MORE PROXIMAL TO TUBE ITSELF, SINCE CUFF IS SOMEWHAT TAUT.\nBS: COARSE BILAT. 'D Q2 FOR COPIOUS GREENISH-YELLOW FROM MOUTH/LUNGS.\nPLAN:. CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611863, "text": "S/MICU Nursing Progress Note\n Remains unresponsive, vented on same settings 450/16/.50/5 suctioning q3-4 hr for thick yellow sputum. BS coarse. BP minimal 50-70/30's HR 80-100's afib, on fentanyl and versed. bolused for grimacing by pt. increased fentanyl to 400mcg/hr. no changes/ DNR/ and to support family.\n" }, { "category": "Radiology", "chartdate": "2152-06-28 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872685, "text": " 3:46 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please evaluate for pneumothorax s/p successful cordis place\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation difficult to ventilate\n\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumothorax s/p successful cordis placement in left\n subclavian and failed attempt at line change over wire in right IJ\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION OF THE CHEST\n\n HISTORY: 80-year-old with respiratory distress and status post intubation.\n Evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to the prior examination of \n obtained earlier at 9:33 hours. Since the prior study, the right IJ line was\n removed, and a left subclavian Swan-Ganz catheter was placed. The tip is in\n the right pulmonary artery. Bilateral patchy infiltration involving both\n lungs and left pleural effusion are again noted, unchanged. No evidence of\n pneumothorax.\n\n IMPRESSION: Interval removal of the right IJ line and placement of a left\n subclavian Swan-Ganz catheter. No evidence of pneumothorax. No other\n significant changes are noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 874619, "text": " 12:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Line placement - L IJ (now w/ L sublclavian pulled)\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 yo F s/p L IJ central line placement, pls assess for PTX, hemothorax, s/p\n line placement (w/ X-ray showing line in place), now w/ removal of other\n central line that had been in same area.\n REASON FOR THIS EXAMINATION:\n Line placement - L IJ (now w/ L sublclavian pulled)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Removal of the left subclavian line.\n\n PORTABLE CHEST X-RAY, AP: Comparison study .\n\n Supine study at 1:04 a.m. demonstrates removal of the left subclavian line.\n The left IJ catheter has its tip over the SVC. The right IJ catheter is also\n in good position over the SVC. The endotracheal tube is in good position\n above the carina. The feeding tube is again noted with its tip over the\n stomach. The lungs are unchanged with multiple areas of\n infiltrate/opacification. There is no pneumothorax.\n\n IMPRESSION: Support lines in good position. No pneumothorax. No significant\n change from the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-10 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 874009, "text": " 12:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval infiltrate\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n MRSA (+) VAP\n REASON FOR THIS EXAMINATION:\n Eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Multifocal infiltrates and respiratory failure.\n\n Lines and tubes remain in place. There has been slight advancement of an\n endotracheal tube, which is now terminating about 2 cm above the carina.\n Other indwelling tubes and catheters are unchanged in position. Cardiac\n silhouette is enlarged but stable. Multifocal consolidative changes are again\n demonstrated. There has been some associated volume loss developing in the\n left upper lobe with apparent elevation of an accessory planar fissure on the\n left. An area of band like discoid atelectasis could potentially mimick an\n elevated accessory fissure, however. Overall, compared to the recent study,\n there has been slight improved aeration in the lung bases, with otherwise no\n significant additional changes.\n\n IMPRESSION: Slight improved aeration in the lung bases. Multifocal opacities\n otherwise unchanged except for some degree of volume loss developing in the\n left upper lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 872936, "text": " 1:51 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: catheter placement.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p swan pulled and changed to quad lumen catheter.\n REASON FOR THIS EXAMINATION:\n catheter placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Exchange of Swan-Ganz to a central line.\n COMPARISONS: Comparison is made to radiograph performed in the same day,\n approximately 5 hours earlier.\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: Interval removal of the Swan-Ganz catheter and interval placement\n of a left subclavian central line. The tip is in the left brachiocephalic\n vein near the junction of the SVC. The NG tube and ET tube are in unchanged\n position. There is no evidence of pneumothorax. radiograph is seen. There is\n interval worsening of bilateral multifocal consolidations.\n\n IMPRESSION:\n 1. Central line tip is in the distal left subclavian vein near the junction of\n the SVC. No other significant change.\n 2. There is interval worsening of bilateral multifocal parenchymal\n consolidations which could be due to multifocal pneumonia versus CHF.\n\n" }, { "category": "Radiology", "chartdate": "2152-06-26 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 872430, "text": " 12:13 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: abominal bleeding?\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fall & RUQ tenderness, possible rib fractures - eval\n for liver injury\n REASON FOR THIS EXAMINATION:\n abominal bleeding?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with fall and right upper quadrant tenderness.\n Evaluate for fractures or liver injury. The patient also has shortness of\n breath. Evaluate for pulmonary embolism.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen and pelvis were\n obtained. Multiplanar reconstructions were obtained for further evaluation of\n the anatomy and pathology.\n\n CONTRAST: 150 ml of IV Optiray was administered.\n\n COMPARISON: Abdominal CT from in .\n\n CT CHEST WITH AND WITHOUT IV CONTRAST: The soft tissue window images reveal\n no significant axillary, mediastinal, or hilar lymphadenopathy. The heart,\n pericardium and the great vessels are unremarkable. There are no filling\n defects within the pulmonary vasculature to suggest the presence of a\n pulmonary embolism. There are bilateral moderate sized pleural effusions,\n right greater than left.\n\n The lung window images reveal bilateral patchy opacities with a large area of\n consolidation involving the right upper lobe and a smaller area of\n consolidation in the left upper lobe. The airways appear patent.\n\n A right IJ line is visualized with its tip in the mid SVC. An endotracheal\n tube is present with its tip about 1 cm above the carina. A feeding tube is\n also present with its tip in the stomach.\n\n CT ABDOMEN WITH IV CONTRAST: There is stable prominence of the intrahepatic\n biliary ducts. No focal liver lesions are identified. There is a stable 14 x\n 19 mm low density area in the head of the pancreas. The spleen is\n unremarkable. The adrenal glands are normal. The kidneys appear slightly\n atrophic but are stable in appearance. Atherosclerotic changes are seen in\n the aorta. The intra-abdominal loops of small and large bowel are\n unremarkable. Scattered large bore diverticula are again noted without\n evidence of diverticulitis. There is no free air or free fluid. A few\n nonpathologically enlarged para-aortic lymph nodes are present.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder, rectum, and sigmoid colon are\n (Over)\n\n 12:13 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: abominal bleeding?\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. There is stable appearance of a left groin hernia with loops of\n small bowel. There is no evidence of obstruction. There is no free air\n present. Again, noted is a calcified fibroid posteriorly. There is no pelvic\n or inguinal lymphadenopathy.\n\n Degenerative changes in the spine are again noted along with diffuse\n osteopenia.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the absence of\n pulmonary embolism.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Moderate sized bilateral pleural effusions, right greater than left.\n Patchy opacities in both lungs along with areas of consolidation in the upper\n lobes, right greater than left. These could represent multifocal pneumonia.\n 3. Stable appearance of cystic lesion in the head of the pancreas.\n 4. Stable mild intrahepatic biliary ductal prominence. No liver laceration.\n 5. Stable left groin bowel containing hernia.\n 6. Stable multiple anterior abdominal wall nodules likely representing\n injection sites.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "INT.SHTH NOT/GUID,EP,NONLASER", "row_id": 872947, "text": " 3:19 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please place Quentin catheter in L groin. (Tried to place R\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ******************************* CPT Codes *****************************\n NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT \n C1894 INT.SHTH NOT/GUID,EP,NONLASER \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with anuric renal failure in need of CVVHD.\n REASON FOR THIS EXAMINATION:\n please place Quentin catheter in L groin. (Tried to place R groin line 5 days\n ago and got into artery. Pt also has large hematoma on R calf).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient sustained acute renal failure and requires dialysis.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. with Dr.\n being present throughout. After sterile preparation of the right neck\n ultrasound was used to locate the right internal jugular vein which was found\n to be patent and compressible. Using ultrasonographic guidance and 5 ml of 1%\n lidocaine in the right internal jugular vein was entered with a 21 gauge\n needle. Over and 018 guide wire which was advanced under fluoroscopy the\n exchange was made for 4.5 micropuncture sheath. An 035 guide wire was then\n advanced into the superior vena cava. After serial dilatation exchange was\n made for 14.5 FR hemodialysis catheter. The tip was placed under fluoroscopy\n at the cavoatrial junction. A final radiograph was obtained which\n demonstrates the catheter in appropriate positioning and the absence of a\n pneumothorax. As on the prior chest x-ray there are areas of marked\n consolidations throughout. There is no pneumothorax. The tip of the left-\n sided central venous catheter ends in the left brachiocephalic vein. There\n were no immediate complications.\n\n Hardcopy images of ultrasound had been obtained at the level of the right\n internal jugular vein before and after placement of the needle.\n\n IMPRESSION: Successful placement of a 15 cm long temporary dialysis catheter\n via the right internal jugular vein ready for use. No pneumothorax.\n\n\n\n" }, { "category": "Echo", "chartdate": "2152-06-22 00:00:00.000", "description": "Report", "row_id": 98426, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. R/O Cor pulmonale.\nHeight: (in) 63\nWeight (lb): 226\nBSA (m2): 2.04 m2\nBP (mm Hg): 130/50\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 10:43\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nStudy technically suboptimal due to limited patient cooperation with the\nstudy.\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. Minimally increased gradient c/w\nminimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve is not well seen. There is a minimally increased gradient consistent\nwith minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The pulmonary artery systolic pressure could not be determined. There\nis no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 98425, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 228\nBSA (m2): 2.07 m2\nBP (mm Hg): 128/68\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 13:12\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild to moderate\n(+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) are mildly thickened. There is a\nminimally increased gradient consistent with minimal aortic valve stenosis.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric (posteriorly directed). The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof (sub-optimal study), the severity of mitral regurgitation seen is\nnow mild to moderate. Mild pulmonary hypertension is now detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872304, "text": " 8:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG tube placement\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation\n\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Nasogastric tube placement.\n\n A nasogastric tube has been placed and terminates within the stomach.\n Allowing for differences in technique, there is otherwise no significant\n change from the previous study performed several hours earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872293, "text": " 5:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable upright chest that is dated .\n\n Comparison is made to previous study of earlier the same day.\n\n INDICATION: Intubation.\n\n An endotracheal tube has been placed, terminating approximately 3.5 cm above\n the carina. The cardiac silhouette remains enlarged, and there is bilateral\n vascular engorgement. There has been interval slight progression in the\n degree of a bilateral slightly asymmetrical alveolar pattern with a perihilar\n predominance. Interstitial opacities are seen predominantly at the lung\n bases, and there are persistent small bilateral pleural effusions.\n\n As compared to the recent study, there has not been a significant interval\n change allowing for differences in lung volumes.\n\n IMPRESSION:\n 1. Satisfactory placement of endotracheal tube.\n\n 2. Persistent bilateral combined alveolar and interstitial pattern, most\n likely due to pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 873710, "text": " 11:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Check OGT placment.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n with increasing WBC. NGT pulled and OGT placed.\n REASON FOR THIS EXAMINATION:\n Check OGT placment.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST\n\n INDICATION: 80-year-old female with respiratory failure and multifocal\n infiltrates. The patient is status post OG tube placement.\n\n TECHNIQUE: AP portable single view of the chest.\n\n COMPARISONS: Comparison is made to radiograph performed in the same day\n approximately 2 hours earlier.\n\n FINDINGS: There is interval placement of feeding tube, (Dobhoff) with the tip\n in the fundus of the stomach. There is a left subclavian central line with\n the tip in the distal brachiocephalic vein near the junction of the SVC. There\n is a right IJ large bore central line with the tip in the distal subclavian\n vein/upper SVC. The ET tube is in good position. There is no evidence of\n pneumothorax. There is noted pulmonary edema and stable bilateral focal\n opacities consistent with multifocal pneumonia.\n\n IMPRESSION: Placement of feeding tube with the tip in the fundus of the\n stomach.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 872880, "text": " 7:37 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ? resolving edema.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation difficult to ventilate\n\n REASON FOR THIS EXAMINATION:\n ? resolving edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, status post intubation, evaluate for\n resolving edema.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: An endotracheal tube is in place in unchanged position. Left\n subclavian venous access sheath with PA catheter with tip terminating in the\n right lower lobe pulmonary artery, advanced in the interval. Nasogastric tube\n with tip in the gastric fundus. The heart size and mediastinal contours are\n unchanged. In comparison with the previous examination, there is interval\n improvement in bilateral patchy opacity suggestive of improving congestive\n heart failure. No pneumothorax. The osseous structures appear unchanged.\n\n IMPRESSION:\n 1) Endotracheal tube and nasogastric tube in stable position. Interval\n advancement of pulmonary artery catheter. 2) Interval improvement in\n bilateral alveolar opacities, likely due to asymmetric pulmonary edema,\n although underlying infection is not excluded.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-12 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 874318, "text": " 9:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?pneumothorax/effusion/consolidation/infiltrate\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n MRSA (+) VAP. On appropriate abx, but WBC increasing.\n REASON FOR THIS EXAMINATION:\n ?pneumothorax/effusion/consolidation/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA positive to rule out pneumothorax, effusion, or\n consolidations.\n\n CHEST AP PORTABLE VIEW.\n\n COMPARISON: .\n\n The endotracheal tube, the Dobbhoff tube, left subclavian and right internal\n jugular venous lines are unchanged. The cardiac size and mediastinal contours\n are stable. Multiple patchy alveolar opacities are seen with stable pulmonary\n edema.\n\n IMPRESSION: Patchy alveolar opacities which may represent pulmonary edema\n superimposed with areas of consolidation in the right lung and left upper\n lobe.\n\n\n" }, { "category": "ECG", "chartdate": "2152-06-24 00:00:00.000", "description": "Report", "row_id": 276317, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , atrial fibrillation now absent\n\n" }, { "category": "ECG", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 276318, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-23 00:00:00.000", "description": "Report", "row_id": 276319, "text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of atrial fibrillation with a rapid ventricular response has\nappeared.\n\n" }, { "category": "ECG", "chartdate": "2152-06-20 00:00:00.000", "description": "Report", "row_id": 276320, "text": "Sinus rhythm\nBorderline first degree A-V block\nPoor R wave progression - probable normal variant\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-20 00:00:00.000", "description": "Report", "row_id": 276321, "text": "Sinus bradycardia\nBorderline first degree A-V block\nPoor R wave progression - probable normal variant\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 276311, "text": "Atrial fibrillation with ventricular premature beats. Low voltage. Non-specific\nST-T wave changes. Compared to the previous tracing atrial fibrillation is new.\n\n\n\n" }, { "category": "ECG", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 276312, "text": "Sinus rhythm\nConsider left atrial abnormality\nRightward axis - is nonspecific\nBorderline low QRS voltage - is nonspecific\nClinical correlation is suggested\nSince previous tracing of , QRS voltages lower but may be no significant\nchange\n\n" }, { "category": "ECG", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 276313, "text": "Sinus rhythm. Possible left atrial abnormality. Compared to the previous\ntracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 276314, "text": "Baseline artifact\nSinus rhythm\nProbable left atrial abnormality although baseline artifact makes assessment\ndifficult\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 276315, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 276316, "text": "Baseline artifact\nSinus rhythm\nProbable left atrial abnormality although baseline artifact makes assessment\ndifficult\nRightward axis - is nonspecific\nSince previous tracing of -, probably no significant change\n\n" } ]
20,522	142,117	1. Upper GI bleed: The patient had an NG tube placed in the Emergency Department, and coffee-ground emesis was suctioned out which did not clear. GI was immediately consulted who did an EGD and found no active sights of bleeding; however, they did find a grade III esophagitis and some gastritis. At that time it was decided that we should stop the anticoagulation, and the patient was to be started on Protonix 40 mg p.o. b.i.d. In addition, GI recommended that the patient go for barium swallow. At that time, it was believed that the upper GI bleed was probably secondary to gastritis, worse with anticoagulation and hiatal hernia. The patient had barium swallow that was done on , that showed a large paraesophageal hernia but no evidence of any twisting or infarction at this time. According to the Radiology attending, it would be ideal if Surgery was consulted. The results were discussed with the patient, by both myself and by the attending Dr. , about the importance of getting Surgery involved, but the patient refused any surgery and stated that she would just take the oral medications at this time. The patient also was informed that if the patient does not go for surgery, then the patient may have her stomach infarcted and could possibly die. She is willing to take those chances. During the hospital course, the patient did not have any coffee-ground emesis, and the patient was tolerating p.o. well. 2. Hypoxia: This was most likely secondary to aspiration pneumonia as per the chest x-ray. The patient did have 8-10 episodes of emesis which would account for that. At this time it was decided that the patient should be started on Levofloxacin and Flagyl for a 14-day course for treatment of aspiration pneumonia. The patient was initially requiring oxygen through nasal cannula, but two days before her discharge, her nasal cannula was removed, and she was doing well in room air, maintaining an oxygen saturation anywhere between 92-96%. The patient continued on antibiotics for ten more days after discharge. 3. Urinary tract infection: The patient's urinalysis showed some white cells and some bacteria in her urine. At that time it was decided that since the patient is getting Levofloxacin for aspiration pneumonia, she will be covered for urinary tract infection. A sensitivity was sent, but it was not back at the time of discharge. 4. Cardiology: As per her echocardiogram report in , the patient has an ejection fraction of 30-35%. The patient is currently not on any cardiac medications. The question was brought up during her hospital course whether to start her on ACE inhibitors, but given the fact that she had an elevated BUN and creatinine, we decided to hold off on any medications at this time. In addition, beta-blocker was also not started because the patient was having a blood pressure anywhere between 90-100 systolic. In addition, Aspirin was also held off because of her bleeding episode. The patient is to follow-up with her primary care physician . in about one week, and this issue needs to be readdressed, and the patient could possibly be restarted on any cardiac medications. 5. Psychiatric: The patient has a history of schizo-affective disorder. The patient is currently stable and is to continue on current medications. 6. Alkalosis: The patient initially presented with a bicarb of 37. Her Alkalosis was most likely secondary to contraction alkalosis given the fact that she was volume depleted and she had these multiple episodes of emesis. The patient received intravenous fluids throughout her hospital course, and her alkalosis had resolved. 7. FEN: The patient was receiving intravenous fluids during her hospital course because she was NPO and also because she developed alkalosis and an elevated creatinine which could indicate the patient was dry and was having prerenal acute renal failure. After receiving intravenous fluids, the patient's creatinine had dropped from 1.6-0.9, and on the day of discharge, her creatinine was 0.9, and her bicarb was down to 27. 8. Heme: The patient's hematocrit has been in the range between 27 and 32-33. Her initial hematocrit was 45, but on recheck was 33. Her initial elevated hematocrit could be secondary to the fact that the patient was very dry. After intravenous fluids, this improved. The question was brought up whether we should transfuse her with 1 U to have her hematocrit above 30 given the fact that she has coronary artery disease, but the patient refused any blood transfusion. It was thoroughly discussed by both myself and the attending, but the patient still refused, and so transfusion was not given. The patient was started on Iron Sulfate 325 mg p.o. q.d.	PT. TRANSFUSE AS NEEDED. K THIS AM 3.1 & BEING REPLACED. PERIPHERAL PULSES PALPABLE. WBC 18.4. MAE X4. 18 G IV X2 LFA. PAN CULTURED. POSITIVE UTI. PLEASE OBTAIN SPUTUM IF EXPECTORATES. 0300 HCT 32.6 FROM 35.7. THANK YOU.. GIVE SUPPORT. REORIENTS EASILY. RIGHT ARM CONTRACTURE WITH WEAKNESS NOTED R/T OLD CVA. SPUTUM NEEDED IF EXPECTORATES. BP STABLE 110-120/40'S. PLEASE RECHECK LATER THIS AM. STATES IS SMOKER. REMAINS IN MICU FULL CODE. COOPERATIVE IN CARE.CV: MONITOR NSR 70-80 NO ECTOPY. D5.45 NS@ 100 CC/HR.RESP: NON PRODUCTIVE COUGH. CONVERSES LITTLE. DENIES SOB.GI: RIGHT NARE NG TO LCWS WITH SMALL COFFEE GROUND LIQUID POSITIVE HEMACULT. BREATH SOUNDS DIMINISHED. INR 1.6 AFTER RECEIVING 4 U FFP & VITAMIN K. TEAM IS AWARE. O2 3L NC SATS 93-96%. WITH SCHIZO AFFECTIVE DISORDER, MONOTONE VOICE. DENIES NAUSEA OR ABDOMINAL TENDERNESS. FOLLOWS ALL COMMANDS. RESUME MEDS THIS AM PER DR. . DISORIENTED TO PLACE & YEAR AT TIMES. NO BM. CONTINUE 6 HOUR HCT DUE @ 0900. CIPRO PER NG STARTED.SOC: LIVES AT CHRONIC CARE FACILITY.PLAN: REPLACE K. CONTINUE Q 6 HOUR HCT. REQUIRING FREQUENT ORAL CARE.GU: FOLEY TO GRAVITY DRAIN WITH CLEAR YELLOW URINE 30-100 CC/HR.ID: T MAX 100.3 ORAL. NURSING TRANSFER NOTE 0700-1500PLS SEE NURSING TRANSFER NOTE IN THE SECTION MARKED 'NURSING TRANSFER NOTE'.	2	[ { "category": "Nursing/other", "chartdate": "2179-11-05 00:00:00.000", "description": "Report", "row_id": 1531917, "text": "MICU NPN 1900-0700:\n\n60 YEAR OLD FEMALE ADMITTED @ WITH UGIB FROM ED, HCT 40, INR 3.7.\n\nNEURO: PT. WITH SCHIZO AFFECTIVE DISORDER, MONOTONE VOICE. CONVERSES LITTLE. DISORIENTED TO PLACE & YEAR AT TIMES. REORIENTS EASILY. MAE X4. RIGHT ARM CONTRACTURE WITH WEAKNESS NOTED R/T OLD CVA. FOLLOWS ALL COMMANDS. COOPERATIVE IN CARE.\n\nCV: MONITOR NSR 70-80 NO ECTOPY. K THIS AM 3.1 & BEING REPLACED. PLEASE RECHECK LATER THIS AM. BP STABLE 110-120/40'S. PERIPHERAL PULSES PALPABLE. 18 G IV X2 LFA. D5.45 NS@ 100 CC/HR.\n\nRESP: NON PRODUCTIVE COUGH. PT. STATES IS SMOKER. SPUTUM NEEDED IF EXPECTORATES. O2 3L NC SATS 93-96%. BREATH SOUNDS DIMINISHED. DENIES SOB.\n\nGI: RIGHT NARE NG TO LCWS WITH SMALL COFFEE GROUND LIQUID POSITIVE HEMACULT. DENIES NAUSEA OR ABDOMINAL TENDERNESS. NO BM. 0300 HCT 32.6 FROM 35.7. INR 1.6 AFTER RECEIVING 4 U FFP & VITAMIN K. TEAM IS AWARE. CONTINUE 6 HOUR HCT DUE @ 0900. RESUME MEDS THIS AM PER DR. . REQUIRING FREQUENT ORAL CARE.\n\nGU: FOLEY TO GRAVITY DRAIN WITH CLEAR YELLOW URINE 30-100 CC/HR.\n\nID: T MAX 100.3 ORAL. WBC 18.4. PAN CULTURED. POSITIVE UTI. CIPRO PER NG STARTED.\n\nSOC: LIVES AT CHRONIC CARE FACILITY.\n\nPLAN: REPLACE K. CONTINUE Q 6 HOUR HCT. TRANSFUSE AS NEEDED. GIVE SUPPORT. PLEASE OBTAIN SPUTUM IF EXPECTORATES. REMAINS IN MICU FULL CODE.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-11-05 00:00:00.000", "description": "Report", "row_id": 1531918, "text": "NURSING TRANSFER NOTE 0700-1500\nPLS SEE NURSING TRANSFER NOTE IN THE SECTION MARKED 'NURSING TRANSFER NOTE'. THANK YOU..\n" } ]
13,638	181,754	The patient was admitted to the Surgical Intensive Care Unit for close monitoring. He had a CT angiogram of his brain, which was negative and the conventional angiogram, which was also negative. The patient has had difficulty with blood pressure control and is now running in the 130s to 140s systolically and will be discharged on new medication for his blood pressure and will follow up with his primary care physician for blood pressure control. He was seen by physical therapy and occupational therapy and cleared for discharge to home. His vital signs have been stable. He has been afebrile.	IN UNIT FOR NEURO CHECKS AND BP CONTROL.NEURO: INTACTCV: A-FEBRILE. RESUMED PREVIOUS ANTIHYPERTENSIVES W/O EFFECT. + BS.ENDO~BS Q 4/HRS. IV ZANTAC ADDED.HEME: STABLE. CONDITION UPDATED.AFEBRILE SR TO SINUS BRADY. LUNGS CLEAR.RENAL: LABS WNL. PT HAS USED URINAL.BREATHSOUNDS CLEAR. ABP >200, NBP L ARM 160 SYS, R ARM 130 SYS- NSURG AWARE. TECHNIQUE: Pre and postcontrast multiplanar T1W images, axial T2W, susceptibility and FLAIR images were obtained. As expected, the T1 hyperintense methemoglobin is, to some extent, visible on the MRA. 0430 GIVEN PERCOCET 2 TABS FOR C/O THROBBING HA. K REPLACEMENTS IN IVF.A. Note is made that the right A1 segment is atretic. MAINTAIN CUFF BP <160 WITH NIPRIDE.R. U/O qs, +BS pt able to tolerate solids. PNEUMOBOOTS ON.ENDO: BS STABLE.ID: LOW GRADE TEMPS. L radial A-line placed, significant ammt fling noted, so NBP monitored for now. BRIEFLY STARTED ON NIPRIDE TO KEEP SBP <160. RETURNED TO ON AND FOUND TO HAVE INTRAVENTRICULAR BLEED. UPDATERETURNED FROM INTERVENTIONAL ARTERIOGRAM. NIPRIDE WEANED.P: FOLLOW UP WITH MRI. CONDOM CATH OFF (PLACED FOR ARTERIOGRAM). Shift NotePt is neurologically intact, MAE to command. Pt c/o some nausea immediately on admission, subsided without intervention. SATS WELL ON 2LNC.GI: TOL GEN DIET.GU: VOIDS PER URINAL.SKIN: INTACT.PAIN: PT DENIES PAIN. NEURO~A+O X3. PT REMAINS NPO FOR ON CALL ANGIO.IVF AT 80ML/HR.PT VOIDING WITHOUT DIFFICULTY. Nitro gtt off, Nipride gtt started MD orders. IMPRESSION: Normal MRA of the brain. R FEMORAL SITE WITHOUT ECHHYMOSIS OR BLEEDING. Pt with 2 periph IVs, both flush easily and sites benign.Resp: Lungs CTAB, sats 94-96% on 2L NP.GI: Abd soft, good BS. IMPRESSION: There is a right lateral ventricle intraventricular hemorrhage with little change from the study performed at approximately 3 AM on . NEURO CHECKS Q 2/HR'S, WNL. Pt c/o lightheadedness that resolved spontaneously, HO aware. R CUFF PRESSURE~126/55/76. NOT REQUIRING SS COVERAGE ON NIGHTS.A/P~ PER NEURO ATTENDING.WEAN SNP OFF THIS AM. AT 0500 NOTICED PT'S FACE AND NECK WERE RED BP UNCHANGED REMAINED 160'S. The distal internal carotid arteries, basilar artery, and major branches of the cerebral arteries are normal. Injection of the right external carotid artery is within normal limits with no evidence of arteriovenous malformation or shunting. Nipride gtt titrating to maintain SBP 140-160's (currently 1mcg/kg/min). RM AIR O2 SAT=95-98,RR=. NEUROSIGNS APPEAR NORMAL. Hct, coags WNL. Injection of the left vertebral artery in the cervical portion is smoothly contoured and injection of the left vertebral artery shows that the vascular apex lacks an origin for the right posterior cerebral artery consistent with its fetal type origin. NIPRIDE WEANED OFF AND PO HYDRALAZINE AND LOPRESSOR BEGUN. PLACED ON 2L NP SATS 97%.LUNGS CLEAR BILAT.GI/GU~NPO EXCEPT MEDS. EKG THIS AM. L ARM CUFF PRESSURE~133/55/77. ART BP~159/59/79. RESULTS: Injection of the right common carotid artery reveals a smooth (Over) 4:18 PM CAROT/CEREB Clip # Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO Contrast: OPTIRAY Amt: 260 FINAL REPORT (REVISED) (Cont) bifurcation in the cervical region. It is characterized by T1 hyperintense methemoglobin, as well as smaller areas of suscptibility effect, most likely deoxyhemoblobin. AS LOW AS 39 TRANGIENTLY DESPITE LOPRESSOR BEING HELD. 1 EPISODE OF P WAVES INVERTING.PLAN TO CHECK BLOODGLUCOSE, CONTINUE TO MONITOR NEURO SIGNS AS ORDERED AND NEEDED. The sheath was kept in the heparinized saline drip. TRANSFER TO NSURG ICU. NO NEURO DEFICITS.TOL REG DIET. PLAN TO RESUME ALL PRE-PROCEEDURE MEDS INCLUDING LOPRESSOR AND WEAN SNP KEEPING SBP <180.NS @ 70CC/HR. Injection of the left external carotid artery is within normal limits with no evidence of abnormality. BP CONTROLLED WITHIN MD PARAMETERS WITH ORAL HYDRALAZINE, LOPRESSOR, AND IV INJECTION OF CLONIDINE.PT READY FOR TRANSFER TO 5.REPORT CALLED TO RN.HISTORY: PT IS 51 Y.O. RSICU NURSING PROGRESS NOTEREVIEW OF SYSTEMS:NEURO: A+OX3. MAP:82, HR 58. Pt moving all extremties, denies any numbness or tingling, visual disturbances. Pt reports +BM on AM. DR. DR. PT C/O "JUST A TOUCH" OF A FRONTAL HEADACHE.L NBP CUFF MEASURING BP ALONG WITH L RADIAL A LINE. TO MAINTAIN A SBP </=160. Injection of the right subclavian artery reveals smooth anatomy and no evidence of stenosis or dissection, and injection of the right vertebral artery shows it to be diminutive vessel with a small caliber and is otherwise free of stenosis or disease. Continue nipride as needed BP WNL OFF OF NIPRIDE. RASH LESS SEVERE THIS AM.CARIAC~REMAINS ON SNP @ 2.5 UCG/KG/MIN. The brain parenchyma is normal. TO GO BY NBP. brother in listed as next of , aware of his hospitalization.A/P: Continue close neuro/hemo monitoring, f/u with Dr. in AM. IVF AT KVO. Comparison is made to the CT exam of the same day. The source images show no abnormal vessels extending to the ependymal region. HR 50'S-6O'S SB W/ OCC PVS'S NOTED.RESP~DROP IN SATS TO 90'S ON RA. TRANSFERRED TO . DC A-LINE. PT REMAINS ORIENTED X3,MOVES ALL EXTREMITIES EQUALLY TO COMMAND. Hemodynamically pt with HTN, SNP infusing, unable to wean SNP.	10	[ { "category": "Radiology", "chartdate": "2130-11-30 00:00:00.000", "description": "MR-ANGIO HEAD", "row_id": 747898, "text": " 4:14 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: 51 yr old s/p intraventricular hemorrhage please evaluate w\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n 51 yr old s/p intraventricular hemorrhage please evaluate with mra/mri with\n and without contrast to r/o vascular malformation or underlying tumor\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Intraventricular hemorrhage.\n\n TECHNIQUE: Pre and postcontrast multiplanar T1W images, axial T2W,\n susceptibility and FLAIR images were obtained. Comparison is made to the CT\n exam of the same day.\n\n FINDINGS:\n\n As seen on the CT study from approximately 3 AM, there is hemorrhage in the\n temporal , atrium and posterior body of the right lateral ventricle. The\n amount of hemorrhage has changed very little. It is characterized by T1\n hyperintense methemoglobin, as well as smaller areas of suscptibility effect,\n most likely deoxyhemoblobin. No hydrocephalus is seen. On the FLAIR images no\n subarachnoid hemorrhage is identified.\n\n There is no evidence of a mass or abnormal enhancement. The brain parenchyma\n is normal.\n\n IMPRESSION: There is a right lateral ventricle intraventricular hemorrhage\n with little change from the study performed at approximately 3 AM on . No\n mass is seen.\n\n MRA OF THE HEAD:\n\n CLINICAL HISTORY: Intraventricular hemorrhage, ? underlying vascular\n malformation.\n\n TECHNIQUE: A 3D time of flight study was derived from overlapping axial slabs\n through the cranium.\n\n FINDINGS:\n\n No abnormal vessels are seen to suggest an AVM. As expected, the T1\n hyperintense methemoglobin is, to some extent, visible on the MRA. The source\n images show no abnormal vessels extending to the ependymal region. Note is\n made that the right A1 segment is atretic. The distal internal carotid\n arteries, basilar artery, and major branches of the cerebral arteries are\n normal. There is no MRA evidence of aneurysm.\n\n IMPRESSION: Normal MRA of the brain. No anbormal vessels are seen near the\n (Over)\n\n 4:14 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: 51 yr old s/p intraventricular hemorrhage please evaluate w\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right lateral venricle hemorrhage to suggest underlying vascular malformation.\n As discussed previously, a conventional arteriorgram is probably more\n sensitive to a small lesion.\n\n" }, { "category": "Radiology", "chartdate": "2130-12-01 00:00:00.000", "description": "VERT/CAROTID A-GRAM", "row_id": 747982, "text": " 4:18 PM\n CAROT/CEREB Clip # \n Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO\n Contrast: OPTIRAY Amt: 260\n ******************************* CPT Codes *****************************\n SEL CATH 3RD ORDER SEL CATH 2ND ORDER \n -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER \n -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER \n ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER \n CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT \n EXT CAROTID BILAT VERT/CAROTID A-GRAM \n VERT/CAROTID A-GRAM EXT BILAT A-GRAM \n -52 REDUCED SERVICES \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNOSTIC ANGIO TO R/O\n VASUCULAR ABNORMALITY\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Intracranial hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of intracranial aneurysm or\n arteriovenous malformation.\n\n INDICATION: This angiogram is being performed to find source of possible\n intracranial hemorrhage in this patient.\n\n CONSENT: Consent was obtained from the patient's family. They were given\n full and complete explanation of the procedure including the risks, benefits,\n and possible complication. They understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought to the endovascular suite and\n placed on the table in supine position. Right and left groin areas were\n prepped and draped in the usual fashion and a 5 FR vascular sheath was\n inserted into the right common femoral artery. The sheath was kept in the\n heparinized saline drip. At this point, a 5 FR Berenstein type 2 catheter was\n used to selectively catheterized the vessels in the following order: Right\n common carotid artery, right external carotid artery, right internal carotid\n artery, right subclavian artery, left common carotid artery, left internal\n carotid artery, left external carotid artery, left subclavian artery, left\n vertebral artery, right subclavian artery, right vertebral artery. With the\n cath in each of these locations, a biplane angiographic run were performed in\n order to acquire multiple digitally acquired angiographic images and digital\n subtraction angiography mode. The catheter was withdrawn from the patient,\n and the 5 FR vascular sheath was removed and an arteriotomy site was sealed\n using a perclose device. The patient tolerated the procedure well and was\n returned to the recovery room in stable condition.\n\n RESULTS: Injection of the right common carotid artery reveals a smooth\n (Over)\n\n 4:18 PM\n CAROT/CEREB Clip # \n Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO\n Contrast: OPTIRAY Amt: 260\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n bifurcation in the cervical region. No evidence of stenosis or dissection.\n Injection of the right internal carotid artery reveals a fetal type posterior\n cerebral artery on the right side. In addition, there is an aplastic right A1\n segment of the anterior cerebral artery. Otherwise, the internal carotid\n artery intracranially shows no evidence of intracranial aneurysm or\n arteriovenous malformation. Injection of the right external carotid artery is\n within normal limits with no evidence of arteriovenous malformation or\n shunting. Injection of the left common carotid artery reveals a smooth\n bifurcation with no evidence of stenosis or disease and injection of the left\n internal carotid artery reveals a prominent left A1 segment of the anterior\n cerebral artery with no evidence of intracranial aneurysm or arteriovenous\n malformation. Injection of the left external carotid artery is within normal\n limits with no evidence of abnormality. Injection of the left subclavian\n artery is free of disease or stenosis or dissection, and the origin of the\n left vertebral artery is free of stenosis. Injection of the left vertebral\n artery in the cervical portion is smoothly contoured and injection of the left\n vertebral artery shows that the vascular apex lacks an origin for the right\n posterior cerebral artery consistent with its fetal type origin. In addition,\n the posterior cerebellar arteries on both the right and left side are\n duplicated and there is a prominent AICA and PICA complex bilaterally.\n Injection of the right subclavian artery reveals smooth anatomy and no\n evidence of stenosis or dissection, and injection of the right vertebral\n artery shows it to be diminutive vessel with a small caliber and is otherwise\n free of stenosis or disease.\n\n IMPRESSION: Negative study for intracranial aneurysm or arteriovenous\n malformation to explain the noted intracranial hemorrhage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439915, "text": "SICU Admit note\nPt is a 51 yr old male who was admitted to from with an Intracranial bleed (R ventricle). Pt recalls having a severe headache with occasional GI upset over the past week. Pt had gone to his PCP and rec'd a prescription for Fioranol which offered little relief. Pt reported to the EW at on with c/o worsening headache and was noted to have blood in his R ventricle. Pt was transferred to under the care of Dr. .\n\nPt arrived to the SICU via CT-Angio at approximately 4AM. Pt was alert and oriented X3, very pleasant and appropriately anxious. Pt moving all extremties, denies any numbness or tingling, visual disturbances. Nitro gtt off, Nipride gtt started MD orders. PT monitored overnight in the SICU.\n\nPMH/PSH:\nHTN\nHypercholestremia\n\"high sugars\" per PCP, diabetes diagnosed\nS/P Wisdom teeth extracted\ns/p chin implant in his early 20's for cosmetic reasons\n\nALL: NKDA\n\nROS:\nNeuro: Pt pleasant, alert and oriented X3. Pupils 3mm and equally reactive to light. Pt moves all extremities, denies any weakness, numbness or tingling. Pt c/o headache, specifically severe in back of head/neck area, some relief from MSO4 IV.\n\nCardiac: Bradycardic, HR 40's without ectopy. Nipride gtt titrating to maintain SBP 140-160's (currently 1mcg/kg/min). L radial A-line placed, significant ammt fling noted, so NBP monitored for now. Hct, coags WNL. Pt with 2 periph IVs, both flush easily and sites benign.\n\nResp: Lungs CTAB, sats 94-96% on 2L NP.\n\nGI: Abd soft, good BS. Pt reports +BM on AM. Pt c/o some nausea immediately on admission, subsided without intervention. NPO except meds maintained overnight.\n\nGU/renal: Pt voiding spontaneously in urinal, claims to have used urinal in EW, has not voided yet in SICU.\n\nSkin: Intact\n\nID: Low grade temp, no treatment\n\nEndo: FS stable, no insulin coverage required\n\nSocial: Pt denies any local family or close friends. brother in listed as next of , aware of his hospitalization.\n\nA/P: Continue close neuro/hemo monitoring, f/u with Dr. in AM. Continue nipride as needed\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439916, "text": "RSICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: A+OX3. NO DEFICITS. HOB UP AT 30.\n MORPHINE X1 FOR HEADACHE PAIN.\n HEADACHE IMPROVING AS DAY PROGRESS.\n\nCV: HR 40-60 SB. NIPRIDE WEANED OFF AND PO\n HYDRALAZINE AND LOPRESSOR BEGUN.\n SBP<160. COZAAR GIVEN.\n\nRESP: ON 3LNC WITH SATS 93%. LUNGS CLEAR.\n\nRENAL: LABS WNL. USING URINAL.\n\nGI: NPO EXCEPT SIPS WITH PILLS. IV ZANTAC ADDED.\n\nHEME: STABLE. PNEUMOBOOTS ON.\n\nENDO: BS STABLE.\n\nID: LOW GRADE TEMPS. NO ANTIBXS.\n\nSKIN: NO ISSUES. TURNS SELF.\n\nSOCIAL: BROTHER IN TOUCH FROM .\n\nA: STABLE. NIPRIDE WEANED.\nP: FOLLOW UP WITH MRI. TRANSFER TO NSURG ICU.\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439917, "text": "NURSING UPDATE\nADMITTED FROM MRI WITH RN. ABP >200, NBP L ARM 160 SYS, R ARM 130 SYS- NSURG AWARE. TO GO BY NBP. BRIEFLY STARTED ON NIPRIDE TO KEEP SBP <160. NO NEURO DEFICITS.\nTOL REG DIET. IVF AT KVO. 2L NC -O2 SAT ON RA 92%\n" }, { "category": "Nursing/other", "chartdate": "2130-12-01 00:00:00.000", "description": "Report", "row_id": 1439918, "text": "CONDITION UPDATE\nD.AFEBRILE SR TO SINUS BRADY. AS LOW AS 39 TRANGIENTLY DESPITE LOPRESSOR BEING HELD. SBP BY CUFF=150-160 (EQUAL IN BOTH ARMS) WHILE A-LINE= 180-200, NIPRIDE TITRATED BY CUFF PER DR. AND SICU/TRAUMA TEAM.\n RM AIR O2 SAT=95-98,RR=.\n PT C/O HA ALL OVER #4 WHICH RESPONDED WELL TO PERCOSET.\n PT REMAINS ORIENTED X3,MOVES ALL EXTREMITIES EQUALLY TO COMMAND. PSERL.\n PT REMAINS NPO FOR ON CALL ANGIO.IVF AT 80ML/HR.PT VOIDING WITHOUT DIFFICULTY.\n K REPLACEMENTS IN IVF.\nA. MAINTAIN CUFF BP <160 WITH NIPRIDE.\nR. CONDITION STABLE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-01 00:00:00.000", "description": "Report", "row_id": 1439919, "text": "UPDATE\nRETURNED FROM INTERVENTIONAL ARTERIOGRAM. R FEMORAL SITE WITHOUT ECHHYMOSIS OR BLEEDING. NEUROSIGNS APPEAR NORMAL. PT C/O \"JUST A TOUCH\" OF A FRONTAL HEADACHE.\n\nL NBP CUFF MEASURING BP ALONG WITH L RADIAL A LINE. SNP INFUSING AT 2.3MCG/KG. DR. HERE. PLAN TO RESUME ALL PRE-PROCEEDURE MEDS INCLUDING LOPRESSOR AND WEAN SNP KEEPING SBP <180.\n\nNS @ 70CC/HR. CONDOM CATH OFF (PLACED FOR ARTERIOGRAM). PT HAS USED URINAL.\n\nBREATHSOUNDS CLEAR. PT BREATHING ROOM AIR WITH SP02 98%.\n\nSB AND NSR. 1 EPISODE OF P WAVES INVERTING.\n\nPLAN TO CHECK BLOODGLUCOSE, CONTINUE TO MONITOR NEURO SIGNS AS ORDERED AND NEEDED. PLAN TO GIVE MEDICATIONS FROM EARLIER TODAY.\n\nPT TALKING ON THE PHONE TO HIS \"NEXT OF \" BROTHER FROM CURRENTLY. PROBABLE TRANSFER OUT OF THE UNIT TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439920, "text": "NEURO~A+O X3. NEURO CHECKS Q 2/HR'S, WNL. NO CHANGES THRU NIGHT. 0430 GIVEN PERCOCET 2 TABS FOR C/O THROBBING HA. AT 0500 NOTICED PT'S FACE AND NECK WERE RED BP UNCHANGED REMAINED 160'S. MAP:82, HR 58. PT MENTIONED NOTHING AND STATED THAT HE FELT FINE EXCEPT HIS VISION WAS FUZZY. \"LIKE THINGS WERE MOVING\". STATED THAT VISION WAS NOT BLURY. HE CALLED IT A FUZZY FEELING AND THATS THE ONLY WAY HE COULD EXPLAIN IT. RESOLVED W/IN 10 MIN. ALSO AT THAT TIME I NOTICED A PETECHIAL TYPE RASH ON HIS LEFT ARM FROM HIS ELBOW TO HIS FINGERS. NO C/O OF ITCHING. DR. AWARE. QUESTIONING IF PERCOCET RELATED. RASH LESS SEVERE THIS AM.\n\nCARIAC~REMAINS ON SNP @ 2.5 UCG/KG/MIN. TO MAINTAIN A SBP </=160. RESUMED PREVIOUS ANTIHYPERTENSIVES W/O EFFECT. 0600 HR~82. ART BP~159/59/79. L ARM CUFF PRESSURE~133/55/77. R CUFF PRESSURE~126/55/76. HR 50'S-6O'S SB W/ OCC PVS'S NOTED.\n\nRESP~DROP IN SATS TO 90'S ON RA. PLACED ON 2L NP SATS 97%.\nLUNGS CLEAR BILAT.\n\nGI/GU~NPO EXCEPT MEDS. + BS.\n\nENDO~BS Q 4/HRS. NOT REQUIRING SS COVERAGE ON NIGHTS.\n\nA/P~ PER NEURO ATTENDING.WEAN SNP OFF THIS AM. DC A-LINE. CHANGE LOPRESSOR TO ATENOLOL HOLD FOR HR < 55. EKG THIS AM. PLAN TO TRANS TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439921, "text": "Shift Note\nPt is neurologically intact, MAE to command. Hemodynamically pt with HTN, SNP infusing, unable to wean SNP. HO aware, hydralazine po dose increased. U/O qs, +BS pt able to tolerate solids. Pt with transient episode of nausea. Pt c/o lightheadedness that resolved spontaneously, HO aware. Pt cleared for floor once SBP <140mmhgx3 hours. See flowsheet for details.\n\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439922, "text": "NIPRIDE OFF AT 1530. BP CONTROLLED WITHIN MD PARAMETERS WITH ORAL HYDRALAZINE, LOPRESSOR, AND IV INJECTION OF CLONIDINE.\nPT READY FOR TRANSFER TO 5.\n\nREPORT CALLED TO RN.\n\n\nHISTORY: PT IS 51 Y.O. MALE WITH HX: HTN, HYPERCHOLESTREMIA. PT WENT TO PCP WITH 4 DAY HISTORY OF HEADACHE. RETURNED TO ON AND FOUND TO HAVE INTRAVENTRICULAR BLEED. (NO NEURO DEFECITS). TRANSFERRED TO . IN UNIT FOR NEURO CHECKS AND BP CONTROL.\n\n\nNEURO: INTACT\n\nCV: A-FEBRILE. BP WNL OFF OF NIPRIDE. NORMAL SINUS RHYTHM WITH SINUS BRADY WHEN ASLEEP.\n\nRESP: BREATH SOUNDS CLEAR. RATE AND EFFORT WNL. SATS WELL ON 2LNC.\n\nGI: TOL GEN DIET.\n\nGU: VOIDS PER URINAL.\n\nSKIN: INTACT.\n\nPAIN: PT DENIES PAIN. NO HEADACHE.\n\nACTIVETY: PT HAS BEEN ON BEDREST.\n\nPLAN: TRANSFER TO 5.\n\n\n\n\n" } ]
46,227	144,943	55 year old male with a history of transferred from with NSTEMI status post drug eluting stent to LAD for intravascular ultrasound. . # CORONARIES: Per the patient's history he likely has a history of stable angina with NSTEMI on the day of admission. At the outside hospital a cardiac catheterization was done which showed prox LAD 80-90% lesion and a drug eluting stent was placed to proximal LAD. There was concern at the outside hospital over the patency of the stent. He was transferred here for intravascular ultrasound which showed widely patent stent. Previous concern was likely effect. No re-intervention was done. Peak CK 450, MB 58, TnT 1.14. Aspirin 325 po qday, Atorvastatin 80 po qday, Plavix 75 po qday were started. Nitro sublingual tabs were given prn for chest pain. . # PUMP: There was no previous history of heart failure or heart failure symptoms. LV gram at the outside hospital showed hypokinesis of anterior wall and apex. Lisinopril 10 po qday and Metoprolol 37.5 po bid were started. . # RHYTHM: The patient has no history of abnormal rhythms. No events were seen on telemetry during admission. ECGs have been showing slightly slurred upstroke of R wave in precordial leads - possible delta waves concerning for accessory pathway. . #Discharge: On , after a thorough workup revealed no ongoing coronary ischemia, and the patient was asymptomatic, he was discharged to home from in good, ambulatory conditions, with stable vital signs. Prior to discharge, post myocardial infarction education was reviewed with the patient including reduction of risk for coronary disease, appropriate exercise after myocardial infarction, and a review of his discharge medications.	He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. 2+ DP and PT pulses b/l . Rt femoral cath site with slight induration and tenderness (unchanged from prior exam). Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. He is tolerating it well and autodiuresing. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: He has previously been on antihyptertensive. Clinical correlation is suggested.TRACING #1 The T wave is now inverted in lead aVL and slight terminalbiphasic appearance of the T wave in lead I. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Rule out active lateral myocardial ischemicprocess. CKs , platelets and K+ pending. CKs , platelets and K+ pending. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. # CORONARIES: Pt with history of stable angina with NSTEMI today. # CORONARIES: Pt with history of stable angina with NSTEMI today. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. NPO for repeat cath in AM with IVUS of proximal LAD. # CORONARIES: Pt likely has history of stable angina with ACS today. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: ECG with NSSTTW and initial cardiac enzymes negative. Rt femoral cath site with slight induration and tenderness (unchanged from prior exam). At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. Became painfree and bp in the 120s to 130s. Became painfree and bp in the 120s to 130s. Became painfree and bp in the 120s to 130s. Now s/p cath with DES to proximal LAD. Now s/p cath with DES to proximal LAD. Now s/p cath with DES to proximal LAD. Proximal portion of the stent looked hazy so pt was transferred to for IVUS. Proximal portion of the stent looked hazy so pt was transferred to for IVUS. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. LV gram at OSH showed hypokinesis of anterior wall and apex. LV gram at OSH showed hypokinesis of anterior wall and apex. LV gram at OSH showed hypokinesis of anterior wall and apex. DISPO: CCU for now ICU Care Nutrition: NPO for cath tomorrow Glycemic Control: None Lines: PIV 20 Gauge - 12:11 AM Prophylaxis: DVT: Angiomax Stress ulcer: Not indicated Code status: Full Code Disposition: CCU care for now	27	[ { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232890, "text": "Sinus bradycardia. Low precordial lead voltage. Early precordial R wave\ntransition. Continued biphasic T wave in lead I and T wave inversion in\nlead aVL which is more prominent. Rule out active lateral myocardial ischemic\nprocess. Followup and clinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232891, "text": "Sinus rhythm. Biphasic T wave in lead I and more prominent T wave inversion in\nlead aVL. Rule out active lateral myocardial ischemic process. Followup\nand clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232892, "text": "Sinus rhythm. The T wave is now inverted in lead aVL and slight terminal\nbiphasic appearance of the T wave in lead I. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2158-10-17 00:00:00.000", "description": "Report", "row_id": 232893, "text": "Sinus rhythm. Early precordial R wave transition. No previous tracing available\nfor comparison.\n\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485899, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable.\n Action:\n CKs cycled.\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on antihyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485887, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable.\n Action:\n CKs cycled.\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486013, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs now down\n to 292. Ensure he has been seen by PT tomorrow. He is voiding through\n condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Height:\n 69 Inch\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH: Angina, CAD, Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:73\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,006 mL\n 24h total out:\n 3,625 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 06:25 AM\n Potassium:\n 4.1 mEq/L\n 04:10 PM\n Chloride:\n 107 mEq/L\n 06:25 AM\n CO2:\n 25 mEq/L\n 06:25 AM\n BUN:\n 10 mg/dL\n 06:25 AM\n Creatinine:\n 0.9 mg/dL\n 06:25 AM\n Glucose:\n 116 mg/dL\n 06:25 AM\n Hematocrit:\n 39.1 %\n 06:25 AM\n Valuables / Signature\n Patient valuables: None.\n Other valuables:\n Clothes: Sent home with wife\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1830\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486011, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485916, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485918, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen: Well nourished, No acute distress.\n HEENT: NCAT, PERRL, OP clear, no LAD\n Cardiovascular: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Abd: + BS, soft, NT, ND\n Pulm: CTAB\n Extrem: no c/c/e. Rt femoral cath site with slight induration and\n tenderness (unchanged from prior exam). Small ecchymosis. No bruit.\n Left femoral cath site with no induration, tenderness or bruit. 2+ DP\n and PT pulses b/l\n .\n Tele: NSR with no significant ectopy\n .\n A/P:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485857, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485859, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485953, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485955, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485956, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485762, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485942, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485944, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485705, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485815, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 485693, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads (per report only). Drug eluting stent was placed to the\n prox LAD. Proximal portion of the stent looked hazy so pt was\n transferred to for IVUS. At OSH he received , ,\n Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1,\n Lisinoprol 2.5 x1. Post-cath CK 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55 yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt with history of stable angina with NSTEMI today. Now\n s/p cath with DES to proximal LAD. 2^nd set of cardiac enzymes CK 321,\n MB 45.9, Index 14.3, TnT 0.33 (post-cath). Concern at OSH over patency\n of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n HR titrate goal 60\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Full Code\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO for cath tomorrow\n Glycemic Control: None\n Lines: PIV\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT: Angiomax\n Stress ulcer: Not indicated\n Code status: Full Code\n Disposition: CCU care for now\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Fellow Admission Note - MICU", "row_id": 485695, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads (per report only). Drug eluting stent was placed to the\n prox LAD. Proximal portion of the stent looked hazy so pt was\n transferred to for IVUS. At OSH he received , ,\n Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1,\n Lisinoprol 2.5 x1. Post-cath CK 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55 yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt with history of stable angina with NSTEMI today. Now\n s/p cath with DES to proximal LAD. 2^nd set of cardiac enzymes CK 321,\n MB 45.9, Index 14.3, TnT 0.33 (post-cath). Concern at OSH over patency\n of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n HR titrate goal 60\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Full Code\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO for cath tomorrow\n Glycemic Control: None\n Lines: PIV\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT: Angiomax\n Stress ulcer: Not indicated\n Code status: Full Code\n Disposition: CCU care for now\n ------ Protected Section ------\n Patient seen and examined, discussed with housestaff Dr. .\n Please see above H&P for complete details. Briefly, 55M recently\n diagnosed hypertension presented with anginal-type chest pain while\n working out today. Improved but not resolved with nitro, aspirin en\n route. ECG with NSSTTW and initial cardiac enzymes negative. Plavix 600\n loaded. Taken to cath where found to have proximal 90% LAD lesion with\n ruptured thrombotic plaque and thrombus in the terminal ramus and D1\n sidebranch. Promus 3.5x18mm stent delivered successfully to LAD lesion\n however note of some proximal stent edge haziness at the LAD ostium\n (?flow artifact vs. small clot vs. plaque shift). Transferred to \n for IVUS evaluation of suspect lesion. Initially planned for\n cardiology floor but developed chest pain prior to transfer and\n therefore diverted to CCU for closer observation. On arrival complained\n of substernal chest discomfort that has now resolved after\n receiving single dose morphine. Plan to continue aspirin, plavix,\n lipitor, metoprolol, lisinopril, and . NPO for repeat cath\n in AM with IVUS of proximal LAD. HR well controlled in 60s. BP\n currently slightly elevated, would titrate lisinopril for goal SBP<130.\n Consider echocardiogram to further assess LV function.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:34 ------\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485812, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 485690, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads. Drug eluting stent was placed to the prox LAD. Proximal\n portion of the stent looked hazy so pt was transferred to for IV\n ultrasound. At OSH he received , , Plavix 600, Nitro gtt,\n Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. Post-cath CK\n 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt likely has history of stable angina with ACS today.\n Now s/p cath with DES to proximal LAD. CEs rising post cath. Concern at\n OSH over patency of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Presumed full\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485814, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485921, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen: Well nourished, No acute distress.\n HEENT: NCAT, PERRL, OP clear, no LAD\n Cardiovascular: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Abd: + BS, soft, NT, ND\n Pulm: CTAB\n Extrem: no c/c/e. Rt femoral cath site with slight induration and\n tenderness (unchanged from prior exam). Small ecchymosis. No bruit.\n Left femoral cath site with no induration, tenderness or bruit. 2+ DP\n and PT pulses b/l\n .\n Tele: NSR with no significant ectopy\n .\n A/P: 55 yo M hx transferred from OSH s/p DES to LAD for IVUS for\n evaluation of stent patency. IVUS showed widely patent LAD stent with\n moderate mid LAD disease (40-50%).\n - continue to trend MB to peak\n - callout to 3, likely home tomorrow.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485808, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" } ]
14,519	182,335	The patient was admitted to the Cardiac Surgery Service for a surgical intervention. On , the patient underwent coronary artery bypass grafting times four with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to diagonal branch, saphenous vein graft to obtuse marginal branch and saphenous vein graft to the posterior lateral branch of the right coronary artery. The procedure was without complications, please see the full operative report for details. The patient was in stable condition. The patient was transferred to the Cardiac Intensive Care Unit for initial management. The patient remained intubated. The patient was gradually weaned off the ventilator as tolerated. The patient was extubated on postoperative day #1 requiring continuous Neosynephrine requirement which was weaned gradually. The patient's vital signs remained stable. His electrolytes were repleted as needed. The patient remained in regular rhythm, although slightly tachycardiac. On postoperative day #2, the patient was transferred to the regular floor in stable condition. The patient continued to do very well. His chest tubes were removed on postoperative day #2. His urine catheter was removed on postoperative day #2 as well. Diabetes consult saw the patient and evaluated his current management of diabetes. The pacing wires were removed on postoperative day #3. The patient remained in sinus rhythm during his stay on the service. The patient was ambulating without difficulty and was cleared by the physical therapy. The patient was discharged on to home with services in stable condition.	PT ASSESSMENT AS FOLLOWS:N: SEDATED ON PROPOFOL, WEANED OFF AFTER REVERSAL, CALM AND FOLLOWING COMMANDS.CV: NSR , NO ECTOPY NOTED, BP STABLE WITH 500CCS LR GIVEN FOR BORDERLINE BP (SYSTOLIC 88). MINIMAL FACIAL AND HAND EDEMA NOTED, + PEDAL PULSES. NO C/O'S NAUSEA.GU; URINE OP WNL AND NOT AN ISSUE OVER NOC.ENDO; PT ON INSULIN GTT AND TITRATED TO BLD SUGARS. PT STARTED ON PERCOCETS DURING THE NOC WITH MINIMAL EFFECT.PLAN; CONT TO ASSESS AND MONITOR TRANSFER TO 2 IF REMAINS STABLE AND ABLE TO PULL WITHOUT DIFFICULTY.CARDIOVAS; SR NO ECTOPY PT DID HAVE A SHORT 7 BEAT RUN OF AFIB DURING THE NOC SELF LIMITING. Sinus rhythmNormal ECGSince previous tracing of : no significant change Sinus rhythmNormal ECGSince previous tracing, no significant change Sinus rhythmNormal ECGSince previous tracing, no significant change INSULIN GTT ON AT 2-4 U PER FLOW WITH 4 U BOLUS GIVEN.SKIN: MED DSG CDI, LEFT LEG WITH ACE WRAP INTACT, NO NOTABLE DRAINAGE. CT TO SUCTION, OUTPUT IS MINIMAL AND SEROSANGUINOUS, SITES INTACT WITH NO NOTABLE CLOTTING AT INSERTION SITE.GI/ GU: ABDOMEN BENIGN, NO COMPLAINTS OF PAIN. PT given calcium 2 amps IV for low value, ct output wnl, pt calm, insulin gtt adjusted per flow. Pt cpap gas is wnl, but pt is still sleepy/ sluggish. PT ADMITTED TO ACCOMPANIED BY ANESTHESIOLOGY TEAM, BILATERAL LUNG SOUNDS CLEAR AND PRESENT. There has been interval resolution of a previous right pleural effusion. The heart size is normal and the mediastinal and hilar contours are unremarkable. BP INITALLY LABILE ON NEO GTT. A AND V WIRES ATTACHED.R: VENT SETTINGS PER FLOW, PT WEANED FROM VENT AS TOLERATED, PROJECTED EXTUBATION FOR THIS SHIFT. INSULIN GTT OFF THIS AM WITH BLD SUGARS WNL.COMFORT; C/O LOTS OF INCISIONAL PAIN TX WITH MS04 SQ AND IV WITH NO EFFECT. LUNGS CLEAR BUT DIMINISHED IN BASES. The pulmonary vascularity is within normal limits. CHEST TUBES DRAINING MOD AMT THIN SEROSANQ DRAINAGE. PT GIVEN 500CC LR WITH GOOD EFFECT AND NEO GTT OFF THIS AM WITH MAP >60.GI; TAKING ICECHIPS AND SIPS OF H20 WITH MEDS. Addendum/ Correction:In initial admission note, Rn noted that Vfib was in or when in fact it happened in cath lab on . SLIGHTLY ANXIOUS AT TIMES.RESP; LUNGS CLEAR DIM THRUOUT. UOP STABLE WITH AVERAGE OF 200CC/HR, CLEAR, YELLOW. LIMA AND SVG USED TO BIPASS LAD, RCA, OM, DIAG. Pt does lift head off pillow only for 1-2 seconds. Frontal and lateral radiographs of the chest were obtained and compared to the next prior study dated . 02 VIA N/C AT 4LM WITH 02 SAT'S AND RR WNL. DENIES ANY C/O'S SOB. ADMISSION TO NOTEPT 62 YO MALE ADMITTED S/P EXPERIENCING CP WITH EXERTION, WITH A + EXERCISE STRESS TEST , FOLLOWED BY A CATH SHOWING 4VESSEL DZ. 7P-7A SHIFT SUMMARY NOTE;NEURO; INITALLY SLEEPY AND EXTUBATED WHEN MORE AWAKE WITH OUT EVENT AT . PT ENCOURAGED TO USE I.S. NO OTHER SKIN BREAKDOWN, SACRUM CDI.PT WIFE INT TO VISIT PT, EDUCATED ABOUT TYPICAL POST OPERATIVE COURSE.RN TO FOLLOW CLOSELY AND WEAN TO EXTUBATE AS TOLERATED. PT HAD VFIB WITH RCA INJECTION AND DEFIBRILLATED 300 JOULES X 1. PT WITH STEROIDS BEFORE CATH SECONDARY TO PRIOR ANAPHYLAXIS FOLLOWING IODINE ADMINISTRATION IN PAST. TODAY, PT HAD C4 BY DR. () CROSS CLAMP 54 MINUTES, BIPASS 67 MINUTES. PCER FUNCTIONING APPROPRIATELY, ON ADEMAND AT 60. KCL 40 MEQ GIVEN FOR KCL OF 3.9. O2 SATS 100%. There are surgical sutures and linear scarring at the right lung base consistent with patient's history of prior wedge resection of fibroelastin scar. Surgical sutures and linear scarring at the right lung base. Preop for CABG. POST OP ABG WNL. ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. PREOP,PT ON AN INSULIN GTT FOR HYPERGLYCEMIA MAX 500+). 10:29 PM CHEST (PRE-OP PA & LAT) Clip # Reason: +ETT\CATH MEDICAL CONDITION: 62 year old man with IDDM, CAD for CABG tomorrow morning REASON FOR THIS EXAMINATION: pre-op cabg FINAL REPORT PREOP CHEST X-RAY, : CLINICAL INDICATION: 62 year old man with diabetes and coronary artery disease. No effusions are currently identified and there are no focal areas of consolidation. COUGHING AND RAISING THICK YELLOWISH SECREATIONS.	8	[ { "category": "Radiology", "chartdate": "2153-10-01 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 770228, "text": " 10:29 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with IDDM, CAD for CABG tomorrow morning\n REASON FOR THIS EXAMINATION:\n pre-op cabg\n ______________________________________________________________________________\n FINAL REPORT\n PREOP CHEST X-RAY, :\n\n CLINICAL INDICATION: 62 year old man with diabetes and coronary artery\n disease. Preop for CABG.\n\n Frontal and lateral radiographs of the chest were obtained and compared to the\n next prior study dated .\n\n The heart size is normal and the mediastinal and hilar contours are\n unremarkable. There are surgical sutures and linear scarring at the right\n lung base consistent with patient's history of prior wedge resection of\n fibroelastin scar. There has been interval resolution of a previous right\n pleural effusion. No effusions are currently identified and there are no\n focal areas of consolidation. The pulmonary vascularity is within normal\n limits.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n Surgical sutures and linear scarring at the right lung base.\n\n" }, { "category": "ECG", "chartdate": "2153-10-03 00:00:00.000", "description": "Report", "row_id": 140693, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 140694, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2153-10-01 00:00:00.000", "description": "Report", "row_id": 140695, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of : no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-03 00:00:00.000", "description": "Report", "row_id": 1451563, "text": " 7P-7A SHIFT SUMMARY NOTE;\n\nNEURO; INITALLY SLEEPY AND EXTUBATED WHEN MORE AWAKE WITH OUT EVENT AT . ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL. SLIGHTLY ANXIOUS AT TIMES.\n\nRESP; LUNGS CLEAR DIM THRUOUT. COUGHING AND RAISING THICK YELLOWISH SECREATIONS. 02 VIA N/C AT 4LM WITH 02 SAT'S AND RR WNL. DENIES ANY C/O'S SOB. CHEST TUBES DRAINING MOD AMT THIN SEROSANQ DRAINAGE. PT ENCOURAGED TO USE I.S. AND ABLE TO PULL WITHOUT DIFFICULTY.\n\nCARDIOVAS; SR NO ECTOPY PT DID HAVE A SHORT 7 BEAT RUN OF AFIB DURING THE NOC SELF LIMITING. BP INITALLY LABILE ON NEO GTT. PT GIVEN 500CC LR WITH GOOD EFFECT AND NEO GTT OFF THIS AM WITH MAP >60.\n\nGI; TAKING ICECHIPS AND SIPS OF H20 WITH MEDS. NO C/O'S NAUSEA.\n\nGU; URINE OP WNL AND NOT AN ISSUE OVER NOC.\n\nENDO; PT ON INSULIN GTT AND TITRATED TO BLD SUGARS. INSULIN GTT OFF THIS AM WITH BLD SUGARS WNL.\n\nCOMFORT; C/O LOTS OF INCISIONAL PAIN TX WITH MS04 SQ AND IV WITH NO EFFECT. PT STARTED ON PERCOCETS DURING THE NOC WITH MINIMAL EFFECT.\n\nPLAN; CONT TO ASSESS AND MONITOR TRANSFER TO 2 IF REMAINS STABLE\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451560, "text": "ADMISSION TO NOTE\nPT 62 YO MALE ADMITTED S/P EXPERIENCING CP WITH EXERTION, WITH A + EXERCISE STRESS TEST , FOLLOWED BY A CATH SHOWING 4VESSEL DZ. PT WITH STEROIDS BEFORE CATH SECONDARY TO PRIOR ANAPHYLAXIS FOLLOWING IODINE ADMINISTRATION IN PAST. PREOP,PT ON AN INSULIN GTT FOR HYPERGLYCEMIA MAX 500+). TODAY, PT HAD C4 BY DR. () CROSS CLAMP 54 MINUTES, BIPASS 67 MINUTES. LIMA AND SVG USED TO BIPASS LAD, RCA, OM, DIAG. PT HAD VFIB WITH RCA INJECTION AND DEFIBRILLATED 300 JOULES X 1. PT ADMITTED TO ACCOMPANIED BY ANESTHESIOLOGY TEAM, BILATERAL LUNG SOUNDS CLEAR AND PRESENT. PT ASSESSMENT AS FOLLOWS:\n\nN: SEDATED ON PROPOFOL, WEANED OFF AFTER REVERSAL, CALM AND FOLLOWING COMMANDS.\n\nCV: NSR , NO ECTOPY NOTED, BP STABLE WITH 500CCS LR GIVEN FOR BORDERLINE BP (SYSTOLIC 88). MINIMAL FACIAL AND HAND EDEMA NOTED, + PEDAL PULSES. KCL 40 MEQ GIVEN FOR KCL OF 3.9. PCER FUNCTIONING APPROPRIATELY, ON ADEMAND AT 60. A AND V WIRES ATTACHED.\n\nR: VENT SETTINGS PER FLOW, PT WEANED FROM VENT AS TOLERATED, PROJECTED EXTUBATION FOR THIS SHIFT. O2 SATS 100%. LUNGS CLEAR BUT DIMINISHED IN BASES. POST OP ABG WNL. CT TO SUCTION, OUTPUT IS MINIMAL AND SEROSANGUINOUS, SITES INTACT WITH NO NOTABLE CLOTTING AT INSERTION SITE.\n\nGI/ GU: ABDOMEN BENIGN, NO COMPLAINTS OF PAIN. UOP STABLE WITH AVERAGE OF 200CC/HR, CLEAR, YELLOW. INSULIN GTT ON AT 2-4 U PER FLOW WITH 4 U BOLUS GIVEN.\n\nSKIN: MED DSG CDI, LEFT LEG WITH ACE WRAP INTACT, NO NOTABLE DRAINAGE. NO OTHER SKIN BREAKDOWN, SACRUM CDI.\n\nPT WIFE INT TO VISIT PT, EDUCATED ABOUT TYPICAL POST OPERATIVE COURSE.\nRN TO FOLLOW CLOSELY AND WEAN TO EXTUBATE AS TOLERATED.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451561, "text": "Pt cpap gas is wnl, but pt is still sleepy/ sluggish. Pt does lift head off pillow only for 1-2 seconds. PT given calcium 2 amps IV for low value, ct output wnl, pt calm, insulin gtt adjusted per flow. Rn to endorse info to night staff.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451562, "text": "Addendum/ Correction:\nIn initial admission note, Rn noted that Vfib was in or when in fact it happened in cath lab on .\n" } ]
24,811	143,739	Mr. a tonsillectomy, uvulectomy, septoplasty, and intramural cauterization of nasal turbinates on . He had 75cc of blood loss and tolerated the procedure well without complications. He was extubated in the PACU but was unable to be weaned from oxygen. He was transferred to the for continuous O2 sat monitoring. He was maintained on humidified oxygen by shovel mask overnight. He was kept off his home BiPAP to prevent bleeding and irritation postoperatively. He had improvement in his O2 saturations with intensive incentive spirometry. His hypoxia was therefore thought to largely be due to postoperative atelectasis, with contribution from his baseline problems with sleep apnea. His O2 saturations were measured with ambulation and were found to be 92-94%. He had mild postoperative pain that was well-controlled with Percocet elixir. He was advanced to a full diet before discharge. He was discharged to home with instructions to follow up with Dr. in 1 week.	IN 1 WK AND CALL DR. HIS PRIMARY MD WITH NEXT F/U APPOINTMENT. PT INSTRUCTED TO MD IF TEMP > 100, CALL IF BLEEDING DOESN'T STOPPED AFTER PRESSURE APPLIED TO NOSE/MOUTH, OR IF PAIN IN NOSE/MOUTH NOT RELIEVED WITH ROXICET. MICU/SICU NSG NOTE: 7:00-3:00PT S/P SEPTOPLASTY/TONSILECTOMY/UVULOPLASTY . HE WAS TRANSFERRED FROM PACU YESTERDAY AND MONITORED OVERNIGHT B/C OF PERSISTENT DESATURATION. MD TEAM, PT STABLE FOR D/C. IN AFTERNOON, AFTER PT ATE LUNCH, PT STATED HE FELT MUCH BETTER AND 02 SATS 91-94% ON RM AIR WITH AMBULATION. PT AMB AROUND RN STATION AND TOLERATING WELL ALTHOUGH 02 SAT IN AM DROPPED TO 82%. PT TO TAKE KEFLEX AS DIRECTED AND ROXICET PRN PAIN. PT INSTRUCTED TO FOLLOW UP WITH DR. NPN -0700Pt is 35 y/o male with hx of sleep apnea who had septoplasty/ tosillectomy/ uvuloplasty and removal of uvular lesion on , transferred to MICU from PACU for O2sat monitoring b/c of persistent desaturation upon removal of O2.Neuro: A&Ox3, follows commands, answers questions appropriately, c/o discomfort to back of throat, pt describes his throat as "feeling swollen." 02 SATS UP TO 95%. THIS AM PT TO HIGH 80S ON RM AIR. Given total of 15ml of Oxycodone-Acetaminophen elixir for discomfort which pt states has not resolved completely but refuses more medicine.Resp: Lungs coarse bilat., O2 on 100%cool neb, RR 12-20, O2 sats 96-100%, no c/o SOB or difficulty breathing.CV: HR 90-105 SR-ST no ectopy, SBP's 130's-150's, pedal pulses palpable.GI: BS (+), no c/o nausea, NPO except for sips of H2O with meds.GU: Voiding into urinal in adequate amts.Skin: Drsg changed x 2 for small amts of sanguinous drainage, current drsg and . PT SIGNED CONSENT FORM AND WIFE ARRIVED AND PICKED UP PT FOR D/C TO HOME. No bloody drainage noted to back of throat.Social: Wife is contact person, no phone calls from family since adm. to MICU.PlanS: Continue to montitor O2 sats, dc home possibly today if O2 sats hold without the assistance of O2 therapy. PT IN AGREEMENT WITH DISCHARGE PLAN.	2	[ { "category": "Nursing/other", "chartdate": "2124-09-12 00:00:00.000", "description": "Report", "row_id": 1584625, "text": "MICU/SICU NSG NOTE: 7:00-3:00\nPT S/P SEPTOPLASTY/TONSILECTOMY/UVULOPLASTY . HE WAS TRANSFERRED FROM PACU YESTERDAY AND MONITORED OVERNIGHT B/C OF PERSISTENT DESATURATION. THIS AM PT TO HIGH 80S ON RM AIR. GIVEN INCENTIVE SPIROMETER AND USING WITH EXCELLENT TECHNIQUE TO FULL VITAL CAPACITY. 02 SATS UP TO 95%. PT AMB AROUND RN STATION AND TOLERATING WELL ALTHOUGH 02 SAT IN AM DROPPED TO 82%. IN AFTERNOON, AFTER PT ATE LUNCH, PT STATED HE FELT MUCH BETTER AND 02 SATS 91-94% ON RM AIR WITH AMBULATION. MD TEAM, PT STABLE FOR D/C. PT INSTRUCTED TO FOLLOW UP WITH DR. IN 1 WK AND CALL DR. HIS PRIMARY MD WITH NEXT F/U APPOINTMENT. PT INSTRUCTED TO MD IF TEMP > 100, CALL IF BLEEDING DOESN'T STOPPED AFTER PRESSURE APPLIED TO NOSE/MOUTH, OR IF PAIN IN NOSE/MOUTH NOT RELIEVED WITH ROXICET. PT TO TAKE KEFLEX AS DIRECTED AND ROXICET PRN PAIN. PT IN AGREEMENT WITH DISCHARGE PLAN. PT SIGNED CONSENT FORM AND WIFE ARRIVED AND PICKED UP PT FOR D/C TO HOME.\n" }, { "category": "Nursing/other", "chartdate": "2124-09-12 00:00:00.000", "description": "Report", "row_id": 1584624, "text": "NPN -0700\nPt is 35 y/o male with hx of sleep apnea who had septoplasty/ tosillectomy/ uvuloplasty and removal of uvular lesion on , transferred to MICU from PACU for O2sat monitoring b/c of persistent desaturation upon removal of O2.\n\nNeuro: A&Ox3, follows commands, answers questions appropriately, c/o discomfort to back of throat, pt describes his throat as \"feeling swollen.\" Given total of 15ml of Oxycodone-Acetaminophen elixir for discomfort which pt states has not resolved completely but refuses more medicine.\n\nResp: Lungs coarse bilat., O2 on 100%cool neb, RR 12-20, O2 sats 96-100%, no c/o SOB or difficulty breathing.\n\nCV: HR 90-105 SR-ST no ectopy, SBP's 130's-150's, pedal pulses palpable.\n\nGI: BS (+), no c/o nausea, NPO except for sips of H2O with meds.\n\nGU: Voiding into urinal in adequate amts.\n\nSkin: Drsg changed x 2 for small amts of sanguinous drainage, current drsg and . No bloody drainage noted to back of throat.\n\nSocial: Wife is contact person, no phone calls from family since adm. to MICU.\n\nPlanS: Continue to montitor O2 sats, dc home possibly today if O2 sats hold without the assistance of O2 therapy.\n\n" } ]
3,482	156,471	This patient is a 56 year-old man with history of severe COPD (FEV1 19%) on home oxygen, with history of CAD s/p MI with CABG and BMS, admitted for COPD exacerbation, intubated and transferred to MICU for hypercarbic respiratory failure, readmitted to floor with trigger for hypoxemia/hypercarbia/respiratory distress. After family discussion , patient decided to go home on hospice and was medically stablized for discharge home to .	Delayed R wave progression is likely a normal variant. Since the previous tracing of P waves are less prominentand precordial lead QRS voltage is more prominent. Compared to the previous tracing of the P wave changes arenew. Delayed R wave progression with late precordial QRS transition.ST-T wave configuration suggests early repolarization pattern. Sinus rhythm. Sinus rhythm. Comparedto the previous tracing the rate has decreased.TRACING #2 Findings arenon-specific. Delayed R wave progression is probably a normal variant.Compared to the previous tracing of the rate has increased.TRACING #1 Consider biatrial abnormality with marked peaked andtall P waves in leads II, III and aVF and marked negative P waves inleads V1-V3. Sinus tachycardia. Otherwise, no diagnostic interval change, although there is a moderatebaseline which makes comparison difficult.	4	[ { "category": "ECG", "chartdate": "2153-05-12 00:00:00.000", "description": "Report", "row_id": 282171, "text": "Normal sinus rhythm. Consider biatrial abnormality with marked peaked and\ntall P waves in leads II, III and aVF and marked negative P waves in\nleads V1-V3. Compared to the previous tracing of the P wave changes are\nnew. Otherwise, no diagnostic interval change, although there is a moderate\nbaseline which makes comparison difficult.\n\n" }, { "category": "ECG", "chartdate": "2153-05-08 00:00:00.000", "description": "Report", "row_id": 282172, "text": "Sinus rhythm. Delayed R wave progression with late precordial QRS transition.\nST-T wave configuration suggests early repolarization pattern. Findings are\nnon-specific. Since the previous tracing of P waves are less prominent\nand precordial lead QRS voltage is more prominent.\n\n" }, { "category": "ECG", "chartdate": "2153-05-07 00:00:00.000", "description": "Report", "row_id": 282173, "text": "Sinus rhythm. Delayed R wave progression is likely a normal variant. Compared\nto the previous tracing the rate has decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-05-07 00:00:00.000", "description": "Report", "row_id": 282174, "text": "Sinus tachycardia. Delayed R wave progression is probably a normal variant.\nCompared to the previous tracing of the rate has increased.\nTRACING #1\n\n" } ]
4,268	121,889	Patient was admitted to the general surgery team with a partial small bowel obstruction. Initially, there had been a report of some coffee ground emesis which was not witnessed. A Hct was checked and remained stable. A GI consult was called. He was kept NPO with an NGT in place. Serial abdominal exams were performed. An endoscopy was not performed secondary to the partial small bowel obstruction and the risk of perforation. The patient was closely monitored with serial KUB's which remained stable. Clinically, his abdomen remained soft and nontender and his hematocrit remained stable. He did demonstrate persistent asymptomatic tachycardia during his first days in the hospital which could not be controlled with metoprolol. He was started on a diltiazem drip and then eventually transitioned to po digoxin with good control of his heart rate. His NGT was discontinued and he was slowly advanced on a diet which he tolerated well. He was tolerating a regular diet, and remained hemodynamically stable and was discharged to rehab on HD9 in stable condition.	ekg obtained indicated a-flutter - dr aware, pt currently in afib. COMPARISON: abdomen portable. endoscopy, serial hcts. Small-bowel obstruction. soft/non-distended, +hypoactive BS. Pt is DNR/DNI. Colon is decompressed. Residual contrast is seen within the large bowel. bs covered with ssri. NA 151 and Dr. aware. Patchy left lung base opacity. Atrial flutter with 2:1 A-V block. cvl placement, ? is soft, +bs, +flatus. Lungs clear and diminished. ABDOMEN SUPINE PORTABLE PLAIN FILM: There has been interval progressive dilation of small bowel into smaller degree large bowel. NG tube is in distal body of stomach. NGT to LCWS. Clincal correlation recommended. Also, it was noted this am that a small amt. Afebrile. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Findings are consistent with partial small-bowel obstruction that could be resolving. These findings are consistent with small-bowel obstruction. COMPARISON: , abdomen plain film. FINDINGS: There is a patchy left lower lobe opacity. c/o to floor. The heart is upper limits of normal in size. UOP adequate via foley. Abdomen soft and hyperactive bowel sounds. Hct stable, last level 34.0. IMPRESSION: Multiple dilated loops of small bowel likely representing partial small bowel obstruction. There are possible decompressed loops of relatively distal small bowel seen in the right pelvis. Dictated. These findings may represent a mechanical small-bowel obstruction. These findings are consistent with persistent small-bowel obstruction with component of colonic ileus. sent for c. diff, dr. was notified. of small loose bm. INDICATION: Shortness of breath. serial hct's initiated. ABDOMEN: Again seen are multiple dilated loops of small bowel, grossly unchanged compared to prior study. Since the previous tracing of asingle ventricular premature beat is seen.TRACING #2 pt without c/o pain. Duoderm to coccyx. HR 90-130s a-fib w/occ. Duoderm intact on sacral area. BP stable. These findings are consistent with unchanged small bowel obstruction. There are multiple sigmoid diverticula. Rule out obstruction. There is loss of joint space in the hips bilaterally that are consistent with degenerative changes. Warm extremities, weak distal pulses. 2 liters nasal cannula. Dilated loops of small bowel in the imaged portion of the upper abdomen. Ulcers on left great toe and foot, covered w/ dry drsg. HR afibb tachy up to 130s. Long segment of dilated small bowel with possible decompressed more distal loops of small bowel in the right pelvis with no identifiable transition point. is soft, nontender, +bs. Weakness noted in LLE, otherwise good strength. Evaluate for passage of contrast into colon. frequency inc. to Q4h. PERLA. Evaluate for resolving obstruction. + peripheral pulses, no edema. The majority of the small bowel is dilated. There are vascular calcifications. Small brown BM x1. COMPARISON: Plain film of . Code status discussed w/pt. abd. Abd. Please see subsequently dictated CT of the abdomen which was obtained following this radiograph and is dictated separately. The large bowel is not dilated. 2. 2. 2. 2. BP stable, sbp 90-120. Rectum and sigmoid colon are filled with stool. Please refer to carevue for details. 3. +MRSA, on abx coverage.PLAN: Monitor hemodynamic status. to monitor. Productive cough. Denies pain. adjust lopressor dosing, transfer to floor. dr. is aware. Dr. is aware. bp 100's-120's. mushroom catheter was placed, spec. Evaluate for progression. ABDOMINAL PLAIN FILM: There are multiple distended loops of small bowel seen throughout the abdomen, predominantly on the right. Sclerotic changes seen within the hips with loss of joint space consistent with degenerative change. Within the imaged portion of the upper abdomen, there are dilated loops of bowel, incompletely evaluated on this chest radiograph examination. Lungs clear bilaterally, O2 sat high 90s on 2L NC. ngt to wall suction draining brown drainage (~ 400cc) Pt was incont. Pelvic bone is sclerotic with thickened cortex/trabeacule and multiple lytic lesions. Large bowel is not dilated and is filled with stool. Possible atrial flutter with variable blockMarked left axis deviationLow QRS voltages in limb leadsNo change from previous A-fib with occasional pvc's, hr frequently up to 130-140's, controlled with q 4hr lopressor and 2 additional single doses. SMall liquid stool. plan: ? Monitor NG output. Emotional support provided. Continue to monitor mental status. LR @ 80cc/h. TECHNIQUE: MDCT acquired images of the abdomen were obtained after the administration of oral contrast. PO lopressor increased with good, but temporary effect. condition updatesee carevue for specifics;pt is alert and oriented x's 3, no c/o pain, moves all extremities. Diffuse mottled appearance of the pelvis and sacrum and lower lumbar spine consistent with patient's reported history of multiple myeloma. Abnormal pelvic bones, suggestive of Paget's disease. NGT to LCS, putting out brown/coffee-ground material. Evaluation for free fluid is limited on this study. PVCs. u/o 15cc'f for 1 hr, primary team was notified, will cont. Gas and contrast are present throughout the colon. 02 sat 99-100 on 2 l n.c., ls are clear. Nursing Progress Note 7a-7pPt is A&Ox3, follows commands and communicates appropriately. condition updateadmitted from er at 0400 - hr in 130-140's (afib), pt received 3mg iv lopressor with good effect, hr down to 80's. (Over) 12:29 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: delineation of obstruction Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE Field of view: 36 FINAL REPORT (Cont) Multiple air fluid levels are seen. ABDOMEN: There are multiple dilated loops of small bowel in the left abdomen consistent with partial small bowel obstruction. There is extensive Paget's disease of the pelvis and sacrum. Non-contrast, limited evaluation of the liver, spleen, pancreas, adrenal glands, and kidneys is grossly unremarkable. Continue to monitor HR. There are a few gas-distended loops of small bowel that are less distended than on the previous film of .	16	[ { "category": "Nursing/other", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 1317578, "text": "condition update\nadmitted from er at 0400 - hr in 130-140's (afib), pt received 3mg iv lopressor with good effect, hr down to 80's. ekg obtained indicated a-flutter - dr aware, pt currently in afib. bp 100's-120's. 02 sat 99-100 on 2 l n.c., ls are clear. pt without c/o pain. alert and oriented x's 3, follows commands and moves all extremities. LR running at 150cc/hr. serial hct's initiated. abd. is soft, +bs, +flatus. ngt to wall suction draining brown drainage (~ 400cc) Pt was incont. of small loose bm. u/o 15cc'f for 1 hr, primary team was notified, will cont. to monitor. plan: ? cvl placement, ? endoscopy, serial hcts.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 1317579, "text": "Nursing Progress Note 7a-7p\n\nPt is A&Ox3, follows commands and communicates appropriately. Weakness noted in LLE, otherwise good strength. Denies pain. Lungs clear bilaterally, O2 sat high 90s on 2L NC. BP stable. HR 90-130s a-fib w/occ. PVCs. HR comes down to 90s after lopressor but only for few hours. frequency inc. to Q4h. Warm extremities, weak distal pulses. No edema. Afebrile. Abd. soft/non-distended, +hypoactive BS. NGT to LCS, putting out brown/coffee-ground material. NPO x ice chips. Small brown BM x1. UOP adequate via foley. Duoderm intact on sacral area. Ulcers on left great toe and foot, covered w/ dry drsg. LR @ 80cc/h. Hct stable, last level 34.0. +MRSA, on abx coverage.\n\nPLAN: Monitor hemodynamic status. Monitor NG output. c/o to floor. Code status discussed w/pt. Pt is DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-12 00:00:00.000", "description": "Report", "row_id": 1317580, "text": "condition update\nsee carevue for specifics;\npt is alert and oriented x's 3, no c/o pain, moves all extremities. A-fib with occasional pvc's, hr frequently up to 130-140's, controlled with q 4hr lopressor and 2 additional single doses. Dr. is aware. + peripheral pulses, no edema. Na+ 154 this am, dr. was notified.\nLS are clear bilaterally, 02 sat 99-100% on 2 liters n.c. Abd. is soft, nontender, +bs. Ngt to lws draining brown drainage. Pt was incontinent of very large liquid brown bm this evening, guiac negative. mushroom catheter was placed, spec. sent for c. diff, dr. was notified. foley is draining adequate atms. clear yellow urine. bs covered with ssri. plan: monitor stool output, monitor heart rate, ? adjust lopressor dosing, transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-12 00:00:00.000", "description": "Report", "row_id": 1317581, "text": "addendum\nto treat na+, ivf changed to d51/2 ns at 100cc/hr as per Dr. . Also, it was noted this am that a small amt. of blood was draining out of ng tube, and has since returned to brown. dr. is aware.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-13 00:00:00.000", "description": "Report", "row_id": 1317582, "text": "Nursing Note 7p-7a:\nNursing Assessment 7p-7a:\n\nPt pleasant and cooperative with care. Alert and orientated x 3 except frequently talking about being afraid of someone out to hurt him and after his wife's money. Dr. aware and social worker to be contact in morning. Emotional support provided. Orientated to person, place, and time. PERLA. HR afibb tachy up to 130s. PT has a floor bed available but awaiting blue team to decide if ready to go to floor d/t tachy 130s. PO lopressor increased with good, but temporary effect. 90-110 an hour after po and lasts approximately 3 hours. Dr. aware and awaiting morning rounds prior to any further med changes or interventions. BP stable, sbp 90-120. NA 151 and Dr. aware. Lungs clear and diminished. Productive cough. 2 liters nasal cannula. Abdomen soft and hyperactive bowel sounds. SMall liquid stool. NPO except ice chips. NGT to LCWS. IVF D5 1/2 NS with 20 KCL at 100 cc/hr. Duoderm to coccyx. Plan: awaiting final decision to transfer to floor. Continue to monitor HR. Continue to monitor mental status. Please refer to carevue for details.\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903532, "text": " 3:42 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for passage of contrast into colon\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n REASON FOR THIS EXAMINATION:\n please evaluate for passage of contrast into colon\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with partial small bowel obstruction. Evaluate\n for passage of contrast into colon.\n\n ABDOMEN: There are multiple dilated loops of small bowel in the left abdomen\n consistent with partial small bowel obstruction. Colon is decompressed. There\n is extensive sclerosis seen within the right hemipelvis greater than left\n hemipelvis, which probably represents Paget's disease.\n\n IMPRESSION: Multiple dilated loops of small bowel likely representing partial\n small bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903395, "text": " 4:55 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for progressions of pSBO\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n REASON FOR THIS EXAMINATION:\n eval for progressions of pSBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old male with partial small bowel obstruction. Evaluate\n for progression.\n\n COMPARISON: , abdomen plain film.\n\n ABDOMEN: Again seen are multiple dilated loops of small bowel, grossly\n unchanged compared to prior study. These findings are consistent with\n unchanged small bowel obstruction.\n\n\n" }, { "category": "ECG", "chartdate": "2138-03-16 00:00:00.000", "description": "Report", "row_id": 270579, "text": "Possible atrial flutter with variable block\nMarked left axis deviation\nLow QRS voltages in limb leads\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 270793, "text": "Possible atrial flutter\nPremature ventricular contractions or aberrant ventricular conduction\nLVH with ST-T changes\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince previous tracing, ventricular rate is slower\n\n" }, { "category": "ECG", "chartdate": "2138-03-10 00:00:00.000", "description": "Report", "row_id": 270794, "text": "Atrial flutter with 2:1 A-V block. Since the previous tracing of a\nsingle ventricular premature beat is seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-03-10 00:00:00.000", "description": "Report", "row_id": 270795, "text": "Atrial flutter with a rapid ventricular response. Since the previous tracing\nof the ventricular rate is increased and non-specific ST-T wave\nabnormalities are seen.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2138-03-10 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 903362, "text": " 6:26 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with abd distension, vomiting\n REASON FOR THIS EXAMINATION:\n obstruction\n ______________________________________________________________________________\n WET READ: JVg MON 9:06 PM\n Multiple dilated loops of small bowel concerning for obstruction. Sclerotic\n changes in pelvis, loss of hip jt spaces, c/w degenerative disease. Dictated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with abdominal distention and vomiting. Rule out\n obstruction.\n\n No comparison studies.\n\n ABDOMINAL PLAIN FILM: There are multiple distended loops of small bowel seen\n throughout the abdomen, predominantly on the right. Multiple air fluid levels\n are seen. These findings are consistent with small-bowel obstruction.\n Pelvic bone is sclerotic with thickened cortex/trabeacule and multiple lytic\n lesions. There is loss of joint space in the hips bilaterally that are\n consistent with degenerative changes.\n\n IMPRESSION:\n\n 1. Small-bowel obstruction.\n\n 2. Abnormal pelvic bones, suggestive of Paget's disease. Clincal correlation\n recommended.\n\n 2. Sclerotic changes seen within the hips with loss of joint space consistent\n with degenerative change.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-12 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903620, "text": " 10:44 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?interval change\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM\n\n History of partial small bowel obstruction.\n\n There are a few gas-distended loops of small bowel that are less distended\n than on the previous film of . Gas and contrast are present\n throughout the colon. NG tube is in distal body of stomach. Findings are\n consistent with partial small-bowel obstruction that could be resolving.\n There is extensive Paget's disease of the pelvis and sacrum.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-13 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903750, "text": " 8:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: resolving PSBO\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with PSBO\n REASON FOR THIS EXAMINATION:\n resolving PSBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with partial small-bowel obstruction. Evaluate\n for resolving obstruction.\n\n COMPARISON: abdomen portable.\n\n ABDOMEN SUPINE PORTABLE PLAIN FILM:\n\n There has been interval progressive dilation of small bowel into smaller\n degree large bowel. Residual contrast is seen within the large bowel. These\n findings are consistent with persistent small-bowel obstruction with component\n of colonic ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 903361, "text": " 6:26 PM\n CHEST (PA & LAT) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST\n\n COMPARISON: .\n\n INDICATION: Shortness of breath.\n\n The heart is upper limits of normal in size. There is no mediastinal or hilar\n lymphadenopathy. The lungs are clear, and there are no pleural effusions or\n pneumothoraces.\n\n Within the imaged portion of the upper abdomen, there are dilated loops of\n bowel, incompletely evaluated on this chest radiograph examination.\n\n IMPRESSION:\n 1. No evidence of acute cardiopulmonary process.\n 2. Dilated loops of small bowel in the imaged portion of the upper abdomen.\n Please see subsequently dictated CT of the abdomen which was obtained\n following this radiograph and is dictated separately.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 903384, "text": " 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: delineation of obstruction\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with obstruction, GIB\n REASON FOR THIS EXAMINATION:\n delineation of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obstruction.\n\n COMPARISON: Plain film of .\n\n TECHNIQUE: MDCT acquired images of the abdomen were obtained after the\n administration of oral contrast. IV contrast was not administered secondary\n to elevated creatinine.\n\n FINDINGS: There is a patchy left lower lobe opacity. No pleural effusion.\n\n The majority of the small bowel is dilated. No wall thickening is\n demonstrated or pneumatosis. There are possible decompressed loops of\n relatively distal small bowel seen in the right pelvis. Large bowel is not\n dilated and is filled with stool. No transition point can be identified.\n There is no intra-abdominal free air. Evaluation for free fluid is limited on\n this study.\n\n Non-contrast, limited evaluation of the liver, spleen, pancreas, adrenal\n glands, and kidneys is grossly unremarkable. There are vascular\n calcifications.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter within the\n bladder. Rectum and sigmoid colon are filled with stool. There are multiple\n sigmoid diverticula.\n\n Bone windows reveal diffuse mottled appearance of the lower lumbar spine and\n pelvis consistent with patient's reported history of multiple myeloma.\n\n IMPRESSION:\n 1. Long segment of dilated small bowel with possible decompressed more distal\n loops of small bowel in the right pelvis with no identifiable transition\n point. The large bowel is not dilated. These findings may represent a\n mechanical small-bowel obstruction. No free air or pneumatosis is seen.\n 2. Patchy left lung base opacity.\n 3. Diffuse mottled appearance of the pelvis and sacrum and lower lumbar spine\n consistent with patient's reported history of multiple myeloma.\n\n This was discussed with Dr. , covering for surgery.\n (Over)\n\n 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: delineation of obstruction\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]
23,811	134,964	1. Hypotension - The patient was initially mildly hypotensive with systolic blood pressures in the 80s. Upon admission it was unclear whether or not the patient was volume overloaded or volume depleted. Initially he was treated with intravenous fluids with a dramatic response in his systolic blood pressure. However, subsequent it was determined that the patient's hypotension may have been related to his rapid ventricular response and right heart failure. Therefore the focus of treatment was changed to controlling his rate. 2. Atrial fibrillation - The patient's Digoxin had been weaned off prior to his admission. It was felt that this potentially had lead to his atrial flutter and atrial fibrillation with rapid ventricular response. The patient was loaded once again with Digoxin and his beta blocker was increased to 100 mg of Lopressor, three times a day. In addition the patient was started on Verapamil since his heart rate had remained mildly tachycardiac in the low 100s. 3. Congestive heart failure - During the initial course of the patient's admission, it was unclear as to whether or not he was volume overloaded or volume depleted. The patient was initially treated with intravenous fluids, however, subsequently he was diuresed when he became symptomatic and short of breath. Chest x-rays revealed evidence of congestive heart failure. The decision was made to have the patient undergo a cardiac catheterization to fully evaluate the hemodynamics to determine the etiology of the patient's heart failure. In addition, plans were made to evaluate the patient's cardiac arteries to determine if he had any component of ischemic cardiomyopathy. 4. Abnormal liver function tests - The patient had an isolated, elevated alkaline phosphatase with a confirmatory elevation in his gamma glutamyl transferase. An ultrasound of the right upper quadrant did not reveal any cholelithiasis or cholecystitis, however, an irregular hepatic contour was seen which is suggestive of underlying chronic liver disease. There was some concern that the patient may have a partial biliary obstruction and the patient was sent for an magnetic resonance cholangiopancreatography to further evaluate the biliary system. Magnetic resonance cholangiopancreatography did not reveal any evidence of biliary dilatation or of any obstructing pancreatic mass. Again seen was a slightly irregular contour of the liver with dilated hepatic veins suggesting chronic hepatic vascular congestion. The patient also revealed a prior history of heavy alcohol use for approximately 20 years, during the mid to mid . It was felt that he may have had some component of vascular congestion from his congestive heart failure as well as possibly some mild cirrhotic changes secondary to his previous alcohol use. 5. Fall - The patient had a mechanical fall during his admission. He did not sleep at all the night before and was extremely fatigued. He was walking in the , dragging his intravenous pole when he tripped over the foot of the pole and lost his balance. He fell backwards, landing on his buttocks and bumped his head. His neurological examination at that time was nonfocal and the head was atraumatic without any evidence of a hematoma. A computerized axial tomography scan of his head at that time did not reveal any extra or intracranial hemorrhage. 6. Rectal bleeding - The patient has a history of rectal bleeding, ever since his brachytherapy for his prostate cancer. The patient has been treated with Argon laser therapy in the past for his rectal bleeding and it is recommended that he follow up with his gastroenterologist for repeat Argon laser therapy. The remainder of the hospital course will be dictated by the covering intern. , M.D. Dictated By: MEDQUIST36 D: 22:34 T: 06:55 JOB#:	Regular tachycardia ( except for 1 beat) - mechanism uncertain - consideratrial flutter or possible atrial tachycardiaLeft bunch branch blockSince previous tracing of , ventricular response more regular History of ASD repairHeight: (in) 70Weight (lb): 215BSA (m2): 2.15 m2BP (mm Hg): 100/67HR (bpm): 110Status: InpatientDate/Time: at 09:21Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Regular tachycardia - mechanism uncertain - consider atrial flutter with 2:1response or possible atrial tachycardiaLeft bunch branch blockSince previous tracing of , no significant change left bundle branch blockSince previous tracing of ,ventricular rate slower AfebrileCV: Hr initially low to mid 100's st with no vea noted. "O: See vs/objective data per carevue.CV: HR 100's afib with no vea. Moderate tosevere (3+) mitral regurgitation is seen.TRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.There is moderate pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Image quality was suboptimal.Conclusions:The left atrium is moderately dilated. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.The aortic valve leaflets are mildly thickened. There is moderatepulmonary artery systolic hypertension. Would hold off on sleeper d/t pt lethargy this am. IV NTG WEANED OFF. Rec'd lasix 10mg x 2 with mild diursis.GI/GU: Abd soft with good bowel sounds, no bm. Compared to the previous tracing atrial flutter persists (again as evidenced byflutter waves in lead VI and the regularity of portions of the ventricularresponse). Correlation with recent ultrasound examination dated confirms the absence of gallstones. There is focal hypokinesis ofthe apical free wall of the right ventricle. R groin has remained d/i with distal pulses palpable.Resp: O2 at 4lnp with sats in mid 90's. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. ?OVER-DIURESED. There is focal hypokinesisof the apical free wall of the right ventricle. High ST take-offs in the precordial leads arenon-diagnostic with the intraventricular conduction delay. (Over) 6:28 PM MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # Reason: r/o partial biliary obstruction Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) PAD 29->15, CVP 10->6, W 15-17, CO 4.4->5.0, CI 2.02->2.29, SVR 1709->1072. Supraventricular tachyarrhythmia - mechanism uncertain - consider atrialtachycardia/"slow" atrial flutterIntraventricular conduction delay - ? MVO2 64-67%.CARDIAC: HR 95-105 SR/ST, NO ECTOPY. ADMISSION NOTEPLEASE SEE FHP FOR DETAILS PMH & CURRENT ADMISSION.NEURO: A&O X3, BUT WHILE DOZING ATTEMPTS MADE TO D/C SWAN X3--NOT RE- ALIZING WHAT HE IS DOING. Compared to the previous tracing the ventricular rate is somewhat slower.Flutter waves are clearly seen in lead VI.TRACING #3 Supraventricular tachycardia which is regular with intermittent increasedR-R intervals, basic ventricular rate about 100. Poor initial R wave progression.Indeterminate QRS axis. Overall left ventricular systolic function is severely depressed.The right ventricular cavity is moderately dilated. Compared to the previous tracing of nodiagnostic change. VERY APOLOGETIC.RESP: O2->5L NP. Right ventricular function. There is no pericardial effusion.Compared with the findings of the prior study (tape reviewed) of ,there has been a marked decrease in overall LV function. Thin and thick slab maximum intensity projection MRCP images were generated. Ambian dc'd. Intraventricularconduction delay of left bundle-branch block type. BP stable high 90's- 110's, on lopressor, verapamil, amiodarone and valsartan. PRESENTLY, U/O 25-80CC/HR. The spleen appears within normal limits. He states a doctor was suppose to start a new med for him to help with the symptoms.A: Decreased ef now on natrecore Gently diuresed with lasix 10mg x 2 Sleep apnea without sign decrease in O2 sat Restless leg syndromeP: ^ activity when able to tolerate Probable c/o in am He is hemodynamically stable with this rhythm, and it was noted that he has been in and out of afib since admit. Tired after 90minutes.Access-2PIV, RIJ PA catheter.Social- /son called pt health care proxy #h , cell# . BOLUSED WITH NATRECOR, & GTT STARTED AT .01MCG/KG. Overall left ventricular systolic function is severely depressed.RIGHT VENTRICLE: Right ventricular wall thickness cannot be determined. However, the overall ventricular response raet is somewhat faster atapproximately 110.TRACING #4 CCU NPNS/O: See vs/objective data per carevue. K 4.1, HCT 40.5, PLAT CT 364K.GI: ABD. HYPERTENSION. The kidneys and adrenal glands appear within normal limits. Noted while sleeping Hr down to the 80's with his apneic periods.Resp: Lungs with diminished aeration throughout, taking his inhalers on own. Supraventricular tachy-arrhythmia with ventricular rate of about 100. Conts on natrecor at .1mcg/kg/min. PT COMFORTABLE, DENIES RESP DISTRESS. RESP CARE NOTEAPPLIED NASAL CPAP @ MIDNOC, EPAP 5CMH20 W/5LPM O2 BLEED IN. At 0030 placed on cpap but cont to notice apneic periods this time with sats decreasing to 89% and hr decreasing to the 80's. Underlyingintraventricular conduction delay. Atrialmechanism cannot be determined with certainty but could be relatively slowatrial flutter with 2:1 conduction, although other atrial tachy-arrhythmias arenot excluded. Compared to the previoustracing of the underlying atrial mechanism now appears to be atrialflutter rather than atrial fibrillation and the overall ventricular responserate is faster.TRACING #1 CO 5.4/CI 2.48/SVR 785. Moderate to severe (3+) mitral regurgitation is seen.Moderate to severe [3+] tricuspid regurgitation is seen. LS I/E wheezes with diminshed BS at bases. Tolerating po cardiac meds well. +BPPP. Pad's basically unchanged, upper teens to low 20's with cvp low 10's.	17	[ { "category": "Nursing/other", "chartdate": "2145-01-25 00:00:00.000", "description": "Report", "row_id": 1573596, "text": "CCU NPN\nS:\"They have to talk to the other doctor about this (cpap), he said I didnt need it anymore.\"\nO: See vs/objective data per carevue.\nCV: HR 100's afib with no vea. BP stable high 90's- 110's, on lopressor, verapamil, amiodarone and valsartan. Pad's basically unchanged, upper teens to low 20's with cvp low 10's. Noted while sleeping Hr down to the 80's with his apneic periods.\nResp: Lungs with diminished aeration throughout, taking his inhalers on own. O2 at 4lnp with sats upper 90's. At 0030 placed on cpap but cont to notice apneic periods this time with sats decreasing to 89% and hr decreasing to the 80's. Resp therapist aware>increased cpap to 8, with no real change in events. He wanted cpap machine off at 3am therefore dc'd.\nGI/GU: Foley drng clear yellow urine. No lasix given. No BM.\nMS: Alert and oriented throughout night, cooperative with care. Rec'd trazadone 25mg for sleep with good effect.\nA: conts with apneic periods\n hemodynamically stable, restarted on dig\nP: prepare for d/c to floor\n increase activity\n check with pulmonary about apnea during sleeping\n" }, { "category": "Nursing/other", "chartdate": "2145-01-25 00:00:00.000", "description": "Report", "row_id": 1573597, "text": "RESP CARE NOTE\nAPPLIED NASAL CPAP @ MIDNOC, EPAP 5CMH20 W/5LPM O2 BLEED IN. PT COMFORTABLE, DENIES RESP DISTRESS. DURING SLEEP, OBSTRUCTIVE PATTERN NOTED W/DESAT FROM 98 TO 89%. EPAP INCR TO 8CMH2O & O2 INCR TO 10LPM. AFTER 2.5HRS OF USE PT C/O INABILITY TO SLEEP AND WANTED MASK REMOVED. MAINTAINED ON 4LPM NC O2 W/SPO2 96-98%. PLAN TO CONTINUE CURRENT SUPPORT AND WILL CONTINUE TO OFFER CPAP QHS. *** NEED TO FIND RESULTS OF MOST RECENT POLYSOMNOGRAPHY STUDY DONE IN @ OUTSIDE FACILTY FOR OPTIMAL CPAP SETTINGS.\n" }, { "category": "Nursing/other", "chartdate": "2145-01-23 00:00:00.000", "description": "Report", "row_id": 1573593, "text": "CCU Nursing PRogress Note\nS-\"I need a beer\" \"I don't mean to get OOB, but\"\nO-Neuro- short term memory issues today. Needs frequent assessment for safety reasons. Found pt standing at side of bed 3 times, despite freq explaination to call for help first. Pt is apologetic but really does not remember why he needs to call for help. Overheard pt tell a visitor \"I could use a nice cold beer\". Unclear how much pt drinks at home. Intern will talk to pt this evening.\nCV-VSS MAPs 58-72 on Natrecor at .01mcg/kg/min, hemodynamics PAD 20-24 with PWP 16-17 CO/CI/SVR 4.7/2.16/851. No c/o chest pain. To restart coumadin this evening.\nResp-freq apneic periods in the am. Pt would be talking to you then fall off to sleep and become apenic for 25seconds, awake and then c/o SOB with rr 32. The cycle persisted most of the morning. Pt states he stopped using his BIPAP machine at home because he thought it wasn't working. Pt to be placed on BIPAP tonight at HS. Would hold off on sleeper d/t pt lethargy this am. O2 sats 88-90% this am on 3lnp increased O2 to 5lnp with improved O2 sats 97%. LS I/E wheezes with diminshed BS at bases. Occ productive cough thin/blood tinged.\nID-afebrile with WBC 15\nGU-foley draining amber urine 30-40cc/hr\nGI-Appetite good, LBM 2 days ago per pt.\nSkin-warm and dry, right groin no hematoma, RIJ PA site eccymotic with small hematoma at site.\nActivity-OOB chair this am with 2 assist, tolerated fairly well. Tired after 90minutes.\nAccess-2PIV, RIJ PA catheter.\nSocial- /son called pt health care proxy #h , cell# . Fiancee into visit and concerned about pt short term memory, states pt took an antidepressant at home, which he has not been on in the hospital-she did not know the name.\nA/P-Pulmonary HTN with severe LV dysfunction prob r/t sleep apnea?\nGOAL MAP> 60 PWP 16-20, lasix prn goal to keep pt even.\nMOnitor for change in MS, sitter at door overnight.\nObsere sleep apnea with BIPAP also Keep O2 sats >92%\n\n" }, { "category": "Nursing/other", "chartdate": "2145-01-24 00:00:00.000", "description": "Report", "row_id": 1573594, "text": "CCU NPN\nS/O: See vs/objective data per carevue. Afebrile\nCV: Hr initially low to mid 100's st with no vea noted. 12:30am noted increasing hr to 110-120's afib, 12lead ekg done, and team aware. He is hemodynamically stable with this rhythm, and it was noted that he has been in and out of afib since admit. Tolerating po cardiac meds well. Bp 90-110's. Conts on natrecor at .1mcg/kg/min. Pad's mid teens to low 20's with cvp 9-11. R groin has remained d/i with distal pulses palpable.\nResp: O2 at 4lnp with sats in mid 90's. Lungs with diminshed aeration, taking inhalers. Attempted bipap but unable to tolerate therefore dc'd, noted 15-25 sec apneic periods while asleep, o2 sats stay above 95% with apnea. Pt states that he does not wear it at home. Rec'd lasix 10mg x 2 with mild diursis.\nGI/GU: Abd soft with good bowel sounds, no bm. Foley drng clear yellow urine.\nMS: Alert and oriented. Knows that he was confused last night, stating that he had a fever, had no sleep and that he had to be tied down which upset him. Cooperative tonight, no attempts to get oob, has 1:1 sitter. Has restless leg syndrome which is very troubling for him. He states a doctor was suppose to start a new med for him to help with the symptoms.\nA: Decreased ef now on natrecore\n Gently diuresed with lasix 10mg x 2\n Sleep apnea without sign decrease in O2 sat\n Restless leg syndrome\nP: ^ activity when able to tolerate\n Probable c/o in am\n\n" }, { "category": "Nursing/other", "chartdate": "2145-01-24 00:00:00.000", "description": "Report", "row_id": 1573595, "text": "CCU NPN 7A-7P\nCV: Natracor dc'd this AM, started on Lasix 20mg po qd, UO 50cc/hr, ~1L neg. BP 100/40's, HR 90-110 afib. PAD's 16-20, PCWP 20, now down to 16. CO 5.4/CI 2.48/SVR 785. No SOB/CP, LS clear. Sating 94% on RA, 98% on 3L. R groin C&D, pulses weak palp.\n\nResp: napping during the day, no apnea noted, maintained sats>90%. Team spoke to him re: importance of wearing CPAP. Goal to try CPAP again tonight.\n\nNeuro: cont with restless leg syndrome, A&Ox3, cooperative. Ambian dc'd. Cont Trazadone. Ordered for his antidepressant Lexapro, it is nonformulary, family stated they would bring it in, possibly tomorrow.\n\nGU: cr up sl today to 1.6, will follow.\n\nGI: appetite good, no BM today.\n\nSoc: S.O. in visiting, pt anxious to go home.\n\nA/P: plan to watch in unit overnight off Natracor, dc swan in AM if does well and transfer to floor. CPAP at hs.\n" }, { "category": "Nursing/other", "chartdate": "2145-01-23 00:00:00.000", "description": "Report", "row_id": 1573592, "text": "ADMISSION NOTE\nPLEASE SEE FHP FOR DETAILS PMH & CURRENT ADMISSION.\n\nNEURO: A&O X3, BUT WHILE DOZING ATTEMPTS MADE TO D/C SWAN X3--NOT RE-\n ALIZING WHAT HE IS DOING. VERY APOLOGETIC.\nRESP: O2->5L NP. O2 SAT 96-98%. RR 16-20. BS CLEAR. MVO2 64-67%.\nCARDIAC: HR 95-105 SR/ST, NO ECTOPY. BRIEFLY IN AF 85-115. HO AWARE.\n BP 107-141/48-82. IV NTG WEANED OFF. BOLUSED WITH NATRECOR,\n & GTT STARTED AT .01MCG/KG. PAD 29->15, CVP 10->6, W 15-17,\n CO 4.4->5.0, CI 2.02->2.29, SVR 1709->1072. R.GROIN SITE C&D\n NO EVIDENCE BLEEDING/HEMATOMA. +BPPP. DENIES CP/SOB. K 4.1,\n HCT 40.5, PLAT CT 364K.\nGI: ABD. SOFT. BS+. NO STOOL. APPETITE GOOD.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. DIURESED WELL\n AFTER LASIX IN CATH LAB. PRESENTLY, U/O 25-80CC/HR. -3.5L FOR\n 24 HRS. HO AWARE. ??OVER-DIURESED. TO DISCUSS ON ROUNDS.\nID: AFEBRILE. WBC 15.5.\nAM LABS SENT. COAGS & CHEMISTRIES PENDING.\n\n59 YR. OLD MALE S/P RIGHT/LEFT HEART CATH. HIGH FILLING PRESSURES.\nPULM. HYPERTENSION. NO CAD.\n" }, { "category": "Radiology", "chartdate": "2145-01-19 00:00:00.000", "description": "MR CONTRAST GADOLIN", "row_id": 818473, "text": " 6:28 PM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: r/o partial biliary obstruction\n Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with elevated alk phos and GGT without transaminitis or\n elevated TBili.\n REASON FOR THIS EXAMINATION:\n r/o partial biliary obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 59 year old male with elevated liver function\n tests.\n\n TECHNIQUE: Nonbreath-holding protocol was used as the patient was unable to\n hold his breath. This includes axial T1 and T2W images precontrast as well as\n multiphasic Gadolinium enhanced 2D axial T1W images. Thin and thick slab\n maximum intensity projection MRCP images were generated.\n\n FINDINGS: The examination is somewhat limited by the inability of the patient\n to hold his breath. There is no evidence of intrahepatic or extrahepatic\n biliary dilatation. The gallbladder is collapsed. Correlation with recent\n ultrasound examination dated confirms the absence of\n gallstones. The common duct is small in caliber. The panreatic duct also is\n within normal limits in size and contour. There is no evidence of obstructing\n pancreatic mass.\n\n The liver has a slightly irregular contour and a prominent caudate lobe. These\n findings may represent the sequela of chronic liver disease. The hepatic\n veins are prominent in size. This fact, coupled with the large bilateral\n pleural effusions, suggest hepatic congestion as a possible etiology. Clinical\n correlation is recommended. No enhancing hepatic masses are seen. No\n significant lymphadenopathy is seen. The spleen appears within normal limits.\n The kidneys and adrenal glands appear within normal limits.\n\n Maximum intensity projection images were generated on a 3D workstation and\n were essential to the interpretation of this case.\n\n IMPRESSION:\n\n 1) No evidence of biliary dilatation. No evidence of obstructing pancreatic\n mass.\n\n 2) Slightly irregular contour of the liver with dilated hepatic veins and\n bilateral pleural effusions, suggesting chronic hepatic vascular congestion as\n a possible etiology. Clinical correlation is recommended.\n\n\n (Over)\n\n 6:28 PM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: r/o partial biliary obstruction\n Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Echo", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 95405, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Right ventricular function. Shortness of breath. History of ASD repair\nHeight: (in) 70\nWeight (lb): 215\nBSA (m2): 2.15 m2\nBP (mm Hg): 100/67\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:21\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. No atrial\nseptal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular wall thickness cannot be determined. The\nright ventricular cavity is moderately dilated. There is focal hypokinesis of\nthe apical free wall of the right ventricle. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Image quality was suboptimal.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\nThe right ventricular cavity is moderately dilated. There is focal hypokinesis\nof the apical free wall of the right ventricle. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Moderate to severe (3+) mitral regurgitation is seen.\nModerate to severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nthere has been a marked decrease in overall LV function. Because the study was\ntechnically difficult, views of the atrial septum were limited. The mitral\nregurgitation is more severe.\n\n\n" }, { "category": "ECG", "chartdate": "2145-01-26 00:00:00.000", "description": "Report", "row_id": 270990, "text": "Supraventricular tachyarrhythmia - mechanism uncertain - consider atrial\ntachycardia/\"slow\" atrial flutter\nIntraventricular conduction delay - ? left bundle branch block\nSince previous tracing of ,ventricular rate slower\n\n" }, { "category": "ECG", "chartdate": "2145-01-22 00:00:00.000", "description": "Report", "row_id": 270991, "text": "Supraventricular tachy-arrhythmia with ventricular rate of about 100. Atrial\nmechanism cannot be determined with certainty but could be relatively slow\natrial flutter with 2:1 conduction, although other atrial tachy-arrhythmias are\nnot excluded. Compared to the previous tracing of multiple abnormalities\nare as previously reported. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-01-20 00:00:00.000", "description": "Report", "row_id": 270992, "text": "Regular tachycardia - mechanism uncertain - consider atrial flutter with 2:1\nresponse or possible atrial tachycardia\nLeft bunch branch block\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2145-01-21 00:00:00.000", "description": "Report", "row_id": 271217, "text": "Supraventricular tachycardia which is regular with intermittent increased\nR-R intervals, basic ventricular rate about 100. Atrial mechanism is not\ncertain but could be atrial flutter with variable block. Underlying\nintraventricular conduction delay. Poor initial R wave progression.\nIndeterminate QRS axis. High ST take-offs in the precordial leads are\nnon-diagnostic with the intraventricular conduction delay. Non-specific\nST-T wave changes elsewhere. Compared to the previous tracing of no\ndiagnostic change. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-01-19 00:00:00.000", "description": "Report", "row_id": 271218, "text": "Regular tachycardia ( except for 1 beat) - mechanism uncertain - consider\natrial flutter or possible atrial tachycardia\nLeft bunch branch block\nSince previous tracing of , ventricular response more regular\n\n" }, { "category": "ECG", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 271219, "text": "Compared to the previous tracing atrial flutter persists (again as evidenced by\nflutter waves in lead VI and the regularity of portions of the ventricular\nresponse). However, the overall ventricular response raet is somewhat faster at\napproximately 110.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 271220, "text": "Compared to the previous tracing the ventricular rate is somewhat slower.\nFlutter waves are clearly seen in lead VI.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2145-01-14 00:00:00.000", "description": "Report", "row_id": 271221, "text": "Compared to the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-01-14 00:00:00.000", "description": "Report", "row_id": 271222, "text": "Probable atrial flutter with atrial rate 250 and variable A-V block.\nPredominant ventricular response rate is approximately 100. Intraventricular\nconduction delay of left bundle-branch block type. Compared to the previous\ntracing of the underlying atrial mechanism now appears to be atrial\nflutter rather than atrial fibrillation and the overall ventricular response\nrate is faster.\nTRACING #1\n\n" } ]
67,306	142,980	Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be hypoxic and hypotensive on presentation diagnosed with RSV pneumonia and superimposed bacterial pneumonia requiring MICU stay for respiratory distress. # RSV/Bacterial Pneumonia/Hypereosinophilic syndrome-Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy. He was recently admitted to the hospitalist service with pulmonary and ID following and treated for pneumonia with voriconazole, azithro and cefepime. ABx except for vori were discontinued and he was ruled out for TB. The cause was thought to be fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was negative for growth at the time. Recently AFB was positive for non-TB. At the time of this presentation his RSV viral culture was found to be positive and patient was treated empirically for superimposed bacterial infection in setting of neutropenia with vancomycin, cefepime, and levofloxacin. ID was consulted and the option of RSV antibody treatment was discussed with the patient and his family who was declined its use. He was aggressively diuresed in attempts of helping his respiratory status. On Mr. continued to decline clinically and requested transition in goals of care to focus on comfort. His empiric antibiotics were discontinued and he left the ICU in accordance with his goals of care. He was transferred to the floor and transitioned to comfort care. Palliative care was consulted at this time. He passed away on at 10:40 AM with his family at his bedside. His family declined an autopsy.	Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. His ARF is most likely pre-renal from diuresis and poor PO. His ARF is most likely pre-renal from diuresis and poor PO. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: BP now improved from admit, and running at baseline (runs low per fmaily and onc) #CHF--BNP elevated from prior baseline, suspect this may be contribtuing to hypoxemia, though primarry issue is RSV --gentle diuresis and repeat BNP --TTE # tachycardia Likely driven by resp distress/failure Improving # ARF: Cr improving with IVF - monitor UOP and urine lytes # Cavitary lung nodule: seen on prior imaging, now appears slightly smaller, s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. AM CXR worsening w/PNA Action: Continue w/ABX regimen, levofloxacin added, and CT chest done. His ARF is most likely pre-renal from diuresis and poor PO. - F/u stool, blood, urine, stool and sputum - CXR today, f/u final report - Add levo, cont vanc/cefepime/vori # AMS: Likely delerium. - F/u stool, blood, urine, stool and sputum - CXR today, f/u final report - Add levo, cont vanc/cefepime/vori # AMS: Likely delerium. - Monitor creatinine - Judicious diuresis, goal will be net even - Hold ace-i #. - Monitor creatinine - - Hold ace-i #. - Monitor creatinine - - Hold ace-i #. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: legally blind -Hypereosinophilic syndrome and associated course: Diagnosed in after presenting with transient ischemic episode (with reported exotropia) and bilateral deep venous thrombosis. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: legally blind -Hypereosinophilic syndrome and associated course: Diagnosed in after presenting with transient ischemic episode (with reported exotropia) and bilateral deep venous thrombosis. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. Hypoxemia Assessment: Action: Response: Plan: #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. 96 11.9 9.7 Pnd 29.8 N:13 Band:0 L:1 M:0 E:86 Bas:0 Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy: 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Low . 96 11.9 9.7 Pnd 29.8 N:13 Band:0 L:1 M:0 E:86 Bas:0 Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy: 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Low . #CHFdiurese, holidng ace-I given cr elevation--at this time does not apepar volume overloaded, neck are flat and xr without eveidence of pulm edema, labs suggest overdiuresis will hold on diurses at thsintime # tachycardia Likely driven by resp distress/failure now diuresis will follow # ARF: cr increaing, suspect this is from diuresis and poor. will hold lasix and monitorup, likely from poor forward flow, may improve with diuresis # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. He has been diuresed and at this time does not appear volume overloaded, neck veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o overdiuresis and his PO intake is minimal --will hold on additional lasix at this time # ARF: BUN and cr increasing, suspect from diuresis, will hold lasix, monitor UOP, check urine sediment and renally dose meds # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Progressive mild cardiomegaly, particular left (Over) 11:27 AM CT CHEST W/O CONTRAST Clip # Reason: Please eval for change in size of mass Admitting Diagnosis: HYPOXIA; CHF FINAL REPORT (Cont) ventricular enlargement.	102	[ { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724331, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile.\n - CXR today\n - UA/urine cx and stool cx r/o c diff\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724333, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - CXR today\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Echo", "chartdate": "2197-03-07 00:00:00.000", "description": "Report", "row_id": 75513, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. Atrial fibrillation. Cerebrovascular event/TIA. Hypoxia. Congestive heart failure.\nHeight: (in) 67\nWeight (lb): 136\nBSA (m2): 1.72 m2\nBP (mm Hg): 89/61\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 12:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- dyskinetic; mid inferior - dyskinetic; lateral apex - akinetic;\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root. Normal ascending aorta diameter. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Significant\nPR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. The patient\nappears to be in sinus rhythm. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with basal inferior mild\ndyskinesis and more distal akinesis as well as akinesis of the distal lateral\nwall. There is mild hypokinesis of the remaining segments (LVEF = 30%). No\nmasses or thrombi are seen in the left ventricle. The diameters of aorta at\nthe sinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\nposterior leaflet is relatively fixed/immobile. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the left\nventricular cavity is slightly smaller and the severity of mitral\nregurgitation and pulmonary artery systolic pressure are slightly reduced.\nRegional left ventricular systolic function is similar.\n\n\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724005, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD:\n EXT:\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Pt w/ increased oxygen requirement\n overnight. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. Patient\n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). Also,\n with elevated BNP element of CHF exacerbation w/ volume overload. PE\n also on the differential, though less likely given viral findings as\n above.\n - F/u final sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 20mg iv x1, goal diuresis negative 1L\n - Repeat echo to eval for changing EF\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724008, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) admitted sepsis (sputum,\n fever, hypotension, hypoxia)\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Cardiovascular: tachy\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : ), tachypenic\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) w/ hypoxic resp failure\n and sepsis\n # Sepsis: baseline BPs in the 80s-90s per family and Oncology team, now\n at baseline, still tachy and low-grade temps, so still meeting sespsis\n criteria. Also with low EF, but does not appear grossly overloaded on\n exam now.\n - continue judicious IVF prn hypotension\n - consider stim/ stress dose steroids if hypotension\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - check urine legionella\n Broad antbx\n # hypoxic resp failure\nPneumonitis. High suspcion this is viral from\n RSV, probable bacterial superinfection, does not appear to have\n significant component of volume overload with insensible losses and neg\n fluid balance. No evidence of hemorrhage and dfa neg for PCP. ? med\n related, etoposide.\n --diuresed gently with good UOP response.\n --cont broad antbx coveragere address utilityt of monoclonal ab\n treatment with ID team\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole, appears slightly smaller on repeat CT\n 3. Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management and repeat bnp\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n # tachycardia\n Likely driven by resp distress/failure\n f/u TTE\n # ARF: Cr up to 1.8 on admit, improving with IVF\n - monitor UOP and urine lytes\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724009, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line to obtain CVP if hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1 per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724011, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n - Place picc line for better access/iv abx\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line or evaluating w/ US to obtain CVP if\n hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724166, "text": "Chief Complaint: hypoxemia, resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n diuresed\n pt and family declined RSV monoclonal ab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 08:00 AM\n Bactrim (SMX/TMP) - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.1\nC (96.9\n HR: 106 (94 - 108) bpm\n BP: 89/58(66) {78/40(50) - 94/72(77)} mmHg\n RR: 29 (23 - 30) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 165 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 165 mL\n Blood products:\n Total out:\n 1,350 mL\n 475 mL\n Urine:\n 1,350 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -310 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 80 K/uL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BNP 16K\n Microbiology: --induced sputum mod resp florse growth, gpc on gs, 2+\n gpr, 1+ gnr\n bl/urine ngtd\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains very hypoxic, but subjectively more\n comfortable. Suspect pneumonitis likely all from RSV. With possibly\n also with bacterial superinfection, and component of volume overload\n given bnp elevateion.\n --cont cough supression, nebs, consider NPPV if fatigues\n --increase diuresis ( 1L neg)\n - broad empiric antbx\n --pt declined RSV monoclonal ab rx\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit, and running at baseline (runs low per fmaily and onc)\n #CHF\ndiurese\n # tachycardia\n Likely driven by resp distress/failure\n Improving\n # ARF: cr up, likely from poor forward flow, may improve with diuresis\n - monitor UOP and urine lytes\n - resume ace-when cr improves\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis: , picc placement\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU for now, improving and possible floor transfer late in\n day\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724167, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n \n [2] 12:10PM\n \n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). He has\n refused monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb, can re-offer as last\n resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724173, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n \n [2] 12:10PM\n \n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). He has refused\n monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724386, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724387, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724456, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species (but final probe pending) admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724582, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Goal\n ------ Protected Section Addendum Entered By: , MD\n on: 15:38 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724586, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Goal\n ------ Protected Section Addendum Entered By: , MD\n on: 15:38 ------\n Addendum\n GOC discussion with pt and his wife. Oncology involved as well. Pt at\n this time wishes to transition to aggressive comfort. All questions\n answered. Pt not interested in home hospice but prefers to remain in\n hospital at this time. Will discontinue blood draws, fluids and\n antbx. Palliative care consulted. Will use ativan for anxiety and\n morphine for airhunger/pain. Can transfer to private floor room.\n Crit care time spent in discussion and meetings: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:26 PM ------\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724097, "text": "Chief Complaint: sepsis/hypoxic resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + for RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Alert, tachypneic with talking\n Cardiovascular: tachy, rr\n Peripheral Vascular: 2+ pedal pulses\n Respiratory / Chest: rales, tachypneic\n + BS, soft, NT\n Skin: warm, diaphoretic\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\ndiffuse asd on imaging from pneumonitis likely\n all from RSV. Possibly also with bacterial superinfection, does not\n appear to have significant component of volume overload, though BNP\n elevated and pulm edema may also be contributing. No evidence of\n hemorrhage and dfa neg for PCP. also includes toxic effect from\n med/ ? etoposide.\n --supportive care with cough supression, nebs, consider NPPV if\n fatigues\n --gentle diuresis\n - broad antbx\n --d/w ID team use of RSV monoclonal ab rx\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit, and running at baseline (runs low per fmaily and onc)\n #CHF--BNP elevated from prior baseline, suspect this may be\n contribtuing to hypoxemia, though primarry issue is RSV\n --gentle diuresis and repeat BNP\n --TTE\n # tachycardia\n Likely driven by resp distress/failure\n Improving\n # ARF: Cr improving with IVF\n - monitor UOP and urine lytes\n # Cavitary lung nodule: seen on prior imaging, now appears slightly\n smaller, s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB,\n and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724381, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=130 and\n creat this am =1.8. most likely overdiuresed in the last couple of\n days. Cxr unchanged and without evidence of pulm edema/effusions. Pt\n currently receiving cefepime,vancomycin and voriconazole to cover\n bacterial and fungal pna( recently has grown penicillin species in\n cx). Pt n no apparent resp distress. Pt with poor appetite and c/o\n difficulty swallowing. Sbp ranging 70-90\ns but no interventions ordered\n by medical icu team\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% and o2 sats followed closely. No further\n diuretics ordered for now. Pt medicated with tessilon pearls for dry\n and nonproductive cough. Nutrition consult placed. Pt drinking\n ensure..\n Response:\n Resp status worse compared to last 24 hrs. still requiring high amts of\n 02\n Plan:\n Continue to follow resp status closely. Will send off repeat sputum\n for gm stain /c&s when able. hold on further diuresis at present\n time. Wean o2 as tolerated to maintain o2 sats> 90%. Dr. and\n oncologist spoke with pt\ns wife and pt remain dnr/dni. We will\n continue to treat but there will be no escalation of care.\n" }, { "category": "Rehab Services", "chartdate": "2197-03-10 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 724566, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 60yo M on chemotherapy with\nhistory of hypereosinophilic syndrome, h/o CVA, afib, and\n syndrome who was previously admitted to from \n- 1/12 cavitary lesion in lung. Patient presented to \nED on w/ concerns of 1 day of fever, productive cough,\nsore throat, weakness, and orthopnea. CT chest on \nrevealed that \"persistent diffuse bilateral pulmonary\nopacifications likely represent severe pneumonia.\" Patient w/\nconcerns for CAP, viral respiratory pathogen such as influenza\nvs. other infection immunocompromised state. We were\nconsulted to evaluate patient's oral and pharyngeal swallowing\nfunction and rule out aspiration while eating and drinking. RN\nreported patient coughing on ice chips and jello, and has had\nminimal PO intake during hospitalization.\nPatient was seen by our department for a bedside swallow\nevaluation in , and was recommended for thin liquids and\nregular solids.\nPMH:\n- DVT three years ago.\n-Hypereosinophilic syndrome (HES)\n-Multiple CVAs, miost recent in (Old R parieto-occipital\n& left parietal infarcts)\n-Atrial Fibrillation\n- syndrome (endomyocardial fibrosis with embolic\nphenomenon/stroke)\n-CHF thought secondary to eosinophilic myocarditis: EF 30% on\nTTE \nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on . Wife and RN present for evaluation.\nFull face mask and nasal cannula in place.\nCognition, language, speech, voice:\nPatient was awake, alert, and oriented to name and place, and\nyear when given two choices. Though output was limited, speech\nappeared fluent and was intelligible. Weak vocal quality.\nTeeth: Intact w/ some debris.\nSecretions: Normal oral secretions.\nORAL MOTOR EXAM:\nTongue protruded midline. Adequate lingual ROM and strength.\nFunctional Labial ROM, mildy reduced strength. Adequate buccal\ntone. Symmetrical palatal elevation. Gag deferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquid (tsp, straw),\nnectar-thick liquid, and puree (alone, and w/ crushed meds).\nPatient had adequate labial seal, but needed to be prompted to\nsuck in through the straw rather than blow out, and to open mouth\nwide to receive puree. Did not assess mastication limited\nPOs. At times, patient appeared to be piecemealing liquid\nboluses. Otherwise, oral transit appeared timely. No oral\nresidue noted following POs. Swallow trigger present. Laryngeal\nelevation felt adequate to palpation. No overt changes in vocal\nquality following POs. Patient noted w/ reflexive coughing on\nthin liquids when following puree. No further coughing noted on\nnectar-thick liquid following puree. No further POs were given,\nas patient was very weak and reported feeling like he was going\nto gag on puree, so it was felt that solid trials were not\nappropriate. O2 sats remained stable at 96-97%%.\nSUMMARY / IMPRESSION:\nMr. presents w/ fatigue, generalized weakness, and s/sx\nof aspiration (coughing) on thin liquid when following puree,\nlikely due to pharyngeal residue. All other trials of\nnectar-thick liquid following puree tolerated w/out coughing.\nGiven patient's current physical state, and his own report that\nhe felt like he was going to gag following puree, we feel that\nsolid POs are not appropriate at this time. Recommend PO diet of\nnectar-thick liquids and purees. PO meds crushed in applesauce.\n1:1 supervision and strict aspiration precautions. Alternate\nbites and sips. If there are concerns of aspiration on this diet\nover the weekend, please keep patient NPO. Recommend Nutrition\nconsult to provide suggestions for high calorie supplements, as\npatient is lactose intolerant, and cannot take Ensure pudding,\nand Ensure liquid would need to be thickened to nectar\nconsistency. Patient's PO intake has been limited, and likely\npoor nutrition is contributing to weakness. Recommend discussion\nregarding supplemental nutrition as indicated, and within goals\nof care pending prognosis. We will follow up early next week to\nsee how patient is tolerating diet.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5 out of 7.\nRECOMMENDATIONS:\n1. Recommend PO diet of nectar-thick liquids and purees.\n2. PO meds crushed in puree.\n3. 1:1 supervision and strict aspiration precautions.\n4. Alternate bites and sips.\n5. If there are concerns of aspiration on this diet over the\nweekend, please keep patient NPO.\n6. Recommend Nutrition consult to provide suggestions for high\ncalorie supplements, as patient is lactose intolerant, and cannot\ntake Ensure pudding, and Ensure liquid would need to be thickened\nto nectar consistency.\n7. Recommend discussion regarding supplemental nutrition as\nindicated, and within goals of care pending prognosis.\n8. We will follow up early next week to see how patient is\ntolerating diet.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\nRamya B.A., SLP/S\n____________________________________\n M.S., CCC-SLP\nPager #\nFace time: 1120-1145\nTotal time: 120 minutes\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724567, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset.\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724569, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724572, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GEN: Agitated, confused\n CV: RRR, no MRG, No JVD\n PULM: Tachypneic, no rales\n ABD: Soft, NTND +BS\n EXT: No edema\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Continues to remain short of breath and\n tachypneic, now also with confusion which could also be contributed by\n hypoxemia. Underlying process primarily secondary to progressive\n infection (RSV). CHF exacerbation on admission, but now appears\n dehydrated. Continues to require supplemental oxygen despite diuresis\n and antibiotics for superimposed infection. Resp viral screen positive\n for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and urine\n leg neg. DFA negative for PCP. currently, cefepime, vanc, and\n vori to cover bacterial and fungal pna (recently has grown penicillium\n species in culture). He has refused monoclonal antibody. Cont to\n consider PE, though less likely. Increasing white count worsening\n eosinophilia, however, possible resistant UTI, follow up cultures.\n - Add levoflox\n - Check vanc trough\n - Cont vanc, cefepime ( for 14 day course) and vori (fungal infxn)\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n - Morphine prn\n - We are likely moving toward CMO\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - F/u stool, blood, urine, stool and sputum\n - CXR today, f/u final report\n - Add levo, cont vanc/cefepime/vori\n # AMS: Likely delerium. Ddx includes ICU induced delerium, uremia \n to ARF, infection (RSV and UTI), hypoNa\n - Gentle boluses of IVFs\n - Cont to treat vanc/cefepime and vori; add levo\n - Haldol prn\n # HypoNa: Likely volume depletion\n - IVFs\n - Urine lytes\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n - IVFs\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n -\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724578, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset. Dr spoke with pt and his wife\n and pt now made cmo. All meds d/c\nd except for prn morphine for\n pain and ativan for anxiety. O2 dace tent mask d/c\nd per request of pt\n and his wife and he remains on 4l/m nc. Will continue with comfort care\n measures and offer emotional support to pt\ns wife and children\n" }, { "category": "Social Work", "chartdate": "2197-03-10 00:00:00.000", "description": "Social Work Admission Note", "row_id": 724557, "text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: This admission at is\n the patient's fifth.\n Past psychiatric history: Unknown.\n Past addictions history: Unknown.\n Employment status: Disable\n Legal involvement: Unknown.\n Mandated Reporting Information:\n Additional Information:\n Patient/Family HX: Dr. admitted this 60 y/o MWM with\n hypereosinophilic syndrome to with hypoxia and CHF. SW met with pt\n and his wife who talked about their hoping to again walk on the beach,\n but then laughed when they eventually discovered that they do not like\n the sand, water, sun, or noise but being able to walk hand-in-hand. Mr.\n talked about feeling that he \"was dead.\" This writer asked if\n he sometimes felt dead or wondered about dying given his medical\n condition, which he said that he did. Shortly afterwards, the pt said\n that he was tired.\n Afterwards, this worker spoke with his wife about the conversation re\n his dying and if she felt that the discussion felt premature. She said\n that after this writer left, he asked if she felt better having talked\n about death. Ms. said that it is difficult for her to raise\n such emotional issues and is appreciative of others broaching the\n topic.\n Assessment: The couple seems to struggle with hopeful talk about the\n future, e.g., walking hand-in-hand, while appearing to try and cope\n with what they see as EOL issues. Ms. seems to be experiencing\n a great deal of stress; it is not clear at this time as to how she\n copes and what supports she has, which this worker will explore in a\n future meeting.\n Plan / Follow up:\n 1. SW will continue to meet with the s to assess their\n coping and to offer support.\n , PhD, LICSW\n PAGE \n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724529, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Tachypneic, no rales\n No JVD\n No edema\n Agitated, confused\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Continues to remain short of breath and\n tachypneic, now also with confusion which could also be contributed by\n hypoxemia. Underlying process primarily secondary to progressive\n infection (RSV). CHF exacerbation on admission, but now appears\n dehydrated. Continues to require supplemental oxygen despite diuresis\n and antibiotics for superimposed infection. Resp viral screen positive\n for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and urine\n leg neg. DFA negative for PCP. currently, cefepime, vanc, and\n vori to cover bacterial and fungal pna (recently has grown penicillium\n species in culture). He has refused monoclonal antibody. Cont to\n consider PE, though less likely. Increasing white count worsening\n eosinophilia, however, possible resistant UTI, follow up cultures.\n - Add levoflox\n - Check vanc trough\n - Cont vanc, cefepime ( for 14 day course) and vori (fungal infxn)\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n - Morphine prn\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - F/u stool, blood, urine, stool and sputum\n - CXR today, f/u final report\n - Add levo, cont vanc/cefepime/vori\n # AMS: Likely delerium. Ddx includes ICU induced delerium, uremia \n to ARF, infection (RSV and UTI), hypoNa\n - Gentle boluses of IVFs\n - Cont to treat vanc/cefepime and vori; add levo\n - Haldol prn\n # HypoNa: Likely volume depletion\n - IVFs\n - Urine lytes\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n - IVFs\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n -\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724531, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC along with onc team yesterday\n O2 weaned to 50% + 4L NC\n diuresis held\n confused and agitated this morning\n ID recommended holding on double GNR coverage\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, bacterial superinfection,\n Remains hypoxic, no improvement with diuresis and now inprogressive\n ARF.\n CXR appears unchanged with diffuse ASD/no effusions. At this time feel\n cardiogenic pulm edema is unlikely to be contibuting.\n Clinically declining. Suspect his chronic hypereosinophilia is further\n complicating this but in setting of underlying infection we are very\n limited in terms of treatment options at this time.\n --Continue supportive care with cough suppression, nebs\n --Consider NPPV if fatigues\n --holding on diuresis (ARF and minimal PO)\n --continue broad empiric antbx to compelte 14 day course and will add\n double GNR coverage given u/a and concern for additional\n superinfection.\n --Morphine for air hunger\n --Check VBG\n # CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # delirium-multiple reasons\nsundowning, uremia, hypxemia, poor PO\n Will optimzie sleep wake, use haldol, gentle hydration for hyponatremia\n # hyponatremia\nsuspect all from hypovolemia/poor PO\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure when MS\n allows\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724510, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724513, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now. Increasing white count worsening eosinophilia, however,\n possible resistant UTI, follow up cultures.\n - Given improvement, may consider staying the course\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723888, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L. Patient RSV positive\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723875, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin SC TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels slightly improved from admission, coughing\n less, no CP or SOB at rest, still fatigued\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: awake, NAD, coughing intermittently\n Neck: supple, JVP 8cm\n Chest: rales throughout post and ant lung fields, loudest at B bases,\n no wheezes\n CV: RRR, no m/r/g, laterally displaced PMI\n Abd: soft NT/ND + BS\n Extr: warm, no edema\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Sputum with oral secretions, sample cancelled\n Studies:\n CXR: RUL cavitary nodule, seen on CT on , and new bilateral lower\n lung field consolidations with air bronchograms and peribronchial\n cuffing\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n 1. Sepsis: baseline BPs in the 80s-90s per family and Oncology team,\n now at baseline, still tachy and low-grade temps, so still meeting\n sespsis criteria. Also with low EF, but does not appear grossly\n overloaded on exam now.\n - continue judicious IVF prn hypotension\n - holding off on stress dose steroids now given that BPs now at\n baseline and has known pulm infections\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - continue vanco/cefepime empirically\n - add levoflox for atypical coverage\n - check urine legionella\n - non-contrast chest CT\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole\n 3. Hypereosinophilic syndrome: acute presentation with dense\n consolidation on CXR most c/w CAP.\n - continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n 5. ARF: Cr up to 1.8 on admision, now improving with IVF\n - monitor UOP and urine lytes\n 6. Prior CVA: per Oncology team, ?weaker than baseline, and c/o\n increased fatigue. Can be sepsis and woresening underlying\n deficits.\n - head CT\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n Communication: with patient and family\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723837, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Weight 135.6\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Fever, cough, hypoxia\n Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Also, recent h/o PNA, treated voriconazole, azithro and cefepime. ABx\n except for vori were discontinued. He was ruled out for TB. AFB was\n positive for non-TB. Also with penicillium species in culture.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state. Other things to be considered include CHF,\n PE or exacerbation of eosinophilic condition.\n -- repeat sputum cx\n -- f/u other bcx/ucx, flu\n -- consider repeat bronch/bal\n -- broad spectrum abx for now given immunosuppression\n - cefepime for neutropenic fever\n - vanc given recent hospitalization\n - vori given penicillium growth\n -- hold on diuresis given concern for infection\n -- repeat echo to eval for changing EF\n -- f/u LENI to eval for DVT, though PNA more likely cause given CXR\n 2. hypotension\n Pt with BP mid 80's at baseline per heme/onc fellow. Similar in the ED.\n Pt given 800cc fluid. Likely related to CHF (EF 30%) vs. possible\n infection/SIRS criteria.\n -- culture and treat for infection as above\n --f/u echo\n --hold on diuresis\n -- may require pressors to manage fluids given possible sepsis and EF\n 30%\n 3. hypereosinophilic syndrome-\n currently tx with etoposide Q2 weeks. Current presentation could be\n related to this syndrome.\n -- f/u heme/onc recs\n -- consider bal\n 4. ARF-baseline 1-1.4.\n Improved to 1.3 with some IVF though UOP still low. Fe Urea 35% and not\n helpful\n -- monitor UOP\n --renally dose meds, avoid nephrotoxins\n 5. CHF-EF 30%. Currently with elevated trop and BNP. Dry weight is 140\n lbs\n -- complete ROMI\n -- f/u ECHO\n -- strict Is and Os, daily weights\n 6. blood per rectum-seen on toilet paper while on commode. Pt did not\n notice symptoms at home.\n -- guaiac stools\n -- active T+S\n -- monitor HCTS.\n 7. s/p CVA-supportive care\n 8. afib-stable\n 9. Hyperkalemia\n Resolved with kayexylate\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724203, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Afebrile. SBP low 80\ns to\n low 90\ns, which is baseline. ST 90\ns to low 100\ns with PVC\ns and will\n rise to 120\ns during coughing spells. Pt diuresed yesterday\ncondom cath\n collecting 30-50 cc/hr of amber urine.\n Action:\n Placed pt on 4 L briefly this AM as pt had prolonged coughing attack\n and unable to bring Sp02 above 80%...guiafenesin PRN for coughs. IV\n abx.\n Response:\n Pt back on 2 L NC with the 100% face tent\nslept most of night except\n one coughing spell in the AM\n Plan:\n Pt DNR/DNI\nneeds CMV viral load\nIV abx\nSBP ok in mid 80\ns as it is pt\n baseline\nkeep Sp02 high 80\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724278, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Pt lungs with crackles in the bases and clear in upper lobes. RR 22-34\n labored at times. Pt having very frequent coughing and some productive\n cough with thick yellow sputum.\n Action:\n Received pt on 50% face tent and 2L N/C. during coughing spell\n increased face tent to 70% and 3 L N/C pt still only 88%. Increased to\n 100% face tent with 3L. sao2 increased when pt relaxed and stopped\n coughing. Decreased back to 70% and 2 L N/C pt is > 90% on this. Pt was\n diuresed yesterday but goal of 1L neg was not met. Pt 500cc neg at\n midnight. Pt had stated that the quiafenesin with codeine helped but\n upset his stomach. Tried 30mg of codeine without the guiafenesin which\n really was not effective. Pt given lasix 40 mg iv when sao2 dropped to\n 84 % and again face tent increased to 100%\n Response:\n Pt still coughs frequently and requires high o2.\n Plan:\n DNI/DNI. Titrate o2 as needed to keep sao2 >90%. Cont with antibiotics\n and lasix as needed. Plan is for a family meeting tomorrow to discuss\n treatment options and plan of care.\n Wife stated pt is legally blind\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724392, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724208, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Afebrile. SBP low 80\ns to\n low 90\ns, which is baseline. ST 90\ns to low 100\ns with PVC\ns and will\n rise to 120\ns during coughing spells. Pt diuresed yesterday, condom\n cath for urine collection.\n Action:\n Guiafenesin w/ codeine being given Q4H (written PRN), x1 dose IV lasix\n (40mg) w/ goal 1L neg today, weaning O2 requirement w/ goal o2sat >90%,\n Vanco and cefepime for abx. CMV load sent.\n Response:\n Pt states Guiafenesin w/ codeine working well though productive cough\n still noted @ times, responded well to 40mg IV lasix, currently\n negative 500cc today, o2 sat > 90% on 50% face tent and 2L NC. HR\n remains low 100\ns today, SBP 90\ns w/ MAP >60.\n Plan:\n Pt DNR/DNI. Adjust fio2 for goal sat > 90%, guiafenesin for cough,\n cont abx, ? additional lasix for goal 1L neg today.\n PICC placed in L arm brachial vein @ bedside and okay to use.\n Wife stated that pt is legally blind but seemed to be having more\n difficulty today. Pt denied difficulty though failed several bedside\n tests w/ this RN and ICU team. Pt states this is no different however\n and that he sees better with the overhead light off. Has hx of CVA but\n every thing appears to be @ baseline @ this time.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723810, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723811, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723815, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724393, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724394, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724395, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724396, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n ------ Protected Section------\n Disregard above note.\n ------ Protected Section Error Entered By: , RD, \n on: 05:00 PM ------\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724397, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated.\n Drinks the Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724405, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated. Had\n been drinking some Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Specifics:\n 60YO Male w/ h/o hypereosinophilic syndrome tx with etoposide, h/o\n CVA, a-fib, CHF (EF 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung, FOB/BAL(now growing AFB,\n non-MTB, and penicillium species but final probe pending) admitted w/\n sepsis (fever, hypotension, hypoxia) and progressive bl ASD. ARF likely\n d/t diuresing, now lasix on hold. Consulted for poor po\ns but now\n ordered for swallow evaluation for dysphagia. If concerned with\n aspiration, recommend change to NPO until swallow study is done. If\n passes swallow evaluation, would change Ensure to Ensure Plus for\n additional calories & protein. If fails swallow study, consider tube\n feeds if within plan of care. Noted plan for family meeting to discuss\n goals of care.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If patient is a risk for aspiration, change diet to NPO\n 2. Await swallow study results\n 3. If passes for po\ns, change to Ensure Plus TID w/ diet per\n speech recommendations.\n 4. Consider appetite/mood stimulants & encourage po\n supplements. Consider tube feeds if still unable to take adequate po\n 5. If fails swallow study, consider Tube feeds. Place NGT &\n strart feeds at 10mL/hr, advance by 10mL every 6hrs to goal 50mL/hr of\n Nutren Pulmonary. Check residuals every 4hrs & hold for 1hr if greater\n than 150mL\n 6. Monitor labs, renal function & hydration.\n Will follow plan.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723820, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Studies:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723821, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen:\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Studies:\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n Sepsis\n -hypotension - IVF boluses judiciously - given CHF / elevated BNP\n careful fluid management\n -pan cx\n -empiric vanc, cefipime pending cx data guidance\n -source sounds respiratory in nature - CAP, flu, etc most likely but\n given recent travel to also think about other potential\n etiologies including PE , blasto. Cavitary lesion +AFB NonMTB not\n likely sepsis source.\n CHF\n -elevated BMP, +Trop, CK nl consistent with strain\n -EKG unchanged\n -careful fluid management\n -repeat echo\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n ARF\n -creat 1.8 up\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723823, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Weight 135.6\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Fever, cough, hypoxia\n Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Recently admitted to the hospitalist service with\n pulmonary and ID following. Started on voriconazole, azithro and\n cefepime. ABx except for vori were discontinued. He was ruled out for\n TB. The cause was thought to be fungal/parasitic/reoccurrence of\n hypereosinophilic syndrome. BAL was negative for growth at the time.\n Recently AFB was positive for non-TB. Etiologies for the above\n presentation include, CAP, viral respiratory pathogen such as\n influenza/paraflu, or other infection that occurs in the\n immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723827, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin SC TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels slightly improved from admission, coughing\n less, no CP or SOB at rest, still fatigued\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: awake, NAD, coughing intermittently\n Neck: supple, JVP 8cm\n Chest: rales throughout post and ant lung fields, loudest at B bases,\n no wheezes\n CV: RRR, no m/r/g, laterally displaced PMI\n Abd: soft NT/ND + BS\n Extr: warm, no edema\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Sputum with oral secretions, sample cancelled\n Studies:\n CXR: RUL cavitary nodule, seen on CT on , and new bilateral lower\n lung field consolidations with air bronchograms and peribronchial\n cuffing\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n 1. Sepsis: baseline BPs in the 80s-90s per family and Oncology team,\n now at baseline, still tachy and low-grade temps, so still meeting\n sespsis criteria. Also with low EF, but does not appear grossly\n overloaded on exam now.\n - continue judicious IVF prn hypotension\n - holding off on stress dose steroids now given that BPs now at\n baseline and has known pulm infections\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - continue vanco/cefepime empirically\n - add levoflox for atypical coverage\n - check urine legionella\n - non-contrast chest CT\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole\n 3. Hypereosinophilic syndrome: acute presentation with dense\n consolidation on CXR most c/w CAP.\n - continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n 5. ARF: Cr up to 1.8 on admision, now improving with IVF\n - monitor UOP and urine lytes\n 6. Prior CVA: per Oncology team, ?weaker than baseline, and c/o\n increased fatigue. Can be sepsis and woresening underlying\n deficits.\n - head CT\n Remainder of plan per resident note.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n Communication: with patient and family\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724401, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated. Had\n been drinking some Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724165, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n \n [2] 12:10PM\n \n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). He has\n refused monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb, can re-offer as last\n resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - Cont to monitor hemodynamics\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724461, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, S/P bronch , now growing AFB,\n non-MTB, and penicillium species (but final probe pending) admitted\n from ED with RSV, fever 101.6, hypotension, hypoxia and generalized\n weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723790, "text": "Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n Sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n It is reported that patient has SBP that hover in the 80\ns-90\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723792, "text": "Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n It is reported that patient has SBP that hover in the 80\ns-90\ns. On\n initial assessment in the ED he was treated with 800cc of IVF.\n Action:\n He has received one 500cc bolus overnight for a MAP less than 60mmHg.\n He has also received antibiotics totaling 300cc.\n Response:\n He has maintained he baseline SBP throughout the shift with no\n symptoms. He continues to deny any discomfort, is alert and oriented\n x3. Urinary output has been poor and the team is aware, he is being\n considered for diuresis.\n Plan:\n Team to discuss possible diuresis in the setting of increased O2\n requirements, poor output and h/o CHF with EF of 30%.\n Hypoxemia\n Assessment:\n As mentioned the patient did present with a new cough, fever and O2\n requirement.\n Action:\n His CXR did show bibasilar infiltrates, he continues on his\n voriconazole, Vancomycin and cefepime.\n Response:\n Patient has been afebrile overnight with persistent cough. He did\n receive Robitussin with some effect, last dose given at 0600.\n Plan:\n Continue to follow lab trends, monitor v/s and observed for respiratory\n distress.\n Patient\ns spouse did spend the night with him.\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723705, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibrosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lung\n sounds rhoncherous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns baseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723776, "text": "Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723729, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibrosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lung\n sounds rhoncherous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns baseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n Hypoxemia\n Assessment:\n Pt arrived to from ed on 2l/m nc in no apparent resp distress.\n Lungs cta but with bibasilar crackles on auscultation. Low grade\n temps.\n Action:\n Resp status monitored closely.\n Response:\n Stable resp status\n Administer\n Administer antibiotics as ordered. Monitor pt\ns resp status closely.\n medical team\ns examination of pt and admission orders.\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723732, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 261\n RUL BRONCH LAVAGE\n 01:32PM 10 1* 2* 80* 3* 42\n BRONCH LAVAGE\n//RML\n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for PE\n -ID c/s.\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n .\n #ARF-baseline 1-1.4. Currentlyl 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/os\n -lasix gtt.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full\n # CONTACT:\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723734, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7 2* 3* 60* 2* 261\n RUL BRONCH LAVAGE\n 01:32PM 10 1* 2* 80* 3* 42\n BRONCH LAVAGE\n//RML\n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for PE\n -ID c/s.\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n .\n #ARF-baseline 1-1.4. Currentlyl 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/os\n -lasix gtt.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full\n # CONTACT:\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723735, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7 2* 3* 60* 2* 261\n RUL BRONCH LAVAGE\n 01:32PM 10 1* 2* 80* 3* 42\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723736, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7 2* 3* 60* 2* 261\n RUL BRONCH LAVAGE\n 01:32PM 10 1* 2* 80* 3* 42\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n ------ Protected Section ------\n Chart reviewed, pt examined, case discussed in detail with house\n officers caring for Mr. . In addition, I would add/emphasize\n the following:\n 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16), h/o CVA,\n afib, CHF (ef 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung- FOB/BAL now growing, AFB, non-MTB, and\n penicillium species but final probe pending now admitted from ED for\n cough (yellow sputum), fever 101.6, sore throat, hypotension, hypoxia\n and generalized weakness x one day. No sick contacts. Recent travel\n to to visit son. In BP 83/53, P103, Sat 86%RA, given IVF\n bolus without improvement of BP. Sat 92% on 2L NC. BNP 13k, Trop\n 0.29, CK 87. WBC 11.9 with 86% eos, 13% polys. Transferred to MICU\n for management of hypotension & fever in setting of patient with\n immunosuppression.\n On exam:\n 99.2 P87 BP71/52, R22, sat 93% 2LNC\n Thin, NAD, supine in bed\n Lungs rales b/l\n CV - rrr\n Abd soft NTND BS+\n CXR- persistent Rt cavitary lesion noted. b/l hilar infiltrates c/w\n CHF\n Hypereosinophilic syndrome on etoposide with cavitary lesion of lung\n presents with sepsis in setting of immunosuppression.\n Sepsis\n -hypotension - IVF boluses judiciously - given CHF / elevated BNP\n careful fluid management\n -pan cx\n -empiric vanc, cefipime pending cx data guidance\n -source sounds respiratory in nature - CAP, flu, etc most likely but\n given recent travel to also think about other potential\n etiologies including PE , blasto. Cavitary lesion +AFB NonMTB not\n likely sepsis source.\n CHF\n -elevated BMP, +Trop, CK nl consistent with strain\n -EKG unchanged\n -careful fluid management\n -repeat echo\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n ARF\n -creat 1.8 up\n Remainder of plan per resident note.\n Patient is critically ill.\n Time spent on care: 45min\n ------ Protected Section Addendum Entered By: , MD\n on: 20:01 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723738, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7 2* 3* 60* 2* 261\n RUL BRONCH LAVAGE\n 01:32PM 10 1* 2* 80* 3* 42\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n Will hold off on lasix gtt for now given persistent hypotension and\n likelihood of infection\n ------ Protected Section Addendum Entered By: , MD\n on: 20:14 ------\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723914, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L, RR in high 30\ns-40\ns. Patient RSV\n positive. VBG: 7.48/34/52 ( per ID if resp status worsening\n patient\n should get IVIG)\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723902, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L, RR in high 30\ns-40\ns. Patient RSV\n positive. VBG: 7.48/34/52 ( per ID if resp status worsening\n patient\n should get IVIG)\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723985, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723989, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Respiratory Failure: Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. Resp viral screen positive for RSV.\n Patient currently, on levo, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture).\n Also, with elevated BNP element of CHF exacerbation w/ volume\n overload. PE also on the differential, though less likely given viral\n findings as above.\n -- repeat sputum cx\n -- f/u other bcx/ucx, flu\n -- consider repeat bronch/bal\n -- broad spectrum abx for now given immunosuppression\n - cefepime for neutropenic fever\n - vanc given recent hospitalization\n - vori given penicillium growth\n -- hold on diuresis given concern for infection\n -- repeat echo to eval for changing EF\n -- f/u LENI to eval for DVT, though PNA more likely cause given CXR\n 2. hypotension\n Pt with BP mid 80's at baseline per heme/onc fellow. Similar in the ED.\n Pt given 800cc fluid. Likely related to CHF (EF 30%) vs. possible\n infection/SIRS criteria.\n -- culture and treat for infection as above\n --f/u echo\n --hold on diuresis\n -- may require pressors to manage fluids given possible sepsis and EF\n 30%\n 3. hypereosinophilic syndrome-\n currently tx with etoposide Q2 weeks. Current presentation could be\n related to this syndrome.\n -- f/u heme/onc recs\n -- consider bal\n 4. ARF-baseline 1-1.4.\n Improved to 1.3 with some IVF though UOP still low. Fe Urea 35% and not\n helpful\n -- monitor UOP\n --renally dose meds, avoid nephrotoxins\n 5. CHF-EF 30%. Currently with elevated trop and BNP. Dry weight is 140\n lbs\n -- complete ROMI\n -- f/u ECHO\n -- strict Is and Os, daily weights\n 6. blood per rectum-seen on toilet paper while on commode. Pt did not\n notice symptoms at home.\n -- guaiac stools\n -- active T+S\n -- monitor HCTS.\n 7. s/p CVA-supportive care\n 8. afib-stable\n 9. Hyperkalemia\n Resolved with kayexylate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723991, "text": "Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n SBP normally run in the 90\ns at baseline.\n Action:\n No action required overnight for his BP.\n Response:\n He has maintained he baseline SBP throughout the shift with no\n symptoms. He continues to deny any discomfort, is alert and oriented\n x3. Urinary output has been poor and the team is aware, he is being\n considered for diuresis as respiratory status has worsened this am.\n Plan:\n Team to discuss possible diuresis in the setting of increased O2\n requirements, poor output and h/o CHF with EF of 30%.\n Hypoxemia\n Assessment:\n Patient received on O2 via NC at 5l/min with sats in the lower 90\ns. O2\n requirement has gone up overnight and now he is on 50% with 2l/min\n supplemental O2.\n Action:\n O2 increased as mentioned above, ABG done and results are still\n pending.\n Response:\n Patient has been febrile overnight with persistent cough. He did\n receive Robitussin with some effect, last dose given at 0430 with\n little effect. He has been given morphine 1mg IV for respiratory\n distress.\n Plan:\n Continue to follow lab trends, monitor v/s and observed for increased\n respiratory distress.\n Wife present with patient all night he does appreciate the support.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723993, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Patient tachypneic, tachycardic. Bl crackles appreciated on anterior\n breath sounds. Alert/oriented.\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Pt w/ increased oxygen requirement\n overnight. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. Patient\n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). Also,\n with elevated BNP element of CHF exacerbation w/ volume overload. PE\n also on the differential, though less likely given viral findings as\n above.\n - F/u final sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 20mg iv x1, goal diuresis negative 1L\n - Repeat echo to eval for changing EF\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724248, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Pt lungs with crackles in the bases and clear in upper lobes. RR 22-34\n labored at times. Pt having very frequent coughing and some productive\n cough with thick yellow sputum.\n Action:\n Received pt on 50% face tent and 2L N/C. during coughing spell\n increased face tent to 70% and 3 L N/C pt still only 88%. Increased to\n 100% face tent with 3L. sao2 increased when pt relaxed and stopped\n coughing. Decreased back to 70% and 2 L N/C pt is > 90% on this. Pt was\n diuresed yesterday but goal of 1L neg was not met. Pt 500cc neg at\n midnight. Pt had stated that the quiafenesin with codeine helped but\n upset his stomach. Tried 30mg of codeine without the guiafenesin which\n really was not effective. Pt given lasix 40 mg iv when sao2 dropped to\n 84 % and again face tent increased to 100%\n Response:\n Pt still coughs frequently and requires high o2.\n Plan:\n DNI/DNI. Titrate o2 as needed to keep sao2 >90%. Cont with antibiotics\n and lasix as needed. Plan is for a family meeting tomorrow to discuss\n treatment options and plan of care.\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724373, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724375, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724077, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien qhrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724078, "text": "Chief Complaint: sepsis/hypoxic resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + for RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Alert, NAD, tachypneic\n Cardiovascular: tachy, rr\n Peripheral Vascular: 2+ pedal pulses\n Respiratory / Chest: (Breath Sounds: Crackles : ), tachypenic\n + BS, soft, NT\n Skin: warm, diaphoretic\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) w/ hypoxic resp failure\n and sepsis\n # Sepsis: baseline BPs in the 80s-90s per family and Oncology team, now\n at baseline, still tachy and low-grade temps, so still meeting sespsis\n criteria. Also with low EF, but does not appear grossly overloaded on\n exam now.\n - continue judicious IVF prn hypotension\n - consider stim/ stress dose steroids if hypotension\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - check urine legionella\n Broad antbx\n # hypoxic resp failure\nPneumonitis. High suspcion this is viral from\n RSV, probable bacterial superinfection, does not appear to have\n significant component of volume overload with insensible losses and neg\n fluid balance. No evidence of hemorrhage and dfa neg for PCP. ? med\n related, etoposide.\n --diuresed gently with good UOP response.\n --cont broad antbx coveragere address utilityt of monoclonal ab\n treatment with ID team\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole, appears slightly smaller on repeat CT\n 3. Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management and repeat bnp\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n # tachycardia\n Likely driven by resp distress/failure\n f/u TTE\n # ARF: Cr up to 1.8 on admit, improving with IVF\n - monitor UOP and urine lytes\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724080, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien q4hrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724145, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: .\n Microbiology: .\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724150, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n \n [2] 12:10PM\n *\n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n - Place picc line for better access/iv abx\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line or evaluating w/ US to obtain CVP if\n hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724134, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Tachypneic in the 30\ns with\n shallow breathing. Afebrile. SBP low 80\ns to low 90\ns, which is\n baseline. ST 90\ns to low 100\ns with PVC\ns and will rise to 120\ns during\n coughing spells. Pt diuresed yesterday\ncondom cath collecting 30-50\n cc/hr of amber urine.\n Action:\n Placed pt on 4 L briefly this AM as pt had prolonged coughing attack\n and unable to bring Sp02 above 80%...guiafenesin PRN for coughs. IV\n abx.\n Response:\n Pt back on 2 L NC with the 100% face tent\nslept most of night except\n one coughing spell in the AM\n Plan:\n Pt DNR/DNI\nneeds CMV viral load\nIV abx\nSBP ok in mid 80\ns as it is pt\n baseline\nkeep Sp02 high 80\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724231, "text": "Chief Complaint:sepsis, hypoxemia, resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n Diuresed\n pt and family declined pavilizumab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 08:00 AM\n Bactrim (SMX/TMP) - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.1\nC (96.9\n HR: 106 (94 - 108) bpm\n BP: 89/58(66) {78/40(50) - 94/72(77)} mmHg\n RR: 29 (23 - 30) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 165 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 165 mL\n Blood products:\n Total out:\n 1,350 mL\n 475 mL\n Urine:\n 1,350 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -310 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n More comfortable appearing, alert\n Rales bl\n RR, tachy\n + BS, soft, NT\n No edema\n Labs / Radiology\n 8.9 g/dL\n 80 K/uL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BNP 16K\n Microbiology: --induced sputum mod resp florse growth, gpc on gs, 2+\n gpr, 1+ gnr\n bl/urine ngtd\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains hypoxic, but subjectively more\n comfortable and requiring less supplemental O2. Suspect pneumonitis\n from RSV is primary issue, with possibly bacterial superinfection, and\n component of volume overload (cardiogenic and noncardiogenic)\n --supportive care with cough suppression, nebs, consider NPPV if\n fatigues\n --diuresis (goal 1L neg)\n - continue broad empiric antbx to compelte course\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit and at baseline\n #CHF\ndiurese, holidng ace-I given cr elevation\n # tachycardia\n Likely driven by resp distress/failure\n Continues to improve\n # ARF: cr up, likely from poor forward flow, may improve with diuresis\n - Will monitor UOP and trend\n - resume ace-when cr improves\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n defer further treatment to onc pending clinical improvement from acute\n resp issues\n Remainder of plan per resident note.\n ICU Care\n Nutrition: would consult nutrition, encourage POs, ensure\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis: , picc placement\n DVT: Boots, sq hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated and all questions answered.\n Arrnaging for additional meeting with onc at family request.\n Code status: DNR / DNI\n Disposition :ICU for now, improving and probable floor transfer\n tomorrow\n Total time spent: during rounds, clinical discussion and family\n meeting: 80 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724061, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien qhrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724353, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM for worsening hypoxia and\n increased O2 requirement\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724357, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM for worsening hypoxia and\n increased O2 requirement\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Physical Exam:\n Pulm: + exp wheezes and anterior crackles; CV: tachy, No JVD; Abdom:\n Soft NT/ND; Neuro: Alert, oriented follows commands\n ------ Protected Section Addendum Entered By: , MD\n on: 12:56 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724363, "text": "Chief Complaint: sepsis, resp distress/hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n more hypoxic overnight with increased FIO2 requirement\n weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Alert, flat affect, NAD\n Rales with scant exp wheeze\n RR\n + BS, NT, soft\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, possibly bacterial\n superinfection,\n He is hypoxic, requiring more FIO2 despite diuresis. CXR appears\n unchanged with diffuse ASD/no effusions. At this time feel cardiogenic\n pulm edema is unlikely to be contibuting.\n --Continue supportive care with cough suppression, nebs\n --consider NPPV if fatigues\n --will hold on additional diuresis, ? component of preload dependence\n with decline related to volume depletion\n --continue broad empiric antbx to compelte 14 day course\n --I suspect a new superinfection is unlikely, however, given\n immunosuppression and now mild leukocytosis -- will repeat nosocomial\n infection workup and add empiric double GNR coverage\n #CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure\n Remainder of plan per resident note.\n ICU Care\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724348, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for gram negative coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724349, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n hypoxic overnight and placed on 100%--> weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains hypoxic, requiring more FIO2 dspite\n diuresis. CXR appears unchanged with diffuse ASD. Suspect pneumonitis\n from RSV is primary issue, with possibly bacterial superinfection, at\n this time feel cardiogenic edema is less liekyl to be contibuting.\n --supportive care with cough suppression, nebs, consider NPPV if\n fatigues\n --will hold on diuresis\n --continue broad empiric antbx to compelte 14 day course, and would\n repeat nosocomial infection workup and add double GNR coverage\n there may be compnent of pre-load dependece with ome worsenign rrelated\n to volume shifts.\n #CHF\ndiurese, holidng ace-I given cr elevation--at this time does not\n apepar volume overloaded, neck are flat and xr without eveidence\n of pulm edema, labs suggest overdiuresis\n will hold on diurses at thsintime\n # tachycardia\n Likely driven by resp distress/failure now diuresis\n will follow\n # ARF: cr increaing, suspect this is from diuresis and poor. will hold\n lasix and monitorup, likely from poor forward flow, may improve with\n diuresis\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression\n #nuturional issues\n #goladsof care\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724426, "text": "Chief Complaint: sepsis, resp distress/hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n more hypoxic overnight with increased FIO2 requirement\n weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Alert, flat affect, NAD\n Rales with scant exp wheeze\n RR\n + BS, NT, soft\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, possibly bacterial\n superinfection,\n He is hypoxic, requiring more FIO2 despite diuresis. CXR appears\n unchanged with diffuse ASD/no effusions. At this time feel cardiogenic\n pulm edema is unlikely to be contibuting.\n --Continue supportive care with cough suppression, nebs\n --consider NPPV if fatigues\n --will hold on additional diuresis, ? component of preload dependence\n with decline related to volume depletion\n --continue broad empiric antbx to compelte 14 day course\n --I suspect a new superinfection is unlikely, however, given\n immunosuppression and now mild leukocytosis -- will repeat nosocomial\n infection workup and add empiric double GNR coverage\n #CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure\n Remainder of plan per resident note.\n ICU Care\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n ------ Protected Section ------\n Addendum\n I met with Mrs. , along with pt\ns oncologist, pulmonary fellow\n , social worker and pt\ns nurse. Updated\n to pt\ns current status and answered all questions. We discussed goals\n of care, options of consulting palliative care to assist, concerns\n about pt\ns mood/ depression and nutritional status/ poor PO intake. We\n will also address these concerns directly with pt. At this time we\n continue with current level of aggressive care. We will ask for a\n formal swallow evaluation and nutrition consult.\n Crit care time spent in discussion and family mtg: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:27 PM ------\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 724620, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset. Dr spoke with pt and his wife\n and pt now made cmo. All meds d/c\nd except for prn morphine for\n pain and ativan for anxiety. O2 dace tent mask d/c\nd per request of pt\n and his wife and he remains on 4l/m nc. Will continue with comfort care\n measures and offer emotional support to pt\ns wife and children\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n HYPOXIA; CHF\n Code status:\n DNR / DNI\n Height:\n 67 Inch\n Admission weight:\n 63.7 kg\n Daily weight:\n 61.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, CHF\n Additional history: hx of hypereosinophilic syndrome dx'd ' after\n presenting with transient ischemic episode and bil dvt,cardiomyupathy\n on chemo. dvt 3 yrs ago, multiple cva's(last in ), old\n parietal-occipital and left parietal infarcts,afib, \n syndrome( endomyocardial fibrosis with embolic phenomenon, chf\n secondary t o eosinophilic myocarditis, ef= 30% on tte and hx of\n cavitating lesion to lung.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:78\n D:52\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 91% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 929 mL\n 24h total out:\n 200 mL\n Pertinent Lab Results:\n Sodium:\n 127 mEq/L\n 05:45 AM\n Potassium:\n 4.4 mEq/L\n 05:45 AM\n Chloride:\n 93 mEq/L\n 05:45 AM\n CO2:\n 22 mEq/L\n 05:45 AM\n BUN:\n 62 mg/dL\n 05:45 AM\n Creatinine:\n 2.0 mg/dL\n 05:45 AM\n Glucose:\n 93 mg/dL\n 05:45 AM\n Hematocrit:\n 25.0 %\n 05:45 AM\n Finger Stick Glucose:\n 124\n 06:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 408\n Transferred to: 1183\n Date & time of Transfer: 1830\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724329, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Improving with diuresis and antibiotics for superimposed\n infection. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724335, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - CXR today\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724410, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=130 and\n creat this am =1.8. most likely overdiuresed in the last couple of\n days. Cxr unchanged and without evidence of pulm edema/effusions. Pt\n currently receiving cefepime,vancomycin and voriconazole to cover\n bacterial and fungal pna( recently has grown penicillin species in\n cx). Pt n no apparent resp distress. Pt with poor appetite and c/o\n difficulty swallowing. Sbp ranging 70-90\ns but no interventions ordered\n by medical icu team\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 6l m nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt drinking\n ensure..\n Response:\n Resp status worse compared to last 24 hrs. still requiring high amts of\n 02 but now with o2 sats of 96% on 50% cool neb mask and 6l/m nc.o2 now\n decreased to 50%cool neb mask and 4l/m nc\n Plan:\n Continue to follow resp status closely. Will send off repeat sputum\n for gm stain /c&s when able. hold on further diuresis at present\n time. Wean o2 as tolerated to maintain o2 sats> 90%. Dr. and\n oncologist spoke with pt\ns wife and pt remain dnr/dni. We will\n continue to treat but there will be no escalation of care. Pt to\n have bedside speech and swallow study tomorrow.\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724295, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724297, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Improving with diuresis and antibiotics for superimposed\n infection. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724485, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, S/P bronch , now growing AFB,\n non-MTB, and penicillium species (but final probe pending) admitted\n from ED with RSV, fever 101.6, hypotension, hypoxia and generalized\n weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n Blood c/s and urine c/s sent\n" }, { "category": "Social Work", "chartdate": "2197-03-13 00:00:00.000", "description": "Social Work Admission Note", "row_id": 724951, "text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: This admission at is\n the patient's fifth.\n Past psychiatric history: Unknown.\n Past addictions history: Unknown.\n Employment status: Disable\n Legal involvement: Unknown.\n Mandated Reporting Information:\n Additional Information:\n Patient/Family HX: Dr. admitted this 60 y/o MWM with\n hypereosinophilic syndrome to with hypoxia and CHF. SW met with pt\n and his wife who talked about their hoping to again walk on the beach,\n but then laughed when they eventually discovered that they do not like\n the sand, water, sun, or noise but being able to walk hand-in-hand. Mr.\n talked about feeling that he \"was dead.\" This writer asked if\n he sometimes felt dead or wondered about dying given his medical\n condition, which he said that he did. Shortly afterwards, the pt said\n that he was tired.\n Afterwards, this worker spoke with his wife about the conversation re\n his dying. She said that after this writer left, he asked if she felt\n better having talked about death. Ms. said that it is\n difficult for her to raise such emotional issues and is appreciative of\n others broaching the topic.\n Assessment: The couple seems to struggle with hopeful talk about the\n future, e.g., walking hand-in-hand, while appearing to try and cope\n with what they see as EOL issues. Ms. seems to be experiencing\n a great deal of stress; it is not clear at this time as to how she\n copes and what supports she has, which this worker will explore in a\n future meeting.\n Plan / Follow up:\n 1. SW will continue to meet with the s to assess their\n coping and to offer support.\n , PhD, LICSW\n PAGE \n" }, { "category": "ECG", "chartdate": "2197-03-05 00:00:00.000", "description": "Report", "row_id": 179927, "text": "Sinus tachycardia. Leftward axis. Non-specific anterior ST-T wave\nchanges. Compared to the previous tracing of no diagnostic\ninterim change.\n\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723703, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibreosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lungs\n sounds rhoncehrous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns abseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n" }, { "category": "Radiology", "chartdate": "2197-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121986, "text": " 11:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for volume overload, worsening infiltrates, and\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with h/o of eosinophilic syndrome CHF and + RSV, with new\n leukocytosis\n REASON FOR THIS EXAMINATION:\n please eval for volume overload, worsening infiltrates, and developing\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with history of eosinophilic syndrome, CHF, and\n positive RSV with new leukocytosis. Evaluate for volume overload or worsening\n pneumonia.\n\n COMPARISON: Portable chest radiograph, .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: Left PICC tip appears to loop upon itself within the region of the\n upper SVC or may be entering the azygous vein and should be pulled back 2cm to\n straighten the line. Cardiomegaly is stable. Unchanged diffuse bilateral\n pulmonary opacifications likely represent severe pneumonia; however, a\n component of pulmonary edema and ARDS cannot be excluded. Low lung volumes\n persist. There is no pneumothorax. Right upper lobe cavitary mass is\n unchanged since and improved since .\n\n IMPRESSION:\n 1. Left PICC tip appears to loop upon itself within the region of the upper\n SVC or may be entering the azygous vein and should be pulled back 2cm to\n straighten the line.\n 2. Persistent bilateral pulmonary opacifications likely represent severe\n pneumonia; however, a component of pulmonary edema and ARDS cannot be\n excluded.\n Dr. was notified of the results at 13:58 on .\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1121523, "text": " 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with weakness, eosinophilic syndrome, fever, h.o CVA in the\n past, now ?AMS\n REASON FOR THIS EXAMINATION:\n Pleaase eval for mass vs. infarct\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 12:30 PM\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n\n 4. Extensive paranasal sinus mucosal thickening.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old man with weakness, eosinophilic syndrome, fever and CVA\n in the past, now with altered mental status.\n\n CT HEAD: Axial imaging was performed through the brain without IV contrast\n administration.\n\n COMPARISON: CT head , MRI brain, .\n\n FINDINGS: Hypodensities and bilateral PCA territories have evolved compared\n to the earlier CT examination, compatible with chronic evolved infarcts. There\n is no hemorrhage, edema, mass effect, or evidence for acute vascular\n territorial infarction. There is no shift of normally midline structures.\n There is prominence of the ventricles and sulci, compatible with age-related\n parenchymal involution. There is mucosal thickening of bilateral sphenoid\n sinuses, ethmoid sinuses, and bilateral maxillary sinuses. The frontal\n sinuses appear well pneumatized. The right mastoid air cells are not well\n pneumatized and there is slight mucosal thickening within the left mastoid air\n cells.\n\n IMPRESSION:\n\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n (Over)\n\n 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. Extensive paranasal sinus mucosal thickening.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1121524, "text": ", F. OMED 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with weakness, eosinophilic syndrome, fever, h.o CVA in the\n past, now ?AMS\n REASON FOR THIS EXAMINATION:\n Pleaase eval for mass vs. infarct\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PFI REPORT\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n\n 4. Extensive paranasal sinus mucosal thickening.\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1121525, "text": " 11:27 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for change in size of mass\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide),\n DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be\n \"hypoxic\" and \"hypotensive\" in the ED.\n REASON FOR THIS EXAMINATION:\n Please eval for change in size of mass\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: SBNa MON 12:14 PM\n Right upper lobe cavitary lesion not sign changed in overall size, but more\n internal cavitation. Interval development of widespread, diffuse ground glass\n opacities and patchy consolidation concerning for infection, hemorrhage, ARDS.\n This is less likely edema. +Splenomegaly. No effusions or lymphadenopathy.\n dw at 12:15 pm via telephone.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, :\n\n HISTORY: Eosinophilic syndrome, DVT and CVA. Fever and cough, hypoxia and\n hypotension.\n\n FINDINGS: Instead of the diffuse, mild, ground-glass opacification that was\n present throughout both lungs on , which had improved since , there is now a much more severe peribronchial infiltrative process with\n large areas of coalescent consolidation as well as smaller acinar involvement\n also throughout both lungs. Etoposide related pulmonary toxicity is an\n extremely rare complication therefore diffuse infection, including\n pneumocystis and viral pathogens, as well as pulmonary hemorrhage are more\n likely. The 34 mm wide thick-walled right upper lobe abscess was 42 mm wide\n on mm on and showed greater marginal irregularity on\n the two prior studies. It no longer reaches mildly thickened costal pleura,\n and there is no pleural or pericardial effusion today. Central lymph nodes\n are not pathologically enlarged. Small granulomatous calcifications are\n present in the subcarinal and both hilar stations. Low-density cardiac\n contents indicate anemia. Moderate cardiomegaly has increased, particularly\n the dilated left ventricle. This study is not designed for subdiaphragmatic\n evaluation except to note severe chronic splenomegaly, the absence of adrenal\n mass or adenopathy in the upper abdomen, or lesions in the imaged portion of\n the unenhanced liver suspicious for malignancy or infection. Small stones\n pool in a moderately enlarged gallbladder, but there is no indication of\n cholecystitis.\n\n IMPRESSION:\n 1. Severe, global peribronchial infiltration, more likely infection\n (pneumocystis or virus) or hemorrhage than Etoposide drug reaction,\n particularly because the latter is extremely rare.\n 2. Persistent anemia. Progressive mild cardiomegaly, particular left\n (Over)\n\n 11:27 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for change in size of mass\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ventricular enlargement.\n 3. Granulomatous lymph node calcifications, probably due to prior\n histoplasmosis. That could be the pathogen for the slowly resolving right\n upper lobe cavity, which continues to involute very, very slowly, but is not\n the cause of the diffuse infection.\n 4. Distended gallbladder, tiny gallstones, no evidence of cholecystitis.\n 5. Chronic severe splenomegaly.\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121850, "text": " 1:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 49cm SL L basilic PICC placed ? tip\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with CHF\n REASON FOR THIS EXAMINATION:\n 49cm SL L basilic PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with congestive cardiac failure with left PICC\n placement. Evaluate PICC placement.\n\n COMPARISON: Portable AP chest radiograph .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: Left PICC tip projects within at least 1 cm below the cavo-atrial\n junction and should be pulled back by 1 to 1.5 cm. Cardiomegaly is stable.\n Right upper lobe cavitary mass is improved since . Persistent\n diffuse bilateral pulmonary opacifications likely represent severe pneumonia.\n Low lung volumes persist. No pneumothorax.\n\n IMPRESSION:\n 1. Persistent bilateral pulmonary opacifications likely represent severe\n pneumonia. 2. Right upper lobe cavitary mass decreased since .\n 3. Right PICC tip 1cm below cavoatrial junction and should be pulled back 1 to\n 1.5 cm. IV nurse was notified at 14:19 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2197-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1122037, "text": " 3:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval PICC line placement\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ?PICC line curled over itself\n REASON FOR THIS EXAMINATION:\n eval PICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line.\n\n Portable AP chest radiograph, .\n\n Currently, the left PICC line tip is at the level of low SVC with no evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121611, "text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide),\n DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be\n \"hypoxic\" and \"hypotensive\" in the ED.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with hypereosinophilic\n syndrome who presents with fever and cough.\n\n Portable AP chest radiograph was compared to chest\n radiograph and chest CT.\n\n Extensive bilateral consolidations are unchanged. The heart size is enlarged\n but stable. There is no apparent pleural effusion. The known cavitating\n lesion in the right upper lobe is unchanged.\n\n Overall compared with chest radiograph of .\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121401, "text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with shortness of breath, known cavitary lesion\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old male with shortness of breath and known\n cavitary lesion. Evaluate for pneumonia or effusion.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISON: Comparison is made to chest CT from .\n\n FINDINGS: Stable appearance of 3.6 x 2.7 cm known right upper lobe cavitary\n mass, given differences in technique. There has been interval development of\n perihilar opacification bilaterally, that likely represents acute moderate\n interstitial pulmonary edema though infection is not excluded. No other areas\n of focal parenchymal consolidation. No pleural effusions or pneumothorax.\n There are low lung volumes. Cardiomediastinal contours are stable.\n\n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification likely\n represents acute moderate interstitial pulmonary edema though infection is\n excluded, and recommend repeat radiographs status post diuresis to exclude\n pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121486, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, to evaluate for change.\n\n FINDINGS: In comparison with study of , there is little change in the\n diffuse bilateral pulmonary opacifications. The right upper lobe cavitary\n mass is again seen. Diffuse bilateral pulmonary opacifications most likely\n reflect acute pulmonary vascular congestion, though supervening pneumonia can\n certainly not be excluded. Low lung volumes persist.\n\n\n" } ]
29,244	183,783	The patient was admitted to the intensive care unit. CT surgery was requested to see the patient. The patient underwent CT chest, abdomen and pelvis with reconstruction and 3-D imaging. The chest portion showed extensive emphysema changes throughout both lungs. There was an 8.2 x 6.7 mm nodular density in the right upper lobe. There is atelectasis present in the base. There were several large intrathoracic mediastinal nodes. There were several scattered sub centimeter mediastinal lymph nodes. CT of the abdomen with and without contrast revealed the left kidney was absent. There is free fluid in the upper abdomen surrounding liver and spleen. The pancreas is atrophic. The right renal gland and right renal kidney appear unremarkable. The pelvis CT with and without contrast revealed streaked artifacts and bilateral hip replacements. Diverticular disease in the sigmoid colon without evidence of diverticulitis. There is no significant pelvic lymphadenopathy. Musculoskeletal shows degenerative changes present in the lumbar spine as well as a well defined sclerotic focus in the left iliac bone most likely a bone island. CT of the abdomen with extensive atherosclerotic disease of the aorta and its branches. The right and left coronary arteries arise from a normal expected anatomical location. The descending aorta at the level of the right main pulmonary artery is 38 x 38 mm. There is extensive concentric noncalcification plaque present in the descending thoracic and abdominal aortas. There are multiple ulcerative plaques throughout the entire course of the descending aorta. The descending aorta at the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. The abdominal aorta in the upper abdomen above the celiac access measures 37.3 x 49.3 mm. The celiac access, superior mesenteric artery are widely patent. Inferior mesenteric artery was not clear to visualize. There is an abdominal aortic aneurysm that measures 63.5 x 65.1 mm in maximum transverse diameter. There is a 24 x 24.6 mm right common iliac aneurysm which contains concentric mural thrombus. CT surgery was consulted after review of the CT scan. In discussion with Dr. and CT surgery Dr. __________ it was determined the patient was not a surgical candidate because of extensive medical problems, respiratory problems. The patient was made DNR, DNI. Blood pressure medications were adjusted to stabilize blood pressure. The patient was transferred out of the ICU to the regular nursing floor on . The patient was discharged to home with well controlled blood pressure without any symptoms. The patient's creatinine at discharge was 1.1. The patient should follow up with the primary care physician for continued blood pressure monitoring and blood pressure medication adjustment. She should call primary care if she develops any chest, back, abdominal pain or near syncopal episodes.	MUSCULOSKELETAL: Multilevel degenerative changes are present in the lumbar (Over) 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? (Over) 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? For example, there is a 17.0 x 12.7 mm pretracheal lymph node, there is a 15.4 x 7.2 mm prevascular lymph node, there is a 22.5 x 16.2 mm precarinal lymph node, there is a 16.4 x 11.3 mm lymph node anterior to the descending thoracic aorta. There is extensive concentric noncalcified plaque present in the descending thoracic and the abdominal aorta. The pancreas is atrophic with prominence of the main pancreatic duct. stent candidate Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM FINAL REPORT (Cont) The abdominal aorta in the upper abdomen above the celiac axis measures 37.3 x 49.3 mm, the celiac axis, superior mesenteric artery are widely patent. Extensive noncalcified and ulcerated plaques throughout the course of the descending thoracic and abdominal aorta with an abdominal aortic aneurysm measuring 65.1 x 63.5 mm in maximum transverse diameter. There is a 8.2 x 6.7 mm nodular opacity in the right upper lobe (image 27, series 2). There is an abdominal aortic aneurysm that measures 63.5 x 65.1 mm in maximum transverse diameter. The right and the left coronary arteries arise from the normal expected anatomical locations. BP 116/67 HR 60-70 NSR with APC/PVC. Alerts The most most recent case for Ms. has triggered some of your PEMS alerts: The angle prox neck to aaa body measurement is greater than or equal to 45.0 (This alert has not been acknowledged.) FINDINGS: CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There are extensive emphysematous changes present throughout both lungs. stent candidate Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM FINAL REPORT (Cont) spine. A 24.6 x 24.6 mm right common iliac aneurysm that does not extend into the iliac bifurcation and 10.5 x 9.1 mm short-segment right external iliac artery aneurysm. CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: Streak artifact from the bilateral hip replacement producing extensive streak artifacts. Rhythm appears to be nsr with very frequent pac's and pvc.==plan medical management and pt is DNR + palpable pulses.Resp: LS exp wheezing. There is a widely patent single right renal artery. Denies pain.CV: HR 60-80s. Free fluid in the upper abdomen is of uncertain clinical significance. There is a 24.6 x 24.6 mm aneurysm of the right common iliac artery which contains concentric mural thrombus. 7a-3pneuro: a+ox2 (reoriented to time), pleasant, following commands, mae, turns with assist x1cv: wandering atrial pacemaker 45-85, occasional pvcs, sbp 125-175, ntg gtt started (now maxed out at 4 mcg/kg/min), nicardipine gtt to be started to keep sbp<120; afebresp: insp/exp wheeze to right side, clear left upper diminished to base, albuterol nebs given, strong productive cough, 02 sats 86-89% on 5L nc (sats >86% ok per )gi: bowel sounds present, npo, sliding scale startedgu: foley to gravity draining clear yellow urinelabs: repleting k+tests: cta thorax-no results at this timeassess: stableplan: maintain sbp<120, depending on ct results taaa repair vs aortic stent vs medical management, keep npo until plan known There is atelectasis present at the lung bases. Pt c/o of lt sided abd pain, team aware, morphine and ativan given. The descending aorta at the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. Her TAA volume is 464.3cc. The right adrenal gland and right kidney appear unremarkable. There are multiple calcified foci in the thrombus within the aneurysm. The ascending aorta at the level of the right main pulmonary artery measures 38.0 x 38.0 mm. Respiratory care:Patient followed for albuterol treatments Q6prn. Pt continues on iv NTG at 4mcg (vicu max) and restarted on po meds and hydralazine added. TECHNIQUE: CT of the chest, abdomen, and pelvis was performed without intravenous contrast followed by CT of the chest, abdomen, and pelvis post- administration of intravenous contrast, reconstructions were performed in the axial, sagittal and coronal planes. CT ANGIOGRAM: There is extensive atherosclerotic disease in the aorta and its branches. 4p-7pPt met with Dr. and Dr. pt not a surgical canidate and family aware. There are several enlarged intrathoracic mediastinal lymph nodes. Denies abd/back pain. Solitary 8.2 x 6.7 mm pulmonary nodule in the right upper lobe along with mediastinal lymphadenopathy may represent a lung primary neoplasm with metastatic disease to mediastinal lymph nodes and may be assessed further as per clinical need. 11:49 AM MMS SUGICAL PLANNING SERVICE Clip # Reason: AAA MEDICAL CONDITION: 69 year old woman with AAA ruptured - REASON FOR THIS EXAMINATION: please apply to above cta torso No contraindications for IV contrast FINAL REPORT This report is for reference only, generated by M2S.	7	[ { "category": "Radiology", "chartdate": "2133-09-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 975914, "text": " 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with AAA ruptured -\n REASON FOR THIS EXAMINATION:\n please eval - ? stent candidate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old female with abdominal aortic aneurysm, for evaluation of\n extent.\n\n TECHNIQUE: CT of the chest, abdomen, and pelvis was performed without\n intravenous contrast followed by CT of the chest, abdomen, and pelvis post-\n administration of intravenous contrast, reconstructions were performed in the\n axial, sagittal and coronal planes. The reconstructions were also performed\n in the 3D imaging lab.\n\n COMPARISON: There is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There are extensive\n emphysematous changes present throughout both lungs. There is a 8.2 x 6.7 mm\n nodular opacity in the right upper lobe (image 27, series 2). There is\n atelectasis present at the lung bases.\n\n There are several enlarged intrathoracic mediastinal lymph nodes. For\n example, there is a 17.0 x 12.7 mm pretracheal lymph node, there is a 15.4 x\n 7.2 mm prevascular lymph node, there is a 22.5 x 16.2 mm precarinal lymph\n node, there is a 16.4 x 11.3 mm lymph node anterior to the descending thoracic\n aorta. There are several scattered subcentimeter mediastinal lymph nodes as\n well.\n\n CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The left kidney is absent\n and most likely represents a congenital absence as there are no surgical clips\n or known history of a nephrectomy. There is free fluid in the upper abdomen\n surrounding the liver and spleen. The scan was performed in the early\n arterial phase. Within these limitations, the liver and spleen do not show\n any focal lesions. The pancreas is atrophic with prominence of the main\n pancreatic duct. The right adrenal gland and right kidney appear\n unremarkable.\n\n CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: Streak artifact from the\n bilateral hip replacement producing extensive streak artifacts. Within these\n limitations, the diverticular disease is present in the sigmoid colon without\n evidence of diverticulitis. There is no significant pelvic lymphadenopathy.\n\n MUSCULOSKELETAL: Multilevel degenerative changes are present in the lumbar\n (Over)\n\n 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n spine. There is a well-defined sclerotic focus in the left iliac bone most\n likely a bone island.\n\n CT ANGIOGRAM:\n\n There is extensive atherosclerotic disease in the aorta and its branches. The\n right and the left coronary arteries arise from the normal expected anatomical\n locations. The ascending aorta at the level of the right main pulmonary\n artery measures 38.0 x 38.0 mm.\n\n There is extensive concentric noncalcified plaque present in the descending\n thoracic and the abdominal aorta. There are multiple ulcerated plaques\n throughout the entire course of the descending aorta. The descending aorta at\n the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. The\n abdominal aorta in the upper abdomen above the celiac axis measures 37.3 x\n 49.3 mm, the celiac axis, superior mesenteric artery are widely patent. The\n inferior mesenteric artery was not clearly visualized. There is a widely\n patent single right renal artery. There is an abdominal aortic aneurysm that\n measures 63.5 x 65.1 mm in maximum transverse diameter. There are multiple\n calcified foci in the thrombus within the aneurysm.\n\n There is a 24.6 x 24.6 mm aneurysm of the right common iliac artery which\n contains concentric mural thrombus.\n\n CONCLUSION:\n\n 1. Extensive noncalcified and ulcerated plaques throughout the course of the\n descending thoracic and abdominal aorta with an abdominal aortic aneurysm\n measuring 65.1 x 63.5 mm in maximum transverse diameter.\n\n 2. Solitary 8.2 x 6.7 mm pulmonary nodule in the right upper lobe along with\n mediastinal lymphadenopathy may represent a lung primary neoplasm with\n metastatic disease to mediastinal lymph nodes and may be assessed further as\n per clinical need.\n\n 3. Free fluid in the upper abdomen is of uncertain clinical significance.\n\n 4. A 24.6 x 24.6 mm right common iliac aneurysm that does not extend into the\n iliac bifurcation and 10.5 x 9.1 mm short-segment right external iliac artery\n aneurysm.\n\n 5. Absent left kidney.\n\n\n (Over)\n\n 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2133-09-09 00:00:00.000", "description": "MMS SUGICAL PLANNING SERVICE", "row_id": 981458, "text": " 11:49 AM\n MMS SUGICAL PLANNING SERVICE Clip # \n Reason: AAA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with AAA ruptured -\n REASON FOR THIS EXAMINATION:\n please apply to above cta torso\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n This report is for reference only, generated by M2S.\n\n ( ), DOB: (Age 69) AAA/TAA\n Date of Service: \n Physician : , MD\n Current Status\n\n\n was last scanned on and is a pre-operative\n AAA/TAA patient. Ms. was previously scanned at Pre-op on -. Her AAA volume is 327.3cc. Her TAA volume is 464.3cc. Her AAA\n diameter is 6.6cm. Her TAA diameter is 5.1cm.\n Alerts\n\n The most most recent case for Ms. has triggered some of your PEMS\n alerts:\n The angle prox neck to aaa body measurement is greater than or equal to 45.0\n (This alert has not been acknowledged.)\n Nb: This note was automatically generated.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-09-09 00:00:00.000", "description": "Report", "row_id": 1641384, "text": "11p-7a\nNeuro: Pt alert and oriented, forgetful of time. MAE. Follows commands. Denies pain.\n\nCV: HR 60-80s. SR occasional pacs, occasional pvcs. NTG weaned to off, see carevue. SBP 100-120s. Goal SBP<140. + palpable pulses.\n\nResp: LS exp wheezing. Sats 87-94%. Pt wears 6Lnc at home. Goal sats 88% or above. Face tent applied ~1 hour for sats 86-87%. Pt refused to wear the face tent, though sats improved 88% or better, see carevue.\n\nGI/GU: Abd softly distended, hypoactive BS. Tender to touch. Denies abd/back pain. Foley draining adequate amts of clear yellow urine, see carevue.\n\nEndo: Per pt's scale.\n\nPlan: Monitor hemodynamics. Goal SBP<140. ?transfer to floor/vicu.\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641380, "text": " 7a-3p\nneuro: a+ox2 (reoriented to time), pleasant, following commands, mae, turns with assist x1\n\ncv: wandering atrial pacemaker 45-85, occasional pvcs, sbp 125-175, ntg gtt started (now maxed out at 4 mcg/kg/min), nicardipine gtt to be started to keep sbp<120; afeb\n\nresp: insp/exp wheeze to right side, clear left upper diminished to base, albuterol nebs given, strong productive cough, 02 sats 86-89% on 5L nc (sats >86% ok per )\n\ngi: bowel sounds present, npo, sliding scale started\n\ngu: foley to gravity draining clear yellow urine\n\nlabs: repleting k+\n\ntests: cta thorax-no results at this time\n\nassess: stable\n\nplan: maintain sbp<120, depending on ct results taaa repair vs aortic stent vs medical management, keep npo until plan known\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641381, "text": "4p-7p\nPt met with Dr. and Dr. pt not a surgical canidate and family aware. At present pt medically management not CMO. Plan to transfer to VICU when be available. Plan to keep sbp<140. Pt continues on iv NTG at 4mcg (vicu max) and restarted on po meds and hydralazine added. Pt c/o of lt sided abd pain, team aware, morphine and ativan given. Pt affect very appropriate and realistic, family aware and agree as well. Rhythm appears to be nsr with very frequent pac's and pvc.==plan medical management and pt is DNR\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641382, "text": "Nursing Progress Note 7PM-11PM:\nPt with stable BP weaned Nitro drip down to 3mcg/kg/min. Aware that she may be transferred to the floor tonight. Good UO via foley. BP 116/67 HR 60-70 NSR with APC/PVC. Family visiting most of the evening.\n" }, { "category": "Nursing/other", "chartdate": "2133-09-09 00:00:00.000", "description": "Report", "row_id": 1641383, "text": "Respiratory care:\nPatient followed for albuterol treatments Q6prn. Breathsounds are coarse with exp. wheezes. Please see respiratory section of carevue for further data.\nPlan: Continue to follow for bronchodilator therapy Q6prn\n" } ]
31,179	169,858	Assesment: Mrs is a 72 year old female with a history of a mechanical mitral valve chronically anticoagulated with coumadin who presents with one week of lightheadedness now with known duodenal ulcer s/p endoscopic injection and clipping of visible vessel.	Osseous structures show degenerative change of the lumbar spine and appear otherwise within normal limits. There is a tortuous atherosclerotic aorta. COMPARISON: No prior abdominal radiograph. IMPRESSION: Post-cardiac surgery as above. HISTORY: Hypertension and weakness. Pulmonary vasculature is unremarkable. Moderate enlargement of the cardiac silhouette persists, as does tortuosity of the aorta. To sicu from EW- GI scoped pt at bedside- clot found in duodenum. Pt has hx htn, anemia and recent gout. To EW this am with c/o weakness, left sided chest pain, and melena. IMPRESSION: No evidence of bowel obstruction or free intraperitoneal air. SINGLE SUPINE VIEW OF ABDOMEN: A moderate amount of gas and stool is seen throughout the colon. No acute pulmonary process. MP-SR,no ectopy, BP stable in low 100's, s/p fluid bolus, FFP,PC's Hct 21.8> 20.5 this am, MICU resident paged. No free subdiaphragmatic gas is evident. A-V conduction delay. The visualized osseous structures are otherwise unremarkable. IMPRESSION: AP chest compared to . Chest x-ray of same date. Diffuse non-specific ST-T wave changes.No previous tracing available for comparison. Sinus rhythm. No effusion or pneumothorax is evident. Injected with epinephrine and clips placed. The cardiac silhouette is borderline enlarged. There is no evidence of free intraperitoneal air on the supine radiograph. trans to floor Small amounts of gas present in nondistended loops of small bowel. COMPARISON: None. Lungs are clear and there is no pleural effusion. Peripheral lines x2 intact, LS clear, NC3lpm,sao2 100% abd soft,no stool or bleeding overnight, s/p scope, epi and banding.Protonix gtt @ 8mg/hr Foley in place, dg lt yellow clr urine ~300/hr Plan-? Versed and fentanyl given for sedation, tol. Interval enlargement of the cardiac silhouette could be due to cardiac decompensation or more likely lower lung volumes difference in patient positioning. Cholecystectomy clips present in the right upper quadrant. The patient has undergone prior median sternotomy and valve replacement surgery. 1:38 PM CHEST (PA & LAT) Clip # Reason: eval for infiltrate Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with GIB and now with new temp to 101 REASON FOR THIS EXAMINATION: eval for infiltrate FINAL REPORT HISTORY: GIB, now with elevated temperature. transfuse ? However, no evidence of vascular congestion, pleural effusion, or acute pneumonia. 11:02 AM CHEST (PORTABLE AP) Clip # Reason: eval for free air Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with doudenal ulcer, s/p EGD with abdominal pain REASON FOR THIS EXAMINATION: eval for free air FINAL REPORT AP CHEST HISTORY: Duodenal ulcer and abdominal pain, look for free air. FINDINGS: The lungs are clear. Pt arouses to voice, denies pain, sleeping in long naps. FINDINGS: In comparison with the study of , the patient has taken a much better inspiration. Hct 18, INR 4.1- pt was on coumadin at home 2nd hx of mitral valve repair 20 yrs ago. 1:24 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna, ptx MEDICAL CONDITION: 72 year old woman with hypotension, weakness REASON FOR THIS EXAMINATION: eval for pna, ptx FINAL REPORT AP CHEST, AT 1326 HOURS. NKDA pr family. 10:31 AM PORTABLE ABDOMEN Clip # Reason: ABDOMINAL PAIN FOLLOWING CLIPPING OF VISIBLE ULCER Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with abdominal pain following cliping of visible ulcer REASON FOR THIS EXAMINATION: eval for free air FINAL REPORT INDICATION: Abdominal pain following clipping of visible ulcer. SICU Progress Note 1900-0700 Stable overnight, Hct trending down to 20.5 this am.INR2.6. nsg admit notePt is a+o x3- speaks mostly Cantonese.	7	[ { "category": "Radiology", "chartdate": "2156-03-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1001412, "text": " 10:31 AM\n PORTABLE ABDOMEN Clip # \n Reason: ABDOMINAL PAIN FOLLOWING CLIPPING OF VISIBLE ULCER\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with abdominal pain following cliping of visible ulcer\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain following clipping of visible ulcer.\n\n COMPARISON: No prior abdominal radiograph. Chest x-ray of same date.\n\n SINGLE SUPINE VIEW OF ABDOMEN: A moderate amount of gas and stool is seen\n throughout the colon. Small amounts of gas present in nondistended loops of\n small bowel. There is no evidence of free intraperitoneal air on the supine\n radiograph. Cholecystectomy clips present in the right upper quadrant.\n\n Osseous structures show degenerative change of the lumbar spine and appear\n otherwise within normal limits.\n\n IMPRESSION: No evidence of bowel obstruction or free intraperitoneal air.\n\n" }, { "category": "Radiology", "chartdate": "2156-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001315, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hypotension, weakness\n REASON FOR THIS EXAMINATION:\n eval for pna, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, AT 1326 HOURS.\n\n HISTORY: Hypertension and weakness.\n\n COMPARISON: None.\n\n FINDINGS: The lungs are clear. There is a tortuous atherosclerotic aorta.\n The patient has undergone prior median sternotomy and valve replacement\n surgery. The cardiac silhouette is borderline enlarged. No effusion or\n pneumothorax is evident. The visualized osseous structures are otherwise\n unremarkable.\n\n IMPRESSION: Post-cardiac surgery as above. No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001416, "text": " 11:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with doudenal ulcer, s/p EGD with abdominal pain\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: Duodenal ulcer and abdominal pain, look for free air.\n\n IMPRESSION: AP chest compared to .\n\n Interval enlargement of the cardiac silhouette could be due to cardiac\n decompensation or more likely lower lung volumes difference in patient\n positioning. Pulmonary vasculature is unremarkable. Lungs are clear and\n there is no pleural effusion. No free subdiaphragmatic gas is evident.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-03-26 00:00:00.000", "description": "Report", "row_id": 1661114, "text": "nsg admit note\nPt is a+o x3- speaks mostly Cantonese. To EW this am with c/o weakness, left sided chest pain, and melena. Hct 18, INR 4.1- pt was on coumadin at home 2nd hx of mitral valve repair 20 yrs ago. To sicu from EW- GI scoped pt at bedside- clot found in duodenum. Injected with epinephrine and clips placed. Versed and fentanyl given for sedation, tol. well. Pt has hx htn, anemia and recent gout. NKDA pr family.\n" }, { "category": "Nursing/other", "chartdate": "2156-03-27 00:00:00.000", "description": "Report", "row_id": 1661115, "text": "SICU Progress Note 1900-0700\n Stable overnight, Hct trending down to 20.5 this am.INR2.6.\n Pt arouses to voice, denies pain, sleeping in long naps.\n MP-SR,no ectopy, BP stable in low 100's, s/p fluid bolus, FFP,PC's\n Hct 21.8> 20.5 this am, MICU resident paged. Peripheral lines x2 intact,\n LS clear, NC3lpm,sao2 100%\n abd soft,no stool or bleeding overnight, s/p scope, epi and banding.Protonix gtt @ 8mg/hr\n Foley in place, dg lt yellow clr urine ~300/hr\n Plan-? transfuse\n ? trans to floor\n\n" }, { "category": "Radiology", "chartdate": "2156-03-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1001824, "text": " 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with GIB and now with new temp to 101\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GIB, now with elevated temperature.\n\n FINDINGS: In comparison with the study of , the patient has taken a much\n better inspiration. Moderate enlargement of the cardiac silhouette persists,\n as does tortuosity of the aorta. However, no evidence of vascular congestion,\n pleural effusion, or acute pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2156-03-26 00:00:00.000", "description": "Report", "row_id": 215477, "text": "Sinus rhythm. A-V conduction delay. Diffuse non-specific ST-T wave changes.\nNo previous tracing available for comparison.\n\n" } ]
54,382	166,909	Patient was admitted to the trauma service on . Extubated; serial Hcts stable; held overnight in ICU due to SOB. Transferred to floor, CT to water seal, foley d/c'd. Increased PTX, CT back to suction. No significant output, so CT pulled. CT chest done, small R PTX and hemothorax; new chest tube placed to suction. Adjusted pain meds; ambulated. CT placed to water seal; CT chest done, showing unchanged R PTX and hemothorax. Thoracics consulted. CXR with worsening R PTX. Thoracentesis by IP, drained 300cc of old thick blood. Stable, awaiting to go to OR with thoracics. On the patient was taken to the operating room for a right VATS washout, evacuation of hemothorax. The patient was noted to have, a fair amount of clot and fibrin as well as old blood in the chest. Two chest tubes were placed and the patient was admitted to the floor post-operatively. His diet was advanced and he was tolerating regular diet on POD1, his pain was controlled with IV medications, this was transitioned to PO. Chest tube outputs were monitored daily as well as vital signs and urine output. On POD #2 the posterior chest tube was d/c'd, and a CXR was completed showing a small apical pneumothorax. On POD#3 the anterobasilar chest tube was discontinued, a CXR was obtained. The patient was deemed fit for discharge on POD #3, at that time his pain was controlled with PO medications, he was ambulatory, voiding, tolerating a regular diet, and breathing without distress.	Response: Pt intubated, on propofol, right CT to sx. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Albuterol nebs prn. Albuterol nebs prn. HCT stablbe. HCT stablbe. Received on CMV, Propofol gtt. Received on CMV, Propofol gtt. Plan: CXR, serial crits, wean to extubate. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. R CT to wall sxn w/ moderate serosang output. R CT to wall sxn w/ moderate serosang output. Trace right medial pneumothorax. There is a trace right medial basal pneumothorax. Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. Right hemopnumo, ? HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. Updated on pts status. Updated on pts status. Updated on pts status. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. CXR okay. CXR okay. Cont R-chest tube. Cont R-chest tube. Action: Admitted to T/SICU from ED at 0615. pt pan scanned in ED. IMPRESSION: PA and lateral chest compared to earlier on : A tiny right apical pleural air collection and right pleural tube unchanged in position may be fissural, with a side port in the right axillary subcutaneous tissue. IMPRESSION: AP chest compared to : Persistent small right pleural effusion and right basal atelectasis, right pleural tube still in place, side port extrathoracic. Right upper lobe anterior opacity, unchanged, likely contusion. There is a small right pneumothorax. There is a small right pneumothorax. There is a small right pneumothorax. Right pleural tube unchanged in position, crossing the right mid and lower chest with at least one side port in the soft tissues of the chest wall. PFI REPORT There is small right pneumothorax. Right lung atelectasis and contusion remain. Enlarging heterogeneous right pleural effusion, now moderate, consistent with progressing hemothorax. A small right pneumothorax is unchanged. IMPRESSION: AP chest centered at the diaphragm compared to earlier on : Very small right apical pleural air collection has increased slightly (see the lateral costal component). Mild thoracic scoliosis and thickened left paraspinal soft tissue, unchanged. Follow up right pneumothorax. SOFT TISSUE STRUCTURES: Very small amount of emphysema is noted in bilateral posterior wall, right more than left, paraspinal in distribution on the left and posterolateral chest wall in distribution on the right. New small right pneumothorax, with air-fluid levels, likely due to recent removal of the chest tube. Hazy opacification over the right lung base probably represents some posteriorly layering right pleural effusion. Minimal atelectasis in the left lung base is noted. IMPRESSION: No change in the degree of pneumothorax on the right. New tiny left pleural effusion. There is intermediate density right pleural effusion which could reflect a hemothorax. Right apical and right basal chest tubes are in place. Right chest tube is in place. Subcutaneous emphysema at the entrance of the old chest tube persists. There is emphysema in the right lateral subcutaneous soft tissues. Unchanged right hyoerdense pleural effusion consistent with hemothorax. Tiny right apical pneumothorax persists with the right chest tube removed. Right upper lobe anterior opacity, unchanged, likely contusion. Unchanged kink at the tip of the chest tube, abutting the right atrium. There is a tiny right apical pneumothorax. FINDINGS: In comparison with the earlier study of this date, the right chest tube has been removed. There is a small right pneumothorax. Small interval increase of the right apical pneumothorax, but the pneumothorax remains small. Opacities in the right lung greater in the lower lobe are unchanged from prior. Small right pneumothorax is also unchanged. Small right pneumothorax is also unchanged. Small right pneumothorax is also unchanged. Right basal chest tube remains in place. Previously described heterogeneous hyperdense fluid collection in the right hemithorax is unchanged in size and consistent with hemoperitoneum. There are persistent small linear opacities in the right mid lung consistent with atelectasis. Non-diagnostic inferior Q wave pattern, may be a normal variantbut cannot exclude prior inferior myocardial infarction. Some loculated right pleural effusion is again seen. REASON FOR THIS EXAMINATION: Status post Chest tube. Effusion consistent with hemothorax. Effusion consistent with hemothorax. Right-sided chest tube is kinked and malpositioned abutting the right atrium. Right-sided chest tube is kinked and malpositioned abutting the right atrium. Right-sided chest tube is kinked and malpositioned abutting the right atrium. There is mild increase in small-to-moderate loculated right pleural effusion. Right apical and right base chest tube remain in place. Chest tube looks kinked. Right pleural effusion and right lower lobe consolidation are stable. The heart is at the upper limits of normal. Since yesterday, a right chest tube is in unchanged position. Associated compressive atelectasis on the right side are noted. Mediastinal, hilar contours and pulmonary vasculature are normal. Right retrocardiac consolidation and left retrocardiac opacities are consistent with atelectasis, although some degree of aspiration cannot be excluded. Cardiomediastinal contours are unchanged. The current study demonstrates recently inserted chest tube.	46	[ { "category": "Respiratory ", "chartdate": "2125-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 667843, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n New admission, pt is SP multiple stab wounds to thorax , mostly\n posteriorly\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667830, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable\n PULM: wean to extubate today\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n RENAL: f/u u/o, f/u cre\n HEME: serial Hct, transfuse prn\n ENDO: RISS\n ID: no Abx\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 35 min\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668072, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Events this shift\n Pt c/o sob/difficulty breathing at 2250. LS clear with dim bases bilat.\n O2 sat 98-100%. Pt placed on 2L NC for comfort. Stat chest xray\n obtained which looked unchanged. Pt kept in ICU overnight for further\n monitoring. Will reassess floor transfer in am.\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Foley d/c at mn, DTV 0800\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable.\n Tolerating regular diet, denies nausea.\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid \n Transfer to floor today\n Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667932, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable, monitor HR and BP\n PULM: wean to extubate today, hemothorax\n monitor CT output, make sure\n output decreasing before extubation\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n (serial HCT), belly exam benign currently\n RENAL: adequate UOP, f/u cr\n HEME: serial Hct Q4 hours for hemothorax,\n ENDO: RISS\n ID: monitor WBC and fver curve\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 33 min\n" }, { "category": "Physician ", "chartdate": "2125-05-19 00:00:00.000", "description": "Intensivist Note", "row_id": 668059, "text": "TSICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n stab wound\n PMHx:\n PMH: asthma\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:40 AM\n EXTUBATION - At 09:43 AM\n Post operative day:\n HD2\n 24hr events: admitted to TICU intubated, right chest tube in place\n admission Hct 40 after 1u transfused at OSH, received 1unit in the ED.\n Extubated in AM. Chest tube output declined. HCT stablbe. Pending tx\n to floor, but in evening developed SOB. CXR okay. Tx nebs.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:40 AM\n Other medications:\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.9\nC (98.4\n HR: 79 (70 - 107) bpm\n BP: 141/74(88) {87/37(49) - 146/94(104)} mmHg\n RR: 23 (17 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,848 mL\n 360 mL\n PO:\n 480 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n Blood products:\n 375 mL\n Total out:\n 3,005 mL\n 180 mL\n Urine:\n 2,115 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,843 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 455 (455 - 455) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 4.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), right chest tube\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 39.3 %\n 12.2 K/uL\n [image002.jpg]\n 08:24 AM\n 12:40 PM\n 04:21 PM\n 09:00 PM\n 02:03 AM\n WBC\n 15.6\n 12.2\n Hct\n 40.0\n 38.8\n 39.9\n 38.3\n 39.3\n Plt\n 304\n 280\n Creatinine\n 1.0\n 0.9\n Troponin T\n <0.01\n Glucose\n 105\n 110\n Other labs: PT / PTT / INR:14.2/25.0/1.2, CK / CK-MB / Troponin\n T:679/5/<0.01, ALT / AST:21/26, Alk-Phos / T bili:66/1.2, Amylase /\n Lipase:47/13, Ca:9.0 mg/dL, Mg:2.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 23yoM with stab wound to the right chest\n Neurologic: dilaudid prn for pain\n Cardiovascular: stable\n Pulmonary: s/p stab wound to R chest. Cont R-chest tube. Output\n minimal. Albuterol nebs prn.\n Gastrointestinal / Abdomen: NPO, H2, serial exams, No evidence of solid\n visceral injury\n Nutrition: Regular diet\n Renal: no issues. foley likely to d/c\n Hematology: serial Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: 36fr CT, foley, PIV, ETT\n Wounds:\n Imaging:\n Fluids: LR at 100 cc/h\n Consults:\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Other: Chest Trauma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 06:20 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667900, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt admitted approx 630 to TSICU. Received on CMV, Propofol gtt. When\n lightened, following all commands, appropriate. R CT to wall sxn w/\n moderate serosang output. VSS. HCT 40.\n Action:\n Vent quickly weaned to PS 5/5\n Propofol weaned\n Extubated approx 0945\n HCT checks q4hrs\n Response:\n Pt doing well, VSS. O2 sats 99%, currently on 40%FiO2 face\n tent. Pt w/ c/o back pain (stab wounds), Dilaudid administered PRN. HCT\n remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668148, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. Sats 99-100% on RA. HCT 40. Foley discontinued @\n midnight. Tol regular diet. Occassional c/o pain in back from/chest.\n Action:\n PRN Dilaudid for pain control\n Due to void\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pain well controlled\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668150, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. Sats 99-100% on RA. HCT 40. Foley discontinued @\n midnight. Tol regular diet. Occassional c/o pain in back from/chest.\n Action:\n PRN Dilaudid for pain control\n Due to void\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pain well controlled\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n S/P STABBING\n Code status:\n Full code\n Height:\n Admission weight:\n 100 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Asthma, no other PMH per pt\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:76\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 360 mL\n 24h total out:\n 730 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:03 AM\n Potassium:\n 3.7 mEq/L\n 02:03 AM\n Chloride:\n 104 mEq/L\n 02:03 AM\n CO2:\n 25 mEq/L\n 02:03 AM\n BUN:\n 8 mg/dL\n 02:03 AM\n Creatinine:\n 0.9 mg/dL\n 02:03 AM\n Glucose:\n 110 mg/dL\n 02:03 AM\n Hematocrit:\n 41.9 %\n 10:58 AM\n Finger Stick Glucose:\n 115\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: valuables w/ ED police\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: TSICU CC564\n Transferred to: CC620\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Respiratory ", "chartdate": "2125-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 667890, "text": "Pt received orally intubated and vented on full ventilatory support. Pt\n weaned to PSV tolerated well. Lung sounds clear, no secretions. Pt then\n extubated, good cuff leak heard prior to extubation. Pt placed on cool\n aerosol via face tent with 35% FiO2, Spo2 100%.\n" }, { "category": "Physician ", "chartdate": "2125-05-19 00:00:00.000", "description": "Intensivist Note", "row_id": 668101, "text": "TSICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n stab wound\n PMHx:\n PMH: asthma\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:40 AM\n EXTUBATION - At 09:43 AM\n Post operative day:\n HD2\n 24hr events: admitted to TICU intubated, right chest tube in place\n admission Hct 40 after 1u transfused at OSH, received 1unit in the ED.\n Extubated in AM. Chest tube output declined. HCT stablbe. Pending tx\n to floor, but in evening developed SOB. CXR okay. Tx nebs.\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:40 AM\n Other medications:\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.9\nC (98.4\n HR: 79 (70 - 107) bpm\n BP: 141/74(88) {87/37(49) - 146/94(104)} mmHg\n RR: 23 (17 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,848 mL\n 360 mL\n PO:\n 480 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n Blood products:\n 375 mL\n Total out:\n 3,005 mL\n 180 mL\n Urine:\n 2,115 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,843 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 455 (455 - 455) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 4.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), right chest tube\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 39.3 %\n 12.2 K/uL\n [image002.jpg]\n 08:24 AM\n 12:40 PM\n 04:21 PM\n 09:00 PM\n 02:03 AM\n WBC\n 15.6\n 12.2\n Hct\n 40.0\n 38.8\n 39.9\n 38.3\n 39.3\n Plt\n 304\n 280\n Creatinine\n 1.0\n 0.9\n Troponin T\n <0.01\n Glucose\n 105\n 110\n Other labs: PT / PTT / INR:14.2/25.0/1.2, CK / CK-MB / Troponin\n T:679/5/<0.01, ALT / AST:21/26, Alk-Phos / T bili:66/1.2, Amylase /\n Lipase:47/13, Ca:9.0 mg/dL, Mg:2.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 23yoM with stab wound to the right chest\n Neurologic: dilaudid prn for pain\n Cardiovascular: stable\n Pulmonary: s/p stab wound to R chest. Cont R-chest tube. Output\n minimal. Albuterol nebs prn.\n Gastrointestinal / Abdomen: NPO, H2, serial exams, No evidence of solid\n visceral injury\n Nutrition: Regular diet\n Renal: no issues. foley likely to d/c\n Hematology: serial Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: 36fr CT, foley, PIV, ETT\n Wounds:\n Imaging:\n Fluids: LR at 100 cc/h\n Consults: Trauma\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Other: Chest Trauma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 06:20 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667984, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt admitted approx 630 to TSICU. Received on CMV, Propofol gtt. When\n lightened, following all commands, appropriate. R CT to wall sxn w/\n moderate serosang output. VSS. HCT 40.\n Action:\n Vent quickly weaned to PS 5/5\n Propofol weaned\n Extubated approx 0945\n HCT checks q4hrs\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt w/ c/o back pain\n (stab wounds), Dilaudid administered PRN. HCT remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667867, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable, monitor HR and BP\n PULM: wean to extubate today, hemothorax\n monitor CT output, make sure\n output decreasing before extubation\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n (serial HCT), belly exam benign currently\n RENAL: adequate UOP, f/u cr\n HEME: serial Hct Q4 hours for hemothorax,\n ENDO: RISS\n ID: monitor WBC and fver curve\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 33 min\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667852, "text": "Trauma, s/p\n Assessment:\n s/p assault from hospital, stab wounds to back and right side.\n Right hemopnumo, ? liver lac.\n Action:\n Admitted to T/SICU from ED at 0615. pt pan scanned in ED.\n Response:\n Pt intubated, on propofol, right CT to sx.\n Plan:\n CXR, serial crits, wean to extubate.\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668031, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n Extubated this am approx 0945\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n ?Daily chest xrays\n Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668038, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Events this shift\n Pt c/o sob/difficulty breathing at 2250. LS clear with dim bases bilat.\n O2 sat 98-100%. Pt placed on 2L NC for comfort. Stat chest xray\n obtained which looked unchanged. Pt kept in ICU overnight for further\n monitoring. Will reassess floor transfer in am.\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable.\n Tolerating regular diet, denies nausea.\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid \n Transfer to floor today\n Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1072414, "text": " 5:13 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: acute inj, right ct placement, hemothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj, right ct placement, hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound acute injury, right\n chest tube placement, and hemothorax.\n\n COMPARISON: None.\n\n SUPINE FRONTAL RADIOGRAPH OF THE CHEST: ET tube is terminating just above the\n carina, approximately 1.5 cm. NG tube is terminating just below the\n gastroesophageal junction. Lung volumes are low causing bronchovascular\n crowding. There is a relative ground-glass appearance of the right lung which\n could be due to posteriorly layering right pleural effusion in the setting of\n trauma, suspicious for a hemothorax. Chest tube is noted projected over the\n right lower lung. There is a trace right medial basal pneumothorax. There are\n no displaced rib fractures. Aortic contour is well defined. Heart size is\n normal. There is no pulmonary edema. Subtle soft tissue emphysema is noted\n in the right lateral chest wall.\n\n IMPRESSION:\n 1. Low positioned ET tube terminating just above the carina.\n 2. Ground- glass appearance of the right lung could reflect a posteriorly\n layering effusion in the setting of trauma or hemothorax.\n 3. Right lateral chest wall emphysema.\n 4. Trace right medial pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072423, "text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u hemothorax, chest tube position\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with stab wounds, s/p chest tube\n REASON FOR THIS EXAMINATION:\n f/u hemothorax, chest tube position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n Comparison study of earlier the same date.\n\n INDICATION: Hemothorax.\n\n Side port of right chest tube is external to the pleural space, but there is\n no evidence of pneumothorax. Interval improvement in diffuse opacities in the\n right hemithorax, likely a combination of improving pleural effusion,\n atelectasis and contusion. Endotracheal tube tip terminates 3 cm above the\n carina, and a nasogastric tube terminates at the thoracoabdominal junction\n with side port well above the GE junction level, as communicated to Dr.\n on . Otherwise no relevant changes since the recent\n radiograph except for the presence of contrast within the renal collecting\n systems, likely related to recent CT examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072866, "text": " 10:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: inc in ptx\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax s/p Ct removal\n REASON FOR THIS EXAMINATION:\n inc in ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:40 P.M. \n\n HISTORY: Hemothorax. Chest tube removed.\n\n IMPRESSION: AP chest centered at the diaphragm compared to earlier on :\n\n Very small right apical pleural air collection has increased slightly (see the\n lateral costal component). Since removal of the right pleural tube there has\n been no increase in right pleural effusion loculated posteriorly. Moderate\n cardiac enlargement stable. Left lung grossly clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 1072421, "text": " 6:02 AM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: acute inj\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound evaluate for acute\n injury.\n\n COMPARISON: None.\n\n LEFT LEG, THREE VIEWS: There are no acute fractures or alignment\n abnormalities. The mineralization is normal and there are no focal lytic or\n sclerotic osseous lesions. Incidental note of fabella is made. Soft tissues\n are unremarkable.\n\n IMPRESSION: Normal radiographic appearance of the left knee.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072814, "text": " 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right hemothorax with a right chest tube\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 12:28 PM\n There is worsened right lower lobe atelectasis. Persistent low lung volumes.\n There is a small right pneumothorax. Right pleural effusion is mainly located\n posteriorly.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: SP right hemothorax drainage and right chest tube.\n\n Small right pneumothorax has increased from yesterday. There has been\n increase in right lower lobe atelectasis. There are persistent low lung\n volumes. Right chest tube is in place. The side hole is outside the pleural\n cavity. There is mild fluid overload. Cardiac size is accentuated by the low\n lung volumes.\n\n Findings were discussed with Dr. at the time of dictation.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072815, "text": ", E. CC6A 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right hemothorax with a right chest tube\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n There is worsened right lower lobe atelectasis. Persistent low lung volumes.\n There is a small right pneumothorax. Right pleural effusion is mainly located\n posteriorly.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072856, "text": " 7:07 PM\n CHEST (PA & LAT) Clip # \n Reason: Change in ptx - pt now on suction.\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax/ ptx\n REASON FOR THIS EXAMINATION:\n Change in ptx - pt now on suction.\n ______________________________________________________________________________\n WET READ: JRCi SUN 8:05 PM\n Small right apical pneumothorax is now trace after patient is on suction.\n Sideport of chest tube remains overlying the chest wall. No subcutaneous\n emphysema detected. Right lung atelectasis and contusion remain.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n HISTORY: Hemopneumothorax and change in chest drainage.\n\n IMPRESSION: PA and lateral chest compared to earlier on :\n\n A tiny right apical pleural air collection and right pleural tube unchanged in\n position may be fissural, with a side port in the right axillary subcutaneous\n tissue. Mild enlargement of the cardiac silhouette exaggerated by low lung\n volumes is stable. Left lung grossly clear. No left pleural abnormality.\n Mild thoracic scoliosis and thickened left paraspinal soft tissue, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072625, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change - PTX w/ CT\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing\n REASON FOR THIS EXAMINATION:\n Interval change - PTX w/ CT\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:46 A.M. ON \n\n HISTORY: 23-year-old man stabbed.\n\n IMPRESSION: AP chest compared to :\n\n Persistent small right pleural effusion and right basal atelectasis, right\n pleural tube still in place, side port extrathoracic. Mild-to-moderate\n enlargement of the cardiac silhouette is exaggerated by low lung volumes but\n stable since the earliest post-traumatic film on . Left lung is\n grossly clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072878, "text": " 4:12 AM\n CHEST (PA & LAT) Clip # \n Reason: change in ptx\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with PTX? hemothorax s/p stabbing\n REASON FOR THIS EXAMINATION:\n change in ptx please perform at 4 am\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Assess pneumothorax.\n\n IMPRESSION: Small right pneumothorax increased between 7:10 p.m. and 10:40\n p.m. on following removal of the right pleural tube and has increased\n minimally subsequent to that. Atelectasis in the right lower lung has\n progressed. Today's lateral chest film raised the possibility of posterior\n pleural collection on the right residing in the major fissure rather than\n along the chest wall, but it is stable. Left lung is clear. Moderate cardiac\n enlargement has not changed.\n\n Dr. paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1072415, "text": " 5:18 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 6:04 AM\n no evidene of traumatic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with stab wounds, evaluate for acute injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT-acquired contiguous axial sizes were obtained through\n the brain. Reconstructions in 2.5 mm thin slices in bone algorithm were made.\n Multiplanar reformations were also generated.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, masses, mass effect,\n or shift of normally midline structures. There is no acute major vascular\n territorial infarcts. -white matter differentiation is well preserved.\n Ventricles and sulci are normal in size and configuration. There are no\n displaced skull fractures. Soft tissues are unremarkable.\n\n Please note there is residual contrast in the venous sinuses from outside\n hospital CT torso, which was done with IV contrast.\n\n IMPRESSION: No acute intracranial process. Evaluation of bleed is somewhat\n limited due to residual contrast in the venous sinuses from outside hospital\n performed CT torso.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072416, "text": " 5:20 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P STAB WOUND. ? ACUTE INJURY.\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 6:13 AM\n Right Lower lobe contusion or hematoma. Right hemothorax, much smaller than\n prior outside hospital study. heart and great vessels are intact.\n\n no pneumothorax. No evidence of tramatic inury to abdomen and pelvis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound. Evaluate acute\n injury.\n\n COMPARISON: Outside hospital study from at 2:30 a.m.\n\n TECHNIQUE: Helical CT-acquired contiguous axial slices were obtained from the\n top of the lungs to the pubic symphysis after administration of intravenous\n contrast. Oral contrast was not administered. Multiplanar reformats were\n generated.\n\n Images are slightly degraded by arm position by the sides, resulting in streak\n artifact.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The right lateral chest tube with\n tip terminating in the medial pleural surface, abutting the right\n heart/pericardial margin. There is emphysema in the right lateral\n subcutaneous soft tissues. There is intermediate density right pleural\n effusion which could reflect a hemothorax. There is also a right lower lobe\n opacity which could reflect atelectasis or in the setting of trauma, pulmonary\n contusion (not well differentiated on this study). Minimal atelectasis in the\n left lung base is noted. There is no left pleural effusion. There is no\n pneumothorax. Heart and great vessels are intact. There is no evidence of\n mediastinal hemorrhage. NG tube is extending into the stomach. ET tube is\n terminating above the carina, 2.2 cm.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n stomach, pancreas, adrenals, kidneys, and abdominal bowel loops are normal in\n appearance. There is a high-attenuation focus in the posterolateral aspect of\n the spleen which in correlation with the sagittal and coronal images appears\n to be artifactual and due to streak. Outside hospital images also were\n unremarkable for the spleen. The NG tube is in good location. There is no\n evidence of solid organ injury. There is no intraperitoneal free fluid or\n free air. There is no mesenteric or retroperitoneal adenopathy. There is no\n evidence of vascular injury.\n (Over)\n\n 5:20 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P STAB WOUND. ? ACUTE INJURY.\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, pelvic\n bowel loops, prostate, seminal vesicles, and urinary bladder are all\n unremarkable.\n\n OSSEOUS STRUCTURES: There are no focal lytic or sclerotic osseous lesions.\n There is no evidence of fractures.\n\n SOFT TISSUE STRUCTURES: Very small amount of emphysema is noted in bilateral\n posterior wall, right more than left, paraspinal in distribution on the left\n and posterolateral chest wall in distribution on the right.\n\n IMPRESSION:\n\n Right pleural effusion and right lower lobe opacity could reflect\n atelectasis/collapse, and in the setting of trauma other consideration include\n contusion. The right chest tube is at the medial pleural reflection abutting\n the right heart margin with no fluid in that location\n\n No evidence of solid visceral injury in the abdomen or pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072591, "text": " 8:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for R sided hemothorax, kinked chest tube.\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with multiple stab to back, with R chest tube.\n REASON FOR THIS EXAMINATION:\n eval for R sided hemothorax, kinked chest tube.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:06 A.M., \n\n HISTORY: Multiple stab wounds. Right chest tube.\n\n IMPRESSION: AP chest compared to 7:16 a.m. on .\n\n There is no appreciable right pneumothorax. Hazy opacification over the right\n lung base probably represents some posteriorly layering right pleural\n effusion. Bibasilar atelectasis is more pronounced now than earlier today\n following extubation. Air in the mediastinum to the left of the trachea could\n be within the esophagus but should be followed to exclude pneumomediastinum.\n Mild-to-moderate enlargement of the cardiac silhouette is exaggerated by low\n lung volumes, comparable to the earlier post-traumatic film at 7:16 a.m.\n Right pleural tube unchanged in position, crossing the right mid and lower\n chest with at least one side port in the soft tissues of the chest wall.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073978, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval chest tubes\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p R VATS\n REASON FOR THIS EXAMINATION:\n Eval chest tubes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 1:05 PM\n Small right pneumothorax is unchanged. Right apical and right base chest tube\n remain in place.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: SP right VATS. Follow up right pneumothorax.\n\n Comparison is made with prior study performed 7 hours earlier. A small right\n pneumothorax is unchanged. Right apical and right basal chest tubes are in\n place. Minimally improved aeration in the right base. No other interval\n change.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073897, "text": " 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX?\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS\n REASON FOR THIS EXAMINATION:\n PTX?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 10:16 AM\n There is small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Persistent low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess pneumothorax S/P right VATS.\n\n Comparison is made with prior study .\n\n There is a small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Left lower lobe atelectasis is\n unchanged. There are low lung volumes. Cardiomediastinal silhouette is\n unchanged with cardiac size top normal.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073898, "text": ", E. CC6A 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX?\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS\n REASON FOR THIS EXAMINATION:\n PTX?\n ______________________________________________________________________________\n PFI REPORT\n There is small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Persistent low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072958, "text": " 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M stabbed 4x, initially placed chest tube, pulled out yesterday, now with\n worsening infiltrate vs effusion\n REASON FOR THIS EXAMINATION:\n assess infiltrate vs effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 8:00 PM\n All tubes and catheters were removed. Heterogeneous right pleural effusion\n increased, consistent with enlarging hemothorax. Small pneumothorax is new.\n Right lower lobe opacity increased, likely atelectasis but underlying\n contusion cannot be ruled out. Lung contusion along the previous chest tube\n course. Right upper lobe anterior opacity, unchanged, likely contusion.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITH CONTRAST\n\n REASON FOR EXAM: 23-year-old stabbed x4. Initially placed chest tube pulled\n out yesterday. Now with worsening infiltrate versus effusion. Please assess.\n\n TECHNIQUE: Chest MDCT was performed following 75 cc of intravenous Optiray\n using 5 mm and 1.25 mm axial slice thickness. Coronal and sagittal\n reformations were also obtained.\n\n FINDINGS: Since , right heterogeneous pleural effusion\n increased, consistent with enlarging hemothorax post-removal of the chest\n tube. A right pneumothorax is also new, with associated air-fluid levels.\n Subcutaneous emphysema at the entrance of the old chest tube persists.\n\n Lung opacities along the previous chest tube course could be related to\n contusion. Right upper lobe anterior opacities could also be contusions,\n unchanged since the prior study. Left basilar atelectasis increased, still\n small. Minimal left pleural effusion is new. All tubes and catheters were\n removed. Airways are patent to the subsegmental levels. There is no lymph\n node enlargement using CT criteria.\n\n This study was not tailored for subdiaphragmatic evaluation except to note\n heterogeneous attenuation of the liver, likely due to perfusion abnormality.\n There is no bone lesion suspicious for malignancy and no bone fracture.\n\n IMPRESSION:\n 1. Enlarging heterogeneous right pleural effusion, now moderate, consistent\n with progressing hemothorax. New small right pneumothorax, with air-fluid\n levels, likely due to recent removal of the chest tube.\n\n 2. Bibasilar atelectasis, mostly on the right, associated with\n parenchymal opacities, likely contusions, in the anterior segment of the right\n (Over)\n\n 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n upper lobe and along the prior chest tube course.\n\n 3. New tiny left pleural effusion.\n\n 4. Heterogeneous attenuation of the liver, likely due to perfusion\n abnormality; this could be evaluated by dedicated liver study if of clinical\n concern (e.g. if suspected hepatic injury).\n\n Results were discussed on the phone with Tevia at 1:40 p.m.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073608, "text": " 12:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for lung expansion\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax S/P thoracentesis\n REASON FOR THIS EXAMINATION:\n Evaluate for lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis, to evaluate for lung expansion.\n\n FINDINGS: In comparison with earlier study of this date, there is slightly\n less opacification of the right costophrenic angle. The chest tube remains in\n place with the possibly abnormally positioned tip. Basilar atelectatic\n changes are seen.\n\n IMPRESSION: No change in the degree of pneumothorax on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073008, "text": " 4:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TO CONFIRM PLACEMENT OF CHEST TUBE RIGHT SIDE\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with stab wound\n REASON FOR THIS EXAMINATION:\n to confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with stab wound.\n\n Portable AP chest radiograph was reviewed in comparison to \n study obtained at 04:12 a.m.\n\n The current study demonstrates recently inserted chest tube. There is\n significant decrease in the amount of pleural effusion compared to the prior\n studies. The pneumothorax seen on the prior chest CT is not well appreciated\n on the current study, although subcutaneous air collection is seen along the\n lower right chest wall. Note is made that the apices were not included in the\n field of view. Right retrocardiac consolidation and left retrocardiac\n opacities are consistent with atelectasis, although some degree of aspiration\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072959, "text": ", E. CC6A 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M stabbed 4x, initially placed chest tube, pulled out yesterday, now with\n worsening infiltrate vs effusion\n REASON FOR THIS EXAMINATION:\n assess infiltrate vs effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n All tubes and catheters were removed. Heterogeneous right pleural effusion\n increased, consistent with enlarging hemothorax. Small pneumothorax is new.\n Right lower lobe opacity increased, likely atelectasis but underlying\n contusion cannot be ruled out. Lung contusion along the previous chest tube\n course. Right upper lobe anterior opacity, unchanged, likely contusion.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073210, "text": " 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: assess PTX, fluid collection on right\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax; CT in place\n REASON FOR THIS EXAMINATION:\n assess PTX, fluid collection on right\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 6:08 PM\n PFI: No pneumothorax. No change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n REASON FOR EXAM: 23-year-old man with pneumothorax, chest tube in place,\n assess pneumothorax and fluid collection.\n\n Since yesterday, a right chest tube is in unchanged position. Right pleural\n effusion and right lower lobe consolidation are stable. There is no\n pneumothorax. Left basilar atelectasis is unchanged. There is no other\n change.\n\n Overall, there is no significant change since yesterday.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073211, "text": ", E. CC6A 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: assess PTX, fluid collection on right\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax; CT in place\n REASON FOR THIS EXAMINATION:\n assess PTX, fluid collection on right\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax. No change.\n\n" }, { "category": "ECG", "chartdate": "2125-05-18 00:00:00.000", "description": "Report", "row_id": 242700, "text": "Sinus rhythm. Non-diagnostic inferior Q wave pattern, may be a normal variant\nbut cannot exclude prior inferior myocardial infarction. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1073394, "text": " 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing w/ chest tube placement, concerning for loculation\n of fluid\n REASON FOR THIS EXAMINATION:\n eval for effusion, empyema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRGe WED 3:27 PM\n PFI:\n 1. Effusion consistent with hemothorax. Small right pneumothorax is also\n unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post stabbing with chest tube placement, concerning for\n loculation of fluid.\n\n COMPARISON: Multiple studies, the most recent chest CT dated .\n\n TECHNIQUE: MDCT axial images through the chest with IV contrast. Multiplanar\n and lung reformats were displayed.\n\n CT OF THE CHEST WITH IV CONTRAST: There is a right-sided chest tube which is\n kinked and abutting the right atrium of the heart. Previously described\n heterogeneous hyperdense fluid collection in the right hemithorax is unchanged\n in size and consistent with hemoperitoneum. There is no evidence of loculated\n pleural fluid. Associated compressive atelectasis on the right side are noted.\n There is a small right pneumothorax. No enhancement of the pleura is noted.\n Dependent atelectasis on the left side. No evidence of pleural effusion on\n the left. The heart is at the upper limits of normal. There is no\n pericardial effusion. There is no mediastinal, hilar, or axillary\n lymphadenopathy.\n\n This study is not designed for infradiaphragmatic evaluation; however, the\n imaged portions of the upper abdomen are within normal limits.\n\n BONE WINDOWS: No suspicious lesions are identified.\n\n IMPRESSION:\n 1. Unchanged right hyoerdense pleural effusion consistent with hemothorax. No\n evidence of loculation. Small right pneumothorax is also unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n\n (Over)\n\n 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The findings were discussed with Dr. at the time of the dictation.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1073395, "text": ", E. CC6A 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing w/ chest tube placement, concerning for loculation\n of fluid\n REASON FOR THIS EXAMINATION:\n eval for effusion, empyema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Effusion consistent with hemothorax. Small right pneumothorax is also\n unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074128, "text": " 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS washout, now s/p CT removal\n REASON FOR THIS EXAMINATION:\n please evaluate for PTX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 12:52 PM\n There is a small right apical pneumothorax. Small-to-moderate pleural\n effusion is increased.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n There is a tiny right apical pneumothorax. Right basal chest tube remains in\n place. There is mild increase in small-to-moderate loculated right pleural\n effusion. Persistent low lung volumes. Cardiomediastinal contours are\n unchanged. Opacities in the right lung greater in the lower lobe are\n unchanged from prior.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074247, "text": " 11:42 AM\n CHEST (PA & LAT) Clip # \n Reason: ? interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p L VATS evacuation of hemothorax\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left VATS, evacuation of hemothorax.\n\n FINDINGS: In comparison with the study of , there is little change. Tiny\n right apical pneumothorax persists with the right chest tube removed. Some\n loculated right pleural effusion is again seen. The appearance of the heart\n and lungs is essentially clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074129, "text": ", P. FA9A 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS washout, now s/p CT removal\n REASON FOR THIS EXAMINATION:\n please evaluate for PTX\n ______________________________________________________________________________\n PFI REPORT\n There is a small right apical pneumothorax. Small-to-moderate pleural\n effusion is increased.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073027, "text": " 6:01 PM\n CHEST (PA & LAT) Clip # \n Reason: Status post Chest tube. XRAY not of great quality. Chest t\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p chest tube.\n REASON FOR THIS EXAMINATION:\n Status post Chest tube. XRAY not of great quality. Chest tube looks kinked.\n Please do PA and Lateral to assess placement of tube\n ______________________________________________________________________________\n WET READ: PXDb MON 7:37 PM\n Apparant kink near the tip, is not noted on lateral view and could reflect\n posterior turn. Increased RLL opacity, could reflect worsening atelectasis.\n ( )\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after insertion of the\n chest tube.\n\n PA and lateral upright chest radiograph was compared to several prior studies\n obtained between and .\n\n There is again worsening of the right lower lung consolidation with potential\n interval increase of pleural effusion. This also might represent recurrent\n aspiration or interval development of infection. There is no pneumothorax.\n The left basal opacity is minimal and consistent with atelectasis. There is\n no appreciable pneumothorax demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073655, "text": " 4:39 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p CT removal on right side please do BEFORE 5:30 pm\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n s/p CT removal on right side please do BEFORE 5:30 pm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, the right chest\n tube has been removed. There has been some increase in the degree of right\n pneumothorax since the previous study. Otherwise, little change except for a\n somewhat better inspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073580, "text": " 10:08 AM\n CHEST (PA & LAT) Clip # \n Reason: assess hemothorax, interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old mans/p stabbing to back; now with CT in place\n REASON FOR THIS EXAMINATION:\n assess hemothorax, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old man, status post stabbin at the back, now with chest\n tube in place. Assess for hemothorax and interval change.\n\n COMPARISON: Chest radiograph on and chest CT on .\n\n PA AND LATERAL CHEST RADIOGRAPHS: A chest tube with right lateral approach is\n seen with the tip kinked and abutting the right atrium. The cardiac\n silhouette is top normal. Mediastinal, hilar contours and pulmonary\n vasculature are normal.\n\n In the right hemithorax, there is interval increase of apical pneumothorax,\n particularly compared to the prior chest radiograph two days ago, but only\n minimally increased compared to the CT yesterday. Increased opacity in the\n right basilar region is also noted, concordant with the CT finding of\n increased pleural effusion. There are persistent small linear opacities in the\n right mid lung consistent with atelectasis.\n\n In the left hemithorax there is minimal blunting at the left costophrenic\n angle, but no evidence of large pleural effusion. There is no left-sided\n pneumothorax. Linear basilar atelectasis persists, but the left lungs are\n otherwise clear.\n\n IMPRESSION:\n\n 1. Small interval increase of the right apical pneumothorax, but the\n pneumothorax remains small.\n 2. Unchanged kink at the tip of the chest tube, abutting the right atrium.\n Repositioning is again recommended.\n 3. Persistent bibasilar atelectasis, with interval increase of right-sided\n pleural effusion since .\n\n Dr. has discussed the findings with primary team, Dr. at\n 11:00 a.m. on the date of this study.\n\n jr\n\n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073979, "text": ", P. FA9A 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval chest tubes\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p R VATS\n REASON FOR THIS EXAMINATION:\n Eval chest tubes\n ______________________________________________________________________________\n PFI REPORT\n Small right pneumothorax is unchanged. Right apical and right base chest tube\n remain in place.\n\n\n" } ]
7,275	199,103	After being treated in the Medical Intensive Care Unit with Dilantin and Ativan for seizures, he was transferred to the neurology floor for further management. He was continued on Dilantin 100 mg three times a day. His levels were therapeutic. His Ativan was tapered to off. He had another routine electroencephalogram the day before discharge which did not demonstrate any epileptiform activity. He continued to receive dialysis for end stage renal disease and also Levaquin for a ten day course of five total doses. The patient was discharged home on .	PNA, he was started on reanal dose levaquin..GI- +bs, abd soft, nontender, no bm. He was brought to the ED where he was febrile, confused and his sbp was 200- 210, he was given labetolol, later in the day he had HD, and was then sent to EEG, it showed non-convulsive status epilepticus and he was given ativan iv and the event resolves itself. also started on ativan 2mg iv q6h.Cv- Hr 70s sr, no ectopy, bp stable, 128/54 - 135/72, denies cp or sob. Peripheral hl x2 intact and patent.Resp- Bil ls cta, sats 94 - 97%, rr low 20s, his cxr showed bibasal patchy infiltrate-? Kept npo x meds overnight. Pt had HD earlier, No urine overnight.Skin - warm, dry and intact.ID- adm temp 99.8, wbc 8.2, cxr,?pna, no cough, LP done in ed gram stain neg, cxs pending, continues on po levoquin. Left ventricular hypertrophy with ST-T wave changes. He was loaded with dilantin 600mg iv as dilantin level was only 4.9, stiil a ? Poor R wave progression - question due to left ventricularhypertrophy. head ct neg, LP cx pending. Left axis deviation - possible left anteriorfascicular block. He had HD yesterday, ? Tmax 99.9, all reflexes intact, MAE, no edema, good pulses. how many liters were taken off. The plan is to follow is dialantin level, make him therapeutic, maintain safety, treat his pNA, follow up on LP cx. He was transferred to micu overnight for poss ativan drip and closer monitoring.Review of system- Pt alert, pleasantly confuse, answer inquires with ease but without warning start removing clothes, monitor wires and heplock, several times he put siderails down by himself and tried to climb out of bed. Pt is a full code, he his on waiting list for a kidney. Compared tothe previous tracing of T wave changes have improved in lead aVL. Admission Note:53yr old with hx of tonic- clonic sz under controll x5 yrs, on dilantin at home, on he was reportedly wandering around in a theatre and then he called is family to say his wallet was missing, his responses were slow if any at all, he was also noted to have facial grimaces and squinting of the eyes, hx includes esrd(2 failed renal transplant) on HD 3x/wk, htn and hep c (please see h/p for more hx). Sinus rhythm. Long QTc interval. as to why his levels were that low.	2	[ { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1359589, "text": "Admission Note:\n53yr old with hx of tonic- clonic sz under controll x5 yrs, on dilantin at home, on he was reportedly wandering around in a theatre and then he called is family to say his wallet was missing, his responses were slow if any at all, he was also noted to have facial grimaces and squinting of the eyes, hx includes esrd(2 failed renal transplant) on HD 3x/wk, htn and hep c (please see h/p for more hx). He was brought to the ED where he was febrile, confused and his sbp was 200- 210, he was given labetolol, later in the day he had HD, and was then sent to EEG, it showed non-convulsive status epilepticus and he was given ativan iv and the event resolves itself. He was transferred to micu overnight for poss ativan drip and closer monitoring.\n\nReview of system- Pt alert, pleasantly confuse, answer inquires with ease but without warning start removing clothes, monitor wires and heplock, several times he put siderails down by himself and tried to climb out of bed. Tmax 99.9, all reflexes intact, MAE, no edema, good pulses. head ct neg, LP cx pending. He was loaded with dilantin 600mg iv as dilantin level was only 4.9, stiil a ? as to why his levels were that low. also started on ativan 2mg iv q6h.\n\nCv- Hr 70s sr, no ectopy, bp stable, 128/54 - 135/72, denies cp or sob. He had HD yesterday, ? how many liters were taken off. Peripheral hl x2 intact and patent.\n\nResp- Bil ls cta, sats 94 - 97%, rr low 20s, his cxr showed bibasal patchy infiltrate-? PNA, he was started on reanal dose levaquin..\n\nGI- +bs, abd soft, nontender, no bm. Kept npo x meds overnight.\n\n Pt had HD earlier, No urine overnight.\n\nSkin - warm, dry and intact.\n\nID- adm temp 99.8, wbc 8.2, cxr,?pna, no cough, LP done in ed gram stain neg, cxs pending, continues on po levoquin.\n\n Pt lives with brother (), he has 2 children and an ex-wife.\n\n Pt is a full code, he his on waiting list for a kidney. The plan is to follow is dialantin level, make him therapeutic, maintain safety, treat his pNA, follow up on LP cx.\n\n" }, { "category": "ECG", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 246806, "text": "Sinus rhythm. Long QTc interval. Left axis deviation - possible left anterior\nfascicular block. Poor R wave progression - question due to left ventricular\nhypertrophy. Left ventricular hypertrophy with ST-T wave changes. Compared to\nthe previous tracing of T wave changes have improved in lead aVL.\n\n\n" } ]
28,394	186,832	# Hematemesis Admitted with etoh cirrhosis complicated by hx of varices with hematemesis. S/p EGD where no active variceal bleeding was noted. Thought due to coagulopathy and gingival bleeding. Patient had EGD here showing grade 3 varices with evidence of recent bleed. 6 bands placed. No bleeding while in house and was discharged from the MICU in stable condition, with stable Hcts and off Octreotide gtt. Patient was tolerating a soft foods diet. He will continue on Cipro 500 mg for a total of 7 days and a ppi PO BID. . # Decompensated alcoholic cirrhosis Due to long-standing etoh. Complicated by portal hypertension, varices (grade III), splenomegaly and consumptive thrombocytopenia. No hx of prior liver biopsy. Current MELD score 20. No evidence of SBP on admission and patient did not receive a paracentesis. RUQ with patent portal flow and moderate ascites. Splenomegaly noted. Patient was continued on lactulose and nadolol. Autoimmune serologies were drawn and pending at the time of discharge. No evidence of alcohol withdrawal. . # Macrocytic Anemia Likely marrow toxicity from long standing etoh. B12/folate nml at OSH. Hct stable from OSH - no prior baseline. He may need outpatient Heme consult if counts do not respond within months of abstinence. . # Pancytopenia: Likely in part due to EtOH-induced marrow suppression, hypersplenism +/- other etiologies. Apparently B12 and folate normal at OSH. Patient did not require blood or platelet transfusion. ANC was 1590 on admission and it is thought that his counts will improve in the absence of EtOH. .	1 PIV dc'd, outof vein after bleeing from site intermittently.GI: tolerating soft solid, bowel sounds present, continues on lactulose. rr normalGI/GU: abd slightly distended-+ BS. Skin WDI.Resp: 95-97% on RA; LS diminished initially; increased aeration and clear after turning/positioning.GI: Abd softly distended, +BS, No BM. US of abdomen organs and blood vessels done, no bleeding or occlusion noted per preliminary read, official result not in yet.GU: -800cc since MN and - 1.6 L for LOS, urine culture atill pending.ID: continues on cirpofloxacin q24hrs, afebrile. 4) Coarse liver echogenicity consistent with history of cirrhosis. Lethargic post procedure. voided small amt of 20cc initially after removal.ID: afebrile. Able to move extremities, written for ativan PRN for CIWA scale > 10, scale had been .CV: hemodynamically stable, SR without ectopy. The liver is somewhat coarsened consistent with the history of cirrhosis. LIVER DOPPLER: GREY SCALE ULTRASOUND: There is a moderate amount of perihepatic ascites. C/O slight pain to right lower quadrant intially after egdCV: NSR with hr 60's, NBP 110-120's with maps >60. transferred to BIDNMC fro further treatment.in MICU, no further bleeding, hct stable. MICU 7: RN Note 1900-0700Events: Admitted to Hospital w/Hematemesis; EGD showed inactive varices. Nursing Progress Note 1900-0700 hours: Full code allergies: nkda** access: 2 piv'sIn brief: pt is a 43 yo M, pmh: mild portal htn, esoph varices, etoh withdrawal, s/p banding x 4 .Presented to OSH with hematemesis x 1 day, hct 32, placed on octreotide and ppi, NGL neg. #18 RUE (KVO and Octretide infusing); #16 LUE (KVO) w/very good blood return (first chem hemolyzed-re-sent K). PIVs wnl.Respi: sats > 95% at room air, lung sounds clear.GI: remains NPO for endoscopy with possible variceal banding this evening. Placed on Octerotide drip. Sm umb hernia. Bowel sound present, no BM this shift.Continues on lactulose TID for increased ammonia level ( titrate for 3 BM / day ). Tcx'd to for work-up.In MICU-no further bleeding noted. (Over) 9:41 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: eval liver with DOPPLERs. Started on clears last night-tol well with moderate amt PO intake. 9:41 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: eval liver with DOPPLERs. In brief: 43 year old with PMH : mild portal htn, esphageal varices, etoh withdrawal, s/p banding x 4 last presented OSH with hematemesis x 1 day, hct 32, on octreotide and ppi, ng lavage and EGD neg for bleeding, thought ti be bleeding from gums. Octreotide dc'd 1600GU: voiding adequately, 1 1L for LOS.ID: continues on ciprofloxacin x 3 daysSkin: intactSocial: patient's brother update with plan of care. Hepatology following, recs to increase cipro to x 7 days for varices infection.Heme: hct monitor , remains stable.Skin: intactSocial: patient has been made aware of the importance of stopping ETOH intake and have agreed upon. EGD with no active bleed found-6 varices banded. Has been on octreotide gtt.NEURO: A & O x3. EGD with no active bleeding, 6 varices banded.neuro: dosing intermittently most of the day, denies pain. Underwent EGD with varices and found to have no active bleeding and thought to be from bleeding gums. Sent for Urinalysis and C&S.Endo: FS 113 and 99.Social: Lives w/roommate. addendum: EGD done 1830, no active bleeding seen. Admission hct is 32 at OSH, s/p NG lavage which was negative, EGD revealed no active bleeding but + for esophageal varices. patient says he is sleepy due to waking up early.respi: sats> 95% at room air, lung sounds clear, dim at bases.CV: hemodynamically stable, SR without ectopy. 5) Moderate ascites. monitor s/s of withdrawal. eval portal flow, r/o liver masse Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED FINAL REPORT (Cont) hct stable. hct stable. Banding of 6 esophageal varices done. Evaluate portal flow, rule out liver lesions. Gastric lavage neg. Main hepatic artery is patent. started on nodalol. TIPS REASON FOR THIS EXAMINATION: eval liver with DOPPLERs. 6) Splenomegaly. On cipro x 7 days for gi prophylaxis with scope.SKIN: no breakdown.SOCIAL: brother called on evenings-plans to visit today.PLAN: -monitor for S & S of bleed, hcts -advance diet as ordered/tol -contm ed regimen and icu plan of care -octreotide gtt -liver recommendations -assess void s/p foley removal -assess S & S of w/drawal Hct decr from 32 on arrival to 29 this morning. Goal tx keep >25.RESP: lungs clear. No bloody stools; no hematemesis.Neuro: AAO x3 but slow to respond. transferred to for further intervention, possible variceal banding and TIPS procedure.NKDAFull codeNeuro: alert and oriented x 3, denies any pain. octreotide gtt. Evaluate liver with Doppler. Hx Etoh (recent stay at detox facility-last drink was Sunday), UGIB, Banding x4 in . Rec'd on 2l nc from egd-placed on RA with sats 94-98%. Transferred to ; arrived ~. on supplemental O2 2 lpm, sats > 95%. Protonix adm. Pt requesting water. advance diet as needed. Cont ppi. Rec'd 6 pack plts. 3) No focal liver lesions. In brief: 43 year old male with histiry of ETOH cirrhosis, portal hypertension, and prior GI bleeding due to esophgeal varices transfered from OSH with hematemesis. OOB early this am, steady gait. Ammonia 144. Knows that it is detrimetal to his health. UOP varied between 30-120/hr after initial output. Enlarged spleen. Brother is primary contact (: number on board).Plan: NPO for Liver/Gall Bladder USN at 0930; TIPS procedure.	7	[ { "category": "Radiology", "chartdate": "2170-10-31 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 984657, "text": " 9:41 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval liver with DOPPLERs. eval portal flow, r/o liver masse\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with etoh cirrhosis, transferred here for ? TIPS\n REASON FOR THIS EXAMINATION:\n eval liver with DOPPLERs. eval portal flow, r/o liver masses\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with known cirrhosis, for possible TIPS. Evaluate\n liver with Doppler. Evaluate portal flow, rule out liver lesions.\n\n COMPARISONS: None.\n\n LIVER DOPPLER:\n\n GREY SCALE ULTRASOUND: There is a moderate amount of perihepatic ascites. The\n liver is somewhat coarsened consistent with the history of cirrhosis. No\n focal liver lesions are identified. There is no intra or extrahepatic biliary\n dilatation. The CBD measures 7 mm. There is equivocal gallbladder wall\n thickening, however, this could be due to third spacing. No cholelithiasis or\n sludge is seen. The right kidney measures 12.1 cm in length. The left kidney\n measures 11.2 cm in length. The spleen is enlarged measuring 15.0 cm in\n greatest diameter and appears bulky.\n\n LIVER DOPPLER ULTRASOUND: The evaluation is limited due to the patient's\n inability to hold his breath. Patency of the main portal vein, anterior\n branch of the right portal vein and left portal vein as well as hepatic veins\n are demonstrated. Evaluation of the posterior branch of the right right\n portal vein and the left portal vein is limited due to patient inability to\n hold his breath. Main hepatic artery is patent.\n\n IMPRESSION:\n 1) Technically limited Doppler study due to inability of the patient to hold\n his breath.\n\n 2) Within these limitations, No definite evidence for intraluminal thrombus,\n however nonocclusive thrombus cannot be excluded.\n\n 3) No focal liver lesions.\n\n 4) Coarse liver echogenicity consistent with history of cirrhosis.\n\n 5) Moderate ascites.\n\n 6) Splenomegaly.\n\n\n\n (Over)\n\n 9:41 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval liver with DOPPLERs. eval portal flow, r/o liver masse\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2170-11-01 00:00:00.000", "description": "Report", "row_id": 1632728, "text": "Uneventful day for Mr. \n\nIn brief: 43 year old with PMH : mild portal htn, esphageal varices, etoh withdrawal, s/p banding x 4 last \n\npresented OSH with hematemesis x 1 day, hct 32, on octreotide and ppi, ng lavage and EGD neg for bleeding, thought ti be bleeding from gums. received 6 units of platelets. transferred to BIDNMC fro further treatment.\n\nin MICU, no further bleeding, hct stable. EGD with no active bleeding, 6 varices banded.\n\nneuro: dosing intermittently most of the day, denies pain. OOB early this am, steady gait. patient says he is sleepy due to waking up early.\n\nrespi: sats> 95% at room air, lung sounds clear, dim at bases.\n\nCV: hemodynamically stable, SR without ectopy. started on nodalol. 1 PIV dc'd, outof vein after bleeing from site intermittently.\n\nGI: tolerating soft solid, bowel sounds present, continues on lactulose. no Bm this shift. Octreotide dc'd 1600\n\nGU: voiding adequately, 1 1L for LOS.\n\nID: continues on ciprofloxacin x 3 days\n\nSkin: intact\n\nSocial: patient's brother update with plan of care. waiting for bed, called out to floor.\n\nplan: transfer once with available bed, monitor s/s of bleed, hct. advance diet as needed. monitor s/s of withdrawal.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632726, "text": "addendum: EGD done 1830, no active bleeding seen. Banding of 6 esophageal varices done. patient given 2 mgs of IV midazolam and 100mcg of fentanyl IV push. Hemodynamically stable the whole procedure. on supplemental O2 2 lpm, sats > 95%. Lethargic post procedure.\n" }, { "category": "Nursing/other", "chartdate": "2170-11-01 00:00:00.000", "description": "Report", "row_id": 1632727, "text": "Nursing Progress Note 1900-0700 hours:\n Full code\n\n allergies: nkda\n\n** access: 2 piv's\n\nIn brief: pt is a 43 yo M, pmh: mild portal htn, esoph varices, etoh withdrawal, s/p banding x 4 .\n\nPresented to OSH with hematemesis x 1 day, hct 32, placed on octreotide and ppi, NGL neg. Underwent EGD with varices and found to have no active bleeding and thought to be from bleeding gums. Rec'd 6 pack plts. Tcx'd to for work-up.\n\nIn MICU-no further bleeding noted. hct stable. EGD with no active bleed found-6 varices banded. Has been on octreotide gtt.\n\nNEURO: A & O x3. No S & S of withdrawal. Slightly shakey on feet with ambulation to chair. Follows all commands. C/O slight pain to right lower quadrant intially after egd\n\nCV: NSR with hr 60's, NBP 110-120's with maps >60. hct stable. octreotide gtt. Goal tx keep >25.\n\nRESP: lungs clear. Rec'd on 2l nc from egd-placed on RA with sats 94-98%. rr normal\n\nGI/GU: abd slightly distended-+ BS. Started on clears last night-tol well with moderate amt PO intake. To advance diet today as tol. Cont ppi. foley dc'd at 2a due to discomfort-was voiding adeq amber, yellow urine (see carevue). voided small amt of 20cc initially after removal.\n\nID: afebrile. On cipro x 7 days for gi prophylaxis with scope.\n\nSKIN: no breakdown.\n\nSOCIAL: brother called on evenings-plans to visit today.\n\nPLAN: -monitor for S & S of bleed, hcts\n -advance diet as ordered/tol\n -contm ed regimen and icu plan of care\n -octreotide gtt\n -liver recommendations\n -assess void s/p foley removal\n -assess S & S of w/drawal\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632724, "text": "MICU 7: RN Note 1900-0700\n\n\nEvents: Admitted to Hospital w/Hematemesis; EGD showed inactive varices. Gastric lavage neg. Ammonia 144. Enlarged spleen. Rec'd six pack platelets. Hx Etoh (recent stay at detox facility-last drink was Sunday), UGIB, Banding x4 in . Transferred to ; arrived ~. Placed on Octerotide drip. Hct decr from 32 on arrival to 29 this morning. No bloody stools; no hematemesis.\n\n\nNeuro: AAO x3 but slow to respond. More clear in am. MAE. Holds arms with slight drift toward bed. No signs of ETOH w/d. Last drink was Sunday. Denies pain. Slept much of the night.\n\nCV: HR 60s SR; BP 1-teens/70s (100/57 at 6am). #18 RUE (KVO and Octretide infusing); #16 LUE (KVO) w/very good blood return (first chem hemolyzed-re-sent K). Compression sleeves on. Skin WDI.\n\nResp: 95-97% on RA; LS diminished initially; increased aeration and clear after turning/positioning.\n\nGI: Abd softly distended, +BS, No BM. Sm umb hernia. Lactulose adm at ~midnight. Protonix adm. Pt requesting water. NPO...ice chips only.\n\nGU: Pt incont x1 at outside hospital. Bedding wet on arrival. on admission with UOP 700 within first hour. UOP varied between 30-120/hr after initial output. Foul smell/Amber color. Sent for Urinalysis and C&S.\n\nEndo: FS 113 and 99.\n\nSocial: Lives w/roommate. Brother is primary contact (: number on board).\n\nPlan: NPO for Liver/Gall Bladder USN at 0930; TIPS procedure. Suggest social service consult for assistance with etoh.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632725, "text": "In brief: 43 year old male with histiry of ETOH cirrhosis, portal hypertension, and prior GI bleeding due to esophgeal varices transfered from OSH with hematemesis. Admission hct is 32 at OSH, s/p NG lavage which was negative, EGD revealed no active bleeding but + for esophageal varices. No intervention given, thought that this is due to bleeding gums. transferred to for further intervention, possible variceal banding and TIPS procedure.\n\nNKDA\n\nFull code\n\nNeuro: alert and oriented x 3, denies any pain. Able to move extremities, written for ativan PRN for CIWA scale > 10, scale had been .\n\nCV: hemodynamically stable, SR without ectopy. pedal pulses easily palpable, no edema noted. PIVs wnl.\n\nRespi: sats > 95% at room air, lung sounds clear.\n\nGI: remains NPO for endoscopy with possible variceal banding this evening. Bowel sound present, no BM this shift.Continues on lactulose TID for increased ammonia level ( titrate for 3 BM / day ). US of abdomen organs and blood vessels done, no bleeding or occlusion noted per preliminary read, official result not in yet.\n\nGU: -800cc since MN and - 1.6 L for LOS, urine culture atill pending.\n\nID: continues on cirpofloxacin q24hrs, afebrile. Hepatology following, recs to increase cipro to x 7 days for varices infection.\n\nHeme: hct monitor , remains stable.\n\nSkin: intact\n\nSocial: patient has been made aware of the importance of stopping ETOH intake and have agreed upon. Knows that it is detrimetal to his health. brother called for update.\n\nplan:\n\nEGD and possible variceal banding this evening; possible call out to floor after EGD if continues to be stable; monitor hct , transfuse < 25\n" }, { "category": "ECG", "chartdate": "2170-10-30 00:00:00.000", "description": "Report", "row_id": 219748, "text": "Technically difficult study\nSinus rhythm\nInferior/lateral ST-T changes\nNo previous tracing available for comparison\n\n" } ]
7,695	118,007	This is a 63 year old male with PMH of severe systolic HF with an EF=25%, afib on coumadin, who presented with hypotension and found to have questionable adrenal insufficiency in the setting of a likely gout flare. . #. Hypotension: Possibly due to adrenal insufficiency, given symptoms of fever, hypotension, diarrhea, high eosinophils, hyponatremia, and hyperkalemia with low cortisol failed ACTH stimulation ( stim 6->10->10). Confounding factors are that colchicine causes diarrhea and allopurinol induces hypereosinophilia. An abdominal CT without contrast showed no evidence of adrenal pathology. Initially, the patient had fever and tachypnea concerning for septic shock possibly from a pulmonary source as a possible pneumonia was seen on CT scan. He did have a normal lactate and no leukocytosis. Septic arthritis was considered given prominent joint complaints and history of gout, although his joint was tapped by and was negative for infection. He was on vasopressors on admission, but weaned off over 48 hours. He was subsequently normotensive with a normal lactate. He was started on IV hydrocortisone in the ICU which was transitioned to oral prednisone on . endocrine team recommended a quick prednisone taper to 20mg on , 10mg on , then off on . The patient's pressures remained stable off of prednisone for greater than 24 hours. Cortisol and free cortisol levels were sent on when the patient was off of steroids for 24 hours and he was sent home on prednisone 5mg daily until he can be followed up in the endocrine clinic. CMV, HIV, RPR, and TSH were all sent to rule out other causes of adrenal insufficiency. HIV, CMV, and RPR negative. TSH was low with high free T4 and low T3 attributed to SICU thyroid. It is therefore unlikely that the patient is panhypopit. The patient said that a PPD placed 3 months prior was negative for Tb. An adrenal MRI was considered to rule out hemorrhage while on coumadin or infection but could not be performed with his ICD in place. . #. Gout: The patient redeveloped right ankle swelling and pain on in the setting of decreasing his prednisone from 20mg to 10mg. Allopurinol was continued and he was restarted on daily colchicine. His uric acid level was 5.8 on . Colchicine was restarted with a 1.2mg dose followed by 0.6 mg dose on . He was started on low dose prednisone 5mg daily both to prevent gout and hypotension (from possible adrenal insufficiency) until he follows up as an outpatient with endocrinology. . #. Infection/sepsis: The patient was febrile and admission blood cultures were growing coag negative staph which was likely a contaminant. CT chest on admission showed an opacity that was read as being consistent with atelectasis vs. PNA. He received empiric broad spectrum antibiotics (Zosyn, vancomycin, flagyl) in the ICU until , but they were discontinued prior to transfer to the floor. The patient remained afebrile, but developed a leukocytosis with peak WBC count of 12.3 on which was likely secondary to a gout flare as the leukocytosis resolved after proper gout treatment and no abx. TTE showed no evidence of vegetations on valves or hardware. tapped his swollen joint in the ICU and it was negative for infection. His central line was removed on and the catheter tip culture was negative. All blood and urine cultures were negative. . #. Hyperglycemia: The patient initially had poor glucose control in the setting of high dose steroids. He required an insulin gtt in the ICU and was started on Lantus/HISS upon transfer from the ICU. His sugars improved dramatically as he was weaned off of steroids and he was discharged on his home Novolog sliding scale. . #. : The etiology was likely pre-renal given that his UA was bland. His creatinine peaked at 4.2 and improved with IVFs. A renal U/S was normal and his creatinine was his creatinine was back down to his baseline of 1.1 upon discharge. His home Diovan was restarted on . Torsemide was held given his hypotension and potential to provoke gout flare. Given his severe CHF, the torsemide may need to be restarted as an outpatient. His ankles did have 1+ edema, but his lungs were clear on discharge. . #. Elevated INR: The patient's INR trended up to 11.5 on requiring vitamin K administration. The etiology of this rise was unclear, but may have been secondary to poor PO intake prior to admission. His Coumadin dose was decreased to 2 mg daily before discharge with therapeutic INRs resulting. . #. CHF: The patient has non-ischemic cardiomyopathy with an EF=25% and severe TR. Initially, all of his cardiac meds except for digoxin were held given his hypotension requiring pressors. He was restarted on his home Diovan 40mg on and his carvedilol 3.125mg was restarted upon discharge. His home torsemide was not re-initiated given his hypotension and the potential of triggering another gout flare. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He should follow-up with Dr. ans an outpatient for further titration of his cardiac meds. . #. Atrial Fibrillation: His home carvedilol was held initially given his hypotension, but was restarted on discharge. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He was continued on Coumadin at discharge after it was initially held for an INR=11. . #. Sinusitis: The patient has had several months of sinus congestion and was started on fluticasone nasal spray. . #. Eosinophilia: His absolute eosinophil count on admission was about 900 and has been noted in past labs. This finding was concerning for malignancy, occult parasitic infection, or Churg-. However, his eosinophilia improved with steroids and ANCA was negative. . #. Communication: Patient and (wife) who works in Radiology for and can be reached at home , cell , work . #. Code: Confirmed full code.	- Hold carvedilol given shock - Hold diovan given shock - Restart digoxin given low level this AM - Hold torsemide and dose as needed. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. Mild retrocardiac atelectasis is again seen. - PM lytes/creatinine . Hypotension: Off of levophed. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. - Check cortisol given h/o recent prednisone use. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. holding torsemide in setting of hypovolemia. Also consider adrenal insufficiency given eosinophilia. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. - Hold carvedilol given shock - Hold diovan given shock - Restart digoxin given low level this AM - Hold torsemide and dose as needed. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. States he feels a lot better than when he came in Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.3 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. Pt is being treated for pna with IV ABXs as noted. Pt is being treated for pna with IV ABXs as noted. Pt is being treated for pna with IV ABXs as noted. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Started on hydrocortisone 100mg q 6hr Response: Felt comfortable after pain med Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.8 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. Hypotension (not Shock) Assessment: Pt on Levophed and Vasopressin at start of shift. Calcified granulomas in the right lower lobe (2:46 and 2:30) are noted. Blood pressures dropped to the 70s systolic and he was given 1L IVF, a CVL was placed and CVP was 13-16. # Atrial Fibrillation: h/o and returned to with dopamine on board. Started on hydrocortisone 100mg q 6hr Response: Felt comfortable after pain med Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.3 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. Tubular blind ending structure in the right lower quadrant likely (Over) 2:21 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: ?	77	[ { "category": "Radiology", "chartdate": "2179-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1131556, "text": " 2:12 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with leukocytosis\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Leukocytosis, rule out pneumonia.\n\n COMPARISON: .\n\n FRONTAL AND LATERAL CHEST: Marked enlarged cardiac silhouette is unchanged.\n Pulse generator electrode tip is in place and appears intact. A jugular\n catheter has been removed. The lungs are better expanded and well aerated.\n There is no pneumothorax or pleural effusion. The mediastinal and hilar\n contours are normal.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 592535, "text": "Chief Complaint: Hypotension/Shock (septic with adrenal insufficiency)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Arm/elbow pain better this AM\n 24 Hour Events:\n Levophed now off - but SBP on 80s\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 09:45 AM\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:51 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Gastrointestinal: Diarrhea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 71 (70 - 78) bpm\n BP: 93/55(67) {77/49(62) - 117/63(78)} mmHg\n RR: 26 (17 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 821 mL\n PO:\n 590 mL\n 60 mL\n TF:\n IVF:\n 1,097 mL\n 761 mL\n Blood products:\n Total out:\n 2,360 mL\n 990 mL\n Urine:\n 2,110 mL\n 990 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.6 g/dL\n 129 K/uL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension: Off of levophed. D/C vanco/zosyn/flagyl given lack of\n source\n Adrenal insufficiency: Cont hydrocort\n acute renal failure: Cr improving but not back to baseline, cont to\n monitor\n Elevated INR: Cont to hold Coumadin\n DM: Cont insulin gtt --> will need to while on steroids\n CHF: No active diuresis for now\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407113, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99% 2L\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n .\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n .\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n .\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension:\n - continue vancomycin, zosyn, flagyl\n - continue hydrocortisone 100IV Q6\n -\n Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean vasopressin, then levophed\n as tolerated\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n - PM lytes/creatinine\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n - 2.5 mg PO vitamin K\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale. Goal FS < 180.\n - Tighten sliding scale\n - consult\n .\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407192, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - trend lactate\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - consider d/c vancomycin, zosyn, flagyl\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n - PM lytes/creatinine\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407193, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - trend lactate\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - consider d/c vancomycin, zosyn, flagyl\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2179-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130656, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF a/w sepsis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF with sepsis.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is substantial enlargement of the cardiac silhouette\n without definite vascular congestion or pleural effusion. The right IJ\n catheter and ICD are unchanged. Mild retrocardiac atelectasis is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "LP ELBOW (AP, LAT & OBLIQUE) LEFT PORT", "row_id": 1130498, "text": " 8:42 AM\n ELBOW (AP, LAT & OBLIQUE) LEFT PORT; SHOULDER VIEWS NON TRAUMA LEFT PORTClip # \n Reason: Please evaluate for fractures, effusions, other abnormalitie\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man w/ h/o CHF p/w sepsis and severe left arm pain involving elbow\n and shoulder.\n REASON FOR THIS EXAMINATION:\n Please evaluate for fractures, effusions, other abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with severe left arm pain.\n\n COMPARISON: None.\n\n THREE VIEWS, LEFT SHOULDER: Examination is limited by nonstandard views as\n well as the overlying pacemaker. There is moderate degenerative change at the\n acromioclavicular joint with narrowing and subchondral sclerosis. The\n glenohumeral joint appears intact. There is no visualized fracture.\n\n THREE VIEWS, LEFT ELBOW: There is no fracture or abnormal alignment. There\n is no joint effusion. Mineralization is normal.\n\n DR. . \n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130499, "text": " 8:43 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: now s/p 3L volume resuscitation, please evaluate for interva\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man w/ h/o CHF p/w sepsis.\n REASON FOR THIS EXAMINATION:\n now s/p 3L volume resuscitation, please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with CHF, sepsis, post-volume resuscitation.\n\n COMPARISON: at 3:14 a.m., six hours prior.\n\n CHEST, AP: Moderate cardiomegaly persists. There is no pulmonary edema or\n pleural effusions. Right internal jugular line again terminates at the\n superior SVC. Right ventricular pacemaker/defibrillator courses in expected\n position. There is no pneumothorax.\n\n IMPRESSION: Cardiomegaly, no edema.\n\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407112, "text": "Chief Complaint: septic shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 63 yo man with h/o systolic HF, dil cardiomyopathy, admitted with\n septic shock. Vasopressin added yesterday. Levophed and vasopressin\n weaned overnight. Feels much better.\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 07:40 AM\n Metronidazole - 08:11 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n vanco\n SSI\n allopurinol\n levophed 0.15\n pepcid\n hydrocort 100mg q6h\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 35.9\nC (96.6\n HR: 77 (71 - 100) bpm\n BP: 112/66(81) {94/54(67) - 112/67(81)} mmHg\n RR: 24 (20 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,441 mL\n 587 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 587 mL\n Blood products:\n Total out:\n 800 mL\n 720 mL\n Urine:\n 800 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -133 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///15/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 10.9 g/dL\n 128 K/uL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:11/31, Alk Phos / T Bili:89/3.6,\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:205 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Fluid analysis / Other labs: Echo yesterday: EF: 15-20%\n Cortisol stim: 6.5-10.1-10.7\n Imaging: CXR: no pulmonary edema\n Microbiology: blood cx: NGTD\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION:\n Shock: have been a combination of dehydration, a viral syndrome,\n and adrenal insufficiency.\n acute renal failure: creatinine improved. continue to watch\n elevated INR: coumadin held. Got 2mg po vitamin K. likely due to\n antibiotics and lack of POs.\n DM: high glucoses. Increase sliding scale\n CHF: holding dig in setting of renal failure. Hold torsemide and\n carvedilol in setting of HOTN.\n AFib: well controlled.\n eosinophilia: check another eosinophil count today.\n Advance to PO diet.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Echo", "chartdate": "2179-05-13 00:00:00.000", "description": "Report", "row_id": 60017, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Valvular heart disease.\nHeight: (in) 68\nWeight (lb): 178\nBSA (m2): 1.95 m2\nBP (mm Hg): 95/43\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 13:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe global\nLV hypokinesis. No resting LVOT gradient. No VSD.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve. Dilated main PA. Dilated\nbranch PA.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. The\nestimated right atrial pressure is 10-20mmHg. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. There is\nsevere global left ventricular hypokinesis (LVEF = 25 %). There is no\nventricular septal defect. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. No masses or vegetations are seen on the\naortic valve. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. No vegetation/mass is seen on the pulmonic\nvalve. The main pulmonary artery is dilated. The branch pulmonary arteries are\ndilated. There is no pericardial effusion.\n\nNo vegetations seen\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is increased, the left ventricle\nis less dilated, and he tricuspid regurgitation is reduced.\n\n\n" }, { "category": "ECG", "chartdate": "2179-05-16 00:00:00.000", "description": "Report", "row_id": 108737, "text": "Probable atrial fibrillation with ventricular paced rhythm, intermittent\nintrinsically conducted beats and ventricular premature beats. Intrinsically\nconducted beats show delayed R wave progression and ST-T wave abnormalities.\nSince the previous tracing of the ventricular rate is slower and\nintermittent ventricular pacing is seen.\n\n" }, { "category": "ECG", "chartdate": "2179-05-13 00:00:00.000", "description": "Report", "row_id": 108738, "text": "Baseline artifact. Probable atrial fibrillation with rapid ventricular\nresponse although baseline artifact makes assessment difficult. Low\nQRS voltage. Delayed R wave progression with late precordial QRS transition.\nModest ST-T wave changes. Findings are non-specific but clinical correlation is\nsuggested. Since the previous tracing of ventricular paced rhythm is\nnow absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-05-12 00:00:00.000", "description": "Report", "row_id": 108739, "text": "Ventricular paced rhythm. Atrial mechanism is uncertain. Since the previous\ntracing of ventricular paced rhythm is now present.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407072, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407073, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407248, "text": "Chief Complaint: Adrenal Insufficiency, shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Needed to be back on levophed for much of the day yestreday but now\n back off\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (69 - 92) bpm\n BP: 114/57(74) {73/37(48) - 136/78(97)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 2 (2 - 2)mmHg\n Total In:\n 2,131 mL\n 233 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 233 mL\n Blood products:\n Total out:\n 1,860 mL\n 1,255 mL\n Urine:\n 1,860 mL\n 855 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n 271 mL\n -1,022 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.8 g/dL\n 151 K/uL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension: Try to keep him off of pressors.\n Adrenal insufficiency: Cont hydrocort - switch to 50mg po q8 hrs\n today. Will repeat stim while in house\n acute renal failure: Cr continues to improve\n Elevated INR: Restart Coumadin\n DM: Cont insulin gtt\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407249, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Micro:\n - Stool studies pending\n - BCx NGTD\n - Urine legionella negative\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - Currently on levophed, but with stable BPs\n will attempt to wean\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - Off Abx\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral taper:\n - Hydrocortisone 50mg PO q 8 hours x 3 days\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n - insulin gtt change to tighter insulin SS this AM as takes PO (will\n confirm with )\n - diabetic diet\n - f/ consult recs\n - would like to transition to subcutaneous insulin today, but could be\n challenging in setting of tapering steroid doses. Will discuss with\n .\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n - d/c foley today\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - plan to restart Coumadin today (3.5 mg)\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - plan to restart Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407231, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR 2.2,..lytes Na 137 and K 4. HCT 27.8\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n BS 100-130\ns, insulin at 2units/hr\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs WBc normal, on low dose of levophed gtt\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407239, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407240, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407241, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Micro:\n - Stool studies pending\n - BCx NGTD\n - Urine legionella negative\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - Currently on levophed, but with stable BPs\n will attempt to wean\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - Off Abx\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral in days and\n taper\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n - insulin gtt change to tighter insulin SS this AM as takes PO (will\n confirm with )\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - plan to restart Coumadin today (3.5 mg)\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - plan to restart Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407352, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors morning of at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to\n prednisone 30mg daily later per pharm recs (although lacks mineralocort\n activity). Will plan for 10-day taper; recommend patient undergo\n re-stimulation later this admission once called out to floor. A-line\n left in while monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Likely due to adrenal insufficiency, given symptoms of\n fever, hypotension, diarrhea, high eosinophils, hyponatremia,\n hyperkalemia then low cortisol with failed ACTH stimulation. Initially,\n patient with marked fever, tachypnea, vasodilated on initial exam\n concerning for septic shock possibly from pulmonary source as possible\n pneumonia on CT scan (although normal lactate and normal WBC count).\n Septic arthritis considered given prominent joint complains and history\n of gout although joint tap negative. On vasopressors at admit, but\n weaned off over 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph, likely contaminant. CT chest on admission with opacity\n atelectasis/pna. Patient has remained afebrile, normal white count.\n TTE w/ no evidence of vegetations on valves or hardware\n - discontinue vancomycin\n - appreciate rheumatology recs: consider repeat tap if clinically\n worsens and appropriate clinical scenario\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - continue glargine 15U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Digoxin continued\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, discontinue\n famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407307, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors this morning at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to pred\n 30mg daily later per pharm recs (although lacks mineralocort activity).\n Will plan for 10-day taper; recommend patient undergo re-stimulation\n later this admission once called out to floor. A-line left in while\n monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///17/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407308, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors this morning at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to pred\n 30mg daily later per pharm recs (although lacks mineralocort activity).\n Will plan for 10-day taper; recommend patient undergo re-stimulation\n later this admission once called out to floor. A-line left in while\n monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. On vasopressors at admit, but weaned off over\n 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph. CT chest on admission with opacity atelectasis/pna. Patient\n has remained afebrile, normal white count. TTE w/ no evidence of\n vegetations on valves or hardware\n - continue vancomycin\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - continue glargine 15U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Continue digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 407049, "text": "Chief Complaint: chest pain\n HPI:\n Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n .\n On arrival to the floor, patient c/o total body pain, and feeling cold.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies cough, shortness of breath, or wheezing. Denies chest pain,\n chest pressure, palpitations, or weakness. Denies nausea, vomiting,\n diarrhea, constipation, abdominal pain, or changes in bowel habits.\n Denies dysuria, frequency, or urgency. Denies rashes or skin changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Metronidazole - 03:29 PM\n Piperacillin - 04:25 PM\n Infusions:\n Norepinephrine - 0.45 mcg/Kg/min\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 09:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n Idiopathic cardiomyopathy, EF 15-20%, clean cath in \n severe tricuspid regurgitation\n diabetes type 2 on sliding scale insulin\n elevated LFTs, thought due to fatty liver\n atrial fibrillation on coumadin\n gout, recent flare treated with prednisone taper, confirmed\n cyrstals in , no other taps in the system.\n peripheral neuropathy\n chronic renal insufficiency, baseline creatinine 1.3-1.8\n hypertension\n .\n Medications:\n Allopurinol 250mg PO qday\n Carvedilol 3.125 PO BID\n Colchicine 0.6mg PO qday\n Digoxin 125mcg PO qday\n Insulin sliding sclae\n Lantus order -> does not need or take\n Spironolactone 12.5mg PO qAM -> d/c'd as per patient\n Torsemide 40mg PO BID\n Valsartan 40mg PO qday\n Warfarin 4mg M/W/Fri, 3.5mg the other 4 days\n .\n Not taking\n -Vivodin -> does not need\n -Ibuprofen -> does not need\n .\n Allergies:\n Unasyn ? causes LFT elevation per d/c summary \n No first-degree relatives with coronary artery disease. His mother had\n breast cancer.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is originally from currently living with his\n wife. Returned to this past fall, but came back to US after\n severe gout flare of his foot. No smoking. He quit alcohol use, no IV\n drug use. He says his diet is generally difficult because he\n feels like any food he eats causes gout flare\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: Joint pain, Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious\n Flowsheet Data as of 04:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.6\nC (99.6\n HR: 74 (74 - 118) bpm\n BP: 124/68(82) {80/43(54) - 124/68(82)} mmHg\n RR: 27 (23 - 32) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n CVP: 17 (10 - 22)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 5,403 mL\n PO:\n TF:\n IVF:\n 2,403 mL\n Blood products:\n Total out:\n 0 mL\n 420 mL\n Urine:\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,983 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n General Appearance: Anxious, Diaphoretic, uncomfortable, rigoring\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, tachycardic,\n irregular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : diminished)\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 137 K/uL\n 9.9 g/dL\n 198\n 3.7 mg/dL\n 60 mg/dL\n 18 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 132 mEq/L\n 28.4 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A4/15/ 08:14 AM\n \n 10:20 P4/15/ 02:00 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 28.4\n Plt\n 137\n Cr\n 3.7\n TropT\n <0.01\n Glucose\n 178\n 198\n Other labs: PT / PTT / INR:40.5/51.5/4.3, CK / CKMB /\n Troponin-T:65//<0.01, Alk Phos / T Bili:/3.2, Differential-Neuts:67.0\n %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %, Eos:11.0 %, Lactic Acid:1.2\n mmol/L, LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Fluid analysis / Other labs: On arrival, WBC 6.3, Hct 29 (baseline high\n 20's), Plt 135,\n Chemistries with Na 132, K 4.5, Cl 98, CO2 21, BUN 61, Cr 4.2, Plt 134\n CK 78\n INR 3.9,\n ABG 7.46/32/130\n Imaging: - Initial film: prominent pulm vasculature, clear lungs (my\n read)\n - Repeat film: decreased lung volumes, apparent increase in cardiac\n silhouette, and mild overhydration vs. artifact (my read)\n - CT C/A/P: Small pleural effusions L > R, prominent pulmonary venous\n system vs. lymphatics (my read), wet read from rads ->\n 1. no definite acute finding to explain pt sx's on this non- contrast\n CT.\n 2. Urinary bladder wall thickening likely under-distension\n Microbiology: -No h/o MRSA, VRE. Does have history of pseudomonas in\n past from wound cultures\n -Blood culture sent in ED.\n ECG: EKG: wide qrs at rate of 71 bpm. Regular. Slow ventricular\n escape rhythm vs. ventricular paced rhythm (pacer spikes in V3/v4/V5)\n .\n Repeat EKG on arrival to ICU: artifact, likely a. fib with rapid\n ventricular response.\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR therapeutic, pneumoboots,\n # Access: peripherals, CVL\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407051, "text": "62 y.o.m with cardiomyopathy, EF 10-15%, ICD/pacer, Afib, and diabetes.\n Has experienced frequent episodes of gout over past few months while in\n - on recent prednisone taper. Right arm pain recently. Then\n developed left should and elbow pain. Does report some cough and SSCP\n with coughing. Some sinus congestion. T 101.4, BP initially 90/40,\n and then dropped to 70s systolic. TLC placed CVP 13-16. Received 3L\n IVF. Dopamine initiated for BP support, Levophed added as pt was noted\n to become tachycardic secondary to dopamine. CT head and torso\n negative. Hx of CRI, creatinine 4.3-> therefore, did not receive\n contrast for imaging. Tx to TSICU as MICU border for further\n monitoring and sepsis workup.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid per resident.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n - Rigors & Tmax 102.5\n - SBP 60-70s\n - V paced with runs of Afib, HR 70-120s.\n - Low urine output 0-25cc/hr. Dark amber urine noted.\n - Creatinine 3.7\n - Anemic at baseline, Hct 28\n Action:\n - Blood cultures obtained, 1000mg Tylenol administered\n - Dopamine and Levophed running to maintain SBP > 90.\n - EKG obtained\n - Bedside ECHO performed\n - CXR for ? infiltrates. Xray\ns of L elbow and shoulder obtained\n - 250cc fluid boluses x4 and 500cc fluid bolus x1 for treatment of low\n uop & to maintain CVP between 15-20\n - Renal US obtained\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407054, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n Tx to TSICU as MICU border for monitoring and sepsis work up.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid. Pt started on prednisone taper.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n - Rigors & Tmax 102.5\n - SBP 60-70s\n - V paced with runs of Afib, HR 70-120s.\n - Low urine output 0-25cc/hr. Dark amber urine noted.\n - Creatinine 3.7\n - Lytes wnl\n - Anemic at baseline, Hct 28\n Action:\n - Blood cultures obtained, 1000mg Tylenol administered\n - Started on triple anbx coverage- IV Vanco, zosyn, and flagyl.\n - Dopamine and Levophed running to maintain SBP > 90.\n - EKG obtained\n - Bedside ECHO performed\n - CXR for ? infiltrates. Xray\ns of L elbow and shoulder obtained to r/o\n fractures, effusions, and/or other possible infectious processes.\n - stim test performed\n - 250cc fluid boluses x4 and 500cc fluid bolus x1 for treatment of low\n uop & to maintain CVP between 15-20\n - Renal US obtained\n Response:\n - Pt remains afebrile, Tmin 98\n - Dopamine gtt weaned off due to tachycardia, Levophed titrated to\n maintain SBP > 90.\n - ECHO & Renal US results pnding\n - Urine remains concentrated. UOP gradually increasing.\n Plan:\n - Hemodynamics\n - Follow up with pnding blood cultures\n - Administer anbx as ordered\n - Maintain SBP > 90, titrate Levophed gtt as necessary\n - Cont to administer fluid boluses- assess for CHF. Maintain CVP > 15.\n - Follow up with stim test and pnding lytes. Replete as necessary.\n - Follow up with Renal and ECHO results\n - Cont to maintain pt safety\n" }, { "category": "Physician ", "chartdate": "2179-05-13 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 407026, "text": "Chief Complaint: HOTN\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yo cardiomyopathy, EF 10-15%, ICD/pacer, AFib. Has had bad gout\n over past few months while in . Recent prednisone taper. Right\n arm pain recently. Then developed left should and elbow pain. Does\n report some cough and SSCP with coughing. Some sinus congestion. T\n 101.4, BP initiall 90/40, and then dropped to 70s systolic. TLC placed\n CVP 13-16. Got 3L IVF. intially got dopamin, and then added\n levophed. CT head and torso without infectious source. With renal\n failure, so didn't get any contrast. Initially tachycardic in TSICU,\n having chills and rigors.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 08:26 AM\n Infusions:\n Norepinephrine - 0.35 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 09:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Meds at home:\n carvedilolol\n allopurinol\n dig\n valsartan\n warfarin\n torsemide\n no CAD in family\n Occupation:\n Drugs:\n Tobacco: none\n Alcohol: none\n Other: from , wife works at \n Review of systems:\n Flowsheet Data as of 01:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.6\nC (99.7\n HR: 77 (77 - 118) bpm\n BP: 87/44(55) {80/44(55) - 96/52(63)} mmHg\n RR: 24 (23 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n CVP: 22 (10 - 22)mmHg\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 4,127 mL\n PO:\n TF:\n IVF:\n 1,127 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,827 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.46/32/130\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, dry mucous membranes\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 137 K/uL\n 28.4 %\n 9.9 g/dL\n 178 mg/dL\n 3.7 mg/dL\n 60 mg/dL\n 18 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 132 mEq/L\n 8.1 K/uL\n [image002.jpg]\n 08:14 AM\n WBC\n 8.1\n Hct\n 28.4\n Plt\n 137\n Cr\n 3.7\n TropT\n <0.01\n Glucose\n 178\n Other labs: PT / PTT / INR:40.5/51.5/4.3, CK / CKMB /\n Troponin-T:65//<0.01, Alk Phos / T Bili:/3.2, Differential-Neuts:67.0\n %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %, Eos:11.0 %, Lactic Acid:1.5\n mmol/L, LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Shock: Septic versus hypovolemic. Can check SVO2 from central\n line. Continue to give IVF boluses gingerly.\n Unclear source of infection. Last SVO2 was 65%. Also\n consider adrenal insufficiency given eosinophilia.\n Continue vanco/zosyn empirically\n Given eosinophilia and steroid courses. Will stim,\n and treat for adrenal insufficiency with hydrocort q6h\n Has rigors and fevers: worrisome for infection. Rheum did not get\n fluid from attempted elbow tap.\n chronic systolic HF: continue Dig. holding torsemide in setting of\n hypovolemia. f/u on TTE\n Afib: better controlled now that dopamine is off.\n eosinophilia: can check stool O+P\n diarrhea: check C. dif, and O+P, may be due to colchicine\n DM:\n NPO for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FUll\n Disposition: ICU\n Total time spent: 50 minutes\n Critically Ill\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407045, "text": "62 y.o.m with cardiomyopathy, EF 10-15%, ICD/pacer, Afib, and diabetes.\n Has experienced frequent episodes of gout over past few months while in\n - on recent prednisone taper. Right arm pain recently. Then\n developed left should and elbow pain. Does report some cough and SSCP\n with coughing. Some sinus congestion. T 101.4, BP initially 90/40,\n and then dropped to 70s systolic. TLC placed CVP 13-16. Received 3L\n IVF. Dopamine initiated for BP support, Levophed added as pt was noted\n to become tachycardic secondary to dopamine. CT head and torso\n negative. Hx of CRI, creatinine 4.3-> therefore, did not receive\n contrast for imaging. Tx to TSICU as MICU border for further\n monitoring and sepsis workup.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid per resident.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n Rigors & fever\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407225, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR 2.2,..lytes Na 137 and K 4. HCT 27.8\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n BS 100-130\ns, insulin at 2units/hr\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs WBc normal, on low dose of levophed gtt\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407097, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:11/31, Alk Phos / T Bili:89/3.6,\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:205 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407100, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >9\n Plan:\n Continue to wean vasopressors, fluid bolus prn for low cvp\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressure improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results, continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful around elbow no erythema noted\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med. States he feels a lot better than when\n he came in\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control steroids and\n sepsis,continue to monitor, ss insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output negative > 200cc, K+\n 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407101, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407107, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99% 2L\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n .\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n .\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n .\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension:\n - continue vancomycin, zosyn, flagyl\n - continue hydrocortisone 100IV Q6\n -\n Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2179-05-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 407119, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n day. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Ht: 68\n Admit wt: 88 kg\n UBW: 81.8kg (dry wt)\n BMI: 27.3\n Pmh: severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Diet Order: clear liquids\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407182, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407204, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407205, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407298, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 285\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407299, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n > Off levophed gtt SBP 90-110mmhg\n >HR 60-70\ns, V paced with occasional pvc\n >voiding yellow clear urine\n > No complaints of pain\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 285\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407300, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n > Off levophed gtt SBP 90-110mmhg\n >HR 60-70\ns, V paced with occasional pvc\n >voiding yellow clear urine\n > No complaints of pain\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 251\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407087, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2. There were no immediate\n complications.\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407088, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2 in the evening after several\n unsuccessful attempts earlier in day over bilateral wrists. There were\n no immediate complications.\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407089, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >9\n Plan:\n Continue to wean vasopressors, fluid bolus prn for low cvp\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressure improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results, continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful around elbow no erythema noted\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med. States he feels a lot better than when\n he came in\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control steroids and\n sepsis,continue to monitor, ss insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output negative > 200cc, K+\n 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nutrition", "chartdate": "2179-05-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 407121, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n day. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Ht: 68\n Admit wt: 88 kg\n UBW: 81.8kg (dry wt)\n BMI: 27.3\n Pmh: severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Labs: K 5.4 PO4 5.3 BUN 64 Creat 3.0\n Diet Order: clear liquids\n 63 year old male came to the ED with chest pain and L arm pain.\n Patient has had gout for the last few weeks. Patient reports poor pos x\n 1 week PTA due to everything he eating making the gout worse. Patient\n is +6.2 kg due to fluid. Patient denies nausea and vomiting. Plan is to\n advance diet. Page with questions.\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407187, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, vasodilation, tachypnea on\n initial exam more consistent with septic shock possibly from pulmonary\n source as possible pneumonia on CT scan (although normal lactate and\n normal WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Adrenal\n insufficiency considered given low cortisol on admission and <25%\n response to cosyntropin may be primary or functional in setting of\n acute illness . PE considered although supratherapeutic INR. Able to\n wean from vasopressin and wean from levophed over the past 24 hours.\n - MAP goal 60-65. need to be less aggressive with MAP target of\n 60 rather than typical 65 given h/o EF 10-15%, but previous BP's noted\n to be normal.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - trend lactate\n .\n #. Infection/Sepsis: No clear source clinically although evidence of\n pneumonia on chest imaging. TTE showing no evidence of vegetations on\n the valves or hardware\n - f/u blood, sputum, urine cx\n - continue vancomycin, zosyn, flagyl\n - Zosyn -> trend LFT's given h/o allergy to unasy-\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids\n -insulin gtt change to tighter insulin SS this AM\n - consult recs\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n - PM lytes/creatinine\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407194, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed off for now. Will follow UOP and re-start vasopressors as\n needed for MAP >60\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - d/c vancomycin, zosyn, flagyl as all cultures have been negative and\n monitor clinically\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral in days and\n taper\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407197, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow inr closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407199, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407200, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n ***Please note, this evening patient noted to become delirious and\n agitated. Refusing turns, blood sugars, dinner ect. Dr. \n made aware. Gave one time dose of Haldol 2.0mg, adequate effect.\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407215, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR\n..lytes\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407267, "text": "Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407268, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407297, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose given pm\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407083, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2. There were no immediate\n complications.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407168, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407169, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM.\n Action:\n FSBS at 10 pm found to be high at 403. MD notified and pt given 10\n units of MD.\n Response:\n FSBS 2 hrs later 396 and given additional 6 units of insulin. FSBS has\n been running high all shift as noted and treated as needed MD q2\n hrs.\n Plan:\n Continue to monitor FSBS q2hrs and treat as needed.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407174, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM.\n Action:\n FSBS at 10 pm found to be high at 403. MD notified and pt given 10\n units of MD.\n Response:\n FSBS 2 hrs later 396 and given additional 6 units of insulin. FSBS has\n been running high all shift as noted and treated as needed MD q2\n hrs. 5 am, pt started on insulin gtt as noted. FSBS now to be checked\n q1 hr.\n Plan:\n Continue insulin gtt until FSBS is 150.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow inr closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407079, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm off coumadin x 1 day INR 9.8 up from\n 4.8 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 248 repeat blood\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407080, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressor improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.8 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.7. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output, K+ 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407081, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressor improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor, ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output, K+ 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407161, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt underlying rhythm Afib, currently V paced HR 70s. Pt off Coumadin,\n INR 11.5. Pt denies chest pain, palpitations. Denies dizziness or\n lightheadedness. Pt noted to have bloody nose x1 this evening. +BM this\n shift, guiaic negative.\n Action:\n Pt rec\nd 2mg PO vit K x2. Remains off coumadin. Stool sample sent.\n Nasal cannula removed and nasal spray given.\n Response:\n Nose bleed resolved. No s/s bleeding at this time.\n Plan:\n Continue to monitor CV and telemetry. Monitor ICD function. Monitor\n PT/INR trend. Monitor s/s bleeding.\n Diabetes Mellitus (DM), Type II\n Assessment:\n BS > 250 this shift. Pt diet advanced from NPO to regular diet. Pt\n reports increased appetite with IV steroid.\n Action:\n Sliding scale tightened recommendation. Pt rec\nd humalog SC\n per scale. Reinforced diet restrictions with pt.\n Response:\n Pt tolerated clears then regular diet for dinner, no N/V. No s/s\n hyperglycemia.\n Plan:\n Continue to monitor GI and FS.\n Hypotension (not Shock)\n Assessment:\n Pt on Levophed and Vasopressin at start of shift. BP MAP 60-70. CVP\n >12, BUN and Cr elevated, adequate u/o. Pt afebrile this shift. C/o\n shoulder pain/stiffness gout. C/o itchiness on back IV\n steroids.\n Action:\n Vasopressin gtt dc\nd. Levo gtt weaned to 0.06mcg/kg/hr. Repeat lytes\n drawn this shift. Medications renally dosed. Pt rec\nd 2mg IV morphine\n x1 and 1000mg tylenol x1, assisted with repositioning q2h for comfort.\n Hot packs for comfort. Sarna lotion to back.\n Response:\n MAP maintained >65. K+ elevated. Pt reports improved comfort. No skin\n breakdown noted.\n Plan:\n Continue to monitor need for vasopressors. Goal MAP >65. Monitor kidney\n function. Bedrest while on vasopressors. Monitor comfort and pain\n management. Continue to follow lytes.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407167, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407255, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n UPDATE: Pt weaned off IV Levophed gtt this AM and doing well OOB\n sitting upright in chair. Insulin gtt cont to infuse awaiting \n recs to wean onto SQ dosing. Excellent dietary intake noted today.\n Clot and hold drawn/sent to blood bank today. The pt is currently net\n even today but remains net input five liters for LOS. The pt has a\n documented allergy to Unasyn. The pts supportive wife visited today\n and kept up to date with pts POC/status by myself and by HO. The pt\n remains a Full Code. Hopefully the pt be c/o to floor .\n Hypotension (not Shock)\n Assessment:\n Pt received on IV Levophed gtt infusing @ 0.02mcg/kg/min with team goal\n to keep SBP values > 90 which is the pts baseline SBP value. The pts\n cultures have been NGTD. Pt without obvious source of infection. AM\n lyte lab values WNL. AM Digoxin value of 0.7 noted.\n Action:\n IV Levophed gtt weaned down/off by 08:15. AM Vanco trough value of\n 23.3\n dose subsequently decreased. CVP values < 5 today. The pt has\n denied c/o dizziness, lightheadedness today. Digoxin dosing changed\n from Stat dosing to QD dosing.\n Response:\n Pt remains normotensive @ this time now off IV Levophed for over six\n hours @ this time.\n Plan:\n Cont to follow the pts SBP/VS values closely and adjust care\n accordingly.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt received/maintained on IV Insulin gtt currently infusing @ 6units/hr\n with last FS value of 194 @ 14:00. Pt has a 10 yr history of DM. FS\n values in the 106-212 range today. IV Steroid dosing for AI dose\n tapered down today.\n Action:\n Pt now being transisitioned off IV Insulin gtt according to recs\n which are now being entered into POE by HO. FS values followed hourly\n today/Insulin gtt rate adjusted accordingly.\n Response:\n Pt without significantly elevated FS values today and should be able to\n wean off IV Insulin gtt over the next 4-5 hours.\n Plan:\n Will cont to follow FS values, follow recs and adjust care\n accordingly today.\n Pain control (acute pain, chronic pain)\n Assessment:\n The pt has denied c/o pain now that he is OOB in chair.\n Action:\n Freq assessed pt for pain today.\n Response:\n No c/o pain by pt today.\n Plan:\n Cont to follow pain assessment and treat with IV Morphine accordingly.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407355, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407356, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407357, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,307 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Vanco level 31.1 Dig 0.7\n Lines / Tubes / Drains:\n A line D/C from the left wrist ,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407358, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,307 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Vanco level 31.1 Dig 0.7\n Lines / Tubes / Drains:\n A line D/C from the left wrist ,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,311 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Dig level 0.4, Vanco level 31.1\n Lines / Tubes / Drains:\n right TLC and right AC 22G.\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: Wife\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC7\n Date & time of Transfer: \n 13:36\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407353, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n .\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407354, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted.\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407359, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors morning of at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to\n prednisone 30mg daily later per pharm recs (although lacks mineralocort\n activity). Will plan for 10-day taper; recommend patient undergo\n re-stimulation later this admission once called out to floor. A-line\n left in while monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Likely due to adrenal insufficiency, given symptoms of\n fever, hypotension, diarrhea, high eosinophils, hyponatremia,\n hyperkalemia then low cortisol with failed ACTH stimulation. Initially,\n patient with marked fever, tachypnea, vasodilated on initial exam\n concerning for septic shock possibly from pulmonary source as possible\n pneumonia on CT scan (although normal lactate and normal WBC count).\n Septic arthritis considered given prominent joint complains and history\n of gout although joint tap negative. On vasopressors at admit, but\n weaned off over 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph, likely contaminant. CT chest on admission with opacity\n atelectasis/pna. Patient has remained afebrile, normal white count.\n TTE w/ no evidence of vegetations on valves or hardware\n - discontinue vancomycin\n - appreciate rheumatology recs: consider repeat tap if clinically\n worsens and appropriate clinical scenario\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n pending improvement in renal function\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - increase glargine 15U to 18U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later but for now does not\n appear volume overloaded and is auto-diuresing\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Digoxin continued\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, discontinue\n famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407360, "text": "Chief Complaint: Hypotension, adrenal insufficiency\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Off pressors since yest AM\n Doing well this AM --> no complaints\n 24 Hour Events:\n EKG - At 11:15 AM\n CALLED OUT\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Gastrointestinal: No(t) Abdominal pain\n Musculoskeletal: No(t) Joint pain\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (60 - 98) bpm\n BP: 109/67(77) {87/55(63) - 116/67(77)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: A Paced\n Height: 69 Inch\n CVP: 11 (11 - 22)mmHg\n Total In:\n 1,660 mL\n 1,319 mL\n PO:\n 720 mL\n 840 mL\n TF:\n IVF:\n 940 mL\n 479 mL\n Blood products:\n Total out:\n 2,055 mL\n 1,300 mL\n Urine:\n 1,655 mL\n 1,300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.8 g/dL\n 157 K/uL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n Other labs: PT / PTT / INR:20.3/32.1/1.9, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension/Adrenal insufficiency: Off pressors and doing well. Now on\n pred 30mg daily. Would consider keeping him on an extended course\n given his symptomatic gout improvement along with necessity for BP for\n the time being. Will need repeat stim as an outpatient.\n GPC in blood cxs --> coag neg staph. Likely contaminant. Will d/c\n vanco. Did recieve extra dose this AM despite level > 30.\n Acute renal failure: Cr down to 1.7\n DM: Now on sq insulin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "RENAL U.S.", "row_id": 1130512, "text": " 9:54 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for abnormalities c/w ATN, pyelo or hydronep\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF, A. FIb, p/w likely septic shock and renal failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate for abnormalities c/w ATN, pyelo or hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old man with renal failure, evaluate for pyelo- or\n hydronephrosis.\n\n COMPARISON: Torso CT, .\n\n FINDINGS: The right kidney measures 10.5 cm and the left kidney measures 11.5\n cm. There is no hydronephrosis. No cysts or stone or solid mass seen in\n either kidney. No perinephric fluid collections are identified. A small\n splenule is identified in the splenic hilum measuring 1.3 cm. The urinary\n bladder could not be evaluated as a Foley catheter is in place.\n\n IMPRESSION: Normal renal ultrasound. No hydronephrosis and no perinephric\n fluid collection identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130442, "text": " 11:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hypotension, cardiomyopathy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hypotension. Clinical concern for congestive heart failure.\n\n COMPARISON: Multiple chest radiographs with the most recent from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Left-sided cardiac pacer is again noted\n with the tip of the electrode not visualized. Heart is enlarged. The aorta\n is mildly tortuous. There is no evidence of pneumonia, pleural effusion, or\n pneumothorax. There is no overt pulmonary edema.\n\n IMPRESSION: Cardiomegaly with no overt pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1130449, "text": " 12:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT ARM WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with c/o of L arm weakness, on coumadin, eval for ICH\n REASON FOR THIS EXAMINATION:\n ICH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:00 AM\n No ICH. If concerned for acute infarct MRI can be obtained.\n tiny air bubbles in the masticator space subq tissues, spinal canal and\n clinoid ar non-specisic. clinical correlation and follow-up ct in 6 hours can\n be helpful.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Left arm weakness, on Coumadin.\n\n COMPARISON: Head CT from .\n\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or\n -white matter differentiation abnormality. The ventricles and extra-axial\n spaces are appropriate for age. There is no osseous lesion to suggest\n malignancy or infection. A few gas bubbles within the masticator space around\n the mandible and inferior to the orbit within the subcutaneous tissues of the\n face, more on the right than left, are partially imaged and nonspecific. There\n is also a tiny focus of air in the spinal canal, likely extradural (2:1).\n There is also a tiny focus of air in the subcutaneous tissues of the forehead.\n Atherosclerotic calcifications of the intracranial carotid arteries are noted.\n Air in the left clinoid at the location of the carotid artery is also seen.\n\n IMPRESSION:\n 1. No acute intracranial abnormality. In case of clinical concern for acute\n infarction, an MRI can be obtained.\n\n 2. Gas within the spinal canal, masticator space, and left clinoid adjacent\n to the carotid artery. This is nonspecific and may potentially be secondary\n to recent line placement.\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1130458, "text": " 2:21 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PATHOLOGY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx CHF, fever with hypotension\n REASON FOR THIS EXAMINATION:\n eval obvious pathology\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 4:06 AM\n 1. no definite acute finding to explain pt sx's on this non- contrast CT.\n 2. Urinary bladder wall thickening likely under-distension\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: History of congestive heart failure, presents with fever and\n hypotension.\n\n COMPARISON: Multiple CTs of the abdomen and pelvis as well as chest\n radiographs with the most recent from earlier same date. Most recent CT\n abdomen and pelvis is from .\n\n TECHNIQUE: Multidetector CT images of the chest, abdomen and pelvis without\n administration of IV or oral contrast as per requested by ordering physician\n were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CHEST CT: Imaged thyroid gland is grossly unremarkable. There\n is a left-sided cardiac pacer with the lead terminating in the right\n ventricle. There is also a right internal jugular intravenous catheter with\n the tip at the mid-distal SVC. A few subcentimeter mediastinal lymph nodes\n with no evidence of lymphadenopathy are noted. There is no hilar or axillary\n lymphadenopathy on this non-contrast study. The aorta demonstrates\n atherosclerotic calcifications. Atherosclerotic calcifications of the\n coronary arteries are also seen. Heart is enlarged. There is no pericardial\n effusion. Bibasilar atelectatic changes and/or pneumonia, left more than\n right are noted. Mild emphysema is likely present. Calcified granulomas in\n the right lower lobe (2:46 and 2:30) are noted. There is no pneumothorax or\n pleural effusion.\n\n NON-CONTRAST ABDOMINAL CT: The unenhanced liver, spleen, pancreas, adrenals\n are unremarkable. Small pericholecystic fluid was also seen on prior study.\n Both kidneys are in normal anatomic location. A focal, somewhat band-like\n calcification in the interpolar region of the left kidney is stable since \n . There is a probable 2-mm nonobstructive stone in the inferior pole of\n the left kidney (2:74). There is no hydronephrosis. Abdominal aorta and\n iliac vessels demonstrate severe atherosclerotic calcifications with no\n aneurysmal dilatation. There is no retroperitoneal hematoma. Evaluation of\n the GI tract demonstrates no evidence of bowel obstruction or bowel wall\n thickening. Tubular blind ending structure in the right lower quadrant likely\n (Over)\n\n 2:21 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PATHOLOGY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n represents a normal appendix.\n\n NON-CONTRAST PELVIC CT: The urinary bladder is collapsed and contains a Foley\n catheter. Air within the urinary bladder is likely secondary to\n instrumentation. Bilateral small fat-containing inguinal hernias are seen.\n The rectum contains stool, otherwise unremarkable. Seminal vesicles are\n symmetric. The prostate gland measures about 5 cm in transverse diameter.\n The urinary bladder wall thickening may be secondary to underdistension. A\n few mildly prominent inguinal lymph nodes are noted. A hypoattenuating\n structure measuring 2.3 cm in the right lower abdomen to the right of the\n urinary bladder is stable.\n\n OSSEOUS STRUCTURES: There is no bony lesion to suggest malignancy or\n infection.\n\n IMPRESSION:\n 1. Left lower lobe atelectasis or pneumonia. Mild emphysema.\n 2. Small amount of pericholecystic fluid was also seen on prior study. Please\n clinically correlate.\n 2. Probable 2 mm nonobstructive left renal calculus.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130460, "text": " 3:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval RIJ CVL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new CVL placed\n REASON FOR THIS EXAMINATION:\n eval RIJ CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: New central venous line placement.\n\n COMPARISON: Multiple chest radiographs, with the most recent from at 23:16 p.m.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There has been interval placement of a\n right internal jugular venous catheter with the tip at the mid superior vena\n cava. There is no congestive heart failure. Heart is enlarged. The aorta is\n mildly tortuous. There is no pneumothorax or pleural effusion.\n\n IMPRESSION: No pneumothorax. Cardiomegaly.\n\n" } ]
20,925	108,197	Pt is a yo male with h/o PD, HTN, CAD who presented with a stable 6 mm left frontal SDH with SAH and small ICH after a mechanical fall. He was admitted to the neuro stepdown unit for close monitoring. We obtained further history to confirm that Mr did not lose consciousness or have another neurological event such as a seizure that may have prompted his fall. It appeared that it was solely a mechanical issue though. 1. C-spine clearance:He had flex/ex films of his C-spine that showed some mild spondylolisthesis, so a CT was recommended. This was obatined and essentially negative for fracture. An MRI was recommended to rulew out ligamentous injury, so this was also obtained. He had only mild ligamentous changes and no neck pain on exam, so his C-spine was cleared. 2. Neuro/SDH: The patient had a stable subdural hematoma after his fall. He had slight mass effect that was not causing symptoms during his admission. He hd a follow-up CT scan that showed no change in the bleed. He then had a follow-up MRI scan scan which showed stability of the bleeding. It also showed no evidence of stroke or other abnormality. Clinically, the patient displayed his baseline memory problems, but was otherwise pleasant and conversant throughout his stay on the floor. He had no complaints and no obvious neurological changes from his baseline. He did have a headache while he was here. Given the bleeding, we wanted to keep his BP well controlled and it stayed in a good range throughout. 3. Pulm:The patient had several episodes of wheezing while he was here. His respiratory rate and oxygen saturations remained normal throughout. A CXR was obtained and showed no obvious reason for these changes, but did show COPD. This may have been causing his wheezing. On speaking with his cregiver, he apparently has similar episodes at home. He was therefore sent home with a nebulizer machine and albuterol q6h prn. Albuterol wasn't used due to his heart condition. 4.CV:Pt was continued on his home antihypertensives and had no issues. He was also continued on his statin. 5.Parkinsonism:Pt was at his baseline neurologically from a Parkinsonism point of view. He was continued on Simemet and Celexa. He was seen by his outpatient neurologist. Also, the PT department taught his caregiver how to care for him better from a Parkinson's point of view. A hospital bed was sent to his house as well. His family wanted to take him home, so they arranged for more constant care for him and had their questions about home care answered by various staff members here. This was an acceptable arangement. They will watch closely to prevent further falls. He will follow up with Dr . He will see his PCP weeks. They can follow-up on his neurologic status, and discuss the need to get repeat CXRs to evaluate the nodule at the base of his left lung.	There is grade I retrolisthesis of C5 on C6 and slight anterior displacement of the anterior aspect of the spinous processes of C6 and C7 with mild narrowing of the spinal canal at these levels. IMPRESSION: Stable appearance of left-sided subdural hematoma, subarachnoid hemorrhage and intraventricular hemorrhage. CT HEAD WITHOUT IV CONTRAST: The left-sided hyperattenuating extraaxial collection consistent with a subdural hematoma is stable when compared to the previous exam. FS 124 ~ no regular insulin required.SKIN: hematoma l side of head. CT scan mild left to right shift, subdural/subarachnoid hematoma. There is a left frontal scalp hematoma. Incidental note is made of an ependymal cyst within the temporal of the right lateral ventricle. Chronic small vessel ischemic changes and an old, pontine infarct are again identified. NURSING NOTE 1900HRS-0400HRSADMIT WITH FALL CT SHOWED SLIGHT RT TO LFT SHUNT WITH SUDURAL/SUBARACHNOID HAEMATOMA....NEURO....BASELINE DEMENTIA WITH SHORT TERM MEMORY LOSS PLUS PARKINSONS...FAMILY HERE TO ESTABLISH BASELINE...IS ORIENTATAED TO PERSON/PLACE AWARE OF FAMILY MEMBERS AND NAMES OBJECTS...FIDIGITY AT BASELINE REQUIRING OBJECTS TO FIDDLE WITH...FULL POWER IN ALL 4 LIMBS AND PUPILS EQUAL/REACTIVE...REPAET HEAD CT LAST PM PLUS XR OF NECK [AWAITING REVIEW] UNABLE TO TAKE OF COLLAR AS OF YET AS PATIENT INCONSISTENT WHEN ASKED ABOUT PAIN...S/B NEURO @ 12MN TO HOLD OF MRI UNTIL THIS AM AS PATIENT STABLE...DENIES ANY PAIN/DISCOMFORT WHEN ASKEDCVS ...RECEIVED ON LABETELOL @ 0.5MGS /MIN TO MAINTAIN < 170...TITRATED DOWN AND SWITHCHED OF @ 12MN AS B/P CONSISTENTLY 140-160 HR @ 65-70BPM SINUS...AFEBRILE ..B/S STABLE...FLUIDS CONTINUE @ 85CC/HRRESP...LUNGS SOUND DIMINSHED BUT SATS MAINTAINED 92-98% RR SATISFACTORYGI...NO PO OVERNIGHT, ABDOMEN SOFT WITH BOWEL SOUNDS NO BOWEL MOTIONGU...VIA ILEOCONDUIT, SATISFACTORY AMOUNT, IV FLUIDS CONTINUESKIN...HAEMATOMA EVIDENT LEFT SIDE OF HEAD [ AREA DRY], NOW BRUISING EXTENDED DOWN TO LEFT EYE, BUT DOES NOT APPEAR TO BE AFFECTING EYE OPENING @ PRESENT...CONTINUE TO OBSERVELINES...X2 PERIPHERL PATENTSOCIAL..X2 DAUGHHTERS VISIST UPDATED LAST PMPLAN...OBSERVE NEURO STATUS, MRI TODAY ? CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is imaged from C1 through T3. Within the remainder of the cervical spine, there is marked multilevel degenerative change with loss of intervertebral disc space height and endplate sclerosis and osteophytosis, most prominent at C5-6 and C6-7. pt with repeat MRI of head (results pending) surgery cleared c-spine - neck collar removed. TECHNIQUE: Axial noncontrast MDCT images were obtained through the head. Hemorrhage is seen layering within the lateral ventricles bilaterally. no fracture of C-spine.PMH: bladder CA s/p vesicectomy and urostomy placement, Parkinson's Disease, HTN, Hyperlipidemia, CAD, CABG, dementia, short term memory loss, spinal stenosis, syncope.Allergies: ?percocet, strawberriesNEURO: pt w/ baseline dementia w/ short term memory loss, parkinsons, oriented to person only. The visualized outlines of the thecal sac appear slightly deformed at C5-6. The visualized portions of the mastoid air cells are normally pneumatized. The subarachnoid hemorrhage within the ambient cistern and layering over the left frontal and parietal lobes is also unchanged. Marked degenerative change with anterolisthesis of C2-3 and of C5-6. FINAL REPORT INDICATION: Head injury and large hematoma, assess for fracture. There is a focal area of sclerosis within the T4 vertebra on the left, a finding that is of uncertain significance and could possibly indicate a bone island. While these findings likely relate to degenerative change, if there is clinical symptomatology referable (Over) 1:43 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: assess for fracture FINAL REPORT (Cont) to these levels, MR of the cervical spine would be more useful for assessing for possible ligamentous injuries. Rotation of C1 upon C2 likely relates to patient head positioning. Marked multilevel degenerative change of the cervical spine with grade I anterolisthesis of C2 on C3 and of C5 on C6. TECHNIQUE: Axial MDCT images were obtained through the cervical spine without intravenous contrast. There is marked multilevel degenerative change of the cervical spine. The prevertebral soft tissues appear unremarkable. CT is limited in its ability to provide intrathecal detail. At C1-2, there is osteophytosis at the atlantoaxial articulation. There is grade I anterolisthesis of C2 on C3. 9:47 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: eval hemorrhage Admitting Diagnosis: HEAD BLEED MEDICAL CONDITION: year old man with SDH/SAH vs interparenchymal -- please schedule close to 22:00PM REASON FOR THIS EXAMINATION: eval hemorrhage No contraindications for IV contrast FINAL REPORT INDICATION: Subdural and subarachnoid hemorrhage. bp stable 148/56 HR 60's SR no vea.IVF D5NS w/ 20 meq kcl @ 85 cc/hrRESP: pt on RA O2 sats ~ 96% rr~20 lungs clear w/ decreased breath sounds @ bases.GI: was npo, on CV/heart healthy diet, grams NA, ground. Stable minimal rightward midline shift. Additional coronal and sagittal reformations are provided.	4	[ { "category": "Nursing/other", "chartdate": "2142-10-28 00:00:00.000", "description": "Report", "row_id": 1536614, "text": "NURSING NOTE 1900HRS-0400HRS\n\nADMIT WITH FALL CT SHOWED SLIGHT RT TO LFT SHUNT WITH SUDURAL/SUBARACHNOID HAEMATOMA....\n\n\n\nNEURO....BASELINE DEMENTIA WITH SHORT TERM MEMORY LOSS PLUS PARKINSONS...FAMILY HERE TO ESTABLISH BASELINE...IS ORIENTATAED TO PERSON/PLACE AWARE OF FAMILY MEMBERS AND NAMES OBJECTS...FIDIGITY AT BASELINE REQUIRING OBJECTS TO FIDDLE WITH...FULL POWER IN ALL 4 LIMBS AND PUPILS EQUAL/REACTIVE...REPAET HEAD CT LAST PM PLUS XR OF NECK [AWAITING REVIEW] UNABLE TO TAKE OF COLLAR AS OF YET AS PATIENT INCONSISTENT WHEN ASKED ABOUT PAIN...S/B NEURO @ 12MN TO HOLD OF MRI UNTIL THIS AM AS PATIENT STABLE...DENIES ANY PAIN/DISCOMFORT WHEN ASKED\n\n\nCVS ...RECEIVED ON LABETELOL @ 0.5MGS /MIN TO MAINTAIN < 170...TITRATED DOWN AND SWITHCHED OF @ 12MN AS B/P CONSISTENTLY 140-160 HR @ 65-70BPM SINUS...AFEBRILE ..B/S STABLE...FLUIDS CONTINUE @ 85CC/HR\n\n\n\nRESP...LUNGS SOUND DIMINSHED BUT SATS MAINTAINED 92-98% RR SATISFACTORY\n\n\nGI...NO PO OVERNIGHT, ABDOMEN SOFT WITH BOWEL SOUNDS NO BOWEL MOTION\n\n\nGU...VIA ILEOCONDUIT, SATISFACTORY AMOUNT, IV FLUIDS CONTINUE\n\n\nSKIN...HAEMATOMA EVIDENT LEFT SIDE OF HEAD [ AREA DRY], NOW BRUISING EXTENDED DOWN TO LEFT EYE, BUT DOES NOT APPEAR TO BE AFFECTING EYE OPENING @ PRESENT...CONTINUE TO OBSERVE\n\n\nLINES...X2 PERIPHERL PATENT\n\n\nSOCIAL..X2 DAUGHHTERS VISIST UPDATED LAST PM\n\n\nPLAN...OBSERVE NEURO STATUS, MRI TODAY ? D/C NECK COLLAR\n" }, { "category": "Nursing/other", "chartdate": "2142-10-28 00:00:00.000", "description": "Report", "row_id": 1536615, "text": "7A-7pm npn/ NSG TRANSFER NOTE\n y.o. male admitted to PMICU (on T-SICU team) s/p fall A home. CT scan mild left to right shift, subdural/subarachnoid hematoma. no fracture of C-spine.\n\nPMH: bladder CA s/p vesicectomy and urostomy placement, Parkinson's Disease, HTN, Hyperlipidemia, CAD, CABG, dementia, short term memory loss, spinal stenosis, syncope.\n\nAllergies: ?percocet, strawberries\n\nNEURO: pt w/ baseline dementia w/ short term memory loss, parkinsons, oriented to person only. MAE, asking for something to drink, HOB elevated 30 degrees, pupils 3mm equal and reactive to light. pt with repeat MRI of head (results pending) surgery cleared c-spine - neck collar removed. no seizure activity. dilantin d'cd. pt get oob w/ assistance. napping on/off. family in at bedside - helps pt stay in bed, pt fidgeting - SR up x4, bed alarm on\nPT/OT consult needed (ordered)\n\nCV/fluids: Labetolol gtt d'cd, pt restarted on 20 mg Lisinopril po qd, Atenolol 25 mg po qd. bp stable 148/56 HR 60's SR no vea.\nIVF D5NS w/ 20 meq kcl @ 85 cc/hr\n\nRESP: pt on RA O2 sats ~ 96% rr~20 lungs clear w/ decreased breath sounds @ bases.\n\nGI: was npo, on CV/heart healthy diet, grams NA, ground. taking sips of H20\nno stool, belly soft, on colace Pantoprazole 40 nmg IV q 24 hrs.\n\nGU: ileoconduit intact, draining clear, yellow urine 40-60 cc/hr\n\nENDO: FS q 6 hrs and cover w/ regular insulin. FS 124 ~ no regular insulin required.\n\nSKIN: hematoma l side of head. right eye w/ blood shot. no breakdown on coccyx. turned side to side.\nabrasion on left elbow and lower arm (from fall)\n\nLINES: 2 peripherals # 20/ #18\n\nSOCIAL: married, lives w/ wife, has a caretaker during the week from 8-5pm to help out. 2 daughters~very involved, full code\n \nWife \n\nA: s/p fall ~ subdural/subarachnoid hemorrhage of left fronto-parietal area\n\nP: continue neuro checks, PT/OT consults, oob to chair, hrt healthy diet, follow bp/hr/O2 sats, monitor hematoma, safety precautions.\n" }, { "category": "Radiology", "chartdate": "2142-10-27 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 881644, "text": " 1:43 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with head injury, and large hematoma\n REASON FOR THIS EXAMINATION:\n assess for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 3:07 PM\n No fracture.\n Marked degenerative change with anterolisthesis of C2-3 and of C5-6.\n These may relate to degenerative change although if evaluation for ligamentous\n injury is of clinical interest, MR is a more sensitive test.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head injury and large hematoma, assess for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\n intravenous contrast. Additional coronal and sagittal reformations are\n provided.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\n imaged from C1 through T3. No fracture is identified in the cervical spine.\n There is marked multilevel degenerative change of the cervical spine. At\n C1-2, there is osteophytosis at the atlantoaxial articulation. In addition,\n there is questionable lucency at the superior aspect of the dens, which could\n represent erosion versus a superiorly projecting curvilinear osteophyte.\n Rotation of C1 upon C2 likely relates to patient head positioning. There is\n grade I anterolisthesis of C2 on C3. Within the remainder of the cervical\n spine, there is marked multilevel degenerative change with loss of\n intervertebral disc space height and endplate sclerosis and osteophytosis,\n most prominent at C5-6 and C6-7. There is grade I retrolisthesis of C5 on C6\n and slight anterior displacement of the anterior aspect of the spinous\n processes of C6 and C7 with mild narrowing of the spinal canal at these\n levels. The visualized outlines of the thecal sac appear slightly deformed at\n C5-6. CT is limited in its ability to provide intrathecal detail. The\n prevertebral soft tissues appear unremarkable.\n\n The visualized portions of the mastoid air cells are normally pneumatized.\n Note is made of prominent vascular calcifications. The visualized portions of\n the lung apices demonstrate no pneumothorax. There is a focal area of\n sclerosis within the T4 vertebra on the left, a finding that is of uncertain\n significance and could possibly indicate a bone island.\n\n IMPRESSION:\n 1. No fracture of the cervical spine.\n 2. Marked multilevel degenerative change of the cervical spine with grade I\n anterolisthesis of C2 on C3 and of C5 on C6. While these findings likely\n relate to degenerative change, if there is clinical symptomatology referable\n (Over)\n\n 1:43 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to these levels, MR of the cervical spine would be more useful for assessing\n for possible ligamentous injuries.\n 3. Sclerotic T4 vertebral body lesion may represent a bone island.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 881685, "text": " 9:47 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval hemorrhage\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with SDH/SAH vs interparenchymal -- please schedule close to\n 22:00PM\n REASON FOR THIS EXAMINATION:\n eval hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural and subarachnoid hemorrhage.\n\n COMPARISONS: Eight hours earlier.\n\n TECHNIQUE: Axial noncontrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: The left-sided hyperattenuating extraaxial\n collection consistent with a subdural hematoma is stable when compared to the\n previous exam. The subarachnoid hemorrhage within the ambient cistern and\n layering over the left frontal and parietal lobes is also unchanged. No new\n intracranial hemorrhage is identified. Hemorrhage is seen layering within the\n lateral ventricles bilaterally. There is a left frontal scalp hematoma. The\n minimal rightward midline shift is stable. The paranasal sinuses are well\n aerated. Chronic small vessel ischemic changes and an old, pontine infarct\n are again identified. Incidental note is made of an ependymal cyst within the\n temporal of the right lateral ventricle.\n\n IMPRESSION: Stable appearance of left-sided subdural hematoma, subarachnoid\n hemorrhage and intraventricular hemorrhage. Stable minimal rightward midline\n shift.\n\n" } ]
91,929	100,463	63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole 5 years ago admitted with acute change in mental status.	Endotracheal tube has been removed, as has the nasogastric tube. FINDINGS: There are postoperative changes seen in the right side from prior subdural hematoma evacuation. Consider prior anteroseptal myocardialinfarction. FINAL REPORT HISTORY: Altered mental status and intubation for airway protection. Bilateral low lung volumes are noted with crowding of bronchovascular markings. Interval extubation and removal of enteric catheter. Minimal poor definition of pulmonary vessels could reflect slight elevation of pulmonary venous pressure. Left hemidiaphragm is more sharply seen, consistent with some decrease in volume loss in the left lower lobe. Mild brain atrophy identified. Cardiac silhouette is accentuated by low lung volumes. pin projects over left tracheal margin. FINAL REPORT HISTORY: Possible right lower lobe consolidation. REASON FOR THIS EXAMINATION: RLL pneumonia? Blunting of costophrenic angles could reflect small effusions or pleural thickening. FINDINGS: In comparison with the study of , there again are lower lung volumes. pneumonia WET READ: EHAb MON 9:02 PM Right perihilar and left retrocardiac densities most likely represent atelectasis, but pneumonia cannot be excluded. ET tube is at the carina and should be repositioned. Poor R wave progression. Additionally, opacification at the left lung base and in the retrocardiac region appears concerning for either pleural effusion versus atelectasis, infectious process such as pneumonia cannot be completely excluded in the correct clinical setting. Non-specific lateral ST segment changes. WET READ VERSION #1 FINAL REPORT EXAM: CT head. CLINICAL INFORMATION: Patient with headache , recent confusion leading to fall and change in mental status and history of subdural hematoma. Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman s/p extubation with possible R LL consolidation. Cardiac silhouette is within upper limits of normal or slightly enlarged. 12:04 PM CHEST (PA & LAT) Clip # Reason: RLL pneumonia? Postoperative changes. No definite pneumonia is appreciated, though in the appropriate clinical setting a supervening consolidation would be difficult to exclude in lower zones. However, in the appropriate clinical setting, supervening pneumonia would have to be considered. 5:15 AM CHEST (PORTABLE AP) Clip # Reason: eval tube position MEDICAL CONDITION: History: 63F with intubated REASON FOR THIS EXAMINATION: eval tube position FINAL REPORT INDICATION: 63-year-old intubated, evaluate tube position. PORTABLE AP CHEST RADIOGRAPH: A feeding tube is noted with tip at the level of the gastric antrum. 6:56 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ? pain projects over the left tracheal margin. Sinus rhythm. 11:51 AM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed or other acute pathology Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman with 9/10 HA since yesterday, recent confusion leading to a fall and change in mental status, with h/o subdural hematoma s/p craniotomy 5yrs ago REASON FOR THIS EXAMINATION: r/o bleed or other acute pathology No contraindications for IV contrast WET READ: AFSN WED 1:03 PM No acute abnormalities are seen. pneumonia Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman admitted for altered mental status and intubated for airway protection now extubated REASON FOR THIS EXAMINATION: ? TECHNIQUE: Axial images of the head were obtained without contrast. FINDINGS: In comparison with the earlier study of this date, the lung volumes have improved. IMPRESSION: No acute intra- or extra-axial hemorrhage, mass effect, or hydrocephalus seen. No previous tracingavailable for comparison. No pneumothorax or pleural effusion detected on this single view. COMPARISON: NONE. There is no acute intra- or extra-axial hemorrhage, mass effect or midline shift seen. There are no prior similar examinations for comparison. Findings were discussed with Dr. at 6:11 a.m. on via telephone at the time of discovery of critical findings.	5	[ { "category": "Radiology", "chartdate": "2109-07-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1251452, "text": " 12:04 PM\n CHEST (PA & LAT) Clip # \n Reason: RLL pneumonia?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p extubation with possible R LL consolidation.\n REASON FOR THIS EXAMINATION:\n RLL pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible right lower lobe consolidation.\n\n FINDINGS: In comparison with the study of , there again are lower lung\n volumes. Cardiac silhouette is within upper limits of normal or slightly\n enlarged. Minimal poor definition of pulmonary vessels could reflect slight\n elevation of pulmonary venous pressure. Blunting of costophrenic angles could\n reflect small effusions or pleural thickening.\n\n No definite pneumonia is appreciated, though in the appropriate clinical\n setting a supervening consolidation would be difficult to exclude in lower\n zones.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-07-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1251563, "text": " 11:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed or other acute pathology\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with 9/10 HA since yesterday, recent confusion leading to a\n fall and change in mental status, with h/o subdural hematoma s/p craniotomy\n 5yrs ago\n REASON FOR THIS EXAMINATION:\n r/o bleed or other acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AFSN WED 1:03 PM\n No acute abnormalities are seen.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT head.\n\n CLINICAL INFORMATION: Patient with headache , recent confusion leading to\n fall and change in mental status and history of subdural hematoma.\n\n TECHNIQUE: Axial images of the head were obtained without contrast. There\n are no prior similar examinations for comparison.\n\n FINDINGS: There are postoperative changes seen in the right side from prior\n subdural hematoma evacuation. There is no acute intra- or extra-axial\n hemorrhage, mass effect or midline shift seen. Mild brain atrophy identified.\n\n IMPRESSION:\n No acute intra- or extra-axial hemorrhage, mass effect, or hydrocephalus seen.\n Postoperative changes.\n\n" }, { "category": "Radiology", "chartdate": "2109-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251277, "text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 63F with intubated\n REASON FOR THIS EXAMINATION:\n eval tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old intubated, evaluate tube position.\n\n COMPARISON: NONE.\n\n PORTABLE AP CHEST RADIOGRAPH:\n A feeding tube is noted with tip at the level of the gastric antrum. ET tube\n is at the carina and should be repositioned. Bilateral low lung volumes are\n noted with crowding of bronchovascular markings. Cardiac silhouette is\n accentuated by low lung volumes. Additionally, opacification at the left lung\n base and in the retrocardiac region appears concerning for either pleural\n effusion versus atelectasis, infectious process such as pneumonia cannot be\n completely excluded in the correct clinical setting. Findings were discussed\n with Dr. at 6:11 a.m. on via telephone at the time of\n discovery of critical findings.\n\n" }, { "category": "Radiology", "chartdate": "2109-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251364, "text": " 6:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman admitted for altered mental status and intubated for airway\n protection now extubated\n REASON FOR THIS EXAMINATION:\n ? pneumonia\n ______________________________________________________________________________\n WET READ: EHAb MON 9:02 PM\n Right perihilar and left retrocardiac densities most likely represent\n atelectasis, but pneumonia cannot be excluded. No pneumothorax or pleural\n effusion detected on this single view. Interval extubation and removal of\n enteric catheter. pin projects over left tracheal margin. Discussed with\n by phone at 9 p.m. on at the time of initial review\n of the study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status and intubation for airway protection.\n\n FINDINGS: In comparison with the earlier study of this date, the lung volumes\n have improved. Endotracheal tube has been removed, as has the nasogastric\n tube. Left hemidiaphragm is more sharply seen, consistent with some decrease\n in volume loss in the left lower lobe. However, in the appropriate clinical\n setting, supervening pneumonia would have to be considered.\n\n pain projects over the left tracheal margin.\n\n\n" }, { "category": "ECG", "chartdate": "2109-07-29 00:00:00.000", "description": "Report", "row_id": 306764, "text": "Sinus rhythm. Poor R wave progression. Consider prior anteroseptal myocardial\ninfarction. Non-specific lateral ST segment changes. No previous tracing\navailable for comparison.\n\n" } ]
899	188,576	71 year old male admitted from outside hospital with mitral valve endocarditis, R PCA infarcts, and ATN for preop evaluation. He underwent preoperative workup including cardiac catherization and infectious disease consult. Cardiac catherization mild single vessel coronary artery disease. He received hydration and creatinine was monitored closely. On he was brought to the operating room and underwent mitral valve replacement #27mm porcine valve. Please see operative report for further details. He was transferred to the cardiac surgery recovery unit requiring vasopressors and blood products. He returned to the operating room that evening due to bleeding and widened mediastinum. He returned to the CSRU and postoperative day 1 he was weaned from vasopressors and sedation. He awoke and responded to voice, weaned to pressure support. On postoperative day 2 he was extubated, chest tubes removed, and transferred to the floor. He continued to progress but on postoperative day 4 he was in atrial fibrillation with hypotension and returned to the CSRU for monitoring and vasopressors. He continued to be in and out of atrial fibrillation and sternal click noted with no drainage. Then on postoperative day 8 there was sternal drainage, erythema, and tenderness. He became asystolic, intubated, and returned to the operating room for reexploration . He returned to with open chest on Nimbex. Plastic surgery was consulted, VAC dressing was placed until he was ready for sternal closure. He was weaned off pressors and underwent flap closure . He required returns to the operating room for sternal exploration due to bleeding. He has continued to progress since sedation was weaned and he underwent a tracheostomy due to failure to wean from the ventilator.	Mild (1+) aortic regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Myxomatous mitral valve leaflets. The right ventricular cavity is mildly dilated.There is mild global right ventricular free wall hypokinesis. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Coccyx maserated with 1 small area of breakdown Dudoerm applied. Mild global RV free wallhypokinesis.AORTA: Mildly dilated ascending aorta. LSC(UNDER BINDER)GU/GI ADEQUATE HOURLY U/O.ABD SOFT. Trivial mitral regurgitation is seen. NIMBEX GTT LEFT AT CURRENT DOSE. replete lytes prn. Cont vasopressin gtt. Amio gtt off d/t HR/rhythm. cpt q2h. wean neo as tol. Dopperable pulses. CREAT STABLE, K+ REPLETED.SKIN: MOD AMT SEROUS DRNG WEEPING FROM UE'S. cdb q1h. FENTANYL AND ATIVAN GTT LEFT AT CURRENT DOSE. tolerating po liquids. ADDITIONAL AMIO IV BOLUS GIVEN AND HR CURRENTLY NSR 89, BP 113/61 AND WEANING NEO. nebs given by rt. pan cx done. Cont abx. Perrla. F/U w/hct, platelets & coags. SpO2 90s, MDIs given as ordered, tan secretions. R ln placed in , oozing slightly.A/P: continue to monitor cv, resp. +dopp pp bilat. k+ & ca low->lytes repleted. Pulses dopplerable. Minimal residual via Dob-hoff. Sputum sample sent.GI/GU: Abdomen soft, nondistended. og->lws w/billious drainage. Small amount of serosanguionous from vac drainage. VAP mouth care done. Resuscitated and take to OR for sternal debridement, laparoscopic mediastinoscopy. lytes repleted KCL, CA gluc. OGT DRG BILIUS SECRETIONS. 0935. remains intubated. shift update:s/p sternal wash & vac dsg applied. Respiratory Care Note: Vent settings unchanged t/o shift. TITRATE NEO PER BP PARAMETERS. Neosynephrine weaning. MDI PER RT. CONT TO HAVE GENERALIZED ANASARCA. requiring ^ doses of neo.+ Resp. Pulses confirmed by doppler. Administering Combivent MDI in line with vent Q4hrs. cr 1.2.endo: fs qid, cover per riss.plan: ? ADDENDUM: RT FEN AND LT CORDIS DC'D AND TIP SENT FOR CX. fluid resussitation as ordered. OR MON IF MORE STABLE PER DR. . START TFGU: UOP GOOD, FOLEY PATENT. PERRLA. Dopoff was coiled in throat, removed this am and new one placed. REPOSOTIONING.DIURESE. hypo bsp. PERRLA.CV: RSR->SB w/o ectopy. Drsg , /staples. extrs w/d. LOPRESSOR HELD AT .GENERALIZED ANASARCA. good diuresis w/lasix.endo: fs covered w/ssri per protocol.id: afebrile. ogt to lwsx for bilous dng. Cisatricurium weaned. 1x ivp lasix w/+diuresis. Has RIJ cath, drsg . Continues on Amiodarone. SCAN NEG. vanco d/c this am. GENERALIZED ANASARCA. Suctioned for mod amts tan sputum. Amiodarone gtt. Confirmed by CXR. Has RIJ cath. PERRLA. On PO amio & lopressor. Sternal drsg w/ old drng prox end. creatinine pnd. Sternal click palpated with NT suctioning and CDB, PA aware. sent am vanco dose. SQ Heparin for DVT prophylaxis. +anasarca, DP, PT by doppler. sent vanco level am. Dopplerable pulses bilat. Picc line to RAC, Multilumen to RIJ, R radial Aline.RESP: LS coarse with EXP whzs. gu: diuresis w lasix regimen. +hypoactive BS ABD soft. VAP care done.GI/GU: abd soft, distended with ecchy areas. gave po lopressor dose. treated wtih bicarb. +3 bilat UE/LE pitting edema. Nebs per RT.GU/GI: Foley to gravity. Occ wheeze noted after suct. Cont on triple abx.GI/GU: Abd softly dist. bs hypoactive. Wean sedation again in am. foley to gravity, low uo treated with volume with good effect.endo: fs qid, cover per riss.plan: s/p omental flap, jp x 3, wean sedation this am. UOP wnl, low last hr.Skin: See flowsheet. gave reglan. hypoactive bs. Neo weaned to off. Wean vasopressin as tolerated. K repleted.Resp: Pt remains intubated on cpap. Advance TF as tolerated. 7a-7pNeuro: Nimbex d/c'd this am. Check abg in am, ?wean vent accordingly as pt tolerates. Ecchymosis accross mid abd L>R. SQ Heparin for DVT prophylaxis. penile & scrotum edema noted. Vasopressin gtt cont. DP/PT diff. vac drsg . Metoprolol PO TID. paralytic and fent/ativan titrated up. +3 bilat LE pitting Edema. +peripheral edema. ON FENATNYL/PROPOFOL/NIMBEX GTTS. ALB/ATR nebs per RT. Occassional resp effort, cough noted. CXR done. Scrotal edema noted. Resp. PT/DP doppler. Dopplerable pulses bilat. pit added and neo weaned as . Wean neo gtt as . neg bowel sounds. Lytes repleted prn. DP/PT doppler.RESP: intubated. monitor sternal incis. SBP labile, see carevue, on and off neo. Pulses dopplerable. Pulses dopplerable. Sternal sutures cdi, covered w/ gauze and abd. Wean neo of tolerated. MDI's given. Generalized anasarca. Dophoff +placement. Monitor JP drng amt. MDI per RT. ETT repostioned and retaped. Nodding appropriatley. MDIs per RT. Hct stable s/p tx. ABD softly distended with +BS. PERLLA. Perrla. Wean neo as VS alow. See and Carevue for detailed documentationNeuro: Remains on ativan, fentanyl, nimbex. Afebrile. Afebrile. Afebrile. Afebrile. BS clear, diminished bliaterally in bases. The right internal jugular line terminates in mid SVC. There is marked suboptimal evaluation as the entire lateral aspect of the right hemithorax is excluded. Sinus tachycardia - Regular supraventricular rhythmPossible old inferior infarctGeneralized low QRS voltagesSince previous tracing, decreased voltages present The right internal jugular sheath terminates in the proximal SVC. d/c rt pleural tube. The patient is semierect. be sinus bradycardia with left atrial abnormality but consider also ectopicatrial rhythmLow QRS voltageProlonged Q-Tc intervalClinical correlation is suggestedSince previous tracing of , sinus tachycardia absent Decrease in pleural effusions is noted bilaterally. Decreased pleural effusions bilaterally. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is beam hardening artifact limiting evaluation. Left internal jugular sheath is present as before. There is a right pleural effusion with associated atelectasis. Bilateral pleural effusions are again noted. Again seen are bilateral pleural effusions, layering posteriorly. A Swan-Ganz catheter has been replaced. Right occipital lobe lesion as described above, of uncertain etiology. There are low attenuations within both kidneys, in the region of the prior described cyst. Near total resolution of the right pleural effusion after pleural catheter placement. Now status post right thoracentesis with catheter placement. Postoperative since with sternal revision and open chest. Position of previously described tracheotomy cannula, right subclavian central venous line unchanged. Resolving left cardiophrenic hematoma. Now status post right-sided thoracocentesis with catheter placement. Rule out hematoma. Bilateral layering pleural effusions are again noted. FINDINGS: Compared with 11/28, the right pleural catheter is no longer identified. FINDINGS: Supine portable abdominal radiograph reviewed.	233	[ { "category": "Echo", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 80459, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Dizziness. Shortness of breath. Source of embolism.\nHeight: (in) 65\nWeight (lb): 152\nBSA (m2): 1.76 m2\nBP (mm Hg): 127/73\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 09:03\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe echo findings were read in conjunction with DR/ .\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). [Intrinsic\nLV systolic function likely depressed given the severity of valvular\nregurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated ascending aorta. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Mild thickening of mitral\nvalve chordae. Torn mitral chordae. Moderate to severe (3+) MR. Eccentric MR\njet.\n\nTRICUSPID VALVE: TR present - cannot be quantified.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n\n1. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.] The left ventricular cavity size is normal.\n2.Moderate to severe (4+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric. The mitral valve leaflets are myxomatous. Torn\nmitral chordae are present. Flail anterior leaflet mitral valve.\n3. The left atrium is moderately dilated. No atrial septal defect is seen by\n2D or color Doppler.\n4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n5. Right ventricular chamber size and free wall motion are normal.\n6. Tricuspid regurgitation is present but cannot be quantified.\n7. Mild pulmonary insuficiency.\n8. The ascending aorta is moderately dilated. Mild simple atheroma in the\ndescending aorta.\n\n\nPOST-BYPASS:\n\n1. Preserved -ventricular systolic function.\n2. Bioprosthteic mitral valve is seated in good position without evidence of\nperivalvular leak. Trace mitral regurgitation. No evidence of mitral stenosis.\nMean gradient of 4 mm Hg.\n3. Rest of study is unchanged from pre-bypass.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-18 00:00:00.000", "description": "Report", "row_id": 80460, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. ?Mitral valve disease.\nHeight: (in) 65\nWeight (lb): 153\nBSA (m2): 1.77 m2\nBP (mm Hg): 83/50\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 08:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. [Intrinsic LV systolic\nfunction likely depressed given the severity of valvular regurgitation.] No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nModerately dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Large vegetation on mitral valve. Torn mitral chordae. Moderate\n(2+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. [Intrinsic left ventricular systolic function is likely\nmore depressed given the severity of valvular regurgitation.] Right\nventricular chamber size and free wall motion are normal. The aortic root and\nascending aorta are moderately dilated. The aortic valve leaflets (3) appear\nmildly thickened but without aortic stenosis. No discrete vegetation is seen\n(cannot be excluded). Mild-moderate (+) aortic regurgitation is seen. The\nmitral leaflets are moderately thickened. A highly mobile, 3.5cm long x 0.6cm\nwide echodensity is seen attached to the left atrial side of the anterior\nmitral leaflet and herniating through the mitral oriface during diastolie and\ninto the body of the left atrium in systole. A second ?8mm ovoid mobile\nechodensity is seen on the left atrial side of the posterior leaflet. These\nare most c/w vegetations. An eccentric jet of at least moderate (2+) mitral\nregurgitation is seen.The tricuspid valve leaflets are mildly thickened. Mild\nto moderate tricuspid regurgitation is seen. There is borderline pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Probable vegetations on the mitral valve with at least moderate\nmitral regurgitation. Mild-moderate aortic regurgitation. Dilated ascending\naorta. Preserved global and regional biventricular systolic function.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 80423, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Congenital heart disease. Endocarditis. Left ventricular function. Prosthetic valve function. Pulmonary embolus.\nStatus: Inpatient\nDate/Time: at 11:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nEmergency TEE study in the operating room following an episode of\ncardiopulmonary arrest.\nLEFT ATRIUM: Normal LA size. No thrombus/mass in the body of the LA. Good (>20\ncm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right\nshunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated ascending aorta. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Normal MVR leaflet\nmotion. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nPRE-BYPASS: The left atrium is normal in size. No thrombus/mass is seen in the\nbody of the left atrium. A patent foramen ovale is present. A left-to-right\nshunt across the interatrial septum is seen at rest. Left ventricular wall\nthicknesses and cavity size are normal. The remaining left ventricular\nsegments contract normally. The right ventricular cavity is mildly dilated.\nThere is mild global right ventricular free wall hypokinesis. The ascending\naorta is mildly dilated. There are simple atheroma in the descending thoracic\naorta. There are three aortic valve leaflets. The aortic valve leaflets are\nmildly thickened. Mild (1+) aortic regurgitation is seen. A bioprosthetic\nmitral valve prosthesis is present. The motion of the mitral valve prosthetic\nleaflets appears normal. Trivial mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is a small pericardial effusion\nwith no evidence of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-23 00:00:00.000", "description": "Report", "row_id": 80524, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Pericardial effusion.\nHeight: (in) 63\nWeight (lb): 154\nBSA (m2): 1.73 m2\nBP (mm Hg): 106/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:02\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). R. A bioprosthetic mitral valve prosthesis is present. There is a\nmoderate sized circumferential pericardial effusion. There are no\nechocardiographic signs of tamponade.\nIMPRESSION: Moderate-sized pericardial effusion without echocardiographic\nsigns of tamponade.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273386, "text": "Neuro: Pt moving upper extremities (lifting and holding) and moving lower extremities on bed. Will move toes and squeeze hands to command. Will also nod yes/no to questions. Pt given Tramodol X1 for incisional pain (pt motioned to chest when asked if in pain).\n\nCV: Pt in NSR entire shift with occasional PAC's. T max 98.4. Palpable pedal pulses. Received Lopressor 25 mg PO and Amio 200 mg PO.\n\nID: Pt receiving Ceftriaxone and Ampicillin. WBC increasing.\n\nResp: Pt on trach collar 15L, 50% FiO2. MDI's given. Inner cannula changed and trach care performed. Lung sounds coarse. Pt not able to mobilize secretions to mouth. Pt suctioned for moderate amt thick tan sputum q2-4 hrs. Passey muir trial performed by speech and swallow. Pt has weak voice-hard to hear.\n\nGI/GU: Pt has been NPO since midnight for US procedures. Started back on TF via Dobhoff @ 1700 (Nutren 2.0 full strength with beneprotein). Pt had speech and swallow exam. Specialist stated that pt would have to perform a video swallow in order to find if pt is not aspirating. Pt has 1 JP drain which drained 45cc serosanguinous draingage this shift. Pt voiding clear, yellow urine via Foley of SQ. Pt had 1 formed brown BM.\n\nProcedures: Pt had US of liver/gallbladder and sinuses.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Reddened area around coccyx-unbroken. Aloe vesta cream applied.\n\nA/P: Pulm toilet. Prepare for rehab. Pt scheduled for MRI.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-03 00:00:00.000", "description": "Report", "row_id": 1273387, "text": "NEURO: ALERT, NODDING/SHAKING HEAD TO QUESTIONS, ATTEMPTING TO MOUTH WORDS BUT NOT ABLE TO READ HIS LIPS. AT ONSET OF SHIFT PT PICKING AT NOSE AND PERIPHERAL IV, BITING AT BLUE CLAMP IN PERIPHERAL IV. SOFT LIMB RESTRAINTS TO BOTH WRISTS. TRAMDOL 50MG AT HS FOR GRIMACING WITH TURNING. ON MRI SCHEDULE.\n\nPULM: TRACH COLLAR ALL SHIFT, SATS 99-100%. LUNGS DIMINISHED BASES. STRONG COUGH, EXPECTORATED SMALL AMT GREEN TINGED THICK TAN SECRETIONS OUT TRACH. VAP PROTOCOL, HOB >30 DEGREES.\n\nCV: SR WITH OCC PAC'S. SBP DOWN LOW 80'S AFTER LOPRESSOR. PALPABLE PEDAL PULSES. D5W AT 100CC/HR DECREASED TO 50C/HR AT 0600, NA 145. WBC DOWN. AFEBRILE. ON AMPICILLIN AND CEFTRIAXONE.\n\nENDO: QID FSBS WITH SSRI COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. + PLACEMENT OF DOBHOOF BY AUSCULTATION X 3. >100CC RESIDUAL AT 2400 FROM DOBHOOF, FEEDING HELD X 2H, RESUMED AT 0300.\n\nGU: FOLEY TO CD QS YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: MRI THIS AM. FOLLOW WBC AND TEMP, AWAIT BLD CX RESULTS, ADJUST ANTIBX AS NEEDED. DISCHARGE TO REHAB WHEN SURGICALLY CLEARED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273223, "text": "NURSING NOTE 1100-1900 EDT\nREVIEW CAREVUE FOR ALL OBJECTIVE DATA\n\nNEURO:LETHARGIC, AROUSABLE TO SPEECH, UNDERSTANDS HE IS IN THE HOSPITAL. HE FOLLOWS SIMPLE COMMANDS, ABLE TO LIFT AND HOLD UPPER EXTRIMITIES AND MOVES LL ON THE BED. ANSWERS YES/NO WHEN QUESTIANS ASKED.C/O PAIN INSICINAL SITE WHEN MOVING, NO MEDS NEEDED.\n\nCVS: HR 70-110, NO ECTOPY NOTED, SBP 90-100, CONTINUED ON NEO 0.5 MIC/KG/MIN. RECEIVED LASIX,PO METPROLOL 25 DOWN TO 12.5MG TID. K 3.7 REPLETED WITH 20MEQ.AMIADRONE D/CED IN AM.\n\nRESP:O2 50% ON FT, O2 SATS >95-98. UNPRODUCTIVE CONGESTED COUGH, NEEDS FREQUENT NASOTRACH SUCTION AND CPT, COPIOUS YELLOW THICK SECREATION. BILATERAL LS COARSE AND DIMINISHED AT THE BASE. ENCOURAGED DEEP BREATHING AND COUGH.\n\nGI/GU: POOR APPETITE, REFUSED TO EAT OR DRINK. ABD SOFT DISTENDED.URINE VIA FOLEY'S CATHETER, YELLOW CLEAR, LASIX IN AM WITH GOOD EFFECT.\n\nSKIN: STERNAL AND MEDIST DRESSING INTACT, RT HAND EDEMATOUS AND GENARALIZED EDEMA PRESENT. HEMATOMA NOTED ON ABD.\n\nID: AFEBRILE, CONTINUED ON VANCO, AMPICILLIN,AND ADDED CEFEPIME.\n\nPLAN: CONTINUE PUL TOILET, WEAN NEO AS TOLERATED, REPLETE LYTES AS NEEDED. ENCOURAGE D/COUGH, AND DIET.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273279, "text": "Respiratory Care\nPt intubated on ventilatory support. Vent settings unchanged this shift ABGs remain acceptable. planned for possible OR procedure today.\nNo vent weaning at this time.\u0013\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273280, "text": "7p-7a\n\nNeuro: Paralyzed on Cisatracurium .3-.33mcg/kg/hr. revealing eye twitches. Sedated on Ativan 1.25-1.5mg/hr. Pain control Fentanyl 70 mcg/hr. Tyradine self rotating bed.\n\nCV: SR-ST up to 115. Lopressor 2.5 mg iv, hr down to 80's. SBP 90-one teens. Presently MAP >100 with care. (increasing Ativan) To start po lopressor this am.\nGums cont to bleed. Also rt eye bloody. (Erythromycin ointment started for eye) Hct stable. PTT ^56.3 from 49.7 team aware.\nChest open, vac dsg to vac sxn. Plastic team in to see pt, no OR today as pressors were just stopped yest eve.\n\nResp: Lungs coarse. Suctioned by RT for green/yellow plugs. Sats 99% on SIMV 60%.\n\nGI/GU: Abd soft, distended with hard lumps from heparin injections. Sm mucousy brown stool this am. Large amts yellow urine out via foley. Nepro tf cont at 40/hr.\n\nSkin: Chest with vac dsg to sxn. Left arm pinhole bleed covered with dsg. Chest tube sites dsg changed- 2 sites open with sang drainage- dress with dsd only per . Duoderm to bottom .\n\nSocial: proxy called overnight, updated.\n\nPlan: Cont to monitor hemodynamics and resp status closely. Monitor chest. To OR for chest closure when Plastics feels pt is ready (off pressors for long enough). Monitor .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273281, "text": "resp care - Pt remains paralyzed and intubated on SIMV+PS 500/16/5/5 .60. RR was increased to 16, resulting in an ABG within normal limits. BS were clear, diminished in bases. MDIs given as ordered.\nContinued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273250, "text": "Neuro: pt paralyzed and sedated with Cisatracurium, Fentanyl and Ativan. Pt has 2 faint twitches on . no coughing noted when suctioned. Ativan decreased to 3mg 2nd to hypotension. No change in vitals noted with stimulation with decreased dose. Pupils equal in size but noreactive.\nResp: No vent changes made sats 98% suctioned for amounts.\nC/V: Pt in and out of afib and NSR most of night. WHen in afib BP would dip into the low 80's when back in NSR BP would be 90's to low100's. But SBP SBP slowly decrease through night even in NSR requiring more Neo presently on at 3mcg with SBP in the mid to high 80's. HO aware to discuss adding another pressor on rounds. Lytes treated as ordered.\nGI: Feeding tube placed by O and xray done to verify placement. Pt started on Tube feeds at 10cc/hr. Hypoactive Bowel sounds present.\nEndo: blood sugars well controlled No insulin required.\nGU: adequate urine outputs. 80-150cc/hr.\nSkin: pt leaking serous fluid from arms and legs. Coccyx maserated with 1 small area of breakdown Dudoerm applied. pt has red rash on his whole coccyx area. 2 small nickel sized skin tears on either hand oozing serous fluid. Vac dressing on chest intact.\nPlan: OR tomorrow am for chest closure if stable. Monitor labs treat as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273251, "text": "resp care\npt remained on imv 500x14 40% 5peep and 5psv with peak/plat 20/16. BS bil. Combivent given as ordered. RSBI held due to paralytics.Will cont to follow. Morning abg wnl.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273252, "text": "Respiratory Care\nPt remains on full ventilatory support as documented on Carevue. Taken to CT for scan of chest and abdomin without incident. Placed on rotating bed. With left side slightly up, pt's SAT decreasing. Suction for amount of pale white/clear secreations. MDI's given as ordered. Possible trip to MRI pending.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273282, "text": "See and Carevue for detailed documentation\n\nNeuro: PERL. Rec'd on ativan , fentanyl and cisatricurium. Patient hypertensive, ativan increased with good result. BP stabilized. Patient later hypertensive with BP increased 160's with cares. Fentanyl increased, later decreased slightly. Cisatricurium dose increased with twitch at 10mA, increased resp, cough with stim and decreased BP. Patient now with stable VS on ativan 2mg/ hour, cisatricurium 0.35mg/kg/hour, fentanyl 85mcg/ hour.\n\nResp: Patient continues on vent. Increased PaCO2 tx with increase vent rate with good result. BS clear, diminished in bases. Continues with some resp effort despite paralytic. Suctioned for small amounts thick tan secretions with MDIs. Continues with large amounts bloody oral secretions. Mouthcare every 2-4 hours.\n\nCV: In NSR. HR 70-80 on lopressor. BP stable thru day with MAP >60.\nIncreased BP treated with sedation. Maintaining temp. Continues on antibiotics. Repeat vanco trough pending. Potassium repleted. Type and hold to blood bank.\n\nGI: On tube feeds, tolerated well with minimal residual. BM x2.\n\nEndo: RSSI per protocol. None required.\n\nGU: Foley to gravity with large amounts urine output. Negative fluid balance.\n\nPlan: Continue to monitor cardiopulmonary staus. Plan for OR in am. Titrate sedation per VS, Maintain BP without pressors.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273343, "text": "ROS:\n\nNeuro: Alert, makes eye contact and tracts. Nods head yes/no to questions asked. Denies pain when asked. Occasionally noted slight random movement in LE and LUE. PERRLA.\n\nCV: RSR w/o ectopy. VSS. Peripheral pulses palpable. Sternal wound w/staples. 3 jps fluid. Generalized edema. Right PICC line. P boots for DVT prophylaxis.\n\n\nResp: remains intubated and on vent, CPAP weaned to w/^ resp rate, denies dyspnea, MV ~ 12/L some abd breathing appears at times w/dyspnea but denies it. VS stable. Sats 98% or >.\n\nGI: Post pyloric pedi tube via right nare w/TF at goal. Abd soft w/active BS.\n\nGU: Foley patent clear yellow urine in QS. Lasix given.\n\nID: Remains on Fluconazole, ampicillin, and ceftriaxone. Vanco level 15.9 this AM, dose not given.\n\nEndo: FSG covered w/RSSI sq\n\nSocial: no contact from HCP\n\nPlan: Return PS back to 12 if appears to become tired or at HS. Mobilize. Pulmonary toileting. Monitor, tx, support, and comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273344, "text": "Remaining tachypnec rate 30-35, HR ^ to 95. PS ^ to 10 and then to 12 d/t continued tachypnea and HR > 90.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273345, "text": "Resp. Care note\nPt received intubated and vented on psv settings as charted on resp flowsheet. PSV level weaned from today. Pt appears labored at times with RR to 30's, psv increased back to 10 with pt settling to RR in mid 20's. Cont present settings and observe for signs of fatigue and need for PSV increase.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273310, "text": "NEURO-SEDATED ON ATIVAN WITH FENTANYL GTT FOR PAIN MANAGMENET.EYES OPEN WITH NO FOCUS,TRACKING OR STARTLE REFLEX. CLOSED MANUALLY BY NURSE AND RE-OPENED SHORTLY AFTERWARD.PERLA. NO MOVEMENT OF ANY TYPE SEEN.\n\nCV- NSR-> AFIB RATE CONTROLLED. CONTINUES ON AMIO GTT. NEO TITRATED TO KEEP SBP > 85.WBC=20.9.ON TRIPLE ABXS. S/P EXPLORATION HCT=30.9. AM HCT=26.6 & 28.2\nJP # 2&4 WITH MOD.AMT.SANG DRG. #1&3 WITH SMALL AMT SANG.DRG.TRANSPARENT DSG . CHEST BINDER ON. ANASARCA. PALP. PULSES.\n\nRESP- REMAINED ON AC VENT SETTINGS. SATS=98-100%. LSC(UNDER BINDER)\n\nGU/GI ADEQUATE HOURLY U/O.ABD SOFT. ABSENT BS.POST PYLORIC TUBE APPEARS TO BE OUT OF POSITION. ATTEMPT MADE TO FLUSH MEDS DOWN\nWITH RETURN OF YELLOW/TAN SECRETIONS ORALLY.\n\nLABS- NO LYTE REPLACEMENT NEEDED. ON INSULIN GTT. CXRU PROTOCOL FOLLOWED. GLUCOSE LO45. ->1 AMP D50.\n\nPLAN- CONTINUE TO TREAT BP AND HR. MONITOR LABS.JP DRG.LABS VALUES.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273311, "text": "Respiratory Care Note:\n Patient returned from OR last eve and placed on rate of 18 with FIO2 increased to 50%. ABGs WNL. BS=bilat, coarse, suctioned for thick yellowish sputum. ET tube resecured 22cm at lip. Patient continues with paradoxical pattern. RSBI=237.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273312, "text": "NEURO: PT. SEDATED ON 50MCG FENTANYL AND 0.5 MG ATIVAN. PT. OPENS EYES SPONTANEOUSLY, APPEARS TO TRACK MOVEMENT OF FINGER IN LEFT VISUAL FIELD ONLY (TO PERIPHERY), DOES NOT OBEY COMMANDS OR SPONTANEOUSLY MOVE ANY EXTREMITIES. PT. DOES NOT NOD HEAD TO ANY QUESTIONS, BUT DOES OPEN EYES WIDER TO SPEECH.\n\nCV: PT. NSR, IN AND OUT OF AFIB AND SINUS TACHYCARDIA THROUGHOUT THE AM, NP NOTIFIED OF RAF (HR 130'S)- 150MG AMIO BOLUS GIVEN. PO AMIO STARTED AND DRIP DC/D. 12.5 MG LOPRESSOR GIVEN AND TOLERATED. CURRENTLY NEO GTT TITRATED TO MAINTAIN MAP >60. ONE UNIT PRBCS GIVEN FOR FALLING HCT.PT. BLOOD PRESSURE INCREASES WITH TURNING, ORAL CARE, AND EYE CARE. HR CURRENTLY 80'S. MAG SULFATE IV GIVEN FOR FREQUENT PVC'S ONCE CONVERTED BACK INTO SINUS RHYTHM. PULSES DOPPLERABLE.\n\nRESP: LUNGS CLEAR IN UPPER FIELDS, DIMINISHED IN BASES. L UPPER FIELDS RHONCHI AT TIMES AND IMPROVED WITH SUCTIONING. PT. ETT SUCTIONED FOR TAN, THIN SECRETIONS, ORALLY SUCTIONED FOR BLOODY SPUTUM. J- DRAINS CONTINUE TO DRAIN DRAINAGE.\n\nGI/GU/ENDO: ABD SOFT-DISTENDED, HYPOACTIVE BOWEL SOUNDS, NEW DOBHOFF PLACED BY NP , PLACEMENT CONFIRMED BY CXR, TUBE FEEDS RESTARTED AT 1200 AND TOLERATING. PT. GIVEN DULCOLAX- ONE SMALL, SEMI-FORMED, GOLDEN STOOL PRODUCED. FOLEY CLEAR, YELLOW URINE- SOME IMPROPVEMENT IN OUTPUT WITH LASIX. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: FENTANYL GTT INCREASED FROM 25MCG TO 50MCG NP .\n\nPLAN: CONTINUE TO WEAN NEO, MONITOR HCT AND SIGNS OF BLEEDING, MONITOR NEURO STATUS, AND SKIN INTEGRITY (AND BREAKDOWN).\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273259, "text": "Nursing 7p-7a\nNeuro: Sedated on fent/ativan gtts. Paralyzed on nimbex gtt. eyelid twitches & +cough required increase in nimbex gtt to max dose. Pt cont w/ eyelid twitches & +cough, MD aware- no tx ordered at this time. No gag. Pupils 2mm, R sluggish, L brisk.\n\nC/V: Bradycardic & junctional in 40s. Hypothermic. EKG done to confirm junctional. Amio gtt off d/t HR/rhythm. Bed warmer & bair hugger applied. As temp increased pt HR increased, currently nsr 60s. Normothermic w/bair hugger (unable to wean off) & bed warmer. Rare pjcs/pacs. Lytes repleated. Dopperable pulses. Cap refil <3sec bilat. Cont vasopressin gtt. Titrated neo gtt to keep map >60. BP very labile. Received 1 prbcs for hct 24. F/U hct 26.6. Platelets decreased to 145. PTT 87. MD made aware of all lab values. No tx at this time.\n\nResp: SIMV, no vent changes. Suctioned yellow thick, changed to blood tinged overnight. MD aware. Lungs coarse throughout, LLL dim.\n\nGi: TF increased to goal 40cc/hr. Stool x2. Guiac neg. Absent BS. Abd soft. IV albumin.\nGu: Adequate HUO. Creat decreased to 2.0.\nEndo: RISS for blood sugars.\nID: IV vanco, ampicillin, fluconazole & ceftriaxone. WBC decreased to 16.6.\n\nSocial: HCP called, updated by RN.\nSkin: See carevue for impaired skin & wounds.\n\nPlan: Wean bair hugger as . Maintain normothermia, monitor hemodynamics. Wean neo if . F/U w/hct, platelets & coags. ?correcting coags. HIT to be collected & sent.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273260, "text": "NEURO: Paralyzed on Cisatracurium drip 0.3 mg, Ativan drip 2.5 mg for sedation, Fent drip 75 mcg for pain/sedation, PERRLA (2mm/brisk), Pt coughs when suctioned thru ETT, at 20mA, MD aware, no spontaneous respirations, movement, no gag reflex\n\nRESP: Intubated on SIMV 500/50%/; lung sounds clear at apices/dim at bases, CXR reveals pleural effusion, Sats >96%\n\nCV: NSR with rare PACs, on Neo 0.25, Pit 2.4, HR in 60s, MAP >60, cap refill < 3 sec, pulses present by Doppler, afebrile, anasarca, sternal VAC dressing with serosang drainage.\n\nGI/GU: Abd soft, distended with petechiae, on TF at 40cc/hr, hold TF starting at 0000 (Pt NPO for debridement), small BM in AM, C. DIff culture sent; Foley in place > 120cc/hr of yellow/clear urine, last K was 3.4, repleted with 40mEq KCl\n\nENDO: Pt on own SSRI, last BG was 148\n\nID: WBCs 14.7, afebrile, C. diff culture sent, Vanco level was 15.\n\nLABS: Last PTT was 76.3, PA notified, HIT screen sent , Plastic team ordered to hold heparin SC for debridement\n\nSOCIAL: No phone call or visit from family/relatives today.\n\nPLAN: NPO after midnight (hold TF), hold heparin, wean Neo as tolerated, f/u C. diff/HIT/MRI results, OR debridement tomorrow, monitor lytes, Hct, coags\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273220, "text": "Neuro: Pt is A&O X3. Pt stated he was seeing spiders on the wall. No pain reported during shift. Left sided weakness-only moves these extremities on bed. Able to lift and hold right-sided extremities. Obeys commands. PERRL.\n\nCV: Pt required 500 cc fluid bolus X2 for hypotension after lopressor given. Neo started for about 3 hours but is now off. Amio gtt started. Pt received PRBC X1 for Hct 27. Hct now 32. Palpable pedal pulses.\n\nResp: Pt now on 4L NC from 10L 40% face tent (pt continuously pulled face tent off). O2 Sats 92-95%. Lungs coarse at apexes, dim at bases. Weak cough.\n\nGI/GU: Pt swallowed pills without difficulty. Clear yellow urine of SQ. +BS, no BM.\n\nInteg: No skin issues at this time.\n\nEndo: RISS-pt has own protocol.\n\nA/P: Treat afib. Ativan? Monitor neuro status. Pulmonary toilet. Encourage activity and PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273221, "text": "shift update:\n\nneuro: a&o x1-2. initially agitated->pleasantly confused. denies pain. mae. turned q1-2hrs. sleeping in short naps this afternoon.\n\ncv/skin: afib initially->lytes repleted->nsr w/pac's & brief runs of afib. no vea. cont on amio gtt. neo restarted after po lopressor d/t sbp in 70's slowly weaning. multiple doses of iv kcl given see flowsheet. ca x2. +pp bilat.\n\nresp: lungs coarse but dim in bases. initially on 4l nc->abg's poor. 50% oft added abg's improved. nebs given by rt. cdb q1h. cpt q2h. nt suctioned for thick yellow. weak cough but expectorating small amts thick yellow this afternoon.\n\nid: afeb. ^wbc's. pan cx done. abx changed to vanco & iv levo.\n\ngi/gu: +bs. tolerating po liquids. poor appetite. foley leaking->changed. lg uop after foley changed.\n\nendo: no insulin per ss.\n\nsocial: minister friend into visit.\n\nplan: cont to monitor neuro status. cont amio. wean neo as tol. replete lytes prn. aggressive pulmonary toilet. ivabx. i&o.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273275, "text": "Nursing Progress Note\nNeuro: chemical paralytic cisatricurium at 0.3 mcg/kg/hy. twitches on r side of face with . Sedation with ativan gtt currently at 1.5 mg/hr. Pain control with fentanyl currently at 80 mcg/hr. No movement, no gag, rare cough with suction.\n\nCVS: HR 60's-70's nsr with increasing pacs. Vasopressin weaning maintain map > 60. Chest remains open covered with VAC dressing to VAC suction unit. Borders red, macerated. Abdomen ecchymotic, multiple skin tears. Skin is glossy r/t large edema in BL and Bues. RIJ multi lumen cath patent, CDI. A line with waveform and notch. Awaiting sternal closure by plastics, will not complete untill patient is off pressors per team. Multiposud boots for sore prevention. Tryadine self rotating bed.\n\nReso: LS dim throughout. Poor airation, suction ett for small thick brown. Sats > 95 on 0.5. MDI's by RT.\n\nEndo: FS BS not requiring ssri coverage at this time.\n\nGU: Foley cath draings conc clear urine.\n\nGI: Abdomen large round soft, bs pos. No wretchign, No bm. Remains on reglan 2 6 hours, IV.\n\nPlan: awaiting word from OR team, ? close today or tomorrow with plastics. wean vasopressin as tolerated.\n\nSee carevue flowsheet and for further details and values.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273276, "text": "Respiratory Care\nPt remains intubated on ventilatory support, no vent changes made this shift. ABGs with a slight respiratory acidosis, good oxygenation. RSBI not performed due to neuro-muscular blocking on board.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273346, "text": "Neuro: Pt nods yes/no to questions. Pt tracks with eyes and grimaces with care. Pt turns head side to side and also was also observed partially lifting left side of body off bed while feeling discomfort with care. Slight movement of left foot noted as well; no movement of right side. Tramadol given X 1 for pain (indicated by pt nodding).\n\nResp: Pt rested on CPAP and PS , 40% FiO2 overnight. Lungs coarse throughout. Pt suctioned for small to moderate amts thick, yellow secretions. RR upper 20's. Pt receiving MDI's.\n\nCV: NSR entire shift. MAP>60. HR 80's. T max 98.7. K repleted. Palpable pedal pulses. Pt has 3 JP drains sanguinous fluid.\n\nGI/GU: Pt receiving Nutren 2.0 with Beneprotein at goal rate (40cc/hr). TF residual 45cc at most. Banana flakes held for brown formed stool X1. Pt voiding clear, yellow urine of SQ via Foley.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Bruising on abdomen. General edema; especially arms and scrotal area.\n\nA/P: Wean vent as appropriate. Pulmonary toilet. Monitor movements of pt's extremities. Pain management as needed. Cont abx.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273347, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. PSV increased 10->12 to rest overnight. Pt continues to have episodes tachypnea to high 30's. BS's coarse, sxing thick yellow secretions. Administering Combivent MDI in line as ordered. RSBI=193. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273348, "text": "BS coarse crackles, occ rhonchi; no change with MDI's. Frequently agitated and tachypneic. PSV to 15. FiO2 to 80% and now weaned to 50%. Transfer to CSRUA.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273380, "text": "Neuro: alert and nodding head to questions correctly, mae-lifts and holds arms and moves legs on bed, oob to chair with , tramodol x 1 for pain.\n\nCardiac: nsr with frequent pac's, bp's wnl's, palpible pedial pulses, skin warm dry and , +1 edema in extremities, afebrile.\n\nResp: on trach mask for shift with good ra sats- team wants patient to go throughout the night on the mask as long as tolerates, lungs dim in bases, right side ct d/c'd today.\n\nSkin: chest with staples is cdi, right and left side old ct dsds are cdi, jp insertion site is cdi,coccyx is pink with no breakdown, compressive sleeves and multipodis boots on, is on air mattress.\n\nGi/Gu: npo-awaiting speech and swallow to come eval for passiur valve, abd soft round and nontender with huperactive bowel sounds, did have x 1 med formed bm today, started h2o flushes for high na, did cut back on lasix to , makes >30/hr of u/o.\n\nPlan: continue trach mask over pm, ?rehab in am, ? speech and swallow in am for eval prior to d/c.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273381, "text": "resp care\npt received on psv mode, placed on trach mask for duration of shift. rr mid 20-to high 30's. ambued with combivent mdi, lavaged and sxned for mostly brown, slightly bld tinged thick sputum. partially expectorates on own. vent is at bedside, hopefully will not need tonight.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273382, "text": "around 1845 patient went into raf in the 120 range-po lopressor given early-2 grms mag given-lytes sent bp sbp running around 98-100-np aware awaiting results of lab lytes-ultra sound in am patient to be npo at mdnight.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273383, "text": "NEURO: PT. ALERT, UNABLE TO ASSESS ORIENTATION, LIFTS AND HOLDS UPPER EXTREMITIES BILATERALLY, LOWER EXTREMITIES MOVE ON THE BED. PT. OBEYS COMMANDS AND NODS \"YES\" OR \"NO\" TO SIMPLE QUESTIONS.\n\nCV: PT. AFIB IN BEGINNING OF SHIFT, CONVERTED BACK TO NSR WITH OCCASIONAL PAC'S. HR 80'S AND SBP 95-110.\n\nRESP: PT. LUNGS CLEAR IN UPPER LEFT FIELD, SLIGHTLY COARSE IN RIGHT UPPER LOBE, DIMINISHED IN LOWER LOBES. PT. SUCTIONED FOR THICK, TAN AND BLOOD-TINGED SECRETIONS- IMPROVEMENT IN BREATH SOUNDS AFTER SUCTIONING. +COUGH, NO EXPECTORATION INDEPENDENTLY. PT. ON AEROSOL TRACH COLLAR THROUGHOUT THE NIGHT WITH OXYGENATION >95%. DRAIN MINIMAL SEROUS DRAINAGE.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TUBE FEEDS TURNED OFF AT MIDNIGHT FOR PROCEDURAL PURPOSES IN THE AM, ONE MEDIUM, BROWN, FORMED BM (GUAIAC NEGATIVE), FOLEY CLEAR, YELLOW URINE- GOOD U/O AFTER ADMINISTRATION OF LASIX. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: TRAMADOL FOR PAIN GIVEN WITH RELIEF PER PATIENT.\n\nPLAN: POSSIBLE REHAB TOMORROW?, ULTRASOUND PROCEDURE, SPEECH AND SWALLOW.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273384, "text": "Resp: pt 50% T/C. Bs are clear with diminished bases. Suctioned for small amounts of tan thick secretions. Ambu/syringe @ hob. MDI's administered Q4 hr combivent/ . Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273319, "text": "Neuro: Pt has been off Ativan since 1800 last night. Pt winces with turns and will scrunch eyes with eye care. Does not track with his eyes. Eyes open spontaneously. . Pt receives erythromycin ointment to right eye and also artificial tears in both eyes. Movement of head seen as well. Pt on 50 mcg/hr Fentanyl.\n\nCV: Pt in NSR entire shift. Max HR=100. T max 99.9. INR 1.1. Hct 25.1. Neo titrated to keep MAP >60. Neo currently at 0.2 mcg/kg/min. K and Ca repleted. Pt has 4 JP drains. Drain #1 most serosanguinous drainage (50 cc this shift). Some oozing from JP site #4 with turns.\n\nResp: Pt on CMV, R=14, TV=400, FiO2=40%, 5 PEEP. Pt suctioned q4h for very small amt white, thick sputum X1. Lungs clear at apexes, dim at bases. Weak gag and cough.\n\nGI/GU: Pt receiving Nutren 2 with Beneprotein at 40cc/hr (goal). No TF residual. +BS, no BM. Buttocks area a bit red; aloe vesta cream applied. Pt voiding clear, yellow urine via Foley in large quantities.\n\nInteg: Pt oozing from arms (especially) and legs. Chucks under arms and legs changed. Pt also has massive scrotal and penile swelling. Groin area elevated.\n\nEndo: RISS per CSRU protocol.\n\nA/P: Monitor pt's resp status and Hct. Pulmonary toilet. Address skin issues.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273320, "text": "respiratory care\npt on the vent fairly well. changes made better with 2mg of mso4. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273321, "text": "UPDATE\nCV: NSR<-> AFIB MULT TIMES TODAY. SBP INITIALLY WNL W/ AFIB BUT DIPPED TO 70'S DURING A.M. EPISODE. MORPHINE ALSO JUST GIVEN AND POSS CONTRIBUTED TO HYPOTENSION. AMIO IV BOLUS GIVEN AND IV NEO RESTARTED BUT BP SLOW TO RECOVER. PT TO IR THIS AFTERNOON FOR PICC PLACEMENT R ANTECUB. PT IN NSR DURING PROCEDURE BUT BACK TO AFIB (AND BRIEFLY A-FLUTTER) THIS EVE, RATE 110-120, BP WNL. ADDITIONAL AMIO IV BOLUS GIVEN AND HR CURRENTLY NSR 89, BP 113/61 AND WEANING NEO. MORPHINE GIVEN AGAIN THIS EVE W/O EFFECT ON BP. CHEST DRAINS W/ SM AMTS DRNG. HCT STABLE.\n\nRESP: RR IN 30-40 RANGE THIS SHIFT W/ RETRACTION OF DIAPHRAGM NOTED. AFTER MULT ADJUSTMENTS BY R.T. AND MORPHINE, PT BREATHING EASIER. SPO2 ALWAYS WNL, BUT ABG CONT TO SHOW RESP ALKALOSIS. LUNG SOUNDS DIMINISHED @ BASES. SUX FOR MOD AMTS THICK, YELLOW SECRETIONS.\n\nNEURO: IV FENTANYL OFF THIS A.M., CHANGED TO INTERMITTENT MORPHINE DOSING PRN FOR COMFORT. EYES OPEN SPONTANEOUSLY BUT PT DOES NOT TRACK OR FOCUS NOR FOLLOW COMMANDS. NO SPONT MVMT OF EXTREMETIES NOTED. WINCES TO EYE CARE AND MOVES MOUTH W/ MOUTH CARE.\n\nG.I.: TF @ 40ML/HR., MINIMAL RESIDUALS. MED FORMED B.M. THIS A.M. AFTER DULCOLAX SUPP.\n\nG.U./RENAL: LG DIURESIS FROM LASIX. I&O CURRENTLY -1600ML. CREAT STABLE, K+ REPLETED.\n\nSKIN: MOD AMT SEROUS DRNG WEEPING FROM UE'S. COCCYX REDDENED. HAIR WASHED.\n\nI.D.: TMAX 101.1. WBC DOWN TO 16. CONT ON IV AMPICILLIN, FLUCONAZOLE, VANCO, CEFTRIAXONE. NEW PICC AS ABOVE.\n\nA/P: TACHYPNEA LESSENED BUT UNRESOLVED W/ MORPHINE AND VENT CHANGES. OXYGENATING WELL. UNSTABLE HR BUT MOSTLY WELL TOLERATED AND RESOLVED X2 AFTER REBOLUS W/ AMIO. R IJ ADV ACCESS TO BE REMOVED AND TIP SENT FOR CX. CONT ABX VIA PICC. CONT TO MONITOR LYTES CLOSELY W/ DIURESIS. HCT Q 12 HRS. LITTLE CHANGE IN NEURO STATUS OFF CONT SEDATION AND PAIN MED.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273277, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on SIMV/PSV w/ PIP/Pplat = 27/22. SpO2 90s, MDIs given as ordered, tan secretions. See resp flowsheet for specifics.\n\nPlan: maintain current support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273278, "text": "NEURO: PT. UNAROUSABLE, SEDATED AND PARALYZED, THIS AM (ON 20) REVEALED 3 TWITCHES, PT. NOT OVERBREATHING VENT, AND NO SPONTANEOUS MOVEMENT NOTED. NIMBEX GTT LEFT AT CURRENT DOSE. 0400 ASSESSMENT REVELAED ONE NP NOTIFIED. NIMBEX GTT LEFT UNCHANGED. FENTANYL AND ATIVAN GTT LEFT AT CURRENT DOSE. PUPILS 2MM AND BRISK.\n\nCV: PT. NSR, OCCASIONAL , PT. CONVERTED TO AFIB FOR A SHORT TIME (HR 100-110 WITH SBP 100, MAP >60, PITRESSIN TITRATED TO MAINTAIN MAP >60- CURRENTLY OFF. CURRENTLY HR 90'S, SBP 95-110, MAP >60. PULSES EASILY PALPABLE. WOUND VAC SANGUINOUS DRAINAGE.\n\nRESP: PT. COARSE THROUGHOUT, SUCTIONED FOR THIN, TAN SECRETIONS- SEE CAREVUE FOR ABGS. PT. ORALLY SUCTIONED FOR BLOOD TINGED SECRETIONS.\n\nGI/GU/ENDO: PT. ABD SOFT DISTENDED, HYPOACTIVE BOWEL SOUNDS, TUBE FEEDS AT 40CC/HR, FOLEY CLEAR, YELLOW URINE. LASIX GIVEN IN AM WITH GOOD EFFECT. LYTES REPLETED. PT. BLOOD SUGARS TREATED PER PATIENT'S PERSONAL RISS.\n\nINTEGUMENTARY: PT. ABDOMEN ECCHYMOTIC, HEMATOMAS PRESENT. PT. COCCYX PINK, DUODERM CHANGED AND IN PLACE. PT. ROTATING IN BED EVERY 10 MINUTES AT 15 DEGREES.\n\nPLAN: CONTINUE TO MONITOR SBP AND HR, CONTINUE TO MAINTAIN MAP >60, PULMMONARY HYGIENE (FREQUENT MOUTH CARE AND NECESSARY SUCTIONING), MONITOR WOUND VAC AND DRESSING, ?PLASTICS CONSULT?, ETC.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273338, "text": "7a-1500\nNeuro: eyes alert all shift, will track at times. squeezed left hand on command once. lt thigh muscle shaking at times but no mvmt of toes. no mvmt on rt side noted. Opens mouth for mouth care and blinks on command. Perrla. mod yellow drng from b/l eyes due to conjunctivits.\nCV: stable. HR 70-80's rare pac. amio decreased to once a day. palp pedal pulses. continues to be edematous\nresp: continues to be orally intubated on CPAP. PS weaned to 10 by 1300. Tolerating well and appears comforatable. MV . No ABG gotten per --following sats and rate. sx thick pale yellow, whitsh sputum\nGI: TF Nutren at 40cc/hr =goal. tolerating well. abd firm with ecchymosis from surgery. no residul. mod soft stool slightly blood streaked from hemmorhoids.\nGU: foley patent. clear yellow. good diuresis from lasix\nPLAN: wean ps as tolerated on vent. continue to assess neuro status. pulm toilet. advance as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273339, "text": "Resp Care\nPt remains intubated on PS. Weaned PS from 15 to 12 to 10 to 5.\nMDI's given. ABG results in normal range on . No other changes given.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273340, "text": " 4p-7p\nassessment unchanged from earlier except ps decreased to 5, pt tolerated well. abg post vent change wnl.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273242, "text": " PT WILL REMAIN INTUBATED/SEDATED/PARALYZED FOR FLAP CLOSURE OF OPEN CHEST AND STERNOTOMY ON . PROPOFOL @ 35MCGKGMIN & NIMBEX @ 0.12MGKGHR WITH NO SPONTANEOUS MOVEMENT. 4 TWITCHES OF LEFT EYE.PERLA @ 3MM/BRISK. 50MCG/HR FENTANYL.NO S/S PAIN.\n\nCV- SR-ST 85-115.IVP LOPRESSOR HELD D/T PRESSOR SUPPORT. LEVOPHED SWITCHED TO NEO FOR HEART RATE CONTROL AND BP.CO/CI 5.2/2.8 BY THERMODILUTION AND 8.5/4.6 BY FICK.SVR LOW.FILLING PRESSURES WNL.T-MAX=99.7 REQUIRING BAIR HUGGAR ON AT ALL TIMES OF WILL BECOME HYPOTHEMIC. WBC=19.4 (22.6 ON ) ON AMPICILLAN/VANCO ABX.NEW LEFT A-LINE PLACE.OLD TIP SENT FOR CX.PT , UP 20KILOS,SKIN WEEPING SEROUS FLUID FROM SCATTERED AREAS.AMIO GTT @ 0.5M/MIN. WITH NO ISSUES OF AFIB.\n\nRESP-REMAINED ON IMV 40% X500X14X . SATS=98%. LS CLEAR UPPERS VERY DIMINISHED LOWERS. SXD (BY RT) FOR THICK YELLOW SPUTUM.\n\nGI-ABD SOFT. ABSENT BS. OGT DRG BILIUS SECRETIONS. HAS NOT BEEN FED YET.?? NO BM ].\n\nGU- RECEIVES IVP LASIX WITH CONT'D DIURESES THROUGHOUT SHIFT.\n\nLABS- K+,CA+ REPLACED PRN.\n\nENDO- INSULIN GTT STARTED FOR REPEATED GLUCOSE LEVELS>120. GTT / GLUCOSE LEVELS BETWEEN 134->118.\n\nMISC.- NO CONTACT WITH FAMILY( NOT SURE IF HE HAS ANY) NO PHONE CALL FROM REVERAND OF HIS CHURCH.\n\nPLAN-CONTINUE WITH HEMODYNAMIC MONITORING,TITRATION OF PRESSORS,PARALYTRIC SUPPORT,GLUCOSE CONTROL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273243, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273244, "text": "Respiratory Care\nPt taken to the OR this shift for a brief period of time to irrigate his chest. return on Tuesday to close his chest. Remains on full ventilatory support. All settings documented in Carevue.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273255, "text": "Respiratory Care Note:\n Patient continues on SIMV/PSV mode of 500 by 14, 50% and 5PS,+5 PEEP. BS=bilat, slightly coarse. He remains paralyzed and sedated. Suctioned for med amounts of pale yellowish sputum. Plan for MRI today and possible closure of chest.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273256, "text": "Nursing Progress Note:\nNeuro: Pt sedated and paralyzed on fentanyl, cisat, and ativan gtts. Pupils 2-3mm sluggish. Severed redness noted to right eye. Team aware. Eye gtts and oinment started OU. 2-3/4 . No gag/cough reflex. No spontaneous respirations and movements noted. Head MRI done and results pending.\n\nCV: SB with pac's and intermittent afib. HR 50-60's. Amio at .25. MAP >60 on vasopressin and neo gtts. Sternum open with VAC drainage. Small amount of serosanguionous from vac drainage. Pulses dopplerable. Skin impaired with bruising to abdomen, duoderm to coccyx, and numerous open blisters to extremeties. Afebrile. Trauma and . Generalized +4 pitting and scrotal edema.\n\nResp: LCTA decreased at bases. Sats 96% on SIMV 14, 500, 50%, . Pt bronched for small amount of thick, yellow secretions. Sputum sample sent.\n\nGI/GU: Abdomen soft, nondistended. No BS noted. Minimal residual via Dob-hoff. Nepro at 30cc/hr. Small stool x1. Foley cath with good UO. Clear, yellow urine.\n\nEndoc: RISS\n\nPain: Fentanyl\n\nID: Started on Vanco qod, next dose tonight and recheck level Friday am. Ampicillin, fluconazole, and ceftriaxone for sepsis.\n\nPlan: To OR Friday for wash out and ?closing of sternum. Continue VAC drainage. Continue antibiotics. Monitor lytes, renal function, and CBC. Continue sedation and paralytics. Advance TF for goal of 40cc/hr if tolerating.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273257, "text": "resp care - Pt remains intubated on SIMV 500/14/5/5 50%. No changes made this shift. Pt went to MRI this PM. BS coarse t/o, clearing on sx of sm amt of secretions. Blood gas is within normal limits. Continued resp support planned.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273258, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnight. BS's diminished, sxing moderate amts yellow secretions. Administering Combivent MDI's in line with vent as ordered. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273341, "text": "Neuro: Pt will at times open eyes to command. Eyes also open spontaneously. Head turns spontaneously. No movement of extremities noted. Pt grimaces with eye care and mouth care. No pain otherwise noted.\n\nCV: NSR entire shift. SBP 90's to low 100's. T max 99.2. K and Ca repleted. Palpable pedal pulses.\n\nResp: Pt rested on CPAP and PS , FiO2 40% overnight. Lung sounds coarse. Pt suctioned for small amts thick, whitish secretions. MDI's given.\n\nGI/GU: Pt receiving Nutren 2.0 with Beneprotein @ 40cc/hr (goal rate). 15cc residual @ 0000. Pt voiding clear, yellow urine of SQ via Foley. +BS, no BM.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Pt has bruising on abdomen and edema of extremities. Pt also has scrotal edema.\n\nA/P: Cont to wean vent as appropriate. Monitor movement of extremities/movement to command. Cont abx. Address skin issues as appropriate. Vanco level pending.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273342, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Initially, pt on psv/cpap of , increased to to rest overnight. BS's diminished, but ess. clear. Sxing small amts brown plugs. RSBI=109 this am. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273230, "text": "Pt experienced asystolic arrest today. Resuscitated and take to OR for sternal debridement, laparoscopic mediastinoscopy. Chest left open. Pt has 7.5 ET, 22 @ lip. BS fine crackles, rhonchi; no change with MDI's.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273231, "text": "NEURO: this AM pt alert oriented x3 but calling out, moaning at times not answering questions. became unresponsive approx 0930 and CPR initiated. rhythm and pressure restored and transfered to OR. From OR on sedated on propofol and paralytic therapy-cisatracurium- initiated. TOF tested on L facial nerve with no twitches. per PA is goal. currently paralyzed and sedated.\nCV: This AM sinus with APC's with runs of Afib with RVR. amio bolus 150 mg admin. pt cardiac arrested approx. 0930 anesthesia MD and rhythm/blood pressure restored p approx 10 min CPR. no shocks delivered. no drugs admin. transfered to OR for sternal debriedment and returned with AFib rate 100's amio gtt initiated and pt converted to SR. PA catheter in place. MAP 60-70's, CO 3.7-4.2 and CI>2.0. neo titrated for MAP 60-90. skin cool and dry with palp. pedal pulses. warmed with bair hugger. sternum remains open. lytes repleted KCL, CA gluc. good response to lasix admin. in OR. +total body edema.\nRESP: this AM pt on cool nebs with neb trx for bialt wheezing. resp arrested and was intubated approx. 0935. remains intubated. ABG improving. lungs clear. VAP mouth care done. no overbreathing vent.\nGI/GU: abd soft distended with mult ecchy areas. no bowel sounds. OGT to LCWS with bilious drainage. foley has clear yellow urine.\nENDO: blood gluc treated with insulin gtt.\nID: on vanco, amp, cefipime\nSKIN: total body edema. chest open with transparent dressing and two JP tubing to LCWS. abd has hematoma and mult ecchy areas. +penis and scrotal edema. pressure points intact.\nSOCIAL: HCP for consent this AM. d/w MD and anesthesia.\nLINES/ACCESS: PICC line L AC, swan , , A line R rad. PIV R FA. R ln placed in , oozing slightly.\nA/P: continue to monitor cv, resp. maintian sedation and paralysis, blood gluc and lytes. can have HOB 30deg. but no turning in bed d/t open sternum PA. VAP care. skin care.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273232, "text": "Resp Care Note:\n\nPt cont intub OETT sedated and paralyzed on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273245, "text": "shift update:\n\ns/p sternal wash & vac dsg applied. plan for or for chest closure.\n\nneuro: remains paralyzed &sedated on nimbix, fentanyl & propofol. left eye twitch remains on ma of 20 dispite increase to 0.25mcg/kg/hr. no spontaneous movements, no gag/cough reflex. pupils equal, non reactive. no visable signs of pain noted.\n\ncv/skin: nsr initially. rate controlled afib upon returning from the or. amio gtt cont. k+ & ca low->lytes repleted. currently in nsr. k+ repleted several times throught the day see flow sheet. neo cont at 2.0mcg/kg/min did have to increase to 2.5 breifly w/afib. weaning levo . goal sbp>90. vac dsg intact. +dopp pp bilat. generalized body edema w/weeping areas noted on arms.\n\nresp: lungs coarse to clear but diminished in bases. no vent changes. abg's acceptable. suctioned for thick yellowish green secreations.\n\ngi/gu: +hypo bs. og->lws w/billious drainage. tube feeding discussed at rounds, no ordered at this point. uop 100cc or greater/hr.\n\nendo: insulin gtt weaned to off. bs ranging 67-111. see flow sheet.\n\nsocial: hcp into visit update given & spoke with . minister into visit also.\n\nplan: continue current plan of care. wean levo goal sbp>90. watch lytes closely->replete prn. or tuesday for flap closure.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273301, "text": "Respiratory Care Note:\n Vent settings unchanged t/o shift. Patient appears comfortable on A/C of 500 by 14 (breathing 20) 50%, and 5 PEEP. BS=bilat with mild exp wheezing scattered t/o. Combivent MDI given app Q4. Suctioned for med amounts of thick yellow sputum. RSBI attempted and within 30 seconds his BP increased with a mean of >105 and RSBI attempt was aborted. Plan to maintain supportive care and monitoring. See Carevue flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273302, "text": "CHEST EXPLORATION\nCV: Afib with HR in 70-80s and rare PVCs noted on .5mg Amio, MAP >60 on 0.3 Neo, anasarca 2+ pitting edema, pedal pulses present, afebrile, Hct 24, given 2 PRBCs, Hct 30\n\nNEURO: Sedated on Ativan & Fent, PERRLA (4mm/brisk), eyelid movement noted but does not follow commands, gag impaired during suctioning\n\nRESP: Taken to OR for chest exploration, MD noted/ligated bleeding, JP drain #2 dark, sanguinous at >40cc/hr, intubated/continues on AC Sats 100%, lung sounds clear, suctioned for moderate blood-tinged secretions, Pt overbreathing vent, last ABG reveals resp. alkalosis\n\nGI/GU: TF at goal, < 5 residual, bowel sounds present, no BM today; Foley in place yellow/clear urine, given Lasix, last K was 3.8 given 20mEq KCl\n\nENDO: Continues on insulin drip at 4 units/hr\n\nSOCIAL: HCP notified of OR procedure, DNR status ordered\n\nPLAN: Monitor hemodynamics, resp, TF, LABS, JP drains for increased bleeding, UO, DNR status ordered today\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273303, "text": "Resp Care\nPt remains on CMV, no vent changes. Pt returned to OR for bleeding, was repaired. Plan to continue with current vent support and for trach in future.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273316, "text": "NEURO: PT. SEDATED ON FENTANYL AND ATIVAN, CURRENTLY RESPONDING TO PAINFUL STIMULI (FOR EX: PT. FLEXED AND WITHDREW SLIGHTLY WITH LEFT HAND WHILE ARTERIAL INSERTION SITE WAS CHLOROPREPED, AS WELL AS RIGHT ARM FLEXED AND WITHDREW SLIGHTLY WHEN PATIENT RECEIVED HEPARIN SUB-Q INJECTION IN R LOWER QUADRANT OF ABDOMEN.) PT. DOES NOT NOD HEAD TO SIMPLE QUESTIONS, DOES NOT MOVE LOWER EXTREMITIES SPONTANEOUSLY OR FOLLOWS COMMANDS. PERRLA.\n\nCV: PT. NORMAL SINUS RHYTHM WITH RARE PAC'S, HR 80'S, BLOOD PRESSURE LABILE AT TIMES- NEO ATTEMPTED TO BE WEANED, BUT MAINLY LEFT AT 1.0 MCG-1.5 MCG DUE TO FLUCTUATIONS IN BLOOD PRESSURE. GTT TITRATED TO MAINTAIN MAP >60. TORSO BINDER (FOR OMENTAL FLAP PROCEDURE STILL ).PULSES DOPPLERABLE- L DORSAL PEDAL PULSE MORE DIFFICULT TO DOPPLER. LABS: HCT STABLE- LEVELS EVERY 8 HRS DUE TO PLASTIC SURGERY ORDER.\n\nRESP: PT. LUNGS CLEAR IN UPPER AND DIMINISHED IN LOWER LOBES. PT. FOUND COARSE, BUT IMMEDIATE IMPROVEMENT WITH SUCTIONING. PT. ETT SUCTIONED FOR THICK, MODERATE TAN/BLOOD-TINGED SECRETIONS. ORALLY SUCTIONED FOR THIN, TAN SECRETIONS. FREQUENT MOUTH CARE- ORAL TISSUE . JP DRAINS DRAINAGE TO BULB SUCTION.\n\nGI/GU/ENDO: PT. ABD SOFT-DISTENDED, +BS, TUBE FEEDS AT GOAL (40CC/HR), ONE SMALL BROWN, SOFT BOWEL MOVEMENT. PT. FOLEY CLEAR, YELLOW URINE- GOOD U/O AND RESPONSE TO LASIX. LYTES REPLETED ACCORDINGLY. BLOOD SUGARS TREATED PER RISS- ?PATIENT'S OWN PERSONAL SLIDING SCALE?.\n\nID: CONTINUES ON 4 DIFFERENT ABX, WHITE CELL COUNT 18.9.\n\nINTEGUMENTARY: UPPER EXTREMITIES CONTINUE TO WEEP WITH EDEMA, PERIANAL AREA HAS SKIN BREAKDOWN AND AMT. OF BLOOD, R HEEL SLIGHTLY RED, BUT SKIN UNBROKEN.\n\nPLAN: CONTINUE TO MONITOR NEURO, WEAN NEO, MONITOR HCT AND SIGNS OF BLEEDING, PULMONARY STATUS, FLUID STATUS AND SKIN INTEGRITY.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273317, "text": "Respiratory Care\nBreath sounds clear, diminished, suctioned for moderate thick tan, WBC 18.9 suggesting ongoing bacterial infection, hemoglobin only 9.9, suggesting ongoing anemia, creatine 1.8, suggesting renal insufficiency, patient stayed into normal sinus rhythm whole day but was tachypneic at times RR ranged 22 to 38, still in acute respiratory alkalosis, ABGs at 1326 revealed an acute respiratory alkalosis with hyperoxemia, no significant progress noted neurologically, no vent changes made up to this point, patient has been treated with Combivent inhaler, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273318, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a respiratory alkalemia with good oxygenation on the current settings.\n\nRSBI = 139.9 on 0-PEEP and 0-PSV (FAILED RSBI).\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273215, "text": " 7p-7a\nneuro: alert, moves both arms to command and spontaneously, left hand grip stronger than right hand grip, moves left leg to command and spontaneously, no movement noted to right leg, able to hold head off bed x 5 seconds\ncv: sr 79-98 with occasional pvcs, sbp 99-125, ct output 0 while lying flat, 40-370 serosanguineous drainage with turns(np aware)\nresp: vent settings to this am (kept at 5/10 overnight for lethargy during day), lungs cta, diminished to bases, 02 sats > 95%\ngi: positive bowel sounds,insulin gtt d/ced at 2100, fingersticks remained wnl overnight\ngu: urine output adequate overnight, slowing this am\nlabs: stable, K+ 4.0 repleted with 20 meq kcl\npain: 1-2 tabs percocet q4hours overnight\nassess: stable\nplan: wean vent this am, extubate when able, to bed, tx to 2 this pm?\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273216, "text": "Resp. Care\nPt. remains on mech vent. Pt. had to be retaped due to cont. tongue movement and oral secr. Pt was on CPAP 10PSV/5peep and 50%.Pt. is being sx for mod amts of thick tan and B/S are scat rhonchi bilat.Pt. is currently on CPAP 5/5, and plan is to wean and extubate this A.M.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273217, "text": "Respiratory Care\nPt was extubated today at 0815. Pt was able to talk, no cough effort, HR 91, RR 28 and non-labored, SpO2 95% of 60% OFM. No stridor was noted. Will continue to follow pt for post extubation care.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-23 00:00:00.000", "description": "Report", "row_id": 1273218, "text": "nursing progress note 1230-7p\nreadmitted from 2 for hypotension. bp on arrival 80/40's sr 90's. a-line placed by dr. . labs sent.\n\nneuro: a/ox3, answers questions but seeing kittens and talking on imaginary phone. increasingly agitated, wanting dentures but spits them out into face tent. follows commands but required multiple redirects to keep oxygen on. moans and grunts - baseline per report, also ? swallowing difficulty. left sided weakness from old cva. bilat legs very weak - transfer. perrla.\n\ncv: initially sr 90's. pac's ^ progressed to afib 110's, up to 130's at times. Dr. notified, 2gm mag sulfate. bp as above responded to ns 500cc and 2 units prbcs for hct 24.4 but dipped w/ afib now 100/60's. +3 distal pulses, 2+ general edema.\n\nresp: lungs on arrival clear uppers dim bases, sats 92-94% on 6l prongs. unable to clear secretions in back of throat but no acute distress. mouth breather. changed to humidified face tent 50% sats improved to 95%. orally sxn multiple times w/ yankower and tonsil tip for tenacious, blood-tinged secretions. gets very agitated. nt sxn x1 by RT w/ similar results. repeatedly removed o2 sats drop to 88%.\n\nendo: custom riss - see flowsheet.\n\ngi: kept npo d/t report of swallowing issues. +bos, no bm.\n\ngu: foley to gravity, clear yellow. adequate huo and brisk response to lasix. CRI, baseline 1.9\n\nplan: post transfusion hct. fluid resussitation as ordered. rate control. ? change meds to iv pending further swallow eval. redirection or distraction to keep o2 on. ? restraints if continues to remove. aggressive pulmonary hygiene and sxn prn.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273219, "text": "Respiratory Care:\n Patient receiving albuterol/atrovent unit dose nebs Q6 for wheezy, congested chest. NT suctioned to attempt to clear without success. He tolerated tx fairly well. He remains on a 4lpm with SpO2>92%.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273233, "text": "NEURO: PARALYZED AND SEDATED ON PROPOFOL. FENT GTT ADDED FOR PAIN MANAGEMENT. TWITCHES ON NIMBEX--NOT WOKEN OR GTTS TITRATED PER DUE TO OPEN CHEST. BP INCREASES SLIGHTLY WITH STIMULI. PERRLA 3MM. NO MVMT OR OVERBREATHING NOTED\nCV: HR 80-90'S SR WITH PAC'S--PT INTO RAF WITH RATES UP TO 125-130 AT 0500--AMIO BOLUS GIVEN AND GTT UP TO 1MG/MIN. NEO TO MAINTAIN SBP>90 AND MAP>60. GENERALZIED ANARSARCA WITH WEEPING AREAS. CI>2. CHEST OPEN WITH IOBAN DSG INTACT, SLIGHT TENTING OF DSG WITH SMALL AMT BLOODY DRNG FROM JP SITES. IF PT NO GO TO OR WILL NEED WASHOUT. PAD 18-22, CVP 15. REQUIRED BAIR HUGGER OVERNIGHT TO MAINTAIN TEMP>36. RT GROIN SITE BLEEDING REQURING DSG CHNG X3 WITH SURGICEL. HCT INITALLY 23 UP TO 26 WITH NO TX ? DILUTIONAL.\nRESP: REMAINS ORALLY INTUBATED ON IMV OVERNIGHT. NO VENT CHANGES MADE EXCEPT WEAN FIO2 TO 50%. LUNGS CLEAR. MDI PER RT. ABG WNL. SATS>97%\nGI: OGT TO LCWS FOR BILIOUS DRNG. ABD OBESE BUT SOFT, NO BS. OGT PLACEMENT CONFIMRED BY AUSCULTATION. BLOODY ORAL SECRETIONS REQUIRING FREQUENT MOUTH CARE\nGU: UOP 30-140CC/HR, LIGHT YELLOW. FOLEY PATENT. SCROTUM EXTREMEMLY EDEMATOUS WITH MILKY EXUDATE FROM AROUND FOLEY. ABRASIONS ON SCROTUM WITH SEROUS DRNG OOZE\nSOCIAL: ANESTH DID PHONE CONSENT WITH HEALTH CARE PROXY FOR OR TODAY. PLASTICS ATTEMPTED BUT NO ANSWER. HCP EXPRESSED WISHES TO RETURN PT TO DNR? PT INSTRUCTED TO BRING SUBJECT UP WITH DR. OR PT PCP. STATED WOULD NOT TAKE ACTION UNTIL AFTER PT MADE THROUGH \"THIS NEXT SURGERY\"\nPLAN: REMAIN SEDATED AND PARALYZED UNTIL OR FOR FLAP CLOSURE. CONT ASSESS HEMODYNAMIC STATUS. TITRATE NEO PER BP PARAMETERS. CONT CURRENT PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273234, "text": "Respiratory Care\nPt remains on current ventilator settings as documented on Carevue as well as ABG results.\nPlan to return to OR this evening as an add-on.\nMDI's given as ordered. Breath sounds diminished throughout.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273292, "text": "7p-7a:\nneuro: sedated on ativan and fentanyl gtts. grimaces and opens eyes to painful stimuli. .\n\ncv: afib 100-120's, treated with amiodarone boluses and iv lopressor. electrolytes repleted. sbp 80's- 140's, map > 60. converted to nsr 80's with sbp > 90. easily palpable pedal pulses bilaterally. hct 21 this am, treated with 1 unit prbc's, ? bleeding from flap per pa , plastics following.\n\nresp: lungs coarse. o2sat > 97%. remains orally intubated, see carevue for vent settings. abg wnl. suctioned for thick white secretions.\n\ngi/gu: abd soft, nd. bs positive. dtube feeding at goal. foley to gravity, good huo. cr 1.2.\n\nendo: fs qid, cover per riss.\n\nplan: ? ct scan to evaluate bleeding, follow hct.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273293, "text": "RESPIRATORY CARE:\n\nPt remains orally intubated, fully vent supported on SIMV. No vent changes made overnight. BS's coarse. Sxing thick white secretions. Administering Combivent MDI in line with vent Q4hrs. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273294, "text": "Resp Care\nPt remains intubated, no vent changes. Pt traveled for chest ct without incident. Plan to continue with current tx.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273240, "text": "NET SEDATED ON FENT/PROP AND PARALYZED WITH NIMBEX. NIMBEX WEANED TO 4 TWITCHES BUT PT NOT MOVING SPONT. SLIGHT COUGH WITH SX. DR. DOES NOT WANT PT MOVING DUE TO RV BEING CLOSE TO BONE. PERRLA. BP DOES RISE WITH STIMULATION.\nCV: HR 80-90'S, NSR WITH PAC'S. AMIO GTT TO 0.5MG/MIN PER DR. . LEVO TITRATED TO MAINTAIN MAP>60 AND SBP>90. CVP 11-15, PAD 18-22. CI>3. PT HAD NEW / SWAN PLACED IN RT IJ, AWAITING CXR CONFIRMATION AND WILL D/C ALL REMAINING LINES DUE TO RISE IN WBC. LT PICC LINE DC'D BY IV. CONT TO HAVE GENERALIZED ANASARCA. DOPPLERABLE PEDAL PULSES. DR. UNABLE TO GET NEW , NEED NEW STICK.\nRESP: REMAINS ON SAME VENT SETTINGS, WEANED FIO2 TO 40% ? THEN WEAN PEEP (CURRENTLY ON 8) LUNGS CLEAR. SX FOR THICK TAN SM. AMTS. SATS>97%.\nGI: OGT TO LCWS. THICK BIKIOUS DRNG. ABD SOFT BUT LG. NO BS. ? START TF\nGU: UOP GOOD, FOLEY PATENT. LG SCROTAL EDEMA.\nENDO: INSULIN GTT STARTED FOR BS 180'S , RAPID BS DROP ---GTT NOW OFF. CONT TO ASSESS Q1HR DUE TO LABILITY.\nSOCIAL: NO CONTACT WITH FAMILY OR FRIENDS\nID: BC X2 SENT OFF OLD LINES, URINE CX SENT AS WELL. CONTINUE REQUIRE BAIR HUGGER TO MAINTAIN TEMP>36. NO CHANGE IN ANTBX. VANCO LEVEL >20 , CONTINUE TO HOLD. CHECK IN AM.\nPLAN: D/C OLD LINES WHEN CXR CONFIRMS PLACEMENT OF NEW LINE. CONT TITRATE LEVO PER ABOVE PAREMENTERS. CONT TO SEDATE AND REMAIN LIGHTLY PARALYZED PER TEAM. FOLLOW CX. ? START FEEDS. ? OR MON IF MORE STABLE PER DR. . CONT CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273241, "text": "ADDENDUM: RT FEN AND LT CORDIS DC'D AND TIP SENT FOR CX. STILL AWAITING CHANGE BY RESIDENT. LEVO REQUIRMENT INCREASING AGAIN SLIGHTLY. CONT REQUIRE BAIR HUGGER FOR TEMP AND CO RISING, CONT PRESENT SEPTIC PROFILE. CONT TO ASSESS AND CONT CURRENT PLAN\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273304, "text": "Update\nDr. from plastic surgery called to bedside to evaluate new swollen r chest. Chest firm to palpation, warm and skin slightly shiny. Possible sq air palpated r and l of sternum around nipple line.\n\nHct repeated and basically unchanged. Plan to recheck Hct @ 2130 and report to Dr. .\n\nMinimal to no drainage from JPs #1 & 3. Jp #2 continues w/significant dark bloody fluid (appears less serous that pre-op today). See flowsheet.\n\nLimb and facial edema appears to be less than pre-op today. Neosynephrine weaning.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273305, "text": "0640 Cartioverted per to SR w/ 150 J for sudden onset of Afib w/vent rate of 120-130 and SBP 70's. requiring ^ doses of neo.+\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273371, "text": "NEURO: Alert, awake, follows commands, PERRLA, currently off restraints, Hoyered from bed to chair and back; tolerated transfers well\n\nRESP: Trach collared and tolerated well with Sats >95%, plan to rest Pt on CPAP overnight, L pigtail minimal drainage serosanguinous, plan to insert R pleural pigtail tomorrow, respirations reg/unlabored\n\nCV: NSR with PACs earlier during the shift, HR in 80-90s, keep MAP between 60-90, pedal pulses present, afebrile. Max temp 99.9.\n\nGI/GU: Abd firm/distended, bowel sounds present, no BM, banana flakes held, continues on TF at goal with minimal residual; Foley yellow/clear urine. On recurring Lasix with good response\n\nENDO: Continues on SSRI\n\nSOCIAL: No phone/visit from family.\n\nPLAN: Monitor resp/hemodynamics/urine output, plan to rest Pt on CPAP overnight, ?discharge to rehab, plan to insert R pleural pigtail tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273372, "text": "Hyperglycemeia\nGlucose remains elevated. 32 units regular insulin given today in divided doses sc for glucose 133-185. need to evaluate for better glucose control. NSR w/PAC. Denies pain. Watching TV most of evening.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273373, "text": "Nursing Progress Note\nNeuro: Alert, attempts to follow commands consistently. Tracks nurse around room. Gag and cough . Moves arms, minimal movement of legs.\n\nCVS: hr 80's sr, occ pac. SBP > 90 no agents. afebrile. Pulses confirmed by doppler. Skin ruddy, . Anasarca trunk and peri area. Peri area excoriated, see carevue for further skin details. Multi boots and csl on/off overnight. Rac PICC 2 lumen patent.\n\nResp: resting on vent overnight, will trach collar again in am. Trach site pink, ties and cannula changed. Suction for small thick secretions. Lungs clear in uppers, dim at bases.\n\nGI: abd obese, tf at goal via dophoff. BS present.\n\nGU: Foley cath with brisk output post lasix dose at midnight. Clear yellow.\n\nPain: Ultram for grimacing with care.\n\nEndo: FS BS covered with ssri scale.\n\nPlan: trach collar again in am, continue monitoring per unit standards. Rehab screening.\n\nSee carevue flowsheets and mars for further details and values.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273374, "text": "Resp: pt on 50% T/C. Pt placed back on vent psv 10/5/50% to rest noc as md. Vt 450 Ve 13, 02 sats @ 99%. BS are coarse bilaterally which clear with suctioning. Suctioned for copious bloody thick secretions at beginning of shift that subsided towards morning. RBSI=75. Plan to continue with trach collar trials today.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-03 00:00:00.000", "description": "Report", "row_id": 1273388, "text": "7a-2p\n\nNeuro: Pt alert, nodding and shaking head no to questions.\nAdmits to discomfort, treated with Tramadol 50 mg po with effect.\n\nCV: SBP low 100's. SR 70's, occ pac's. 1+peripheral edema.\n\nResp: Lungs coarse, clear but dim bases after suctioned for thick green sputum. Sats 100% on 15L trach collar @50%. RR 28. Trach care done 10 am.\n\nGI/GU: Abd soft, +bs. Last bm moderate, soft, brown.\nVideo swallow this am, pt tolerated thin and thick liquids but had some back flow. ASPIRATION pt to sit up for 30 min after eating. Tolerated whole pill, swallowed with water. Pt to restart tube feeds to keep up nutrition as po intake with not be enough. Dopoff was coiled in throat, removed this am and new one placed. CXR revealed good placement at 1pm today.\n\nSkin: Chest staples dry and . Coccyx pink, no breakdown.\nJP to left chest mod amts ss fluid.\n\nEndo: covered with regular insulin sliding scale. BS at noon 127, covered with 4 units regular insulin.\n\nSocial: Proxy aware of transfer to NE , .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273270, "text": "ROS:\n\nNeuro: Sedated and paralyzed on ativan, fentanyl, and cisatracurium. Intermitent cough reflex noted. PERRLA.\n\nCV: RSR->SB w/o ectopy. Titrated vasopressin to 2.4 to keep MAP > 60. Open chest wound w/VAC drsg fluid. Has RIJ cath. Has left radial ABP line. Peripheral pulses palpable w/ease.\n\nResp: Remains orally intubated and on Vent, AC 60%. Lungs clear and diminished in bases. Sx thick yellow secreations at times. No resp distress noted, = rise and fall of chest. Sats 98% or >\n\nGI: Pedi tube via right nare w/TF infusing w/ minimal residual. Abd soft w/active BS throughout abd. Protonix for Gi prophylaxis.\n\nGU: Foley patent clear yellow urine in QS.\n\nEndo: No coverage RSSI\n\nLytes: K and mag repleted.\n\nSocial: No contact from family or friends this shift.\n\nPlan: Pulmonary toileting. Continue w/current tx reg. Monitor, tx, support and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273271, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on SIMV settings. No vent changes made during the night. Remains paralyzed. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273272, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on SIMV/PSV w/ PIP/Pplat = 23/20. No secretions suctioned, SpO2 mid 90s. MDIs given as ordered. ETT secure/patent. Alarms on/functioning. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273273, "text": "See and Carevue for detailed documentation\n\nNeuro: PERL. Continues to be sedated and paralysed. No eye twitch noted. Cisatricurium weaned. Twitch noted at 20 .\n\nResp: Stable on vent , abg as noted. BS clearm diminsihed in bases. Initially no cough, no with cough with suction. Minimal secretions. Chest remains open\n\nCV: In NSR, BP stable on vasopressin. Initially pulses by doppler, now palpable. Potassium and calcium repleted thru shift.\n\nGI: Tube feeds advanced, tolerated well with residula < 100ml. No BM, no bowel sounds.\n\nGU: Foley to gravity with large amounts urine.\n\nEndo: RSSI per protocol, none required.\n\nPlan: Continue cardiopulmonary monitoring. Maintain BP with vasopressin. Repelte lytes as needed. ? plan for flap closure this week.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273274, "text": "Nursing Progress Note\n0330 converted to a fib rate 120, with bursts to 145. Map at the time > 70. Lopressor 5 mg iv per pa, converted to sr 70;s with MAP > 60. Vasopressin now at 1.6, continue prior documented plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273333, "text": "NEURO- EYES OPEN,BLINKING,NO TRAKCING OR FOLLOWING ANY COMMANDS.NO BODY MOVEMENT.FACIAL GRIMACING WITH ALL STIMULI.\n\nCV-NSR. BP STABLE.STAYED OFF NEO ALL NOC.K+=3.4-> REPLETED PRN. GENERALIZED ANASARCA. RT UPPER ARM WEEPING LARGE AMOUNT SEROUS FLUID.\n\nRESP-CPAP/PS ALL NOC. SXD FOR THICK WHITE SPUTUM.LS COURSE-> CLEAR. SATS=100%.\n\nGI- ABD LARGE ROUND SOFT. PASSED 2 SMALL BLOOD STREAKED STOOL.JP'S MIN S/S FLUID. NEPRO@ GOAL RATE OF 40CC/HR.\n\nGU- DIURESING WELL FRIM LASIX.\n\nLABS- GLUCOSE AND K+ COVERED WITH SS. PRN\n\nPAIN- ULTRAM 50MG GIVEN X1 FOR FACIAL GRIMACING.\n\nPLAN- CONTINUE TO MONITOR HR/BP. RESP STATUS.TUBE FEED.LABS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273295, "text": "NEURO~RESPONDING TO STIMUI WITH GRIMACING. OPEN EYES INT. NOT FOLLOWING COMMANDS. CONT ON FENT AND ATIVAN GTTS. TIITRATING THROUGHOUT THE DAY.\n\nCARDIAC~SR/AFIB. 70'S-131. GIVEN AMIO BOLUS @ 1700. INEFFECTIVE CURRENTLY AFIB ^ 119-131. HO AWARE. HCT 25. RECIEVED 2 UNITS OF FFP THIS AM FOR ^COAGS. REPEAT COAGS WNL. EPISODES OF HYPOTENSION SBP 80'S TEAM AWARE, FOLLOWING MEANS. BILAT PEDAL PULSES BILAT W/ DOPPLER. TO CT SCAN THIS AM TO CHECK FOR HEMATOMA IN CHEST PER PLASTIC . SCAN NEG. D5W W/ NA+ HCO3- @ 85CC'S/HR X 6 HRS.\n\nRESP~CONT ON SIMV SEE FLOW SHEET FOR SETTINGS MAINTAINING SATS OF 100%. LUNGS COARSE THROUGHOUT. SX FOR AMTS OF THICK SEC.\n\nGI/GU~NPO SINCE 0700. ? RETURN TO OR. TO RESTART TF THIS EVENING.\nQD LASIX ~ HUGE DIURESIS. CALLED BY PLASTICS TO CHECK FOLEY PLACEMENT. CT~> CATHETER TIP IN URETHERA. PLACEMENT OK. HYPOACTIVE BS .\n\nENDO~ TX W SSRI PER CSRU PROTOCOL.\n\nA/P~HEMODYNAMICALLY UNSTABLE. AFIB ^ 119-131. W/ SBP~80'S TO BE GIVEN A CA++/ K+/ & AMIO BOLUS PER DR.. TO TRANSFUSE W/ 2 UNITS OF PRBC'S FOR HCT OF 25. CONT W/ ICU INTERVENTIONS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273359, "text": "neuro: pt alert @ shift change, slept mostly overnight; attempts to communicate by mouthing words & pointing w/left hand; follows commands, moves lle on bed, able to lift/hold lue; wiggles rt toes, rue lift/fall. +.\n\ncv: sr, no ectopy. k & calcium repleted; bp stable 90s-110s. palpable pulses. extrs w/d. compression sleeves on. afebrile. continues on ivab.\n\nresp: ls clr, o2sats 100%, on cpap .50 fio2 , resp rate 10s, vt 300s-400s~no distress. ? trach placement on days.\n\ngi/gu: npo overnight; doboff placed previous shift, unable to flush, MD made aware~doboff removed by Dr. ; unsuccessful attempt made to replace doboff, pt to have doboff placed on day shift per Dr. ; +bs, no bm, abd soft distended, nt. adequate huo-clr yellow.\n\nendo: bs monitored per csru ss protocol-rssi coverage required overnight.\n\nsocial: no phone calls from pt family/friends this shift.\n\nplan: continue monitoring cardioresp status; monitor labs, replete lytes; ? placement of trach & doboff on days. continue w/current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273360, "text": "RESPIRATORY CARE NOTE\\\n\nPatient continues to be intubated and ventilated on PS ventilation all through noc. No vent changes made. RSBI completed on PS 5=83. BLBS are coarse. Sxn for thick blood-tinged secretions this AM. Plan to wean PS as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273361, "text": "Respiratory Care\nBreath sounds bilaterally clear, suctioned for small amounts of thick tan secretions, patient was afebrile and stayed into normal sinus rhythm whole day, blood pressure stayed within range, RR 15 to 26 on PSV, sat 99 to 100, WBC 13.2 ? ongoing bacterial infection, hemoglobin only 9.1 ?anemia, patient was treated with Combivent and Flovent inhalers, ETT rotated and retaped 22 at lips, patient sat in a chair for about three hours, no ABGs nor vent changes made today, plan is for patient to have tracheostomy tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273298, "text": "POD#3 Omental/prepectoral flap\nAfebrile today. Frequent changes in BP with frequent runs of afib followed by NSR. No ectopics. Neosynephrine titrated to keep MBP >60. Continues on Amiodarone. Extremities warm. Anasarca noted. Extremities elevated on pillows.\n\nBreathsounds clear at apices but diminshed or absent at bases. CXR and CAT scan reported to show bilateral effusions. No plans for vent weaning today. Patient placed on control ventilation to minimize WOB. Minimal ett secretions. Continues on VAP protocol. Some old bloody secretions removed with subglottal suctioning.\n\nTubefeeds at goal via r nasal post-pyloric tube. Banana flakes to resume tid. Abd soft distended. Hypoactive bowel sounds. Incontinent large, pumpkin colored soft stool. FIB placed. Peri-rectal skin .\n\nGlucose elevated. Arms edematous. Red/purple bruising r upper arm (?site of prior blood pressure cuff readings). Insulin sc changed to CSRU glucose management protocol. See flowsheet.\n\nFoley yellow urine w/white sediment. Penis grossly edematous. Continues on lasix 20mg iv qd.\n\nNo gag, no cough noted. Spontaneous l hand movement, tongue movement and brief, limited eye opening. Ativan gtt decreased. Continues on Fentanyl. Blood remains present in OD sclera. Continues on eye gtts and erythromycin OD.\n\nDr. in and sternal dsg changed. DSD to upper sternal staple line only. Lower staple line to be left open to air. JP drains # 1, 2, 3 continue on bulb suction. #2 noted to be a significant amount of thin, bloody drainage.\n\nHct to ~24. 1 PRBC given, Hct to ~27. Cultures pending. Plan to monitor closely.\n\nPhone report to \"health care proxy\". He would like to be notified when Mr. is more awake.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273299, "text": "Resp Care\nPt remains intubated, was placed on CMV for increasing WOB. Plan to keep on CMV and trach in future.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273300, "text": "ROS:\n\nNeuro: Sedated on Ativan gtt at 0.75 mg/hr. Fentanyl gtt at 30 mcg/hr. Appears comfortable. PERRLA.\n\nCV: Afib until ~ 0300 then RSR rate 80. Amiodarone gtt. Neo on at 0.5 mcg to maintain MAP > 60. Sternal drsg w/ old drng prox end. Drsg , /staples. Has RIJ cath, drsg . Peripheral pulses palpable w/ease. Generalized edema. SQ heparin for DVT prophylaxis.\n\nResp: Remains orally intubated and on vent. Lungs clear to coarse, sx thick yellow via ETT. Intermitent cough. No resp distress noted, = rise and fall of chest. Sats 97%. ABGs w/metobolic alcolosis. MDIs per RT.\n\nGI: ABD obese w/active BS x's all 4 quads of abd. Post pyloric pedi tube via right nare w/TF infusing at goal. Protonix for GI prophylaxis.\n\nGU: Foley patent clear yellow urine in QS.\n\nID: Afebrile. Remains on triple antibiotic coverage.\n\nLytes: K 3.4, repleted w/40 KCL. IC 1.1, repleted w/2 Gm ca+ gluc.\n\nEndo: Insulin gtt off when glucose down to 66.\n\nSocial: No contact from guardians\n\nPlan: Mobilize, pulmonary toileting, Monitor, tx, support, and comfort. Reassurance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273375, "text": "mr was placed on 50% T.M. for most of the day.mid afternoon he was placed back on while he was havinf a CT inserted on his right\nchest .1200 cc of bloody fluid was drained from his R pleura.\nBS:ronchoreous,suctionned bloddy secretion.he was then placed back on 50% T.M,spo2 95% and RR 26.MDI administerd as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273334, "text": "shift update:\n\nneuro: spontaneous eye opening. grimaces w/care. movement on bed noted in rue & bilat le. pt's minister into visit & pt appeared to be tracking conversation between nurse & minister. when asked if he was mad re his health he shrugged his shoulders. pearl.\n\ncv/skin: nsr w/rare->frequent pac's noted. lytes repleted. sbp stable high 80's->high 90's. am lopressor held d/t sbp<100. +pp.\n\nresp: lungs coarse. suctioned thick yellow secreations. attemped to wean ps->rr imediately increased>30.\n\ngi/gu: +bs. tf cont at 40cc/hr. inc lg soft formed stool. uop adequate. good diuresis w/lasix.\n\nendo: fs covered w/ssri per protocol.\n\nid: afebrile. cont on ivabx.\n\nsocial: minister into visit/pray w/pt.\n\nplan: cont current plan of care. attempt to wean ps if tolerates. ?trach & peg this week. replete labs prn.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273335, "text": "BS coarse crackles, rhonchi; no change with MDI's. Suctioned for moderate amount thick yellow secretions. Attempted again to lower PSV to 14 but rate > 40. Back on PSV 17. Continue to attempt to wean PSV. Probable trach/PEG this week.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273336, "text": "NEURO- AWAKE/ALERT/EYES OPEN. TRACKING VOICE AND RN POSITION AT TIMES. OPENED MOUTH TO COMMAND. PURPOSEFUL FACIAL GRIMACING AND TIGHTENING OF EYES/JAW WITH CARE. NO MOVEMENT OF EXTREMETIES.\n\nCV- AFEBRILE. WBC=16.1 HCT=27.0 NSR. BP STABLE. LOPRESSOR HELD AT .GENERALIZED ANASARCA. WEEPING SEROUS FLID FROM RT ARM.\n\nRESP- TOLERATING CPAP/ 17PS. WEANED PS DOWN TO 15 BUT PT BECAME MORE TACHPNEIC. LS COURSE-> CLEAR AFTER SXING THICK CLEAR SPUTUM.\n\n\nGI- NEPRO @ 40CC/HR VIA NASAL DOBHOFF.\n\nGU- ADEQ. U/O. DIURESING WELL FROM LASIX.\n\nPAIN- 50MG ULTRAM X1.\n\nPLAN- SLOW WEAN OF PS.SXING. REPOSOTIONING.DIURESE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273337, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. PSw weaned to 15. well. Lungs sl coarse/sxd amt thick sputum. RSBI this am on 0 PEEP/5 PS was 96. Continue slow wean.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273362, "text": "Nursing 7a-7p\nNeuro: Alert most of shift. Nodding yes/no appropriately to questions. Attempts to mouth words, this RN unable to interpret. PERRLA. + hand grasps, L>R. Moves bilat legs on bed. PO ultram for c/o pain. Apprehensive w/transfers & repositions, reassured frequently. OOB to chair x3hr. ROM done, bilat LE very stiff.\n\nC/V: NSR 60-80s. Rare- occasional pacs. Lytes repleated. On PO amio & lopressor. SBP 90-130. Skin W&D. Slightly hypothermic, bed warmer on- improved to normothermic. JP x2 to bulb sx w/min drainage.\n\nResp: CPAP 50% 10/5. No vent changes this shift. Sats >99%. Suctioned for mod amts tan sputum. VAP protocol.\n\nGi: Dophoff placed at bedside. Confirmed by CXR. TF resumed @ goal 40cc/hr. Banana flakes for loose bm in am.\nGu: HUO <30 x1. 1x ivp lasix w/+diuresis. Otherwise adequate HUO, on ivp lasix.\nEndo: RISS.\n\nSkin: See carevue for incisions/impaired skin.\nSocial: No call/visit from family friends.\nID: Mult iv antibiotics. Erythromycin oint for eyes.\n\nPlan: Add-on case for trach in OR tomorrow. TF to be shut off at midnight. Pulm toilet. Monitor lytes. Reorient & reassure frequently.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273235, "text": "csru update\nevents: remains w/ open chest. possible closure this afternoon.\n\nneuro: paralytic d/c this am. remains sedated on propofol and w/ fentanyl drip. pupils diff to assess. reactive to light.\n\ncv: vs/hemos as per flowsheet. pt w/ met acidosis on am abg w/ hct 26. 1 unit prbc transfused. bp drifting to low 80's though map remained > 60. 2nd U transfused. attempt not to tirate up neosynephrine r/t possible OR for chest closure w/ flap. 4+ anasarca, extrems warm. distal pulses by dopller. CO/CI wnl. afib / vent responce in 80's much of day. ? return to 1st avb this afternoon. amiodarone drip cont.\n\nresp: lungs coarse when no longer on paralytic. TV down to 500cc this am. abg as per flowsheet. met acidosis. o2 sats high 90's. chest open w/ drains to lwsx for serosang.\n\ngi/gu: abd soft. hypo bsp. ogt to lwsx for bilous dng. insulin gtt to off. no bm. reglan held. foley w/ uop 25-50cc/hr.\n\nskin: 4+ anasarca including lg amt scrotal swelling. weeping serous dng fluid. no turn r/t open chest.\n\nid: requiring bair hugger to maintain temp > 36. wbc 19 this am. chest open. vanco d/c this am. remains on ampicillin and cefipime,\n\nassess: met acidosis w/ drifting BP.\n\nplan: cont to monitor vs/hemos/labs closely. ? OR this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273236, "text": "See and Carevue\n\nNeuro: Rec'd patient moving all in bed. No purposeful movement noted. Chewing at ETT with some blood noted a lip and in mouth. Making resp effort, slight ?cough intermittently. Patient restart on cisatricurium, no without movement. PERL. Minimal change in VS with stim.\n\nResp: Patient coarse thru out. Suctioned for sputum culture, small thick blood tinged pluggy secretions. Poor recovery. Decreased SAT, FiO2 increased to 60% with improvement. Metabolic acidosis treated with bicarb.\n\nCV: Patient in NSR-> NST. Afib resolved.On amio. Patient with increase in HR 80->110 with acidosis. Stable BP on neo. CO/CI unchanged. Calcium and potassium repleted. Bicarb for acidosis. Lactate stable at 1.2. Blood, sputum and urine cultures sent.\n\nEndo: Glucose stable off g insulin gtt.\n\nGI: OGT to LWS with large amount of output. Reglan given.\n\nPlan: Continue cardiopulmonary monitoring. Replete lytes as needed. Correct acidosis. Continue to evaluate for sepsis. Antibiotics as ordered.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273237, "text": "Resp Care Note:\n\nPt cont intub with OETT and on vent as per Carevue. Lung sounds coarse after suct sm th brn sput. MDI given as per order. ABGs stable on present vent settings. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273238, "text": "NEURO: paralyzed with cisatracurium and sedated on propofol and fentanyl gtts. TOF with zero twitches L facial on 20 MA. goal NP is <2 twitches. no motor or verbal response. no gag or cough.\nCV: at beginning of shift sinus with APC's converted in to Afib--> amio bolus admin and converted back to sinus. converted back to Afib 0530 on amio gtt. MAP goal 60-90. on neo at beginning of shift switched to levo. MAP 60's-70 on levo. CO 3.5-4.5 CI>2.0. PA pressures elevted systolid 40's. Sternum remains open. skin cool, +anasarca, +weeping serous fluid. pedal pulses by doppler. good response to lasix IV. bair hugger for goal body temp 36.0\nRESP: lungs coarse bilat. suctioned for tan secretions- thick. VAP care done and old blood and clots suctioned from mouth. intubated. at beginnng of shift O2 low, PEEP increased to 8 NP. stable on vent. acidotic later in shift. treated wtih bicarb. no overbreathing.\nGI/GU: abd soft distended with ecchy areas no bowel sounds. OGT with bilious drainage LCWS. Foley with clear yellow urine. penis/scrotum edema. + abrasion on scrotum with serous drainage.\nENDO: blood gluc rising pt place on insulin gtt.\nID: WBC rising. lactate 2.2 . ampicillin IV. ceftriaxone IV ordered awaiting ID approval.\nSKIN: sternum open covered with transparent dressing. abd with ecchy, skin weeping serous fluid. +anasarca.\nLINES/ACCESS: PA cath, R rad A line, R , L AC PICC- flushed, is sluggish but patent.\nSOCIAL: pt's minister visited pt this evening.\nA/P:maintain paralysis and sedation, monitor cv goal MAP 60-90, monitor resp, ABG acidocis, bair hugger normothermia, skin care as able (bath not done d/t inability to hold body temp off bair hugger). no turns in bed d/t open chest. lytes, blood gluc. plan to go to OR 0730 for sternum revision.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273239, "text": "Respiratory Care\nPt remains on mechanical ventilation, supportive settings. Slowly weaning Fi02 as documented in Carevue.\nBilateral breath sounds diminished thoughout. MDI's given as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273367, "text": "neuro: pt more interactive. awake initial shift. slept most noc. nod head and non-verbal cues appro. cooperative to care. maex4. more strength L>R. minimum r leg and toes movement. perrla.\n\nid: wbc rising 17 today?? low grade temp. con't multi abx. sent am vanco dose. erythromycin ointment for OD - sclera red-but improving\n\ncv: sr w rare pacs. map >60. sbp mid 80s-100s. gave po lopressor dose. po amiodarone. bodily edema improved to 1pitting now. skin w/d. palpable pulses. pneumaboots on.\n\nresp: trach #8 portex - site sl drg. remain on cpap .50/10/5. vt 400s-500s, w db ^700s. sat >99%. ls cta, diminish both bases. sxn sm-scan amt blood-tinged. rr mid 10s-low 20s. no distress. trach care done. vap protocol.\n\ngi: tf at goal via dobhoff. no residual. gu: diuresis w lasix regimen. reglan scheduled. creatinine pnd. banana flakes. endo: treat bs per riss protocol\nwound: see careview. sternal/abd incisions healing. heels . JP x2 from sternal drain sm amt . multipodus boot\n\ncomfort: med w ultram prn for incis pain w relief. no relative call. update status to pt and provide support\n\na/p: s/p Trach in OR. no changed in Vent. uneventful noc.\nwean to trach collar today-pulm toilet. wound care. to chair. PT/OT consults. Rehab screening. f/u abx and ?elevated wbc. con't vap protocol\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273368, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 Portex DIC trach. BLBS are coarse. Sxn for thick yellow secretions. Tolerating PS 10/5. plan for future trach mask trial. RSBI completed on PS 5=91.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273369, "text": "NEURO: PLEASANT, MOUTHING WORDS. SEDATED BRIEFLY ON PROP FOR CT PLACEMENT\nCV: BP DOWN TO 79 AFTER PROPOFOL NOW CLIMBING BACK UP. HR 70'S WITH OCC PAC'S. PALP PEDAL PULSES\nRESP: LT PLEURAL PIGTAIL TUBE PLACED BY M. COURNTEY. DRAINED 700CC INITIALLY NOW NOTHING. DRNG. LUNGS DIM AT BASES. PLACED ON TRACH COLLAR 60% THIS AM RR 25-30, APPEARED COMFORTABLE, ABG WNL. BACK ON CPAP FOR PIGTAIL PLACEMENT WITH SEDATION.\nGI: AT GOAL ON TF AT 40CC/HR. NGT PLACEMENT CONFIRMED BY AUSCULTATION\nGU: FOLEY PATENT. DIURESING WELL FROM LASIX\nENDO: BS COVERED BY SSR, SEE FLOWSHEET\nPLAN; CONT TRACH COLLAR TRIALS. ? SPEECH SWALLOW IN AM IF TOLERATING WELL. CONT ASSESS CARDIO/RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273370, "text": "Respiratory Care\n\n Pt received on PSV 10/5 placed on T-mask tolerating well B/S dim in bases. Sx'd small thick tan. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273212, "text": "Neuro: pt sedated overnight with propofol 30mcg and prn morphine x1 for pain. Pupils equal and reactive. Propofol weaned off this am pt has not woken yet, off for 1/2 hour.\nResp: Vent on SIMV with rate of 12 decreased from 14 MV of pt is not overbreathing the vent. O2 sats 95%. Suctioned for scant amounts.\nChest tubes patent draining serous sangunious drainage 20-40cc/hr no air leak detected.\nC/V: pt apaced most of night until this am underlying rhythm 88 sinus rhythm Pacer placed on back up mode of 60. pt required volum 1000 cc for low filing presse-ures low Blood pressure and decreased SVO2 along with a base excess on ABG of -5. pt also required small dose of neo for BP. Pulses palbable in feet.\nGI: OGT drainig scant amounts of green bilious fluid.\nEndo: Insulin drip weaned off for blood sugar of 69 and has not had to be restarted. blood sugars in the 70's to 90's.\nGU: excellent urine output most of night greater than 100 cc/hr.\nSkin: chest dsg intact no drainage noted. Pt has a large ecchymotic area in left lower abdonmin and groin area.\nPlan: wake and wean and possible extubate when ready. Neo for BP>\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273213, "text": "Respiratory Care\nPt remains intubated and on vent support. Vent changes were SIMV to PSV w/CPAP. Other changes were FiO2 from 0.40 to 0.50. Lung sounds were clear and diminished in the bases. Pt was suctioned for scant amounts of thinl clear secreretions. Last ABG showed a compensated mixed disorder with mild hypoxemia. Care plan is to continue to wean as tol with target volumes of >350 mL. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-27 00:00:00.000", "description": "Report", "row_id": 1273227, "text": "7P-7A\nNEURO: A/Ox3. Confused at times. Moves and lifts extremities. PERRLA. PO Percocet for ABD/INCS pain with good effect. Afebrile.\n\nCV: NSR 80's. Rare PAC's noted. Lytes repleted prn. PO Amio . NEO GTT weaned to off and restarted for MAP < 60 @ 0.5mcg/kg/min. Dopplerable pulses bilat. Sternal click palpated with NT suctioning and CDB, PA aware. No new drainage noted to sternal dsg. SQ Heparin for DVT prophylaxis. +3 bilat UE/LE pitting edema. Picc line to RAC, Multilumen to RIJ, R radial Aline.\n\nRESP: LS coarse with EXP whzs. NT suctioned for blood tinged thick sputum. Weak cough effort. IS to 500. O2Sat <94% on 60% face mask. Nebs per RT.\n\nGU/GI: Foley to gravity. HUO >30cc. BUN/CR 18, 1.6 Lasix PO BID. Scrotal edema noted. Abd pain per pt PA aware. +hypoactive BS ABD soft. Bruising noted secondary to SQ Heparin. PPI for GI prophylaxis.\n\nENDO: FSBS per ordered SS.\n\nID: Afebrile. IV Vanco check trough today. IV Ampicillian &IV CefePIME continue.\n\nPLAN: Continue aggressive pulmonary toileting!!!!! Wean Neo GTT to off. ? D/C Multilumen, culture cathether tip.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-27 00:00:00.000", "description": "Report", "row_id": 1273228, "text": "See carevue for objective data.\n\nAlert/oriented. Yelling out this AM \"go away! I want to die\". Support provided. Ultram/percs for pain with good effect. Much more appropriate affect this PM.\nShort period of AFIB which was self-limiting. Received 5 mg lopressor IV and po dose which was tolerated well. PAC's noted on monitor but no further AFIB. Neo currently off. Goal MAP>60.\nNon-compliant with pulmonary hygiene despite several attempts. NT sx X1 with poor results. Remains on face mask. Sats adequate.\nLasix dose increased to 40 mg po BID. Crackles auscultated right base. Total body edema remains.\nSternal dressing changed this AM and no staining noted. + sternal click. Team aware.\nTaking diet fair. Boost shakes/puddings tolerated well.\nNo BM. C/O some abd distention. Team aware.\nRIJ dc'd. Double lumen PIC patent.\n\nContinue current POC/support pt/pulmonary hygiene as tolerated/pain control.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273229, "text": "S. I think I am going to die. It hurts all over.\nO. Neuro a/ox3 moaning and yelling out given oxycodone 2 x2 with good relief of discomfort. Pupils equal and reactive, mae, fc\nResp exertional I/E wheezes given neb tx x2 with some resolution of symptoms ABG on 100% 7.34/39/112/-. CPT and TCDB done pt with productive cough swallowing sputum\ncvs BP <70/ at 1900 started on neo and given 1liter of lr. Neo remained on all night on .6mcg/kg/min. Hct 31.3 Sternum staples in place oozing blood from mid staple site dsg saturated changed. HR 70-130 nsr to afib lopressor po held bp given amiodarone as ordered po. Lytes repleted. Skin anasarca weeping PP+\nGI coughing after swallowing abed snt BS+ stomach ecchymotic no stool\ngu u/o 35 for 3 hrs given 1l LR for low bp with improvement u/o also given lasix as ordered BUN 20 cr 1.6\nendocrine BS 64 tx\naccess lt picc, rt radial a line\na. s/p MVR blding from staple site\nhypotensive, afib, ? ability to swallow, exertional I/E wheezes\np. monitor blding from sternum, check hct, monitor bp , wean neo as tolerated, give lopressor when bp stable, vigorous pulm toliet, monitor swallowing ability have hob at 90% when taking po monitor\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273296, "text": "NEURO-ON FENTANYL & ATIVAN GTTS. NO PURPOSEFUL OR NON-PURPOSEFUL MOVEMENT SEEN. BP AND RR RESPONSIVE TO STIMULI,REQUIRING A COUPLE OF ATIVAN BOLUSES AND INCREASE IN DOSE.SPONTANEOUS ATTEMPTS TO OPEN EYES SLIGHLTY.\n\nCV- AFIB. RATE BETWEEN 115-125. AMIO BOLUS FOLLOWED BY AMIO GTT@ 0.5MG/HR. HYPOTENSIVE WITH SBP LOW=65.NEO GTT STARTED AND TITRATED TO KEEP MAP> 60.BECOMES HTN WITH STIMULI OR SPORADIC COUGHING EPISODES.AFEBRILE. WBC=17.1 ON VANCO,AMPICILLLAN,&CEFTRIAXONE.HCT=25.4->TRANSFUSED 2UPRBC WITH REPEAT HCT=28.1 SKIN W/D. SMALL AMT SANG. SEEPAGE THROUGH SUPERIOR EDGE OF STERNAL DSG. JP.S WITH OUTPUT.\n\nRESP- ASYNCHRONOUS BREATHING WITH INCREASED RR TO 29. SHORT,SHALLOW BREATHS AND \"BUCKING \" THE VENT. SATS MAINTAINED BETWEEN 98-100%. LS TIGHT. INH.GIVEN AND VENT SETTINGS CHANGED TO CMV TO REST PT .\nOCC. COUGHING EPISODE. SXD X1 WITH NO RETURN OF SECRETIONS.\n\nGI/GU- ABD SOFT,LARGE,ECCYHMOTIC WITH HYPOACTIVE BS.NEPRO RE-STARTD @20CC/HR AND ADVANCED TO 40CC/HR LATER IN SHIFT. NO STOOL. U/O LOW BUT ADEQUATE MOST OF SHIFT DECREAINIG TO 8 & 7CC/HR. MD NOTIFIED. BLOOD INFUSING. U/O INCREASED TO 45CC/HR.\n\nLABS- K+ REPLETED PRN.INSULIN GTT STARTED FOR GLUCOSE LEVELS > 130 X 2. CSRU PROTOCOL FOR SSCI IMPLEMENTED AND FOLLOWED.\n\nPAIN- FACIAL GRIMACING WITH TURNING &/OR MOUTH CARE.\n\nPLAN- PLACE BACK ON IMV VENT SETTINGS AND ATTEMPT TO WEAN MORE IF TOLETATED. TITRATE FENTANYLY &/OR ATIVAN GTTS IF POSSIBLE. CONTINU WITH ICU MONITORING.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273297, "text": "resp care\npt initially on imv 500x14 50% 5peep but pt became increasingly out of phase with the vent. RR inc to > 30, tachy and hypertensive. Pt changed to a/c with improvement in WOB. Combivent given as ordered with some in cough.Suct for sput. Pt changed back to imv this am with inc in wob. RSBI attempted but >150. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273363, "text": "shift cover 2300-0700\n\nneuro: pt more awake at initial shift- watching tv. head appro to questions. grasp stronger l>r, move rle but minimumly. perl. slept most of noc\n\nid: low grade temp. wbc still ^- con't multi abx. sent vanco level am. erythromycin ointment to OD\n\ncv: sr. map 60-70. on po lopressor/amiodarone. skin w/d. con't bodily edema - more so both ues. palpable pulses. pneumatic boots.\n\nresp: cpap .50/10/5. sat>98%. breathing even. no distress. sxn sm-mod amt secretion.\n\ngi: tf at goal 40cc/hr. stopped at midnoc for OR tracheostomy in am.\nendo: treat bs w protocol dose d/t npo\ngu: bun and creat rising. huo adequate on lasix regimens\nwound: see careview\ncomfort: gave ultram x1 dose for discomfort w effect. no family/friend call . provide support and explain to pt status/icu enviroment\n\na/p: npo preop for OR trach in am.\npulm toilet. support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273364, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on PS settings through noc. No vent setting changes. Plan for trach placement today. RSBI completed on PS 5=92. BLBS remain coarse. Sxn for thick yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273214, "text": "Neuro: Off propofol since 0500, slow to awake, follows command inconsistently, movement noted on LUE, weak grasps with R hand, unknown status on LE, no movement noted, hx of bilat knee replacement; PERRL 3mm; per friend stated to be wheel-chair dependent\n\nCV: Tachycardic high 90's-100's; off neo, MAP >65; K repleted in AM; increasing PAC's in PM, lytes rechecked; started on PO lopressor & IV lasix\n\nRESP: Intubated on pressure support & CPAP, 50% FiO2; improving ABG; lung sound clear, dim @ bases; CT draining minimal serrousang drainage\n\nInteg: Intact, redness noted on sacral area, skin protectant applied; old bruise noted on L lower abdomen; sternal drsg amount of serrousang drainage\n\nGI: NPO; OGT to low cont suction with small amount of billous drainage; carafate & protonix given\n\nGU: Foley draining yellow clear urine, minimal UO in PM, 20 mg IV lasix given with fair response\n\nEndo: Follow protocol\n\nSocial: Case manager and social worker contact regarding placement and spokeperson\n\nA/P: monitor hemodynamics; monitor labs; work on extubation; DC plan; ?DC CT in AM\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273266, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on SIMV settings. OR last noc for sternal washout. Chest remains open. Paralyzed. No vent changes made during the noc.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273267, "text": "NEURO: at beginning of shift moving mouth, coughing and SBP climbing. increased doses of cisat., fent and ativan with good response. now no vital sign change with interventions, twitches light coughing only with in line suction. pupils = NR.\nCV: sinus rhythm all noc. no ectopy noted K and mag repleted. neo weaned off and pitressin down to 1.2 labile bp over noc much titration required. +anasarca, DP, PT by doppler. chest remains open with VAC dressing.\nRESP: lungs clear at upper, dim. at bilat. bases. remains intubated, no vent changes over noc. ABG stable. VAP care done.\nGI/GU: abd soft, distended with ecchy areas. NG tube residual high >150. tubefeeds held. bowel sounds absent. foley with clear yellow urine.\nENDO: blood gluc covered with RISS\nID: remains on vanco, amp, fluconazole, ceftriax.\nSkin: open chest with vac, mediastinal DSD. abrasion to scrotum. + anasarca. buttocks with rash. multipodus boots on. triadyne bed rotating L only. bloody gums with oral care\nSOCIAL: no calls this shift.\nA/P: monitor cv, resp, maintain paralysis, sedation. keep intubated. wean presssors as . VAP mouthcare. lytes and blood gluc.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273287, "text": "7p-7a:\nneuro: sedated and paralyzed overnight. . fentanyl gtt for pain with good effects.\n\ncv: afib 100-120's, treated with amiodarone bolus with conversion to sr 80-90. no ectopy noted. electrolytes repleted as needed. neo gtt weaned to off, sbp 90-120's. remains on albumin qid. easily palpable pedal pulses bilaterally.\n\nresp: lungs coarse at times. remains orally intubated on full mechanical ventilation. see carevue for settings. hypoxic initially with po2 of 61, improved to 100 this am. suctioned for minimal secretions.\n\ngi/gu: abd soft, ecchymotic. bs hypoactive. dophoff tube clamped. foley to gravity, low uo treated with volume with good effect.\n\nendo: fs qid, cover per riss.\n\nplan: s/p omental flap, jp x 3, wean sedation this am.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273288, "text": "RESP CARE: pt recieved from OR s/p chest closure. Pt intubated/on SIMV, settings per carevue. PEEP increased to 8 following low Pa02 post-op. Oxygenation improved. Lungs dim/coarse bilat. Sxd small amount thick yellow sputum. MDIs given per /no sign improvement noted. No RSBI this am, pt recieving NMBA and FI02 .60/\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273289, "text": "Resp Care\n\nPt remains intubated and on simv/psv. MV is being maintained in the 7-8L range with an abg of 7.42/43/99/26. BS are diminished and suctioning small amts of tan yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273290, "text": "7a-7p\n\nNeuro: Nimbex d/c'd this am. Ativan decreased to 1mg/hr. Fentanyl decreased to 50mcg/hr. Pt responding to stimuli, moving mouth with care. Grimace to painful stimuli. PERL.\n\nCV: SBP 80-130 (Maps 60-90). SR 80-90's. 3JP's cont to drain dnge, output decreasing. Hct 26.1 this am (down from 29 last night) Next hct in am ok with Dr (plastics). +pedal pulses with doppler.\n\nResp: Pt remains intubated on full mechanical ventilation. ABG wnl. Sat 99-100%. Lungs clear, dim bases.\n\nGI/GU: Abd soft, no bs noted. Advancing TF Nepro, presently at 30cc/hr. Minimal to no residuals, due to advance to goal of 40cc/hr at 10pm. RISS, covered today. UOP wnl, low last hr.\n\nSkin: See flowsheet. Bleeds easily from pinhole sites one left arm, one rt forehead. aware. Bottom wnl.\n\nSocial: no calls today.\n\nPlan: Cont to monitor hemodynamics and resp status closely. Wean sedation again in am. Advance TF as tolerated. Monitor JP drains.\nMonitor chest site closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273291, "text": "7p-7a:\nuo low throughout night, treated volume. hct 21 this am, 2 units prbc's given, cxr done. ? bleeding from flap site, awaiting plastics.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273365, "text": "Nursing 7a-7p\nResp: Pt traveled to OR for trach placement today. #8 Portex inserted without difficulty. Reversed in OR. Placed on cpap 50% 10ps/5 peep once in CSRU. Breathing unlabored. Lungs clear dim in bases. Suctioning sm amt blood tinged sputum. Trach site with min sanginous drainage.\n\nC/V: NSR 60-70s w/rare pacs. K+ repleated. SBP 80-120. Map >60, team accepting maps >60. +PP.\n\nNeuro: Awake & alert most of shift. More interactive today than yesterday. Mouthing words, this RN unable to interpret. No dexterity to write. PERRLA. MAE. Follows commands. PO ultram for c/o incisional pain.\nAct: Hoyered OOB to chair. Passive & active ROM done.\n\nGi: TF resumed @ goal 40cc/hr. Loose bm x1 in am, banana flakes resumed.\nGu: HUO <30x2 in afternoon. 1x ivp 20mg lasix MD . On schuled ivp lasix.\nEndo: RISS.\nSocial: friend called & stated would visit today.\nID: Afeb, mult iv antibiotics. Erythromycin oint OD.\nskin: See carevue.\n\nPlan: Pulm toilet. Increase act as . ?rehab screen. Monitor I/Os, lytes. Vanco trough to be drawn tonight.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273366, "text": "Respiratory Care\nBreath sounds bilaterally coarse, suctioned for smlll thick white secretions, patient was afebrile, stayed into normal sinus rhythm whole day, RR 13 to 26, WBC 14.9 ?bacterial infection, hemoglobin only 9.2 ? anemia, patient went to OR this morning to have tracheostomy, cameback at 0900 am Portex size 8 with inner cannula inserted, cuff pressure 22cmh2o\nsince tracheostomy patient has been suctioned for small amounts of thick, blood-tinged secretions, has been treated with Combivent and Flovent inhalers, no vent changes made nor ABGs drawn up to this point.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273268, "text": "See and Carevue for detailed documentation\n\nNeuro: Rec'd on ativan, fentayl, cisatricurium. Attempt to decrease cis with spont resps noted and cough with reposition. Gtt increased. Otherwise remains paralysed, sedated. No change in VS with noxius stim.\n\nResp: Continues on vent. No changes made. BS clear, without wheeze. Suctioned for amounts secretions. Mouth care done with bloody secretions noted in mouth.\n\nCV: In NS brady with HR 50-60. BP stable. Pulses by doppler. Rec'd on vasopressin 1.2units. Patient with large output s/p lasix. BP with MAP <60. Vasopressin increased with good result, unable to wean and maintain BP>60. Potassium and calcium repleted. Afebrile, antibiotics continue.\nVAC dressing to open chest . Skin exam as noted in care view.\n\nGI: Restart feeds. Start residual 25ml. No bowel sounds noted.\n\nGU: Foley to gravity with large output s/p lasix. Negative balance.\n\nPlan: Continue cardiopulmonary montioring. Advance feeds if tolerated.\nRemain sedated, paralysed. Wean vasopressin as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273269, "text": "Respiratory care\nPt remains intubated on same simv setting no changes this shift. BS clear, suction small amts of secrections, pt remans paralyzed. Plan to continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273328, "text": "neuro- eyes open all shift. no tracking or startle reflex.blankly staring outward. no motor response or movement seen.\n\ncv- nsr->afib,hr>115. on p/o amiodarone .neo gtt @ 0.25mcgkgmin.md notified. no lopressor given.k+ repleted. afebrile. wbc=17.9 hct=28.4. bilateral upper extremities seeping large amounts serous fluid. left radial a-line site macerated,pink and maloderous.generalized anasarca.abdominal binder around chest to protect sternal flap and .\n\nresp-multiple vent changes made d/t tachypneia with \"guppy-like\" breathing.sats maintained >95%. lung sounds course. sxd. thick yellow/tan sputum.diuresing well with lasix.extra dose ivp lasix this shift.ett with positional air leak.\n\ngi- abd soft. hypoactive bs. no stool. nepro @ 40cc/hr. difficulty checking residuals with dobhoff.\n\ngu- diuresing well from ivp lasix.\n\nlabs- lytes/glucose covered with sliding scales.\n\nplan- continue to monitor resp.system,hemodynamics,skin care.labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273329, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support; however, patient was \"guppy-breathing.\" PSV increased to 17 cm, resulting in a more synchronous ventilatory pattern. No morning abg results at this time.\n\nRSBI = 154.1 on 0-PEEP and 5 cm PSV.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273330, "text": "BS coarse crackles, improving with suction; no change with MDI's. Suctioned for small amount thick yellow secretions. Attempted to wean PSV to 14 but pt became tachypneic and stressed. Will continue to attempt to wean as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273354, "text": "neuro:pt awake, perl. track. sleep most of noc. squeeze hands strength more rh vs. lh. move lle, no movement of rle. head appro to questions. fc consistently. occasional bodily shaky w stimulations, but resolve on own.\n\nid: low grade temp. on multi abx. sent am vanco random.\n\ncv: sr rare pacs. map >60. on po lopressor/amiod. bodily edemadous more so both ues, scrotum. skin w/d. palpable pulses. pneuma boots on.\n\nresp: remain on cpap .50/12/5. no weaning per team . sat 100%. no distress. breathing even. ls coarse, sxn sm-mod lt yellow. rr low 10s-mid 20s.\n\ngi: tf at goal, no residual. dobhoff was pulled out at 2300. npo after midnoc for tracheostomy procedure in am. dr. was informed->plan to place dobhoff in am.\nendo: no coverage for bs 116 d/t npo\ngu: inconnt smear amt soft bm. gave reglan. held colace/bananaflakes. diuresis w lasix\n\nwound: bodily edemadous w multiple skin abrasions throughout. dsd on rlarm cdi - llarm w sma areas of blacken skin. abd bruises w few areas of skin abrasions. buttock red/bruises - but and heels ->applied vesta cream. multi podus boots. sternal-abd wound w stables-cdi\n\ncomfort: pt denies pain. no family or relative call . orient pt to icu/status - provide suppport prn\naccess: picc line patent\n\na/p: long recovery from . plan for trach today. need dobhoff placement. pulm toilet. abx.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273355, "text": "addenum:\nJP x3 from sternal/. to bulb sxn -drain drg ->#2 has most amt.\n\nVAP protocol\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273356, "text": "Resp Care: Pt continues on PSV 12/5 50% 02. No changes overnight. LS coarse bilaterally. pt sxn'd for small-large amounts of thick yellow secretions. MDI's given as ordered. PLAN: continue to wean PS as pt tolerates, to OR for trach.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273357, "text": "Respiratory Care\nBreath sounds bilaterally clear and diminished, suctioned intermittently for small thick yellowish secretions, patient was afebrile, stayed into normal sinus rhythm whole day, RR 15 to 25, WBC 14.5 ? bacterial infection, treated with Combivent and Flovent inhalers, PS weaned down from 12 to 10, bedside tracheostomy postponed for specialist unavailability, Hemoglobin only 9.4 ?anemia, ETT rotated and retaped 22 at lips with nurse help,no ABGs done today, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273358, "text": "See and carevue for detailed documentation\n\nNeuro: Patient alert thru day. Nodding appropriately to questions. Tramadol x1. Patient with increased strength in UE, reaching for tubes. UE now restrained.\n\nResp: Plan for trach today, not done to schedule conflict. Remains on vnet, In NAD. Suctioned for moderate secretions. Less secretions then in past. BS clear, slightly coarse. Continues on MDI.\n\nCV: In NSR, BP stable. Afebrile. Continues on antibiotics. Potassium repleted.\n\nEndo: RSSI per protocol.\n\nGU: FOley to gravity with good output s/p lasix.\n\nGI: Feeding tube placed. Small smear stool today.\n\nSocial: Health care proxy updated via phone.\n\nPlan: Continue cardiopulmonary monitoring. Restart feeds tonight. Reeval for trach in am.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273208, "text": "Respiratory Care\nPt was received from OR intubated. Pt placed onto vent vent changes were FiO2 from 1.0 to 0.50 per ABG. Lung sounds were noted to have crackles throughout. Pt was suctioned for scant amount of thin white secretions. Last ABG showed acute metabolic acidosis. Care plan is to continue therapy and when stable to start cardiac wean. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273331, "text": "7a-7p\n\nNeuro: Eyes open, blinking but pt not responding to verbal stimuli. Responds to pain with grimace. Moving head at times but not extremities. PERL.\n\nCV: SBP 90's to low 100's. Neo weaned to off. BP presently 94/45.\nSR 90's with rare pac's. 3 JP's 20-30cc. K repleted.\n\nResp: Pt remains intubated on cpap. ABG this am wnl with peep 5, ps 17. Attempted to wean ps to 14 but pt rr ^35. PS back to 17, pt tolerating. Next abg in am. Sats 100%. Lungs coarse, sxn for small amt thick white sputum. Cont on triple abx.\n\nGI/GU: Abd softly dist. TF cont at 40cc/hr, minimal residuals. Mod size soft br bm today after dulculax supp. Foley yellow urine, ^amts.\n\nSkin: See careview.\n\nSocial: Proxy called in for update today.\n\nPlan: Cont to monitor hemodynamics/resp status. Check abg in am, ?wean vent accordingly as pt tolerates.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273332, "text": "resp care\nPt remained on psv17/peep5 and 40% with volumes of 400-600cc and rr 20's to 30's. BS coarse rhonchi. Suct for thick creamy tan sput. Combivent mdi given as ordered. Occ wheeze noted after suct. RSBI done on 5psv/opeep=110. Will cont to follow with slow psv wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273224, "text": "Respiratory Care\nBreath sounds revealed bilateral coarse rhonchi, and diminished at the bases,nasotracheally suctioned intermittently for copious thick yellowish secretions, was afebrile , had few episodes of sinus tachycardia, but mostly stayed into normal sinus rhythm, HR ranged 77 to 111, has been treated around 1700 with Albuterol and atrovent via small nebulizer, sat ranged 94 to 98, patient is on 60% , continue to be monitored closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-26 00:00:00.000", "description": "Report", "row_id": 1273225, "text": "7P-7A\nNUERO: A/Ox3. Disoriented @ times. MAE. PERRLA. Tramadol PO for pain with good effect. Afebrile. Anxious at times.\n\nCV: ST @ beginning of shift. Converted to Afib 120's. 150mg AMIO bolus x1. Lytes repleted prn. Remains in Afib. NEO GTT to maintain MAP >60. SBP 90-100 on 0.6mcg/kg/min. Dopplerable pulses bilat. +3 bilat LE pitting Edema. SQ Heparin for DVT prophylaxis. Metoprolol PO TID. Double lumen to RIJ. R Radial Aline.\n\nRESP: LS coarse with whzs, dim @ bases. ALB/ATR nebs per RT. Weak cough effort, poor IS effort. NT suctioned with difficulty for thick bloody secretions. ABG adequate. 02 SAT 92-96% 60% Face tent.\n\nGU/GI: Foley to gravity with adequate HUO. Scrotal edema noted. Lasix PO BID. ABD snt +BS PPI for GI prophylaxis. Tolerating sips of H2O, swallows pills without difficulty.\n\nENDO: FSBS coverage per Ordered RISS.\n\nID: IV Ampicillin, IV Vancomycin and IV CefePIME.\n\nAM LABS PENDING AT TIME OF NOTE.\n\nPLAN: Aggressive Pulmonary tolieting!!!! Wean NEO GTT. Encourage PO intake/solids. Increase activity.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-26 00:00:00.000", "description": "Report", "row_id": 1273226, "text": "NEURO: alert, Ox3 to , , president. this evening stated he was in , easily re-oriented. , lifts and holds all extremities this AM weaker as day wore on. following commands.\nCV: sinus rhythm with APC's lytes repleted KCL. SBP 80's-100's MAP 60's-70 neo titrated to maintain MAP 60-90. skin warm, dry. +peripheral edema. DP/PT diff. to palp.\nRESP: lungs coarse throughout increasing o2 requirement on high flow mask. NT suctioned for small amt. thick yellow. coached and encouraged CDB, I/S and flutter valve use. pt with weak cough and poor I/S effort. sats 93-95%.\nGI/GU: +hypoactive bowel sounds abd soft distended. speech/swallow eval at bedside today went well until 10 min p eval dry heaving. medicated with anti emetic and meds and sips clears post. foley with clear yellow.\nENDO: blood gluc not requiring RISS\nSKIN: pressure points intact. abd LLQ hematoma. sternal dressing noted to be saturated with sang drainage post dry heaving dressing changed and pressure dressing applied. +sternal click noted by MD. will cont. monitor.\nPAIN/COMFORT: c/o incisional pain unrelieved with acetamin/tramadol. percocet admin PO 1 tab with good result--> pt napping.\nLINES/ACCESS: L AC PICC line placed in IR today. plan to d/c 3 lumen and culture tip.\nSOCIAL: no calls this shift.\nA/P: continue to monitor resp, cv. aggressive pulm toilet. neo for MAP 60-90. d/c 3 lumen and send tip for cx. borderline resp status with increasing o2 requirement. lytes, blood gluc., skin care. monitor sternal incis. for drainage.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273209, "text": "Nursing Admission Note: S/P MVR porcine\n\nArrived from OR @ 16pm. Intubated and sedated with prop 30. Pt very wet and oozy in OR-bled @ 1300-Given multiple blood products. Out on neo .3 2 MT CT's to sxn-no airleak-420cc sang dng on arrival-pleuravac changed r/t kicked over by MD. CO by TD 3.4-2.4 with CI 1.6-1.3. MVO2 sat-58 with much better CO/CI. CXR obtained and ET tube withdrawn 2cm.\n\nNeuro: Sedated with prop 30. PERRL. L foot drop.\nCV: Tachycardic 110's-103 ST without VEA, Hct 20.8 Transfused with 3u PRBC's. CO 3.4-2.4 TD with low CI 1.3. MVO2 sat sent 58 which gives CO 5.8/CI >3. CVP 20-22 with PAD 20-30. palp pedal pulses. K and Ca repleted.\nResp: Intubated on SIMV/12/550-weaned to 40%. ET pulled back 2cm. CXR done. 2 MT to sxn-minimal output very clotty/chunky. No airleak. ABG's met alk with -6 BE.\nID: On post op vanco as well as ampicillin 2gm q 8.\nGU: Foley to gd with uo>50cc/hr. CRI.\nGU: Abd obese,softly distended, no BS. Ecchymosis accross mid abd L>R. OGT placed.\nEndo: On insulin gtt per CTS protocol-see flowsheet.\nIncisions: Sternum and CT with DSD-D/I.\nComfort: MSO4 2mg IV X1 given.\nA/P: Fluid resucitation, watch hct, repeat CXR. Watch for s/s tamponade.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273210, "text": "cont. w rising & almost equal filling pressures,increased vea,hypotension to the 70's in t requiring increased neo & calcium chloride with worsening acidosis & dropping svo2. telephone update given to dr. ,no new orders given. dr. called immed. to bedside by me,cxr repeated which revealed mediastinal widening that had progressed from earlier.dr. notified & pt. transported to o.r. for re-exploration.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273211, "text": "Resp. Care\nPt. did not do well Post Op. He was sedated and on mech vent but pt. failed to make any urine and no output from his chest tubes. The pt. became hypotensive. A CXR was taken that showed a widening of the mediastinam. The pt. was taken back to the OR where they evacuated a clot. He has been sedated all shift and at 0530, NSG is going to start to wean the sedation, and then to start to wean from vent.See carevue for ABGs and RSBI results.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273261, "text": "Respiratory care\npt remains on simv settings without changes, Suctioning small amts of yellow secrections, MDI as ordered. Plan to return to oR tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273262, "text": "Resp: pt on simv 14/500/+5/50%. Ett 7.5 retaped and secured 20@ lip. Alarms on and functioning. Ambu/syringe @ hob. Bs are coarse bilaterally. Suctioned for copious amounts of bloody, clots secretions. MDI's administered Q4 with no adverse reactions. AM ABG 7.39/42/69/26. Fio2 increased to 60%. Plan trip today to OR for debridment.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273283, "text": "Respiratory Care:\nPatient remains on SIMV/PSV settings with no parametr changes made throughout the night. Still receiving paralytics. Latest abg results determined a fully compensated metabolic alkalemia with very good oxygenation.\n\nNo RSBI measured at this time. Plan is to go to OR this am for closure of chest.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273284, "text": "Neuro: pt sedated with Fentanyl and Stivan doses decreased some overnight. Cistracurium increased 2nd to 4 twitches and some coughing when ETT manipulated pt remained with4 twitches and cough and dose left at present rate.\nResp: No vent changes made, Suctioned for small ETT repositioned to right side of mouth.\nC/V: blood pressure dippinightly overnight after lopressor dose given total of 1 l NS with improvement in BP This am Bp 110-120/50's. Heart rate sinus rhythm in the 80's\nGI: tolerating tube feeds, stopped at midnight 2nd to npo for OR closure of chest today. Pt passing liquid stool this am to resume banana flakes when returned from OR. Stool quaiac neg\nEndo: blood sugars well controlled.\nGU: Adequate urine outputs 70-150cc/hr.\nSkin: pt remains with scrotal edema area has 1 small abrasion on backside of scotum elevated to help with swelling. Coccyx has old skin tear now healed Duoderm removed. Pt on Tridyne bed rotating 20 degrees every 10 minutes side to side and tolerating well.\nSocial: Reverend in to visit last evening , He will be out of town until the 12th and has left a number of another Reverend who will cover for him in case he is needed over next several days.\nPlan: return ot or for flap closure of chest today\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273285, "text": "resp care - Pt remains intubated on SIMV+PS 500/16/5/5/ 60%. ABG was within normal limits. BS clear, dim in bases. Sx amount of clear thin secretions. Meds given as ordered. Plan to go to OR @ 1800 for chest closure.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273286, "text": "See and Carevue for detailed documentation\n\nNeuro: On cisatricurium with 4 eye twitch at 20mA. Occassional resp effort, cough noted. No gag. BP stable on ativan and fentanyl gtts.\nNo changs in sedation. PERL.\n\nResp: Continues on vent. BS clear, diminished in bases. Suctioned for small amounts thick white secretions. Large amounts bloody oral secretions. Chest open to VAC. To OR for flap closure.\n\nCV: In NSR, BP stable. Potassium and calcium repleted. Afebrile. Lopressor held.\n\nGI; NPG for OR.\n\nGU: Foley to gravity with large urine output s/p lasix.\n\nEndo: RSSI per protocol. None required this shift.\n\nPlan: Continue cardiopulmonary monitoring. Evaluate s/p OR for wakeup.\nContinue to support. Slow wean narcotic/ benzo eval for withdrawl.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273253, "text": "NEURO: sedated, paralyzed. this AM coughing and sbp rising abruptly when in line suctioned. paralytic and fent/ativan titrated up. now 0-1 twitch on , no coughing, no overbreathing, no vital sign response to sitmulation. Pupils equal, fixed.\nCV: sinus rhythm with bouts of afib. lots of atrial ectopy. k repleted. MAP goal 60-90. labile today. pit added and neo weaned as . CI>2.0 today. continues on amio. +anasarca. remains with vac on sternum. DP/PT doppler.\nRESP: intubated. lungs diminished bilat. suctioned for yellow-->brown thick sputum. this afternoon desatting to 90% when turns on R side in triadyne bed. bronched this evening some plugs removed. will repeat ABG. pt traveled to CT chest/abd today.\nGI/GU: this AM dobhoff gastric changed by NP cxr confirmed post pyloric. tolerated readi-cat prep. tubefeeds held today for CT, bronch and MRI. abd soft, distended, ecchy. neg bowel sounds. foley with light yellow urine. lasix decreased to QD. +penis and scrotum edema with abrasion and peeling skin on scrotum.\nENDO: blood gluc covered with pt custom sliding scale.\nID: ceftriax/ampicillin/fluconazole\nSKIN: switched to triadyne bed. has rash on buttocks. duoderm to buttock intact. sternum with VAC dressing mediastinal DSD intact. MPboots on. skin weeping serous fluid +anasarca.\nLINES/ACCESS: RIJ trauma introducer. PA cath pulled for MRI. L rad a line.\nSOCIAL: HCP called for update.\nA/P: monitor cv, resp. follow ABG, wean neo as . triadyne bed ok to turn to 20 degrees not tolerating R side. plan MRI. resume tubefeeds p MRI. ?OR tomorrow. unlikely MD. follow lytes, blood gluc. maintain paralysis, sedation.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273254, "text": "neuro: pt remains I/S/P, on fentanyl/ativan/cisatracurium gtts; no left facial movements/twitching via , but rt facial twitching noted, and insp changes noted when sxn'd by RT~>paralytic titrated up; slight change in vitals in response to stimulation. pt tolerates triadyne rotational bed. pupils equal & nonreactive. ? travel to mri today.\n\ncv: pt in/out of rate controlled afib early in shift, then converted to sb~ aware, amio gtt continues @ 0.5. bp stable 100s-140s, sbp decreases marginally when in af but remains over 100. pitressin & neo gtts continue, but able to wean neo slightly; dp/pt by doppler. extrs w/d, +anasarca, scattered skin weeping serous fluid from both arms and rt leg. +4 edema all extrs. penile & scrotum edema noted. vac drsg . lytes repleted. afebrile. ? to OR today.\n\nresp: ls clr, dim @ bases. o2sats >94% on simv @ .50 w/rate of 14. sxn'd for sm amt thk tan sputum. abgs wnl. vap care done.\n\ngi/gu: tf nepro restarted @ 10cc/hr, 20cc resids adv as per order, absent bs, abd soft, slightly distended. adequate huo, clr yellow, creatinine 2.3.\n\nendo: bs monitored per ss; rssi coverage required this AM.\n\nsocial: pt's minister visited last night.\n\nplan: continue monitoring cardioresp status. monitor neuromuscular response, maintain sedation & paralysis. monitor labs. wean neo as tolerated. ? travel to mri & OR today. advance tf as tolerated. continue w/current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273246, "text": "NEURO-INTUBATED/SEDATED/PARALYZED. ON FENATNYL/PROPOFOL/NIMBEX GTTS. LEFT EYE TWITCHES.NO S/S PAIN.SPONTANEOUS COUGH X1. PERLA @ 3MM/BRISK.\n\nCV- T-MAX=99.5.IN/OUT OF NSR/AFIB-RATE CONTROLLED. ON AMIO GTT. NEO TIRATED UPWARD WITH AFIB.CO/CI/FILLING PRESSURES WNL.VAC DSG OCCLUSIVE OVER STERNUM. SCATTERED AREAS ON BILATERAL ARMS,RT LOWER LEG WEEPING SEROUS FLUID.\n\nRESP- REMIANED ON IMV/PS 40%X00/14/5.5. LS DIM IN UPPERS,VERY DIM (ALMOST ABSENT) IN BASES. ABG WNL. SATS=95-98%.\n\nGU/GI- ABD SOFT, ABSENT BS. OGT -> LCWSX WITH BILIOUS DRG. DIURESING AT LEAST 100CC/HR.\n\nLABS-K+ REPLETED Q2H. CA+ X1.\n\nPLAN- KEEP I/S/P/ UNTIL . TO HAVE FLAP REAPAIR DONE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273247, "text": "Respn Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent as per Carevue. Lung sounds ess clear after suct sm loose bld tinged sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273248, "text": "Respiratory Care\nPt remains on full ventilatory support as documented on Carevue. Suction for small amounts of thick yellow secreations. MDI's given as ordered. Bilateral breath sounds diminished. No changes made this shift.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273249, "text": "NEURO: Paralyzed and sedated on ativan/fentanyl. changed from propofol this AM. 3 lid twitches on . no cough/gag no overbreathing.\nCV: sinus rhythm with much A and V ectopy. KCL and MAG repleted. remains on amio gtt. neo titrated to maintain MAP 60-90. CO 3.8-4.0 CI >2.0 fick 3.30. PA elevated 40's/20. +anasarca, weeping fluid. sternum open with vac dressing. PT/DP doppler. remains on bair hugger to maintain body temp >36.0.\nRESP: intubated. lungs clear/diminished bases. suctioned for yellow secretions. no overbreathing. VAP care done. ABG stable no vent changes.\nGI/GU: abd soft skin ecchy. absent bowel sounds. tubefeed trial at 10/hour today did not tolerate. residual 50 cc at 5 hours. OGT to LCWS with bilious/tubefeed drainage. foley changed today. urine yellow, cloudy. penile and scrotal edema +serous drainage from skin.\nENDO: blood gluc covered with RISS. pt custom sliding scale.\nID: fungal blood cx sent today. on ceftriax./ampicillin. fluconazole IV started today.\nSKIN:HOB up to 30 degrees today. no turns. MP boots on. Sternal VAC dressing intact. mediast. DSD changed. +anasarca and weeping serous fluid from arms and legs.\nACCESS/LINES: L rad a line, RIJ trauma and PA cath.\nSOCIAL: Plastics spoke with HCP updated. friend called for update.\nA/P: continue to monitor cv, resp. blood culture results and abx. maintain MAP 60-90. maintain paralysis/sedation. no turns, can have HOB 30 degrees. lytes and blood gluc. bair hugger for body temp goal >36.0. plan to return to OR for sternal closure wed. .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273263, "text": "Nursing 7p-7a\nNeuro: Sedated on fent/ativan gtts. Paralyzed on nimbex. & +cough w/ETT suction, team aware. PERRLA. Sluggish. R eye bloodshot & eyelid drooping, not new, team aware.\n\nC/V: NSR 60s. Intermittently SB 50s. Normothermic. Titrating neo gtt. Unable to titrate off. Vasopressin gtt cont. Dopperable pulses. Cap refil <3 sec. Copious amts serosang drainage from oral cavity. PTT 49. Platelets 150s. Hct 24, no tx at this time.\n\nResp: Fio2 increased for pa02 of 69. No other vent changes. Suctioned for copious amts blood tinged sputum. Lungs coarse throughout, dim in LLL.\n\nSkin: see carevue for impaired skin, incisions.\nID: Vanco trough sent today. On iv ampicillin, fluconazole, ceftriaxone and iv vanco.\nEndo: RISS.\nSocial: HCP called, updated by RN.\n\nPlan: Travel to OR for debridement & vac dsg change at 1600 per plastics. Wean neo gtt as . Pulm toilet. ROM as . Skin care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273264, "text": "Nursing Progress Note:\nNeuro: Pt sedated and paralyzed via ativan, fentanyl, and cisat gtts. No spontaceous respirations or movements noted. + cough, - gag reflex. PERL 2mm sluggish. on max cisat. Team aware.\n\nCV: SR. HR 60's. BP 100/50's on vasopressin and low dose neo. Afebrile. Pulses dopplerable. Capi refill normal. Transfused 2u prbc's for hct 24.7. VAC dressing to sternum.\n\nResp: LCTA decreased at basses. Sats 97% on simv 14, 500, , 60% Minimal blood tinged secretions when ett suctioned.\n\nGI/GU: Abdomen soft, nondistended. NPO. Pedi tube clamped. Foley cath with good diurese from Lasix.\n\nEndoc: RISS\n\nID: Vanco, ampicillin, ceftriaxone, fluconazole\n\nPlan: To OR ~1600 for sternal debridement.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273265, "text": "See and Carevue for detailed documentation\nNeuro: Remains on ativan, fentanyl, nimbex. No response/ change in VS with noxious stim. . PERL, sluggish. R eye hemorrhage.\n\nResp: Continues on vent. BS clear, diminished bliaterally in bases. Suction for white secretions.\n\nCV: BP stable on vasopressin, neo. In NSR 60. Afebrile. Hct stable s/p tx. Potassium repelted. Continues on albumin.\n\nSkin: Open chest with VAC dressing . See carevue for details re:incisions, exam.\n\nEndo: RSSI per protocol, none required.\n\nGI: NPO for OR.\n\nGU: Good urine output s/p early lasix dose.\n\nSocial: HCP by MD for OR.\n\nPlan: Continue cardiopulmonary monitoring. To OR tonight for debridement of chest. Wean neo of tolerated. Continue to assess for neuromuscular blockade. Replete lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273322, "text": "Respiratory Care: Pt to IR for PICC line this afternoon. Remains on current vent settings, RR down to 10, for acidosis. No other changes this shift.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273323, "text": "7p-7a\nCorrection on neo 0.5mcg/kg/min at present time.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273349, "text": "7A-7P\nNEURO: Alert. PERLLA. Tracking with eyes. Moving & LL extremities. Moving RUE, no movement to RLE. Follows commands. Nodding appropriatley. Tmax 99.3. Tramadol via feeding tube for pain with good effect. OOB to chair today with lift.\n\nCV: NSR no ectopy. SBP 100-110's. RUE ultrasound to evaluate swelling and discomfort. Compression sleeves for DVT prophylaxis. Palpable pulses bilat. JP bulb x3 S/S fluid.\n\nRESP: Remains orally intubated CPAP+PS 40-50%. 5PEEP 5-15PS. RR 20-30's. LS coarse diminished at bases. Suctioned for thick white/tan sputum. MDI per RT. When OOB to chair 02 sat 88-90%.\n\nGU/GI: Foley to gravity with adequate UO. IV Lasix started . ABD softly distended with +BS. PPI for GI prophylaxis. Tolerating nutren with beneprotein TF via peditube @ goal 40cc/hr. Max residual 10cc.\n\nID: Multiple IV Antibiotics. Vano level 11.4 dose given.\n\nENDO: FSBS coverage per RISS.\n\nPLAN: Monitor Resp Status. Pulmonary toliet. Assess/treat pain.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273350, "text": "Nursing Progress Note:\nNeuro: Opens eyes spontaneously. PERL 3mm brisk. Tracks. Follows commands by squeezing hands and moving toes. No movement to Rt leg. Weak cough. Gag reflex .\n\nREsp: Lungs coarse. Sats 100% on cpap 5/15/50% Suctioned for small amount of thick, yellow secretions. RR 20's\n\nCV: SR w/o ectopy. HR 80's. PICC . KVO. K repleted. Pulses palpable. Afebrile. Buttocks with redness noted.\n\nGI/GU: Abdomen soft, distended. BS present. BM x1. Nutren 2.0 w/ beneprotein at 40cc/hr. Foley cath. Good diurese with lasix.\n\nID: Vanco, ceftriaxone, ampicillin\n\nEndoc: RISS\n\nPlan: Wean PS. Continue antibiotics. Monitor and replete lytes. Pulmonary hygiene.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273351, "text": "RESP CARE: Pt continues on PSV 15/5 50%. Pt is tolerating well with no episodes of tachypnea overnight. LS: coarse and diminished bilaterally. Pt suctioned for moderate-large amounts of thick yellow secretions. Pt manually ventilated and suctioned for copious amounts of secretions due to occlusion of ETT. TX's given per . PLAN: wean PS as tolerated by patient.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273352, "text": "See and Carevue for detailed documentation\n\nNeuro: Alert, follows commands, nods yes/no. Became restless, tachypneic, diaphoretic OOB in chair. Calm with back to bed.\n\nResp: Continues on vent. PS 12, PEEP 5 50%. No further wean today. BS coarse, diminished in bases. Suctioed for moderate amounts thick yellow secretions.\n\nCV: NSR, no ectopy. BP stable. Afebrile. Strong peripheral pulses. JP with small-> moderate amount drainage. RUE skin abrasion with vaseline dressing. Other skin areas as noted. Continues on antibiotics.\n\nGI: Tolerating tube feeds. Small BM x2. Abd soft, distended.\n\nGU; Foley to gravity with good amounts urine s/p lasix.\n\nEndo: RSSI per protocol.\n\nPlan: Continue to monitor cardiopulmonary status. Wean vent as tolerated. Continue antibiotics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273353, "text": "Resp Care\nPt remains intubated on PSV 12/5 50%. Pt suctioned for mod amt of thick tan sputum. Pt up in chair for part of the day. ETT repostioned and retaped. MDI's given. No current ABG results. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273313, "text": "Respiratory Care\nBreath sounds mostly clear, left lung rhonchi, suctioned intermittently for small thick yellowish secretions, and moderate thick tan oral secretions, patient is on Amiodarone, Ativan, Fentanyl and Neosyneph,stayed mostly into sinus tachycardia, WBC 20.2 suggesting bacterial infection, hemoglobin 9.6 suggesting anemia. FiO2 decreased from 50% to 40%, Tidal Volume decreased from 500cc to 400cc to fight hyperventilation, ABGs at 1319 revealed a decrease in hyperventilation with hyperoxemia, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273314, "text": "Nursing Progress Note:\nNeuro: Sedated on ativan and fentanyl gtts. Perl 3mm brisk. Opens eyes spontaneously but doesn't appear to track or focus. No spontaneous movements noted. No response to noxious stimuli. No gag noted. Coughs when suctioned.\n\nResp: LCTA decreased bases. Sats 98% on AC 14, 400, 40%, peep 5. Minimal secretions via ETT.\n\nCV: Converted to afib with HR 100-110. Pt converted to NSR on his own. Frequent PAC's. Pulses dopplerable. Anasarca. Afebrile. Received 1u rbc for hct 24.3. Repeat HCT 27. Pulses dopplerable. K repleted. Trauma and . JP X5 with minimal serosangunous drainage.\n\nGI/GU: Abdomen soft, distended. BS present. Nutren + beneprotein at 40cc/hr. No stool for shift. Foley cath. UO adequate. Diurese with Lasix.\n\nEndoc: RISS SC\n\nID: Vanco, ampicillin, ceftriaxone\n\nInteg: Abrasion to upper extremeties, moderate amount of serous drainage.\n\nPlan: RBC tag study to assess bleeding. Monitor rhythm and lytes. Pulmonary toilet. HCT Q6h. Continue current antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273315, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a respiratory alkalemia with good oxygenation.\n\nRSBI = 150.2 on 0-PEEP and 0-PSV(Failed RSBI). SPO2 plummeted to 87% during measurement.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273385, "text": "resp care\nfollowed for mdi's,airway management. tolerating 40% trach mask in no acute distress. sxning thick tan sputum. fair cough but not able to expectorate on own. pmv placed in conjunction with speech/swallow therapist. speech is audible , should be able to tolerate intervals of pmv with staff present.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273306, "text": "Code status reversed, Now a FULL CODE\n\nROS:\n\nNeuro: Sedated on ativan. Fentanyl gtt for pain mngt. Eyes open several times this shift, does not seem to focus or tract. PEARRLA.\n\nCV: RSR w/intermit Afib rate 80's -> 110. Neo titrated to keep MAP > 60. Peripheral pulses palpable. Has RIJ cath w/distal port transduce for CVP. Has left radial ABP. Sternal drsg w/ drng, mod amt, no ^ in amt from beginning of shift. Has 3 JPs w/large amt comming from JP #2. Amiodarone gtt on at 0.5 mg. SQ heparin and P boots for DVT prophylaxis.\n\nResp: Remains oraly intubated on vent. Lungs clear to coarse, sx small yellow via ETT. MDIs per RT. Right side of chest still firm and slightly swoolen (larger then left side). No change in swelling or firmness throughout shift. No resp distress note, = rise and fall of chest.\n\nGI: Abd swollen w/old ecchymosis. Active BS x's 4 quads of abd. Post pyloric pedi feeding tube via right nare w/TF at goal. Protonix for GI prophylaxis. Small mushy brown stool. Banana flakes TID. Peri anal area red, moisture barier cream applied. ? yeast\n\nGU: Foley patent clear yellow urine in QS.\n\nID: Remains on triple ABX coverage.\n\nEndo: insulin gtt titrated per FSG and CSRU protocol.\n\nLabs: Pending AM draw\n\nPlan: Pulmonary toileting. Mobilization. Obtain nystanin powder for bottom d/t ? yeast looking. Wean neo as VS alow. Monitor, tx, support, and comfort. Monitor JP drng amt. Monitor Hct. Tx, support, and comfort.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273307, "text": "Respiratory Care:\n Patient asynchronous with vent despite attempts to change mode. BS present bilat, suctioned for small amounts of thick yellow, receiving bronchodilators. Reccommend increase in sedation at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273308, "text": "Respiratory Care\nbreath sounds bilaterally diminished, suctioned for small, thick, pale yellow, treated with combivent inhaler, cardioverted at 0640 am, stayed mostly into A-fib, WBC 19.3 suggesting bacterial infection, hemoglobin, 6.8 suggesting anemia, often patient was asyncronic with ventilator, was mostly tachypneic, FiO2 dropped from 50% to 40%, will continue to be mechanically ventilated and closely monitored.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273309, "text": "See and Carevue for detailed documnetation\n\nNeuro: Patient continues on ativan weaned 0.75->0.5. Fentanyl increased in am for cardioversion, weaned to 25mcg. Patient without command following. Opens eyes spontaneously, to verbal stim. PERL. Patient with chewing motions, +cough, no gag. Does not localize pain.\n\nResp: Continues on vent, tachypneic. Briefly decreased on settings. Patient with drop in BP, increased WOB. Suctioned for moderated amounts thin clear secretions.\n\nCV: In afib, HR 80-90. Increase in PVC, rec'd magnesium with improvment. Potassium and clacium repleted. Patient with neo requirement. Rec'd FFP x2 units. Repeat HCt 18. Rec;d 2units PRBC_> to OR for exploration. JP drainage 10-30ml per hour thru day. Dressing .\n\nEndo: Restart in insulin gtt per protocol.\n\nGI: Tolerated feeds thru day. NPO for OR. Loose watery BM x2\n\nGU: Foley to gravity with moderated amounts of urine.\n\nPlan: Continue cardiopulmonary monitoring. Continue to replece blood loss as needed. Continue sedation, plan for wena when stable. Repelte lytes as needed.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273324, "text": "7p-7a\nNeuro: Pt opens eyes, does not follow commands, does not RN in room, does not move any extremeties. Perrla. Morphine 2mg ivp given for pain shown by increase in BP.\n\nCV: HR 80-90s in and out of Afib. At present 80s SR no ectopy, lytes repleted prn. SBP labile, see carevue, on and off neo. At present time SBP 102, on 0.5mcg/kg/min. PICC to Right arm patent and . Left radial arm reddened. Dopplerable pedal pulses. Generalized anasarca. Bilat upper extremties oozy moderate amts of serous fluid. Sternal sutures cdi, covered w/ gauze and abd. binder to sternal area. Received 1 unit of PRBCs, no adverse reactions, repeat hct 28.\n\nResp: LS clear- coarse, diminished bases. Sats >98%. RR 25-35. Trial of CPAP RR increased to 40's. On CMV rate 10, FiO2 40% Peep 5, see carevue for abgs. Suctioned for small amts of thick yellow secretions via ett.\n\nGI/GU: Abd soft, round, hypoactive BS. TF residual at 0030 250cc, given back to pt, TF on hold, PA aware. Dophoff +placement. Foley adequate amts of clear yellow urine.\n\nSkin: Stg 2 2cm round to coccyx area, duoderm on and . See carevue for further details.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamcis. Monitor pulmonary status. Follow labs and treat as appropriate. Pain control. Monitor neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273325, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a respiratory alkalemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to the patient's elevated rr.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273326, "text": "Respiratory Care note.\nPt remains on settings as noted in careview. No secretions suctioned from tube. BS coarse bilaterally. No plans to extubate today. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273327, "text": "NEURO: Spontaneously opens eyes, but does not track or follow commands, twitch noted on L hand otherwise no movement of any EXTs.\n\nRESP: Intubated with Sats 96%, LS clear to auscultation, Pt has strong cough and ETT suctioned for small, white, thick secretions\n\nCV: NSR with HRs in 80s, one episode of afib, given 2grams Magnesium Sulfate, back in sinus rhythm, keep MAP >60 and currently on 0.25mcg Neo, anasarca, pitting +3, upper EXTs has moderate drainage, pulses by Doppler\n\nGI/GU: TF stopped at 1600 for high residual >150mL, restarted at 1800 at goal 40mL/hr with TF residual at 120mL, bowel sounds hypoactive; Foley in place yellow,clear urine with good response to Lasix, K 4.0 repleted with 20mEq KCl IVPB\n\nENDO: Continues on SSRI\n\nWOUND: Duoderm changed for stage 2 ulcers, replaced bed with Kinair\n\nSOCIAL: No family call or visit today.\n\nPLAN: Monitor neuro, resp, hemodynamics, lytes, continue with ICU interventions\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273376, "text": "R Pleural Chest Tube In\nNEURO: Alert, awake, follows command, Pt able to lift/hold L upper , moves on bed all other EXTs, PERRLA (3mm/brisk), Gag/Cough , Hoyered to chair/bed\n\nRESP: Trach collared with Sats >95% on 50%, plan to rest Pt on CPAP overnight, L pleural chest tube discontinued, R pleural pigtail drain inserted and drained about 1100 mL of serosanguinous fluid, lung sounds clear at apicals/coarse at bases, respirations reg/unlabored\n\nCV: NSR with occasional PACs, HRs in 80-90s, MAP >60, pedal pulses present.\n\nGI/GU: Abd soft, continues on TF at goal via Dobhoff, large/formed/ brown stool today; Foley yellow/clear urine at greater >70-80mL/hr\n\nENDO: Continues on SSRI\n\nID: Vanco level was 21.2, held Vanco.\n\nSOCIAL: No phone call/visit from visitors today\n\nPLAN: Continue to monitor resp/hemodynamics/neuro/urine output, ?discharge to rehab\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273377, "text": "neuro: pt alert overnight, follows commands, nods approp to questions. moves le's on bed, able to lift/hold both ue's. tramadol for nonverbal c/o pain w/good effect. +.\n\ncv: sr 80s, no ectopy. K repleted. bp stable 100s. palpable pulses. extrs w/d. compression sleeves on. hct stable, wbc 20.6, made aware. continues on ivab. afebrile.\n\nresp: ls clr, bases dim. o2sats >97% on cpap @ .50 fio2, vt 300s-500s. rr 20s-30s, briefly tachypneic, high 40s, sxn'd for sm thk bld tinged secretions, returned baseline within 2 minutes. rt pleural ct to lcs & rt jp to bulb sxn drained s/s this shift. trach care done.\n\ngi/gu: tf nutren w/beneprotein @ goal 40cc/hr. no resids; +bs. no bm. abd soft, nt, nd. adequate huo-clr yellow. bun 55, creatinine 1.6. NA 150, made aware.\n\nendo: bs monitored per ss protocol-required rssi coverage overnight.\n\nsocial: no phone calls from family/friends overnight.\n\nplan: continue monitoring cardioresp status; trach collar in AM, oob~>chair; ? d/c rt pleural tube. ? rehab screen.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273378, "text": "ADDITIONAL NOTE:\n\nBLOOD, URINE & SPUTUM CULTURES SENT PER .\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273379, "text": "Resp: pt on 50% t/c and placed back on vent psv 10/5/50% to rest noc. BS are coarse bilaterally. Suctioned for small to moderate amounts of tan/rusty secretions. Sample sent. No abg's this shift. Plan to continue with T/C trials this am.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273222, "text": "CSRU NPN\n\nS:\" SO WHAT DAY IS IT AGAIN?\"\n\nNEURO: A/O X2. NEEDS FREQ RE- ORIENTATION TO TIME. UNDERSTANDS HE IS IN THE HOSPITAL. YELLS OUT OCCASSIONALY FOR NO APPARENT REASON. STATES HE IS LONELY AND JUST WANTS SOMEONE IN THE ROOM. HE FOLLOWS SIMPLE COMMNADS. CAN LIFT AND HOLD UPPER . MOVES LOWERS ON BED. MUCH MORE QUIET AS EVE PROGESSED, LESS CONFUSED. ABG'S WNL\n\nCV: GIVEN LASIX AND LOPRESSOR AS ORDERED ,BUT IN STAGGERED DOSES. HR PRIOR TO LOPRESSOR 100 NSR W PAC'S OCCASSIONAL. SBP 110-120. GIVEN LASIX AS ORDERED 1 HR AFTER LOPRESSOR. HAD 400CC OUT. BP SLOWLY DRIFTING DOWNWARD AFTER LASIX GIVEN, SBP 85-90. NEO TITRATED TO 0.8 MCG/KG/MIN. SPOKE WITH DR AND UPDATED ON PT. LOPRESSOR AND LASIX NOW ON HOLD. REMAINS ON AMIO 0.5MG/MIN HR STABLE 70-80. ORDER GIVEN TO BOLUS PT W 500CC NS WHICH WAS COMPLETED. SLOW RISE IN SBP WITH FLUID AND ^ NEO.\n\nRESP: HAS NON PRODUCTIVE CONGESTED COUGH. PT NEEDS AGGRESSIVE PULM TOILETING. NASOTRACH SUCTIONED FOR THICK YELLOW SECRETIONS. BS COURSE AND DIMINISHED BILAT. FREQ CPT AND C/DB CURRENTLY ON 50% FT AND 4L NP. ABG'S WNL. NEBS Q6/HR. SATS 96-98%. RR BECOMES TACHYPNIC W ACTIVITY. RR-28-30 , BACK TO 20'S W REST.\n\nGI: POOR APPETITE FOR SOLIDS. TAKES MEDS W LIQ AND WELL. ABD SOFT NON TENDER. NO STOOL .\n\nGU: FOLEY DRAINING CL YELLOW LOS + 12600CC.\n\nSKIN: + BILAT EDEMA TO BILAT LEGS AND SCROTUM. R HAND EDEMATOUS AND BILAT UPPER ON PILLOWS. HAS SEVERAL BLISTERED AREAS ON LOWER CHEST ? D/T TAPE. STERNAL AND MEDIST. DSG CHG PER FLOW.\n\nID: AFEBRILE CON'T ON VANCO AND LEVO. + PNA\n\nLABS: PER FLOW. LYTES REPLETED X2. BS WNL.\n\nA/P: CON'T AGGRESSIVE PULM PLAN. HOLD LOPRESSOR AND LASIX TO BE D/CD BY TEAM. NEED ORDER. WEAN NEO IF BY PT. CON'T PER NSG JUDGEMENT\n" }, { "category": "ECG", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 201914, "text": " be sinus bradycardia with left atrial abnormality but consider also ectopic\natrial rhythm\nLow QRS voltage\nProlonged Q-Tc interval\nClinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 201915, "text": "Sinus tachycardia - Regular supraventricular rhythm\nPossible old inferior infarct\nGeneralized low QRS voltages\nSince previous tracing, decreased voltages present\n\n" }, { "category": "ECG", "chartdate": "2148-11-18 00:00:00.000", "description": "Report", "row_id": 201916, "text": "Sinus rhythm\nShort PR interval\nLeftward axis\nSince previous tracing, QRS changes in lead V2-V3 - ? lead placement\n\n" }, { "category": "Radiology", "chartdate": "2148-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932152, "text": " 7:43 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o collection vs tamponade\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n r/o collection vs tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for collection versus tamponade.\n\n COMPARISON: Comparison is made to study performed two hours earlier.\n\n PORTABLE CHEST: Again seen is endotracheal tube, Swan-Ganz catheter, median\n sternotomy wires, surgical clips overlying the midline, nasogastric tube,\n left-sided chest tube, and mediastinal drain. Cardiac silhouette appears\n larger compared to previous study. There has also been interval widening of\n the already widened mediastinum. No new focal consolidations are seen within\n the lungs.\n\n IMPRESSION: Interval increase in size of cardiac silhouette and widening of\n the mediastinum. While this may be partially due to patient's reverse\n Trendelenburg positioning, cardiac tamponade and mediastinal hematoma cannot\n be excluded. This was discussed with Dr. immediately following\n completion of the study, who reported clinical concern for tamponade and that\n patient would be returning to the OR.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932173, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion, tubesplacement,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n effusion, tubesplacement,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair. Evaluate effusion, tube\n placement.\n\n Bedside AP chest radiograph dated compared to AP chest\n radiograph dated . In the interval, there has been interval\n decrease in the widening of the mediastinum. Patient has had a resternotomy.\n There are low lung volumes. There are bilateral pleural\n effusions and bibasilar consolidations, representing atelectasis and/or\n infiltrate. There is pulmonary vascular congestion. ET tube, Swan- Ganz\n catheter, mediastinal tubes, are in the standard positions. Nasogastric tube\n courses below the diaphragm, and is out of view.\n\n IMPRESSION: Pulmonary vascular congestion, bilateral pleural effusions,\n consistent with fluid overload/CHF. Interval decrease in the\n mediastinal widening\n\n\n\n\n\n\n\n\n\n\n\n\n\n .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932562, "text": " 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n eval for effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 11:46 A.M.\n\n HISTORY: Status post CABG and central line change with shortness of breath.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Per technologist report, the patient would not hold still for the\n radiograph. There is marked suboptimal evaluation as the entire lateral\n aspect of the right hemithorax is excluded. The patient is markedly rotated.\n This is a marginal diagnostic examination.\n\n There is opacity of the mid and lower left hemithorax as previously noted,\n which is likely due to multiple factors such as atelectasis and pleural\n effusion. A concomitant pneumonia cannot be excluded. Pulmonary vascular\n clarity is indistinct, although this may be in part an element of motion.\n Failure cannot be excluded.\n\n IMPRESSION: Nearly non-diagnostic radiograph secondary to patient compliance.\n Consider repeat study once the patient is appropriately sedated or can comply\n with technologist instructions.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932509, "text": " 2:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change\n\n REASON FOR THIS EXAMINATION:\n R/O infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 15:23 HOURS.\n\n HISTORY: Status post CABG and central line change.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are markedly diminished with resultant bronchovascular\n crowding. A right internal jugular approach central line remains stable in\n course and position. The mediastinum is widened, likely in part due to\n technique. The cardiac silhouette size is difficult to establish, but is\n grossly stable. There is poor opacification of the retrocardiac left lower\n lobe, possibly due to collapse. There are bilateral pleural effusions.\n Median sternotomy wires remain linearly alignment.\n\n IMPRESSION: Markedly diminished lung volumes. There is left lower lobe\n collapse with bilateral small pleural effusions. An element of superimposed\n mild edema cannot be entirely excluded given limitation as above.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 932419, "text": " 5:23 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check rt ij placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change\n REASON FOR THIS EXAMINATION:\n check rt ij placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 71-year-old man status post coronary artery bypass graft surgery\n and recent change to central venous catheter.\n\n CHEST, SUPINE PORTABLE VIEW: Comparison is made to an earlier radiograph of\n the same day. The patient is status post recent sternotomy with overlying\n staples and sternal wires in the midline. The cardiac and mediastinal\n contours are unchanged. The tip of a new right internal central jugular\n venous catheter terminates in the distal superior vena cava. There is\n persistent left lower lobe opacity, which may represent atelectasis. . There\n is also a left-sided pleural effusion, but no evidence of pneumothorax on this\n supine view.\n\n IMPRESSION: Tip of a new central venous catheter in superior vena cava.\n Otherwise, no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932137, "text": " 5:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, tamponade, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post mitral valve replacement.\n\n COMPARISON: .\n\n PORTABLE CHEST: Endotracheal tube seen with tip approximately 1 cm above the\n carina, pointing towards the right main stem bronchus. Right-sided Swan-Ganz\n catheter seen with tip overlying the proximal main pulmonary artery.\n Nasogastric tube is seen with tip overlying the stomach. Left-sided chest\n tube seen with tip overlying the left lower lung. Mediastinal drains seen\n with tip overlying the mid chest. Median sternotomy wires and surgical\n staples seen overlying the midline.\n\n Mediastinum appears widened, possibly representing post-surgical changes\n although this appearance is concerning for mediastinal hematoma. Cardiac\n silhouette appears enlarged. There is large left lower lobe opacity\n consistent with atelectasis, effusion, or consolidation. Patchy air space\n opacity seen in the right lung, likely representing mild pulmonary edema.\n\n IMPRESSION: Postoperative changes. Endotracheal tube with tip pointing\n towards the right main stem bronchus. Widened mediastinum possibly\n representing postoperative changes versus mediastinal hematoma. New left\n basilar opacification. Findings discussed with , PA, at 6:15\n p.m., .\n\n" }, { "category": "Radiology", "chartdate": "2148-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932642, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 A.M., \n\n HISTORY: Status post CABG and central line change, now short of breath.\n\n IMPRESSION: AP chest compared to :\n\n Left lower lobe is still collapsed accompanied by small-to-moderate pleural\n effusion. Small right pleural effusion stable. Postoperative widening of the\n cardiomediastinal silhouette is less pronounced suggesting remission and\n volume overload. Upper lungs clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 931816, "text": " 7:22 PM\n CHEST (PA & LAT) Clip # \n Reason: preop MVR\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with endocarditis\n REASON FOR THIS EXAMINATION:\n preop MVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with endocarditis.\n\n PA AND LATERAL CHEST RADIOGRAPH: The study is somewhat limited in this\n patient with cannot lift arm due to pain. The comparison was made with the\n prior study dated . Cardiac and mediastinal contours are\n unchanged compared to the prior study, and again note is made of tortuous and\n calcified thoracic aorta. Previously noted CHF is not seen on the present\n study. Again note is made of bibasilar atelectasis with bilateral pleural\n effusion, persistent since prior study, slightly decreased. There is no\n evidence of pneumothorax.\n\n IMPRESSION: Decreased bilateral pleural effusion with bibasilar atelectasis.\n No evidence of CHF. Tortuous aorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-26 00:00:00.000", "description": "PICC W/O PORT", "row_id": 932841, "text": " 11:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc, pt s/p MVR(endocarditis).Picc for antibx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ****************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n *************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n please place picc, pt s/p MVR(endocarditis).Picc for antibx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post mitral valve repair requiring IV\n access for antibiotics.\n\n RADIOLOGISTS: Doctors and . Dr. , the attending\n radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The patient was brought to the Radiology Suite and placed\n supine on the angiography table. Following a preprocedure timeout including\n the patient's name, and two patient identifiers, the left arm was sterilely\n prepped and draped. As no suitable veins were visible, ultrasound was used to\n identify the left brachial vein, which was patent and compressible.\n Approximately 3 cc of 1% lidocaine were administered for local anesthesia.\n Using ultrasound guidance, a 21 gauge needle was used to access the left\n brachial vein. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 inch guidewire was inserted\n through the needle and into the vein. Then the needle was exchanged for a 4\n French micropuncture sheath. The guidewire was advanced into the SVC and based\n on the markings on the wire, a PICC line was trimmed to a length of 42 cm. The\n PICC was then advanced over the wire and into the SVC under fluoroscopic\n guidance. The wire and peel-away sheath were removed. The catheter was\n flushed, capped and heplocked. Finally, the catheter was StatLocked into place\n and a sterile transparent dressing was applied. A final fluoroscopic image\n was taken demonstrating the tip of the PICC in the distal SVC.\n\n IMPRESSION: Successful placement of a 5 French double lumen 42 cm PICC by way\n of the left brachial vein with the tip in the distal SVC. The line is ready\n for use.\n\n\n\n\n\n\n\n\n\n (Over)\n\n 11:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc, pt s/p MVR(endocarditis).Picc for antibx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932795, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, now with shortness of breath.\n\n Bedside AP chest radiograph dated compared to AP portable\n chest radiograph dated .\n\n Since previous study, there has been no significant change in the radiographic\n appearance of the chest. There is persistent left lower lobe collapse, small\n right pleural effusion, moderate left pleural effusion. There is no\n pneumothorax. Right IJ terminates at the expected location of mid SVC. There\n is a stable enlargement of cardiomediastinal silhouette since most recent\n surgery.\n\n IMPRESSION: Persistent left lower lobe collapse, small right pleural\n effusion, moderate left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932379, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG and chest tube removal.\n\n AP view of the chest dated is compared to the prior from yesterday.\n The patient has been extubated and the Swan-Ganz catheter has been removed as\n well as the nasogastric tube. The right internal jugular sheath terminates in\n the proximal SVC. Median sternotomy clips and wires are in stable position.\n The aorta is tortuous. There is mild cardiomegaly. There is opacity at the\n left lung base which probably represents atelectasis and moderate left pleural\n effusion. There is a small right pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Status post CABG with left lung base atelectasis and effusion.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932959, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for sternal dehisence, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, now w/ sternal click\n REASON FOR THIS EXAMINATION:\n eval for sternal dehisence, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG with sternal click.\n\n Portable AP chest dated is compared to the prior from the yesterday.\n This film is poor quality secondary to patient positioning and patient large\n body habitus. The patient is semierect. The right internal jugular line\n terminates in mid SVC. Left subclavian central venous catheter terminates at\n the cavoatrial junction. The cardiac silhouette appears enlarged. There are\n large bilateral pleural effusions with bibasilar opacities, probably\n representing compressive atelectasis, however, consolidation within the left\n lower lobe cannot be excluded. There is no pulmonary vascular congestion or\n pneumothorax. The patient is status post median sternotomy and CABG, and\n mediastinal wires and clips are in stable position.\n\n IMPRESSION: Allowing for technical differences in the films, no significant\n short interval change. Large bilateral pleural effusions. No radiographic\n evidence of sternal dehiscence.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937565, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for tube position, other pathology\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n Assess for tube position, other pathology\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 10:24 A.M.\n\n HISTORY: Post-tracheostomy.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: There is moderate-to-severe pulmonary edema. Bilateral layering\n pleural effusions are evident and may have slightly increased in size since\n the prior examination. The patient has undergone tracheostomy, consistent\n with given history. The tube is in standard position. An enteric feeding\n tube is noted. The distal tip is seen but cannot be adequately assessed with\n the given radiograph. The previously noted drains remain stable in position.\n Likewise, a right upper extremity PICC line has not changed.\n\n IMPRESSION: Moderate-to-severe bilateral pulmonary edema with bilateral,\n possibly enlarging, pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 936295, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:14 A.M. \n\n HISTORY: Status post CABG. Sternal wound closed.\n\n IMPRESSION: AP chest compared to through 14:\n\n Large bilateral pleural effusion, increased mildly on the right and\n substantially on the left. Heart size normal. Mediastinal vascular\n engorgement noted. Lungs are obscured by large pleural effusions, but\n generally clear. ET tube, nasogastric feeding tube, right PIC or central\n venous line, and midline drains are in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 938097, "text": " 9:06 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: SP VALVE REPLACEMENT ,NOW RISING WBC ,EVAL FOR CHOLECYSTITIS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with valve replacement, now rising wbc\n REASON FOR THIS EXAMINATION:\n assess for cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man with aortic valve replacement now with rising white\n blood cell count. Evaluate for cholecystitis.\n\n PORTABLE RIGHT UPPER QUADRANT ULTRASOUND STUDY: The liver is of normal\n echogenicity. There are no focal or textural abnormalities. No liver masses\n are present. The main portal vein is patent and its flow is hepatopetal.\n There is no ascites. No intrahepatic or extrahepatic biliary ductal\n dilatation, and the common bile duct measures 4 mm in diameter. Images of the\n gallbladder demonstrates tumefactive sludge present. However, there is no\n gallbladder wall thickening, gallbladder wall edema, or pericholecystic fluid\n present.\n\n IMPRESSION: Sludge in the gallbladder without son signs of acute\n cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934933, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 8:52 A.M. :\n\n INDICATION: Status post CABG. Postop sternal revision. Evaluate for\n pneumonia.\n\n FINDINGS: Compared with , allowing for differences in technique and\n patient positioning, no obvious significant interval changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933919, "text": " 6:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man status post CABG, postop sternal revision and open\n chest.\n\n COMPARISON: at 10:47 a.m.\n\n SUPINE CHEST: Compared to the exam of eight hours earlier, there has been\n interval worsening and consolidation of both lungs, more prominent on the\n left. The large left pleural effusion has increased in size. The large right\n effusion appears relatively stable. The Swan-Ganz catheter has been removed.\n The appearance of the chest is otherwise stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933207, "text": " 3:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval sternal revision \n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval sternal revision \n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post bypass surgery performed to date. Sternal revision\n of open chest. Evaluate chest after sternal revision.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position. Comparison is made with a previous portable chest\n examination with patient in semi-erect position obtained eight hours earlier\n and apparently prior to the latest operation. During the interval, the\n patient has been again intubated. The ETT terminate in the trachea some 2 cm\n above the level of the carina. A left jugular vein approach central venous\n line is present carrying a Swan-Ganz catheter seen to terminate in the\n proximal PA. A new drainage tube from below enters the mediastinum. The\n previous multiple sternal wires have been removed and apparently the sternum\n has been divided with two longitudinally directed retainers indicating wound\n edges. There is no gross interval change in the mediastinal contours\n indicating significant cardiac enlargement. Related to the now supine\n position, the pleural effusions have layered more posteriorly resulting in a\n diffuse increased density bilaterally. No striking large new pulmonary\n infiltrates can be identified nor is there any conclusive evidence of\n significant pulmonary congestion. Also evaluation of the pulmonary\n vasculature is somewhat limited. The widening of the superior mediastinum is\n compatible with the patient's supine position.\n\n Further followup is recommended considering the presence of apparent size of\n the bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935082, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest,\n s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after sternum revision.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip, the feeding tube, the right internal jugular line is in\n unchanged standard positions. The two mediastinal drains has been inserted.\n The pulmonary edema _____ and bilateral large pleural effusions are grossly\n unchanged. The left lower lobe atelectasis is stable.\n\n IMPRESSION: Two new postsurgical drains inserted. Otherwise, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933122, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, now w/ sternal click, poor pulmonary toilet\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM \n\n HISTORY: Coronary artery disease status post CABG, now with sternal click and\n poor pulmonary toilet, rule out pneumonia.\n\n FINDINGS: An AP semi-upright portable chest radiograph shows bilateral\n pleural effusions with that on the right probably increased over the past\n several days. The patient's right internal jugular central venous catheter\n has been removed. PICC line tubing extending from the left ends at the level\n of distal SVC. Degree of cardiomegaly appears unchanged. The eight sternal\n wires and midline skin clips are intact. The lateral and inferiormost portion\n of the left chest is not included in the view of the film.\n\n CONCLUSION: Increase in right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933482, "text": " 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swann placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval swann placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Status post CABG with sternal revision.\n\n One portable view at 14:49. Comparison with . Bilateral pleural\n effusions persist. These partially obscure the inferior portions of both\n lungs. Post surgical changes again noted in the mediastinum. An endotracheal\n tube remains in place. A Swan-Ganz catheter has been replaced. The current\n Swan-Ganz catheter ends in the region of the pulmonary outflow tract. A left\n PICC line remains in place. Left internal jugular sheath is present as\n before. A nasogastric tube remains in place.\n\n IMPRESSION: Replacement of Swan-Ganz catheter. There is no other significant\n change. Bilateral pleural effusions persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 933877, "text": " 12:50 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infectious source\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with rising WBC, sepsis\n REASON FOR THIS EXAMINATION:\n r/o infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated white blood cell count, sepsis.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast axial images through the chest, abdomen and pelvis as\n requested by the referring service. Multiplanar reformats were performed.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The patient has a surgically open\n anterior chest wall. Air extends to the soft tissue around the clavicles.\n There is no pneumothorax. There are large bilateral pleural effusions as well\n as atelectasis of much of both lungs. There is a small amount of aerated left\n upper and right upper lobes. There are coronary artery calcifications as well\n as aortic calcifications. The endotracheal tube extends to the carina\n possibly entering the right main stem bronchus. No definite lymphadenopathy\n within the axilla, hila, or mediastinum. There is a small pericardial\n effusion.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is beam hardening artifact\n limiting evaluation. The liver, spleen, adrenal glands, pancreas appear\n unremarkable. The gallbladder is unremarkable, without visualization of the\n known stones. There are low attenuations within both kidneys, in the region\n of the prior described cyst. There is atherosclerotic calcification of the\n descending aorta. Large and small bowel are not dilated. There is no\n lymphadenopathy or free air. There is a small amount of free fluid in the\n lower abdomen in the pericolic gutters. Focal fluid collections. There is\n diffuse anasarca.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is no free fluid or\n lymphadenopathy. The bladder, sigmoid colon, and rectum are normal.\n\n BONE WINDOWS: No destructive lesions to indicate osteomyelitis.\n\n REFORMATTED IMAGES: Severe degenerative change within the spine, which is\n stable. Scoliosis.\n\n IMPRESSION:\n\n 1. Scan limited by severe beam-hardening artefact. No definite intrathoracic\n or intra-abdominal mabscess. Large bilateral pleural effusions, small\n (Over)\n\n 12:50 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infectious source\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pericardial effusion, and anasarca.\n\n 2. Small amount of ascites.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934445, "text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON .\n\n HISTORY: Postop sternal revision, open chest, question pneumonia.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube continues to be low, less than 2 cm above the\n carina. The right IJ catheter tip is at the junction of the internal jugular\n vein with subclavian vein. The oral tube is coiled in the stomach, pointed\n upwards. Again seen are bilateral pleural effusions, layering posteriorly.\n There is dense opacification of the right chest and left lower lobe, which may\n be due to effusion/infiltrate/volume loss. Compared to the prior film, there\n has been slight increase in the opacity in the right upper lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934008, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch, eval pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n s/p bronch, eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG, sternal revision.\n\n CHEST\n\n The tip of the endotracheal tube remains too low as on the prior chest x-ray\n and should be withdrawn to a better position. Bilateral pleural effusions are\n again noted. Consolidation and collapse in the left lower lobe is probably\n present.\n\n Since the prior chest x-ray, the Swan-Ganz catheter has been removed. The\n sheath remains. The position of the nasogastric tube is unchanged.\n\n IMPRESSION: Bilateral effusions, probable collapse, consolidation left lower\n lobe. Endotracheal tube too low. Dr. informed.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935242, "text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, sternal revision.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP SUPINE: The supine nature of the film causes the\n bilateral pleural effusions to layer posteriorly. This obscures the lung\n fields and evaluation for pulmonary edema is limited, although a component is\n likely present. Lines and tubes are in unchanged position. Surgical staples\n are seen over the mediastinum.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937704, "text": " 12:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx/assess effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n r/o ptx/assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG and sternal revision, tracheostomy.\n\n The left costophrenic region is not included on the film. Tracheostomy tube\n is 6 cm above carina. Right PICC line is in mid SVC. Feeding tube extends\n into duodenum but distal end is not included on this film. Bilateral chest\n wall drains. No pneumothorax. There is a right pleural effusion with\n associated atelectasis. There is atelectasis at the left base and probably a\n small left pleural effusion difficult to evaluate for reasons described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937299, "text": " 9:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the Dobbhoff tube.\n\n The Dobbhoff tube is coiled within the oropharynx and proximal esophagus with\n its tip still being in the distal portion of the esophagus. The right PICC\n line tip is in the mid SVC. The ET tube is partially obscured by the _____,\n but its tip terminates 3.2 cm above the carina. The mediastinal drains are\n again present. The bibasilar atelectasis and large bilateral pleural\n effusions are again noted with _____ improvement comparing to the previous\n chest radiograph. No evidence of congestive heart failure is present. These\n findings were communicated to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935409, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia/effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia/effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 71-year-old man status post CABG, sternal revision.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The tip of the endotracheal tube is more proximal since the previous study and\n is 3.3 cm from the carina. There is a Dobbhoff tube which is pointing\n cephalad near the gastroesophageal junction. There is a right IJ central\n venous line with a distal lead tip in the upper SVC. Bilateral drains are\n identified. There are bilateral pleural effusions, right greater than left.\n Only a small amount of aerated lung seen in the upper lung fields bilaterally.\n The cardiac silhouette is prominent. Overall, these findings remain stable.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938280, "text": " 12:55 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Assess for feeding tube placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Dobhoff placement\n REASON FOR THIS EXAMINATION:\n Assess for feeding tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n DOBBHOFF TUBE PLACEMENT\n\n A single AP view of the chest is obtained at approximately 13:05\n hours. The Dobbhoff tube has its tip remaining in the gastric fundus. There\n is more of the catheter within the stomach but it remains coiled. The\n remainder of the study is essentially unchanged since the prior examination\n with increased density in the left base consistent with atelectasis/airspaces\n disease. Right-sided PICC line and tracheostomy tube are unchanged. Patchy\n bibasilar atelectasis persists.\n\n IMPRESSION:\n\n No significant adverse interval change. Dobbhoff tube has more of the\n catheter within the stomach; however, the tip of the tube remains in the\n gastric fundus.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935808, "text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n check dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check Dobbhoff tube placement.\n\n COMPARISON: .\n\n TECHNIQUE AND FINDINGS: AP radiograph of the chest. Tip of the endotracheal\n tube is approximately 3.1 cm from the carina. The Dobhoff tube is again\n identified with the tip within the stomach and pointing cephalad to the left.\n Right internal jugular central venous is unchanged in position. Bilateral\n drains are again seen and unchanged. Decrease in pleural effusions is noted\n bilaterally. No pneumothorax is identified.\n\n IMPRESSION: Dobbhoff tube with tip within the stomach and pointing cephalad.\n Decreased pleural effusions bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-04 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 934018, "text": " 2:28 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o mycotic aneurysm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n r/o mycotic aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with sepsis, assess for mycotic aneurysm.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain without IV\n contrast including FLAIR, gradient-echo, and diffusion-weighted images. MR\n angiogram of the brain with 3D time-of-flight imaging and reformatted images.\n\n No prior studies for comparison.\n\n FINDINGS: There is moderate-to-severe generalized brain atrophy, with\n extensive increased signal in the white matter of both cerebral hemispheres\n and around both lateral ventricles, consistent with small vessel ischemic\n changes. Several small focal areas of susceptibility artifact are seen in\n both cerebral hemispheres, and the cerebellum. In the right occipital lobe,\n there is a 7-mm rounded lesion, which has increased signal on T2 and FLAIR\n sequences, restricted diffusion, and has a ring of decreased\n signal on gradient-echo and T2-weighted images. No other areas of abnormal\n restricted diffusion are identified. There is mild bilateral maxillary,\n sphenoid, and ethmoid sinus mucosal thickening. Mild opacification is also\n seen in both mastoid air cells, with a fluid level in the right mastoid\n sinus. A subgaleal soft tissue fluid collection is seen overlying the left\n temporal bone, measuring at least 3.8 x 0.7 cm in axial dimension.\n\n MR normal signal intensity in both vertebral, the\n basilar, both internal carotid, anterior, middle, and posterior cerebral\n arteries. There is very limited depiction of the distal vascular distribution\n of the middle cerebral arteries. No overt aneurysm or stenosis is identified.\n However, evaluation for mycotic aneurysm is not achieved, given the lack of\n visualization of the peripheral vasculature.\n\n IMPRESSION:\n\n 1. Right occipital lobe lesion as described above, of uncertain etiology. The\n intense restricted diffusion may suggest a small involving infarction with\n surrounding hemorrhage. Given the patient's history of sepsis, an abscess is\n also possible.\n\n 2. Areas of susceptibility artifact seen scattered throughout both cerebral\n hemispheres suggestive of amyloid angiopathy. Multiple cavernomoas is an\n alternative diagnosis.\n\n 3. Subgaleal fluid collection over the left temporal bone- etiology\n uncertain.\n (Over)\n\n 2:28 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o mycotic aneurysm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. MR no stenosis or aneurysm centrally. Evaluation\n for a mycotic aneurysm is unsatisfactory, as there is no clear visualization\n of the distal intracranial arterial vasculature, which is the usual locale for\n mycotic aneurysms.\n\n Findings were discussed with at approximately 5:20pm on .\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933852, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH FROM .\n\n HISTORY: Coronary artery disease status post CABG postop day 1. Sternal\n revision. Assess Dobbhoff feeding tube placement.\n\n FINDINGS: An AP portable supine chest radiograph shows Dobbhoff feeding tube\n coiled back upon itself in the stomach with the metallic tip directed upwards\n towards the GE junction. Swan-Ganz catheter placed via right IJ Cordis is in\n place with the tip at the level of the main pulmonary outflow tract directed\n towards the right main pulmonary artery. Endotracheal tube tip remains low,\n projected 2.5 cm above the carina. Penrose drains and sternal skin clips seen\n on yesterday's study are no longer present. Hazy obscuration of both\n hemidiaphragms with posteriorly layering pleural effusions are again noted\n though these appear slightly smaller, especially on the right.\n\n CONCLUSION: Dobbhoff feeding tube coiled back upon itself in the stomach.\n Unchanged but slightly low location of endotracheal tube tip.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 933774, "text": " 7:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: dobhoff position\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sepsis, s/p AVR, open chest\n REASON FOR THIS EXAMINATION:\n dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, status post Dobhoff tube placement.\n\n COMPARISON: None.\n\n FINDINGS: Supine portable abdominal radiograph reviewed. Tip of a Dobhoff\n nasogastric tube projects over the stomach cardia traversing the GE junction.\n Advancement is recommended for more optimal placement. Abdominal radiograph\n demonstrates a dense left lower lobe retrocardiac consolidation, and bilateral\n pleural effusions. No dilated bowel loops are identified. Significant\n degenerative changes in the lumbar spine including dextroscoliosis is noted.\n\n IMPRESSION: A Dobhoff tube at GE junction. Advancement for more optimum\n placement is recommended. Dr. and I discussed these findings.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937429, "text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check NG tube placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n Check NG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post sternal revision _____ NG tube placed.\n\n CHEST:\n\n The tip of the nasogastric tube lies within the region of the pylorus. No\n other changes are seen since the prior chest x-ray of , bilateral\n effusions, cardiomegaly and evidence of failure persist.\n\n IMPRESSION: Nasogastric tube in pyloric region.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937875, "text": " 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for fluid collections, pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n Assess for fluid collections, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG with sternal revision, status\n post closure and right-sided thoracentesis.\n\n COMPARISON: .\n\n SEMI-UPRIGHT FRONTAL CHEST: Tracheostomy tube is 6.3 cm above the carina.\n The feeding tube tip is not visualized but is below the diaphragm. A right-\n sided PICC tip overlies the central superior vena cava. There is a new right-\n sided pleural catheter with its tip overlying the lung base. There has been\n near total resolution of the right pleural effusion. The cardiac and\n mediastinal contours are stable. There is continued opacification of the\n retrocardiac left lower lobe. Pulmonary vascularity appears within normal\n limits. No pneumothorax is seen. Vertically oriented midline skin staples\n are again identified.\n\n IMPRESSION:\n 1. Near total resolution of the right pleural effusion after pleural catheter\n placement. No pneumothorax.\n 2. Persistent left lower lobe retrocardiac opacity could be atelectasis or\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934779, "text": " 7:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:39 A.M., .\n\n HISTORY: Status post CABG and sternal revision.\n\n IMPRESSION: AP chest compared to through :\n\n Moderate left pleural effusion has decreased since . Severe left\n lower lobe atelectasis persists. Moderate enlargement of the cardiac\n silhouette is longstanding. Large right pleural effusion unchanged. ET tube,\n right jugular line, and a nasogastric feeding tube are in standard placements.\n Apparent widening of the superior mediastinum contiguous with adjacent pleural\n abnormality is due in part to vascular engorgement.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937946, "text": " 9:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 10:30 a.m., \n\n INDICATION: Multiple recent surgeries as above. Now status post right\n thoracentesis with catheter placement. Evaluate for pneumothorax.\n\n FINDINGS: Compared with 11/28, the right pleural catheter is no longer\n identified. No pneumothorax seen.\n\n No other dramatic interval changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937368, "text": " 4:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sternal revision reopened status post closure of open chest.\n\n PORTABLE AP CHEST.\n\n Comparison done to the prior film done today at 9:53 a.m. In the interval,\n the Dobbhoff tube has been repositioned and now is seen beyond the projection\n of the film and probably beyond the stomach. The right-sided central venous\n catheter tip overlies the mid SVC. There is moderate cardiomegaly. Bilateral\n layering pleural effusions are again noted. Left retrocardiac atelectasis\n persists. Note that the left lateral chest wall is not included in the film.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "P SINUSES, COMPLETE MIN 3 VIEWS PORT", "row_id": 938111, "text": " 10:28 AM\n SINUSES, COMPLETE MIN 3 VIEWS PORT Clip # \n Reason: r/o sinusitis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n r/o sinusitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sinusitis.\n\n Two radiographs of the skull partially demonstrate the presence of a VP shunt.\n The visualized catheter tubing demonstrates no kinking or discontinuity. No\n previous radiographs are available for comparison. The paranasal sinuses are\n pneumatized and aerated. The mucosal thickening and mastoid air cell\n opacification seen on the MR examination of are not evident on\n today's radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-13 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 935282, "text": " 9:41 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for hematoma\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p AVR w/ sepsis, sternal dehisence s/p closure, with droping\n HCT\n REASON FOR THIS EXAMINATION:\n eval for hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post AVR and sepsis. The postoperative\n course was complicated by a mediastinitis and sternal dehiscence. The patient\n is status post omental flap.\n\n The patient presents with dropping hematocrit. Rule out hematoma.\n\n TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. 130 ml of\n nonionic contrast were administered. Nonionic IV contrast was used due to\n rapid bolus necessary for this study.\n\n CT CHEST: The patient is status post median sternotomy and near complete\n removal of the sternum. There is interval placement of an omental flap and\n closure of the skin. No evidence of new hematoma. A small fluid collection\n near the left cardiophrenic angle measuring 45 x 22 mm (2:38) appears to be\n slightly smaller than the previous study from , and also more\n hypodense. The findings are consistent with a resolving hematoma.\n\n The vessels supplying the flap are patent. Tiny pericardial effusion\n unchanged. Severe coronary artery calcifications and stents in the coronary\n arteries. Calcifications of the aorta. Large bilateral pleural effusions\n with associated atelectasis, similar to . ET tube is located\n 1-1.5 cm from the carina and could be withdrawn approximately 1 cm. A feeding\n tube with the tip in the stomach. Right IJ Cordis catheter within the upper\n right brachiocephalic vein.\n\n CT ABDOMEN: Small amount of free fluid in the abdomen with simple\n characteristics. No evidence of hematoma within the abdomen. The liver,\n spleen, and adrenal glands are within normal limits. The proximal portion of\n the pancreatic duct is slightly dilated measuring 8 mm, but the distal\n pancreatic duct is unremarkable. This is of unknown clinical significance.\n Multiple hypodense areas in the kidneys bilaterally, likely representing\n cysts. Some of the hypodense areas are too small to be characterized. No\n retroperitoneal lymphadenopathy. Multiple surgical clips in the regions of\n the harvesting of the omentum. Small periportal nodes do not meet CT criteria\n for pathology. Multiple nodules in the subcutaneous tissues in the anterior\n abdominal wall, likely from medication injection.\n\n CT PELVIS: There is malposition with the Foley catheter likely with the\n balloon in the urethra. (2:123.) The rectum, urinary bladder, distal\n (Over)\n\n 9:41 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for hematoma\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ureters, intrapelvic bowel loops are unremarkable. Small amount of simple\n free fluid in the pelvis.\n\n BONE WINDOWS: There are degenerative changes of the spine, but no suspicious\n lytic or blastic lesions. Healing fracture of the right twelfth rib.\n\n IMPRESSION:\n 1. No reason to explain dropping hematocrit.\n 2. Resolving left cardiophrenic hematoma.\n 3. Viable flap.\n 4. Large bilateral pleural effusions and associated atelectasis. The pleural\n effusions have simple characteristics and are unchanged since prior study.\n 5. Hypodense areas in the kidneys likely representing cysts, but some are too\n small to be characterized.\n 6. Mild dilatation of the central portion of the pancreatic duct measuring up\n to 8 mm of unclear significance. Correlate with history of simple ascites.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938166, "text": " 3:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dht placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n dht placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Status post bypass surgery. Postoperative since with\n sternal revision and open chest. Now status post right-sided thoracocentesis\n with catheter placement.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n sitting semi-upright position and analysis is performed in direct comparison\n with a similar study dated . Position of previously\n described tracheotomy cannula, right subclavian central venous line unchanged.\n The Dobhoff NG tube has been withdrawn partially and is now terminating in the\n fundus of the stomach. No pneumothorax has developed. The left lower lobe\n diffuse density has cleared up slightly but still partial atelectasis remains.\n Also, the left lateral pleural sinus is obliterated.\n\n IMPRESSION: Stable chest findings with mild improvement of left-sided pleural\n densities and left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-19 00:00:00.000", "description": "PICC W/O PORT", "row_id": 936165, "text": " 10:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ***************************** CPT Codes *****************************\n PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 71-year-old man status post MVR, needs IV\n access.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\n used to identify the right basilic vein, which was patent and compressible.\n The right arm of the patient was then prepped and draped in standard sterile\n fashion. After injection of 5 cc of 1% lidocaine, 21-gauge needle was\n advanced into the right basilic vein under ultrasonographic guidance. Hard\n copies of the images before and after the venipuncture were obtained. A 0.018\n guidewire was then advanced through the needle into the distal part of the SVC\n under fluoroscopic guidance. The needle was then exchanged for a 5 French\n micropuncture sheath. Based on the markers in the guidewire, it was decided\n that a length of 43 cm would be suitable. The line was then trimmed to this\n length and advanced over the wire into the distal part of the SVC. The wire\n and the peel-away sheath were then removed. The line was flushed, heplocked\n and statlocked. A dressing was applied, and final fluoroscopic image of the\n chest demonstrated tip of the catheter to be located in the distal part of the\n SVC. The patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of a 43 cm long double lumen line with the\n tip in the distal part of the SVC. The line is ready for use.\n\n\n\n\n\n\n\n (Over)\n\n 10:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-12-25 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 937123, "text": " 5:32 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: R/O DVT PT HAS LINE IN AND RT ARM SWELLING\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PICC in R and increased swelling.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC in right arm. Increased swelling. Rule out DVT.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, spectral, and color Doppler\n analysis of the right internal jugular vein, subclavian vein, axillary vein,\n brachial veins, cephalic vein, and basilic vein was performed. PICC catheter\n is seen in one of the brachial veins. There is normal flow, compressibility,\n augmentation, and waveforms in the right jugular vein, axillary vein, and\n brachial veins. No evidence of thrombus in the basilic or cephalic veins.\n\n IMPRESSION: No evidence of right upper extremity DVT.\n\n" }, { "category": "Radiology", "chartdate": "2149-01-03 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 938254, "text": " 10:15 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: R/O ASPIRATION, PT W/ ORAL DYSPHAGIA\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old, rule out aspiration.\n\n FINDINGS: Video oropharyngeal swallow study was performed in conjunction with\n the speech and swallow department. Various consistencies of barium were\n administered to the patient. NG tube is noted coiled within the nasopharynx.\n Please note the study was performed with tracheal cuff deflated. Note was\n made of mild-to-moderate impaired oral bolus handling. Unremarkable\n pharyngeal phase. There was trace penetration noted both with thin barium and\n with nectar. No more significant aspiration. Please see full speech and\n swallow report for more details and treatment recommendations.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934116, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pneumonia in a patient after sternal revision.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is still low, 1.7 cm above the carina, but the patient's neck\n is in flexion.\n\n The right internal jugular line catheter tip is at the junction of the\n internal jugular vein with the subclavian vein. The oral tube is coiled\n proximally but still most likely within the gastric fundus. The bilateral\n pleural effusion seems to be enlarged since the previous chest radiograph and\n underlying pulmonary congestion is likely.\n\n IMPRESSION:\n 1. Borderline position of the ET tube.\n 2. Massive bilateral pleural effusion, slightly increased with underlying\n pulmonary congestion.\n\n\n" } ]
70,884	171,528	As mentioned in the HPI, Mrs. underwent a cardiac cath on which demonstrated severe left main disease. Cardiac surgery was consulted and she was emergently taken to the operating room and underwent a coronary artery bypass graft x 2. Please see operative report for surgical details. In summary she had CABG x2 with: left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to obtuse marginal artery. her bypass time was 42 minutes and crossclamp time was 31 minutes. She tolerated the operation well and following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Later this day she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on beta-blockers and diuretics and gently diuresed towards her pre-op weight. On post-op day two her chest tubes were removed and she was transferred to the step-down unit for further recovery. Post-op she was in atrial fibrillation (has a history of chronic atrial fibrillation) and Coumadin was started. Once on the stepdown floor her hospital course was uneventful. She worked with the nursing and physical therapy staff to increase strength and endurance, her progress was slow. On post-op day three epicardial pacing wires were removed. On POD4 she was cleared for transfer to rehabilitation at either Rehab on the whichever the family chooses.	The ascending aorta is mildlydilated. There are simple atheroma inthe aortic arch. Mild mitral annularcalcification. Mildly dilated ascending aorta. Mildly dilated descending aorta. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Sinus bradycardia with slight P-R interval prolongation. Mild non-specific ST segmentflattening throughout. There is a small fibrinous echodensity in the left ventricularoutflow tract 1 cm below the right coronary cusp. There is mild regional leftventricular systolic dysfunction with mild hypokinesis of the distalanterolateral wall as well as the anterior wall and apex, The right ventricledisplays normal free wall contractility. The descending thoracic aorta is mildly dilated. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. SlightQ-T interval prolongation. Mildspontaneous echo contrast in the LAA. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Traceaortic regurgitation is seen. Mild regional LV systolicdysfunction.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. There appears to be one millimeter ofST segment elevation in lead aVL with downsloping ST segments and T waveinversions in leads III and aVF. QRS amplitudeis diminished in the limb leads. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Mild spontaneous echo contrast is present in the left atrialappendage. Ability to assess repolarization abnormalitiesis degraded by baseline artifact. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Baseline artifact has resolved.TRACING #1 Earlyanterior R wave transition persists. Valvular functionis unchanged. The thoracic aorta is intact after decannulation. Focal calcifications inaortic root. Sinus rhythm with P-R interval prolongation. Atrial fibrillation. Borderline leftventricular hypertrophy by voltage criteria. Hypertension. Left ventricular wallthicknesses and cavity size are normal. No atheroma in ascending aorta.Simple atheroma in aortic arch. The patient appears to be in sinusrhythm. Baseline artifact. Normal LV wall thickness and cavity size. The left atrial appendage emptying velocity is depressed (<0.2m/s).No atrial septal defect is seen by 2D or color Doppler. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. There arecomplex (>4mm) atheroma in the descending thoracic aorta. Compared to the previous tracing of , the rateis slightly slower, the computed P-R interval is slightly longer. Complex(>4mm) atheroma in the descending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Abnormal ECG. The patient was under general anesthesia throughout theprocedure. Early anteriorR wave transition. NewST segment elevation in lead aVL and ST segment depressions in the inferiorand right to mid-precordial leads are concerning for an acute ischemic process.Clinical correlation is suggested.TRACING #3 Compared to tracing #1 the rate is faster and no longerbradycardic. I certify I was present in compliance with HCFAregulations. No ASD by 2D or color Doppler.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. No AS. Coronary artery disease. No othersignificant changes from the pre-bypass exam. Intraoperative TEE for emergent CABGHeight: (in) 63Weight (lb): 147BSA (m2): 1.70 m2BP (mm Hg): 150/95HR (bpm): 50Status: InpatientDate/Time: at 15:41Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. Computed P-R and Q-T intervals are longer. A TEE was performed in thelocation listed above. Dr. was notified in person of the results in the operating room at the time ofthe study.POST BYPASS There is noemal biventricular systolic function. No TEE related complications. Chest pain. There is no pericardial effusion. Baseline artifact is significant. There are also downsloping ST segments likelyin lead II, as well as in leads V2 and V3 and possibly lead V4. Depressed LAA emptying velocity(<0.2m/s) All four pulmonary veins identified and enter the left atrium.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.	3	[ { "category": "Echo", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 100657, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Atrial fibrillation. Chest pain. Coronary artery disease. Hypertension. Intraoperative TEE for emergent CABG\nHeight: (in) 63\nWeight (lb): 147\nBSA (m2): 1.70 m2\nBP (mm Hg): 150/95\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 15:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA. Mild\nspontaneous echo contrast in the LAA. Depressed LAA emptying velocity\n(<0.2m/s) All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Mild regional LV systolic\ndysfunction.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. No atheroma in ascending aorta.\nSimple atheroma in aortic arch. Mildly dilated descending aorta. Complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was under general anesthesia throughout the\nprocedure. No TEE related complications. The patient appears to be in sinus\nrhythm. Results were personally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS: No spontaneous echo contrast is seen in the body of the left\natrium. Mild spontaneous echo contrast is present in the left atrial\nappendage. The left atrial appendage emptying velocity is depressed (<0.2m/s).\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. There is mild regional left\nventricular systolic dysfunction with mild hypokinesis of the distal\nanterolateral wall as well as the anterior wall and apex, The right ventricle\ndisplays normal free wall contractility. The ascending aorta is mildly\ndilated. There is a small fibrinous echodensity in the left ventricular\noutflow tract 1 cm below the right coronary cusp. There are simple atheroma in\nthe aortic arch. The descending thoracic aorta is mildly dilated. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr.\n was notified in person of the results in the operating room at the time of\nthe study.\n\nPOST BYPASS There is noemal biventricular systolic function. Valvular function\nis unchanged. The thoracic aorta is intact after decannulation. No other\nsignificant changes from the pre-bypass exam.\n\n\n" }, { "category": "ECG", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 303030, "text": "Sinus bradycardia with slight P-R interval prolongation. Borderline left\nventricular hypertrophy by voltage criteria. Mild non-specific ST segment\nflattening throughout. Compared to the previous tracing of , the rate\nis slightly slower, the computed P-R interval is slightly longer. Early\nanterior R wave transition persists. Baseline artifact has resolved.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 303029, "text": "Baseline artifact. Sinus rhythm with P-R interval prolongation. Slight\nQ-T interval prolongation. Ability to assess repolarization abnormalities\nis degraded by baseline artifact. There appears to be one millimeter of\nST segment elevation in lead aVL with downsloping ST segments and T wave\ninversions in leads III and aVF. There are also downsloping ST segments likely\nin lead II, as well as in leads V2 and V3 and possibly lead V4. Early anterior\nR wave transition. Compared to tracing #1 the rate is faster and no longer\nbradycardic. Computed P-R and Q-T intervals are longer. QRS amplitude\nis diminished in the limb leads. Baseline artifact is significant. New\nST segment elevation in lead aVL and ST segment depressions in the inferior\nand right to mid-precordial leads are concerning for an acute ischemic process.\nClinical correlation is suggested.\nTRACING #3\n\n" } ]
17,546	194,805	79 yo m with ischemic cardiomyopathy (EF: 15-25%), s/p NSTEMI, hx of AFib, HTN recently admitted to for CHF exacerbation and treated with lasix was readmitted after 7 second pause while on COreg at rehab (digoxin was d/cd at this time). After decreasing the coreg to 6.25mg , he experienced RVR to 130s-140s. He received 10mg IV diltiazem with good rate control and was referred here for ICD placement. On admission, his troponin was up to 0.58 from 0.18 8 days PTA without EKG changes. On night of admission, patient was "Triggered" for increased HR and decreased urine output. His rate responded to metoprolol (4mg IV). He subsequently developed a 9 second pause on tele. Pacer pads were placed and patient was evaluated for the CCU and transferred for closer monitoring. EP was consulted and he was started on heparin for ACS.	IMPRESSION: Stable cardiomegaly and probable left pleural effusion. Unchanged cardiomegaly, failure, bilateral effusions, and opacity at the left lung base. Mild mitral annularcalcification. Moderate to severe (3+)mitral regurgitation is seen.7.The tricuspid valve leaflets are mildly thickened.IMPRESSION: No intracardiac thrombus. Left pleuraleffusion.Conclusions:1. Pulses d/d bilaterally post removal and dsd placed and maintained d/i. Regular narrow complex rhythm which may represent sinus tachycardia with aprolonged P-R interval. ]RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.AORTA: Simple atheroma in aortic arch. ]3.There is moderate global right ventricular free wall hypokinesis.4.There are simple atheroma in the aortic arch and the descending thoracicaorta.5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis isnot present. PORTABLE AP CHEST RADIOGRAPH: Again seen is stable cardiomegaly. Regular narrow complex tachycardia - mechanism uncertain - may be atrialflutter or atrial tachycardiaVentricular premature complexRight bundle branch blockLeft anterior fascicular blockConsider prior anterior myocardial infarctionST-T wave abnormalities - cannot exclude in part ischemiaSince previous tracing of , ventricular response now regular Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. co/ci/svr 3hrs off iabp 7.9/4.1/466 cont with ?septic numbers. Physiologic(normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. There is a retrocardiac opacity and a small left pleural effusion, which is unchanged. Unchanged left lower lobe atelectasis and bilateral effusions. Patient was made a . Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINDINGS: A right subclavian Swan-Ganz catheter ends in the mid right pulmonary artery. The rhythm appears to be atrial fibrillation. PATIENT/TEST INFORMATION:Indication: R/o intracardiac thrombusHeight: (in) 64Weight (lb): 165BSA (m2): 1.80 m2BP (mm Hg): 117/50HR (bpm): 123Status: InpatientDate/Time: at 13:33Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. Continued cardiomegaly with small bilateral pleural effusion. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There is a probable left pleural effusion. Atrial fibrillationRight bundle branch blockLeft anterior fascicular blockConsider prior anteroseptal myocardial infarctionProbable left ventricular hypertrophyST-T wave abnormalities - cannot exclude in part ischemia or left ventricularhypertrophySince previous tracing of , ventricular rate slower and ventricularectopic activity Dr pronounced patient. A single-lead pacemaker is identified with the lead in satisfactory position. Small left pleural effusion. There is severe globalhypokinesis, with relative preservation of the basal inferolateral wall. Left ventricular cavity isdilated, with severely depressed systolic function. Bilateral effusions (left greater than right) are unchanged. FINDINGS: Endotracheal tube ends in satisfactory position, 4 cm above the carina. Baseline artifactAtrial fibrillation with rapid ventricular responseVentricular premature complexesRight bundle branch blockLeft anterior fascicular blockConsider prior anterior myocardial infarctionProbable left ventricular hypertrophyST-T wave abnormalities - cannot exclude in part ischemia or left ventricularhypertrophySince previous tracing of , ventricular response now irregular andfaster, and ventricular ectopy present 2:58 PM CHEST (PORTABLE AP) Clip # Reason: eval for chf MEDICAL CONDITION: 79 M, CHF, now with sob REASON FOR THIS EXAMINATION: eval for chf FINAL REPORT INDICATION: History of shortness of breath, evaluate for CHF. Vasopressin 2.4u/hr added to regime. Ptt supratherapeutic at 131.6. ABG 7.46/31/130. Heparin gtt resumed for ? Remains on IABP 1:1 via r groin with variable unloading points. Pt remains +4.2L LOS.ID: Tmax 99.8 PR. Continues on IABP support at 1:1 via R femoral line. Repeat ABG7.44/39/122. Received vanco 1gm IV. Down to 3.7(8.4).Resp: LS clr in apexes. Heparin supratherapeutic. NGT via R nares. pt on Milrinone 0.28mcgs/kg/min and Levophed 0.4mcgs/kg/min. Bun/Cr 61/3.1. Milrinone weaned to off w/ addition of Neosynephrine - tolerating w/ MAP > 60. Cont on abx. Radial line placed and left fem multi lumen placed.Started Levo 0.1-.5mcg/kg/min after intubation. ?further iabp wean. Abd firm and distended but with BS x4. D-dimer >. Swan placed in R axillary site initially notable for slight ooze which has been resolving . am bun/creat-66/4.9. Pt received 2 gm Ca Gluconate w/ repeat Ion Ca 1.05. & RN @ BS. Mvenous 75-79. LS rales 3/4 up bilaterally.ID low grade temp 100.3 po with elevated WBC 18.8. Pt cont on Lisinopril/ASA/ Lipitor. Site remains CDI. stable #"s on iabp 1:2. rising bun/creat.p:contin presnt management. H/O GIB.Cont CO 7.20-7.9/CI 3.7-4.14/ 600-516. PA 63-53/20. Pt on Heparin 600u/hr with ptt 87. ,rrtpt. MgSO4 1.6. ?dc lasix gtt. HCT stable at 32.5. PTCA during this admission. CO/CI/SVR appear septic 9.2/4.82/583 at 12noon after Vasopressin initiated. cont iapb support. CRI at baseline 1.5-1.7. 0400 #'s w iabp 1:1-iabp mean 55, pad 25, & co/ci/svr 7.9/4.14/547 2hrs later after being on iabp 1:2-iabp mean 58, pad 29, & co/ci/svr 7.2/3.77/522. Fair augmentation w/ systolic unloading of points and diastolic unloading of points. BUN/creat 64/3.4 slightly up. Abd distended and firm. +BS x 4 quadrants. Anuric since admission. ccu nsg progress note.o:minimally to noxious stim-presently on prop gtt. BS are hypoactive. Electively intubated #8.0 22mm at the lip. Distal pulses dopplerable. Hold diuretics, Put on Flovent and Albuterol MDI PRN. transferred to CCU. CA 7.7 recd 2 amps ca gluc. UOP 10-18cc following Diuril/ 80 mg IV Lasix and 20 mg/hr Lasix gtt. Experienced tachy brady syndrome and impressive pauses requiring transfer to CCU. Bibase rales audible with upper coarse bs. Currently undergoing repletion w/ 2 gm Mag sulfate. ABP 90-108/40. had been on coreg and dig.on floor agitated 1mg ativan IV x2 change in MS . Sats cont 93-95% with most recent abg 7.47/35/72. BB held per HO. Pt extubated to RA per physician. Cont on IABP 1:1 and Levophed gtt to maintain goal MAP>65. 4pm, placement checked and 60cc bilious material aspirated. Impaired gag upon suctioning.GI - NGT clamped throughout day. TTE today to RO Thrombus.EP consult for cardioversion. VVI set at 60 bpm. Pt. Goal to diurese pt and maintain MAP's with IABP, inotropy with vasopressors.Continu CCU Nursing Progress Note 7am -7pmS/O: ID - Initially rec'd pt with core temp 96.6. Heparin restarted at 1530 at rate of 400u/hr - repeat PTT at 2130. Cont on iv abx Vancomycin which is dosed q48hrs and Aztreonam q8hrs.	29	[ { "category": "Echo", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 65904, "text": "PATIENT/TEST INFORMATION:\nIndication: R/o intracardiac thrombus\nHeight: (in) 64\nWeight (lb): 165\nBSA (m2): 1.80 m2\nBP (mm Hg): 117/50\nHR (bpm): 123\nStatus: Inpatient\nDate/Time: at 13:33\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely depressed LVEF. [Intrinsic\nLV systolic function depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications. The rhythm appears to be atrial fibrillation. Left pleural\neffusion.\n\nConclusions:\n1. The left atrium is dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler.\n2. Left ventricular wall thicknesses are normal. Left ventricular cavity is\ndilated, with severely depressed systolic function. There is severe global\nhypokinesis, with relative preservation of the basal inferolateral wall.\n[Intrinsic left ventricular systolic function may be more depressed given the\nseverity of valvular regurgitation.]\n3.There is moderate global right ventricular free wall hypokinesis.\n4.There are simple atheroma in the aortic arch and the descending thoracic\naorta.\n5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is\nnot present. Trace aortic regurgitation is seen.\n6.The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\nmitral regurgitation is seen.\n7.The tricuspid valve leaflets are mildly thickened.\n\nIMPRESSION: No intracardiac thrombus. Severely depressed left ventricular\nsystolic function. Moderately severe mitral regurgitation.\n\nCompared to the previous report of , the MR is more severe and the RV\nfunction appears worse.\n\n\n" }, { "category": "ECG", "chartdate": "2162-01-19 00:00:00.000", "description": "Report", "row_id": 140582, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nVentricular premature complexes\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of , ventricular response now irregular and\nfaster, and ventricular ectopy present\n\n" }, { "category": "ECG", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 140578, "text": "Regular narrow complex rhythm which may represent sinus tachycardia with a\nprolonged P-R interval. Left axis deviation. Right bundle-branch block. Prior\ninferior wall myocardial infarction. Possible prior anterior wall myocardial\ninfarction. Diffuse ST-T wave changes. Compared to the previous tracing the\nrate is faster.\n\n" }, { "category": "ECG", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 140579, "text": "Regular narrow complex tachycardia - mechanism uncertain - may be atrial\nflutter or atrial tachycardia\nVentricular premature complex\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nST-T wave abnormalities - cannot exclude in part ischemia\nSince previous tracing of , ventricular response now regular\n\n" }, { "category": "ECG", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 140580, "text": "Lead V6 absent\nAtrial fibrillation with rapid ventricular response\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of the same date, ventricular rate increased\n\n" }, { "category": "ECG", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 140581, "text": "Atrial fibrillation\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anteroseptal myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of , ventricular rate slower and ventricular\nectopic activity\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893859, "text": " 5:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm NGT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 M, CHF, sob, hyperkalemia, s/p NGT placement for kayexelate\n\n REASON FOR THIS EXAMINATION:\n confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 79-year-old male patient with CHF, shortness of breath,\n nasogastric tube placement.\n\n COMMENTS: Portable semierect AP radiograph of the chest is reviewed and\n compared with the previous study of yesterday.\n\n There is increased opacity in the left lower lobe indicating pneumonia or\n aspiration. There is slight increase in small bilateral pleural effusion.\n There is continued marked cardiomegaly. The previously identified mild\n congestive heart failure has been improving. There is continued tortuosity of\n the thoracic aorta with calcification.\n\n A nasogastric tube terminates in the gastric body.\n\n IMPRESSION:\n\n 1. Left lower lobe pneumonia versus aspiration.\n\n 2. Improving mild congestive heart failure. Continued cardiomegaly with\n small bilateral pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST FLUORO WITHOUT RADIOLOGIST", "row_id": 893950, "text": " 2:52 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: PACEMAKRE LINE PLACEMENT\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n Chest fluoro without radiologist present was performed in the CCU. Check\n pacer line placement. 42 seconds of fluoro time was used. No images were\n submitted.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 894030, "text": " 7:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chf ? PNA\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF. Intubation.\n\n FINDINGS: Endotracheal tube ends in satisfactory position, 4 cm above the\n carina. An NG tube passes beyond view into the distal stomach. A pacemaking\n device overlies the right chest with pacer electrodes in stable position\n compared to the previous day. An intraaortic balloon pump is positioned with\n its distal tip at the top of the aortic arch. Moderate cardiomegaly is\n unchanged. Mild failure is unchanged. Bilateral effusions (left greater than\n right) are unchanged. Left lower lobe atelectasis is also stable.\n\n IMPRESSION: The tip of an intraaortic balloon pump overlies the top of the\n aortic arch. Unchanged cardiomegaly, failure, bilateral effusions, and\n opacity at the left lung base.\n\n This was discussed with Dr. at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893920, "text": " 12:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate ET tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chf ? PNA\n\n REASON FOR THIS EXAMINATION:\n evaluate ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old with CHF, question pneumonia, evaluate endotracheal\n tube placement.\n\n COMPARISON: at 5:39.\n\n AP SUPINE CHEST RADIOGRAPH: Endotracheal tube is seen approximately 4 cm\n above the carina. Nasogastric tube is seen with tip within the stomach. An\n opacity in the left lower lobe indicates pneumonia or aspiration. There is a\n small left pleural effusion. There is continued marked cardiomegaly. There\n is mild CHF. Continued tortuosity of the thoracic aorta with calcification.\n The right lung base cannot be evaluated secondary to technical factors.\n\n IMPRESSION:\n\n 1. Left lower lobe pneumonia Vs. aspiration. Small left pleural effusion.\n\n 2. Mild congestive heart failure. Continued cardiomegaly.\n\n 3. Nasogastric tube.\n\n 4. Endotracheal tube in appropriate position.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893973, "text": " 7:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: rule out pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF now has a new VVI pacemaker and SG atheterchf ?\n\n REASON FOR THIS EXAMINATION:\n rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n INDICATION: 79-year-old man with CHF, new VVI pacemaker.\n\n CHEST PORTABLE: Comparison is made to a prior study from earlier the same\n day. There is cardiomegaly, which is unchanged. The pulmonary vasculature is\n prominent. There is a retrocardiac opacity and a small left pleural effusion,\n which is unchanged. The ET tube is unchanged in position. A single-lead\n pacemaker is identified with the lead in satisfactory position. A Swan-Ganz\n catheter is noted with its tip in the right hilum.\n\n IMPRESSION:\n 1. Status post pacemaker implantation with a single lead in satisfactory\n position.\n 2. Swan-Ganz catheter in appropriate position.\n 3. No change in the appearance of mild CHF and retrocardiac atelectasis and\n small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893792, "text": " 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 M, CHF, now with sob\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of shortness of breath, evaluate for CHF.\n\n COMPARISON: .\n\n PORTABLE AP CHEST RADIOGRAPH: Again seen is stable cardiomegaly. Mediastinal\n contours are stable in appearance. There is minimal perihilar haziness,\n without any overt prominence of the pulmonary vasculature. There is a\n probable left pleural effusion. There is opacity in the left retrocardiac\n area which may represent atelectasis.\n\n IMPRESSION: Stable cardiomegaly and probable left pleural effusion. No\n definite CHF.\n\n" }, { "category": "Radiology", "chartdate": "2162-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 894185, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with sepsis, CHF now has a new VVI pacemaker and SG\n atheterchf ?\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, CHF. Swan-Ganz catheter placement.\n\n FINDINGS: A right subclavian Swan-Ganz catheter ends in the mid right\n pulmonary artery. An endotracheal tube ends in satisfactory position 4 cm\n above the carina. An NG tube passes beyond view into the stomach. A\n pacemaking device overlies the right chest with pacing electrodes in unchanged\n position compared to . An intra-aortic balloon pump ends 1 cm from\n the roof of the aortic arch. Moderate cardiomegaly is unchanged. CHF is\n slightly improved compared to the previous day. Left lower lobe atelectasis\n and small bilateral effusions (left greater than right) are unchanged. No\n pneumothorax is identified.\n\n IMPRESSION:\n 1. Improved CHF. Unchanged left lower lobe atelectasis and bilateral\n effusions.\n 2. The tip of an intra-aortic balloon pump ends 1 cm from the roof of the\n aortic arch as previously communicated to Dr on .\n\n" }, { "category": "Nursing/other", "chartdate": "2162-01-23 00:00:00.000", "description": "Report", "row_id": 1492209, "text": "Event Note\nReceived patient at 2300 with Heparin at 400u/hr..Levophed at .5 mcg/kg/min...Phenylephrine at 1 mcg/kg and vasopressin 2.4 u/hr. Heart rate 130 st .with SBP by aline 90 systolic. At 2200, patient dropped his HR to 70's..v-paced with multi focal pvc's..and profound drop in SBP to the 50's...Dr aware. Phenylephrine infusion titrated to max dose and a bolus of IVF one liter given ..Dopamine infusion begun. Family called and at bedside. After discussion with patient's wife and children. Patient was made a . A priest was called and last rites were given. All pressors were stopped and patient was extubated per family wishes. Dr pronounced patient. Family declined autopsy.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492205, "text": "CCU Nursing Progress Note 7am-3pm\nS: Orally intubated and sedated\n\nO: See careview for all objective data.\n\nID - t max 99.5 core. cont on abx, vanco q48hrs, Aztreonam and Flagyl started. Steriods started today. WBC 16.2\n\nCV - Pt on 1:3 and 1:3 iabp, unloading points attempting to maintain maps > 60 with Levophed 3.5 up to 5mcgs/kg/min and Milrinone maintained at 0.28mcgs/kg/min. Heparin off at10am and iabp placed on 1:1. IABP removed at 11:03 am without incident. Pulses d/d bilaterally post removal and dsd placed and maintained d/i. co/ci/svr 3hrs off iabp 7.9/4.1/466 cont with ?septic numbers. Pheneylephrine started at 3pm at 0.5mcgs/kg/min and will attempt to decrease milrinoe. HR remains st 130's with occ pvc's. Heparin will resume at 400u/hr at 3:30pm.\n\nResp - cont on AC 40%/450/13br/5 peep. pt will overbreath vent 3-10br/min. Sx for thick yellow/tan mucous plugs. bs are bronchial/coarse.\n\nGU - foley intact to cloudy urine. BUN/CREAt 66/4.0 today. Lasix cont 20mg/hr but u/o approx 30cc/hr.\n\nGI - NGT to lis draining dark bilious drainage. Bowel sounds are hypoactive this afternoon.\n\nSedation - Maintained on 50mcgs/kg propofol and pt is unarousable.\n\nSocial - Wife and daughters and spoke at lenght with DR. . Pt is now dnr. We will cont support and attempt to change milrinone in favor of neo, but no cpr/shock. Family asking questions about how pt will look when he dies. They wish him to be comfortable\n\nA/P: pt cont with septic looking co/ci. Attempt to start neo and d/c milrinone d/t possible sepsis. Heparin restart at 3:30pm. turn and position or sit up after 5pm (6hrs post iabp removal), cont support of family through this difficult time.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492206, "text": "resp therapist\npatient still on the vent doesn't improve stays on same settings.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492207, "text": "CCU Addendum: 1500-1900\n\nNursing staff and Dr. (CCU fellow) met w/ family to discuss plan of care and end of life issues. Pt.'s family verbalized concern that pt. be comfortable and not experience prolonged suffering. Decision made to continue current medication regimen (including antibiotic course) and re-evaluate/ meet w/ family each day to discuss goals of care. Family agreeable to this. Milrinone weaned to off w/ addition of Neosynephrine - tolerating w/ MAP > 60. Heparin restarted at 1530 at rate of 400u/hr - repeat PTT at 2130. PM labs pending. No vent adjustments - remains on AC/0.40/450/13/5 - maintaining O2 sat > 93% w/ adequate tidal volumes. Continue to monitor - provide emotional support and comfort to pt./family.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-23 00:00:00.000", "description": "Report", "row_id": 1492208, "text": "Resp Care\nPt removed from ventilator and extubated per Dr. . Pt extubated to RA per physician. & RN @ BS. Pt per family wishes.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492194, "text": "CCU NPN: please see flowsheet for objective data\n\n79 yo man with freq admissions for CHF,last time a week ago,at 6 second pause noted,tachy brady admitted to 6 for pacer placement. had been on coreg and dig.on floor agitated 1mg ativan IV x2 change in MS . in Afib 100-118 then increased to 130-140 while pushing 5mg lopressor BP 80/ only received 4mg. then had 9 second pause. ABG drawn 7.51/30/78 on 2l NP,lactate 6.5 and K noted to be 5.8,NGT placed given kaexalate,calcium,dextrose and insulin. transferred to CCU.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492195, "text": "CCU NPN addendum:\n\nResp: crackles 1/2 up rr 30-36. has exp wheezes,on 2l NP on 6 now on 40% face mask. sats 97 received 80mg lasix last evening at 10pm,no response.\n\nPain: has been complaining of left testicular pain.had rt inguinal hernia repair last month,steri-strips in place.\n\nSkin: tip of nose and lips bluish secondary to amiodorone,according to nurse who knows pt,color has improved.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492196, "text": "CCU Nursing Progress Note\nS-\"I can't breath too good.\"\nO-Neuro-lethargic but arousal to voice. Oriented to person only \"\". Calling out for - his wife. Asking to go to the bathroom and reminded about foley catheter. Moving all extremites, no need for restraints. Started Propofol gtt 50mcg/kg/min after intubation, with good sedative effect.\nCV-Intermittantly hypotensive early this am SBP 78-98 with RAF 110-130. Radial line placed and left fem multi lumen placed.\nStarted Levo 0.1-.5mcg/kg/min after intubation. Goal to maintain MAP >60. Pre cardioversion bedside TEE revealed no LV clot\nbut 4+MR <20%. After TEE pt HR decreased to 60-70 AF ECG obtained, no DCV planned until temp pacer in place. One 4.4 second pause noted on monitor. As pt was getting ready to be transferred to the EP lab, noted long pause > 5seconds then asystole. Transcutaneous pads in place, started to external pace pt rate 80 MA 60 with no pressure via aline. CPR started and pt received total 2mg atropine and 2mg epinephrine. Increased MA 100 with good capture and pressure 130. Emergent temporary pacer placed over wire left fem multi lumen with fluro for final placement and confirmation. Temp pacer rate set at 80 MA 20 with stim threshold 5, at full asych sensing. NO underlying rhythm noted. SBP 88 on levo at .5mcg/kg/min. Heparin transiently on this am at 1100u/hr but off since 0800.\nResp-rr 30 slightly SOB with minimal movement in bed. O2 sats dropping to 83% while HOB flat and on 100% face tent. Electively intubated #8.0 22mm at the lip. CXR pulmonary edema with pleural effusions. Vent settings at 100% 550x14AC PEEP 5 7.51/34/468/28, adjusted rr and FIO2 to new vent settings 60% 500x10AC PEEP 5, ABG 7.42/26/343. Minimal secretions white and thin sent for culture. LS rales 3/4 up bilaterally.\nID low grade temp 100.3 po with elevated WBC 18.8. Received vanco 1gm IV. Blood cultures sent x2 from new aline and multi lumen access.\nGU-BUN/Cr elevated 52/2.5 foley in place but no urine output noted until ~10cc at 1400.\nGI-NGT in place with some blood noted in right nare after placement.\nHCT stable 35.9(40) Elevated liver enezymes LDH 1753, AST 1571, ALT 1011. Abd firm and distended but with BS x4. No stool.\nEndo-blood sugars 130-150.\nSkin- please see careview for multiple open areas that are being treated with wet to dry.\nAccess- Attempted central access RIJ, but pt unable to lie flat without dropping sat. LEft radial aline placed, left multi lumen placed then changed over wire for emergent temp pacer. 2 PIV\nSocial-married with daughters, into visit and very upset over pt condition. MD/nursing staff keeping them informed of all procdures and evenets.\nA/P-CHF with known lo EF, now with tachy/brady syndrome, hypotension, no urine output and probable cardiogenic shock requring temp pacer, IABP and PA catheter for close hemdynamic monitoring.\nGoal MAP > 60 with PAD 18-20, following hemodynamic monitoring closely. Goal to diurese pt and maintain MAP's with IABP, inotropy with vasopressors.\nContinu\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492197, "text": "CCU Nursing Progress Note\n(Continued)\ne to keep family aware of POC and any procedures as discussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492198, "text": ",rrt\npt. remained on ventilator, weaned fio2 down to 40%, rate down to 15, sx'ing scant secretions from pt.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492199, "text": "CCU NURSING PROGRESS NOTE 1900-0700\nS: Intubated and sedated.\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: Pt remains sedated on Propofol at 50 mcg/kg/min. PEARL. 2mm in size. Brisk to sluggish in response. No spontaneous movement noted. Wrist restraints remain off.\n\nCV: AFib/ rare Vpacing. VVI set at 60 bpm. HR initially 70-80s. But HR gradually trending up to 1-teens following Milrinone load and gtt which remains at 0.28 mcg/kg/min for inotropic support to improve poor UOP. Continues on IABP support at 1:1 via R femoral line. Site remains CDI. Waveform slightly improved following aggressive flushing. ? against wall or kinking. Fair augmentation w/ systolic unloading of points and diastolic unloading of points. ABP 90-108/40. Levophed gtt titrated from .25 mcg/kg-0.40 mcg/kg/min to maintain MAPs> 65. Swan placed in R axillary site initially notable for slight ooze which has been resolving . PA 63-53/20. CVP 16-10. PCWP 17-15. CO 7.20-7.9/CI 3.7-4.14/ 600-516. Mvenous 75-79. HCT stable at 32.5. Ion Calcium .95. Pt received 2 gm Ca Gluconate w/ repeat Ion Ca 1.05. MgSO4 1.6. Currently undergoing repletion w/ 2 gm Mag sulfate. Heparin gtt resumed for ? future cath in addition to anticoagulation for 6 wk hx of Afib. Ptt supratherapeutic at 131.6. Heparin gtt held x 1hr and then decreased by 450 units to 650 units/hr per sliding scale. INR 6.0. Pt was given 10 mg SC Vitamin K+. Repeat INR 5.8 this am. BB held per HO. Pt cont on Lisinopril/ASA/ Lipitor. Distal pulses dopplerable. Lactate improving . Down to 3.7(8.4).\n\nResp: LS clr in apexes. Crackles auscultated way up posteriorly. ABG 7.46/31/130. FIO2 and RR decreased. Repeat ABG7.44/39/122. Pt remains on AC 40%/ 15*500/ 5 peep.\n\nGI/GU: NPO. NGT via R nares. Abd distended and firm. +BS x 4 quadrants. No stool. H/o Crohns ds currently stable. Cont on abx. F/C to gravity. Anuric since admission. UOP 10-18cc following Diuril/ 80 mg IV Lasix and 20 mg/hr Lasix gtt. CRI at baseline 1.5-1.7. Bun/Cr 61/3.1. Pt remains +4.2L LOS.\n\nID: Tmax 99.8 PR. Sputum/BC sent on prior shift. U/A sent but ? contamination. Need to obtain additional U/A once urine becomes available.\n\nEndo: BS 98-111. No coverage indicated.\n\nSocial: No calls or visitors . Pt is married w/ 3 dtrs. HO spoke to family in great length on prior shift.\n\nSkin: Unchanged. Dsgs to preexisting ulcers stable. No new breakdown.\n\nA/P: 79 yo male w/ extensive h/o CAD, HTN, CHF of 30% and new onset Afib (6wk). Recently admitted from for increased incidence of pauses. Experienced tachy brady syndrome and impressive pauses requiring transfer to CCU. Temp wire/ PPM placed for 9 sec pause. IABP support for presumed cardiogenic shock and PCWP of 40. Pt not to diuretics alone requiring additional Inotropic support. Cont on IABP 1:1 and Levophed gtt to maintain goal MAP>65. PCWP goal 18-20. Heparin supratherapeutic. Held and decreased per sliding scale. Cont to monitor for s/s of bleeding. H/O GIB.\nCont\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492200, "text": "CCU NURSING PROGRESS NOTE 1900-0700\n(Continued)\nto aggressively diurese. Wean Levophed and IABP as tolerated. ? PTCA during this admission. Cont to follow hemodynamics. Repeat PTT at 12 noon. Cont supportive care. Keep family updated in POC.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492201, "text": "resp care\n79 years old male intubated on for pulmonary edema also has a left sided pleural effusion, was in a-fib, ?pacer for tachy/bradycardia,went to echo on ,where left atrium and left ventricle are deemed dilated. Patient was hypotensive, ?sepsis or ischemia. TTE today to RO Thrombus.EP consult for cardioversion. Hold diuretics, Put on Flovent and Albuterol MDI PRN.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492202, "text": "CCU Nursing Progress Note 7am -7pm\nS/O: ID - Initially rec'd pt with core temp 96.6. Warmed with blankets and gradual warming to 98.6 core. Cont on iv abx Vancomycin which is dosed q48hrs and Aztreonam q8hrs. WBC 13.6 and 13 today\n\nResp - Cont orally intubated on AC 40%/500/15-13 br/5 peep. Sats cont 93-95% with most recent abg 7.47/35/72. Bibase rales audible with upper coarse bs. Sx q2-4 hrs for small-mod amts tannish secretions.\n\nNeuro - Cont on propofol 50mcgs/kg/min. Pupils and reactive. No response to painful stimuli. Impaired gag upon suctioning.\n\nGI - NGT clamped throughout day. 40cc bilious material returned early in shift. 4pm, placement checked and 60cc bilious material aspirated. LIS started and immediately 450cc bilious material drained. Aspirates currently bloody. BS are hypoactive. No stool noted today.\n\nCV - HR Initally Afib rate 110-120, and converted to ST rate 110-120 with rare apc's and occ pvc's. No paced complexes noted, as pt has temp screwed in pmr. Remains on IABP 1:1 via r groin with variable unloading points. Augmentation is good. pt on Milrinone 0.28mcgs/kg/min and Levophed 0.4mcgs/kg/min. Vasopressin 2.4u/hr added to regime. Able to slightly decrease Levophed to 0.35mcg/kg/min. CO/CI/SVR appear septic 9.2/4.82/583 at 12noon after Vasopressin initiated. At 6pm CO/CI 7.6/3.98/600/\nPAD's 23-25 throughout day with PCWP approx 10point lower than PAD. CVP 11-13. Pulses d/d bilat.\n\nGU - Foley cath patent small amts yellow urine which was sent for ua today, approx 30cc/hr. Cont on 20mg/hr IV lasix gtt.\n\nHeme/Chem- HCT 32.2. Pt on Heparin 600u/hr with ptt 87. Heparin decreased to 400u/hr (ptt due 10pm). INR 5.5. D-dimer >. BUN/creat 64/3.4 slightly up. LDH down this afternoon 4950 from >11,000. CA 7.7 recd 2 amps ca gluc. stim test performed.\n\nSocial - Family vss throughout day. Daughter spoke with Dr. this am and is aware of plan to cont full support of pt through tomorrow , then reassess plan. Wife and daughters spoke with Dr. and are aware of plan per multidisiciplinary rounds.\n\nA: 79yom s/p 9 sec pauses req ETT/DCV/pmr/iapb placement, cg shock and ?septic shock, responding poorly to pressors and inotropes.\n\nP: Cont support with current regime of levophed, pitressin and milrionone and attempt to levophed as tolerated. cont iapb support. PTT at 10pm. cont diuresis, Cont vent support as necessary with freq sx as needed, monitor GI status/GIB, monitor labs for change, keep family informed of plan/progress.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492203, "text": "ccu nsg progress note.\no:minimally to noxious stim-presently on prop gtt. attempted pressor wean-levophed, wo success (did not tolerate slightest decrease in dose). 0400 #'s w iabp 1:1-iabp mean 55, pad 25, & co/ci/svr 7.9/4.14/547 2hrs later after being on iabp 1:2-iabp mean 58, pad 29, & co/ci/svr 7.2/3.77/522. minimal uo. positive i&o. am bun/creat-66/4.9. elevated lft's. low grade t.\n\na:pressor dependent. stable #\"s on iabp 1:2. rising bun/creat.\n\np:contin presnt management. ?further iabp wean. ?dc lasix gtt. ?discussion w family re:overall prognosis & code status.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492204, "text": "resp care\npt remained on a/c 450x13 40% 5peep with peak/plat 22/18. BS coarse bil. Sats 92-94. Flovent given as ordered. Will follow as needed.\n" } ]
2,338	147,143	Patient was admitted on for acute onset dyspnea. Patient is a 61 yom with h.o. of severe systolic and diastolic function s/p AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam.	CAD s/p 5v CABG, CHF s/p AICD, systolic and diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea Dyspnea (Shortness of breath) Assessment: Pt adm this am via ED c/o SOB x3 d. denies throughout shift. I would emphasize and add the following points: 61M CAD (5v CABG, AICD for VT, EF 20%), hypothyroidism, AF, GIB on coumadin, PVD p/w several days progressive weakness - presented with AF c RVR to ED, developed hypotension following lopressor, CXR c ?CHF / pneumonia, abx / lasix given. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Action: Response: Plan: Impaired Physical Mobility Assessment: Action: Response: Plan: TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Pt with crackles in his lung bases bilaterally, upper lobes clear. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Depression: Will continue on home regimen of Citalopram and Bupropion. Depression: Will continue on home regimen of Citalopram and Bupropion. Depression: Will continue on home regimen of Citalopram and Bupropion. Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. Nutrition: Cardiac diet, replete lytes PRN Glycemic Control: Lines: Right IJ - discontinue Prophylaxis: DVT: Heparin SC TID Stress ulcer: VAP: Comments: Communication: Comments: Code status: FULL CODE Disposition: Pending resolution of symptoms ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:26 AM Multi Lumen - 06:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Pt with crackles in his lung bases bilaterally, upper lobes clear. Nutrition: Cardiac diet, replete lytes PRN Glycemic Control: Lines: Right IJ Prophylaxis: DVT: Heparin SC TID Stress ulcer: VAP: Comments: Communication: Comments: Code status: FULL CODE Disposition: Pending resolution of symptoms ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:26 AM Multi Lumen - 06:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR.	30	[ { "category": "ECG", "chartdate": "2159-08-24 00:00:00.000", "description": "Report", "row_id": 149477, "text": "Atrial fibrillation with rapid ventricular response. Since the previous tracing\nthe rate is slower. Early different morphology beats remain.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-08-24 00:00:00.000", "description": "Report", "row_id": 149478, "text": "Probable atrial fibrillation with rapid ventricular response with two wider\ncomplex beats, probably ventricular. Conducted complexes have intraventricular\nconduction delay of left bundle-branch block type. There are multiple\npseudofusion beats. Since the previous tracing of conducted complexes\nare now prevalent.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388362, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt with crackles in his lung bases bilaterally, upper lobes clear. SpO2\n 97-100% on 2L NC, pt states no SOB or DOE.\n Action:\n CXR took this morning, pt encouraged to cough and deep breath. Daily\n weight taken.\n Response:\n Venous PH 7.42, pt states being comfortable with breathing and shows no\n signs of distress. Pt\ns weight is 112kg.\n Plan:\n Titrate supplemental O2, encourage pt to deep breath, and encourage pt\n to use IS. Daily weights, pt is on a heart healthy low sodium diet \n to his Heart Failure.\n Impaired Physical Mobility\n Assessment:\n Pt at times with a flat affect and slow to manage ADL\ns on own.\n Action:\n Pt helped with turns however lower extremities unable to move them as\n well as upper extremities.\n Response:\n Pt is a min assist X 1 for turns/\n Plan:\n Pt could benefit from a PT and OT consult. Encourage pt to be OOB.\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388346, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 388341, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Unclear as to the exact etiology of the Lactate level. I\n suspect the lactate level may be from a nutrition poor hypoperfusive\n state at a cellular level given the hypoglycemia on chem panel as well\n as poor forward flow. Would expect mixed venous sat to be decreased\n however, this test was obtained on the floor after pt received\n Furosemide which would have improved forward flow. Other causes to\n consider include possible infection, however given the mild\n leukocytosis and lack of febrile history this is unlikely. Thiamine\n defiency could also cause the same issues, as well as cyanide toxicity.\n - will recheck Lactate level\n - will give Thiamine 200mg IV x 1\n - will f/u blood and urine cultures\n - will check daily cultures for surveillance\n - will continue to monitor SvO2\n .\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 61M CAD (5v CABG, AICD for VT, EF 20%),\n hypothyroidism, AF, GIB on coumadin, PVD p/w several days progressive\n weakness - presented with AF c RVR to ED, developed hypotension\n following lopressor, CXR c ?CHF / pneumonia, abx / lasix given. Labs\n notable for AG acidosis (>20) and lactate 13, glucose 42, elevated\n LFTs, ARF. Ab CT (I-) s clear pathology.\n Exam notable for Tm 96.8 BP 100/70 HR 81 / vpaced RR 19 with sat 98 on\n 2LNC CVO2 73%. Obese man, NAD. Coarse BS. RRRs1s2 2/6Sm. Soft +BS,\n non-tender, no rebound. 1+ edema. Labs notable for WBC 11K, HCT 38, K+\n 4.2, Cr 1.4, lactate 9, BNP 6K, Tn 0.05. CXR with cardiomegaly and B\n ASD, EKG AF vs VT.\n 61M DCM, AG acidosis with markedly elevated lactate, abnormal LFTs and\n ARF. Agree with plan to r/o infection (pancx, monitor off abx), run\n meds for interactions (no obvious culprits), and give IV thiamine. No\n compelling evidence for dead bowel, occult infection, compartment\n syndrome, malignancy, mitochondrial or glycogen storage disease though\n hypoglycemia may contribute - will check CO / CN levels as well as tox\n screen and osm gap, and will ask family about possible exposures.\n Suspect he is recovering from a low flow state d/t poor forward flow,\n possibly precipitated by episodic AF c RVR. For AF c RVR - consult EP\n re interrogation and continue sotalol, not an anticoag candidate; will\n also check TFTs. Will trend LFTs and consider HIDA - possibly passed\n stone? ARF somewhat better, not far off baseline, hold diuretics today,\n likely resume in AM, check sed for calcium oxalate crystals. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:01 PM ------\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388348, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388427, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Pt c/o with bed on CC7. Transfer held due repeat INR check, last INR\n was 4.7. If stable will be able to transfer.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388326, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea\n Dyspnea (Shortness of breath)\n Assessment:\n Pt adm this am via ED c/o SOB x3 d. denies throughout shift. Oriented,\n lethargic. Lungs dim, craclkes at bases this afternoon. O2 sats high\n 90\ns on 2 L n/c. abd large, soft, distended. Denies pain, nausea. NPO\n this am. LFT elevated and trending up. Presep cath in place and\n ranging 70\ns this am, now drifting to 50\ns. lactate elevated but\n improving. sbp 90\ns, V paced in 70\ns. cvp ~20. distal pulses by\n Doppler, left leg edematous w/ long standing wound left foot. Wifwe in\n this afternoon and updated.\n Action:\n Monitor labs as ordered\n Restarted home meds.\n Cardiac diet began\n EP consult, pacer interrogated\n Wound care consult\n Team aware of drifting pre CVo2 sat drifting to 50\n Response:\n Stable shift\n LFT not yet peaked\n Lactate improved 11-> 4\n Plan:\n Lasix 40mg iv after Kcl repletion\n Pulm hygiene\n Monitor CVo2\n Cont meds\n Am cxr\n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "ICU Attending Addendum", "row_id": 388410, "text": "MICU ATTENDING ADDENDUM\n 9:50a\n I saw and examined Mr. with the ICU team for the key portions\n of the services provided. I agree with the ICU team note from today,\n including the assessment and plan. I would emphasize and add the\n following points:\n 61 y/o man with complex cardiac disease presented with AFib with RVR\n complicated by hypotension and profound lactic acidosis. He reports\n feeling MARKEDLY improved, particularly with his dyspnea.\n 97.4 68 100/59 15 98% on nasal cannula. CVP 19. Distant\n heart. Course breath sounds. Looks chronically but not acutely ill.\n Abdomen is soft. Left TMA is dressed.\n Meds: SQH, H2B, bupropion, celexa, digoxin, levothyroxine, sotalol.\n CXR shows improved pulmonary edema.\n Labs show markedly decreased lactate; creatinine is slightly improved;\n bili and transaminases improved.\n A/P\n 61-year-old man with resolved/resolving global hypoperfusion state.\n Evaluation for other causes of lactic acidosis has been unrevealing\n (see Dr. \ns note from yesterday). Suspect this was related to AF\n with RVR rather than infectious trigger, though cultures still\n pending. Appreciate EPs help. Would aim to run about even today, then\n potentially resume home lasix tomorrow. Other issues as per ICU team\n note today. To floor today.\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388402, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 113 kg\n Daily weight:\n 112 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: Contact\n PMH: GI Bleed, Renal Failure\n CV-PMH: CAD, CHF, MI, Pacemaker\n Additional history: BiV ICD , osteomyelitis lt foot.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:66\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 1,320 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:34 AM\n Potassium:\n 3.4 mEq/L\n 03:34 AM\n Chloride:\n 99 mEq/L\n 03:34 AM\n CO2:\n 31 mEq/L\n 03:34 AM\n BUN:\n 29 mg/dL\n 03:34 AM\n Creatinine:\n 1.4 mg/dL\n 03:34 AM\n Glucose:\n 103 mg/dL\n 03:34 AM\n Hematocrit:\n 33.1 %\n 03:34 AM\n Finger Stick Glucose:\n 94\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC711\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388284, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388286, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.Pt admitted to MICU for further monitoring.\n Pt alert oriebted x3 but very lethargic.On 4lit NCO2.LS with fine\n crackles and diminished base.Pt mostly sleeping.Labs sent and\n monitoring cont Svo2.Svo2 72-80.\n Vitals stable.CVP 20-23.?needing more diuresis.Team to re-evaluate.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388287, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.Pt admitted to MICU for further monitoring.\n Pt alert oriebted x3 but very lethargic.On 4lit NCO2.LS with fine\n crackles and diminished base.Pt mostly sleeping.Labs sent and\n monitoring cont Svo2.Svo2 72-80.Lactate down to 11.2 from 13.7.\n Vitals stable.CVP 20-23.?needing more diuresis.Team to re-evaluate.\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388288, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that yesterday evening he noted sudden onset of shortness of\n breath. He denies any fevers, chills, nausea, vomiting, chest pain,\n melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n On the floor,\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Pt has been noted to be afebrile with no compliants of\n diarrhea, cough, skin lesions/infections. He also only shows mild\n leukocytosis which is suprising given the high lactate level. High\n lactate may be a combination of infection ?PNA given ground glass\n opacities on CT scan as well as poor cell perfusion secondary to poor\n forward flow and cardiac output.\n - will recheck Lactate level\n - will f/u blood and urine cultures\n - will continue on broad spectrum antibiotics with Zosyn/Vanc/Levo\n - will check daily cultures for surveillance\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388295, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Pt has been noted to be afebrile with no compliants of\n diarrhea, cough, skin lesions/infections. He also only shows mild\n leukocytosis which is suprising given the high lactate level. High\n lactate may be a combination of infection ?PNA given ground glass\n opacities on CT scan as well as poor cell perfusion secondary to poor\n forward flow and cardiac output.\n - will recheck Lactate level\n - will f/u blood and urine cultures\n - will continue on broad spectrum antibiotics with Zosyn/Vanc/Levo\n - will check daily cultures for surveillance\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388302, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Unclear as to the exact etiology of the Lactate level. I\n suspect the lactate level may be from a nutrition poor hypoperfusive\n state at a cellular level given the hypoglycemia on chem panel as well\n as poor forward flow. Would expect mixed venous sat to be decreased\n however, this test was obtained on the floor after pt received\n Furosemide which would have improved forward flow. Other causes to\n consider include possible infection, however given the mild\n leukocytosis and lack of febrile history this is unlikely. Thiamine\n defiency could also cause the same issues, as well as cyanide toxicity.\n - will recheck Lactate level\n - will give Thiamine 200mg IV x 1\n - will f/u blood and urine cultures\n - will check daily cultures for surveillance\n - will continue to monitor SvO2\n .\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388283, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that yesterday evening he noted sudden onset of shortness of\n breath. He denies any fevers, chills, nausea, vomiting, chest pain,\n melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n On the floor,\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - will diurese with IV Furosemide\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt's transaminitis may be\n secondary to congestive hepatopathy.Unclear though as\n - will continue to trend LFTs\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Given lack of fevers and only mild leukocytosis I suspect\n that his elevated lactate may be from poor cell perfusion secondary to\n poor forward flow and cardiac output. At this time though infection\n would also have to be considered given the appearance of ground glass\n opacities in the CT scan, it also difficulty to completely rule out\n infiltrate given the amount of fluid overload.\n - will recheck Lactate level\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine, ASA toxicity. Do\n not suspect Methanol or Ethylene glycol posioning given pt's history of\n exposures.\n - will check ASA level\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388391, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388394, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388397, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 113 kg\n Daily weight:\n 112 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: Contact\n PMH: GI Bleed, Renal Failure\n CV-PMH: CAD, CHF, MI, Pacemaker\n Additional history: BiV ICD , osteomyelitis lt foot.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:66\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 1,320 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:34 AM\n Potassium:\n 3.4 mEq/L\n 03:34 AM\n Chloride:\n 99 mEq/L\n 03:34 AM\n CO2:\n 31 mEq/L\n 03:34 AM\n BUN:\n 29 mg/dL\n 03:34 AM\n Creatinine:\n 1.4 mg/dL\n 03:34 AM\n Glucose:\n 103 mg/dL\n 03:34 AM\n Hematocrit:\n 33.1 %\n 03:34 AM\n Finger Stick Glucose:\n 94\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC711\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388370, "text": "Chief Complaint: 61 yo male hx of CAD s/p CABG, CHF with AICD and EF of\n 20 %, hypothyroidism and afib admitted to the ICU with dyspnea, concern\n for run of V-tach and elevated lactate.\n 24 Hour Events:\n - lactic acidosis workup\n -osmolar gap = 1\n -lactic acid trending down = 13.7 -> 11.2 -> 9.0 -> 4.8\n -serum tox = negative\n -co-ox = 2\n -CN = pending\n - EP consult: pacer interrogation reveals no evidence of ventricular\n arrythmias, recommend switching to amiodarone from sotalol.\n - emailed Dr. re: use of Sotalol with EF of 20% - reports\n patient had reaction to amiodarone and recs continuing Sotalol until\n f/u with him next week\n - lactate trend: 13.7 -> 11.2 -> 9 -> 4.8 -> 3.4\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:07 AM\n Furosemide (Lasix) - 06:20 PM\n Heparin Sodium (Prophylaxis) - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (68 - 83) bpm\n BP: 100/59(69) {79/38(48) - 105/79(84)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 112 kg (admission): 113 kg\n Height: 72 Inch\n CVP: 19 (2 - 26)mmHg\n CO/CI (Fick): (10.1 L/min) / (4.3 L/min/m2)\n SvO2: 78%\n Total In:\n 340 mL\n PO:\n 240 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 2,008 mL\n 820 mL\n Urine:\n 1,758 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,668 mL\n -820 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.39/33/106/31/-3\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 130 K/uL\n 10.0 g/dL\n 103 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 29 mg/dL\n 99 mEq/L\n 136 mEq/L\n 33.1 %\n 8.5 K/uL\n [image002.jpg]\n 05:44 AM\n 07:23 AM\n 09:45 AM\n 12:49 PM\n 12:59 PM\n 07:31 PM\n 03:34 AM\n WBC\n 11.5\n 10.0\n 8.5\n Hct\n 38.0\n 32\n 34.4\n 33.1\n Plt\n 182\n 138\n 130\n Cr\n 1.4\n 1.3\n 1.4\n 1.4\n TropT\n 0.05\n TCO2\n 21\n Glucose\n 90\n 98\n 99\n 75\n 103\n Other labs: PT / PTT / INR:43.7/42.5/4.7, CK / CKMB /\n Troponin-T:90//0.05, ALT / AST:, Alk Phos / T Bili:192/3.3,\n Lactic Acid:3.4 mmol/L, Albumin:3.5 g/dL, LDH:986 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.8 mg/Dl\n Micro\n - Legionella \n negative\n - HCV \n pending\n - MRSA, Blood Urine \n pending\n Imaging\n - CXR -\n Assessment and Plan\n ##. Elevated Lactate: patient initially noted to have lactate to 13.7\n at admission with unclear etiology. Workup showed negative tox screen,\n normal carboxy hemoglobin, absence of osmolar gap and no signs or\n symptoms concerning for infection. Lactate rapidly trended down\n throughout day. SVO2 continued to drop suggesting adequate O2\n extraction by peripheral tissues making septic shock less likely.\n - continue to trend lactate\n rapid fall with transaminitis may suggest\n episode of SVT with aberrancy and poor forward flow\n - f/u initial blood and urine cultures in setting of possible infection\n .\n ##. Dyspnea: likely do to fluid overload associated with prolonged SVT\n with abberancy. Cardiac enzymes cycled and stable which are below his\n prior baseline. AICD interrogated by EP and found no ventricular\n arrhythmias and only evidence of SVT with aberrancy and patient\n subjectively improved after resolution of arrhythmia.\n - f/u CXR for interval improvement s/p diuresis\n - continued gentle diuresis for fluid overload\n ##. Transaminitis/hyperbilirubinemia: patient with initial\n transaminitis at presentation now resolving, likely suggest hepatic\n congestion vs. shock liver from prolonged hypoperfusion. Imaging\n showed no evidence of cholecystitis or hepatitis.\n - continue to trend LFTs\n resolving\n - consider HIDA scan if continued abnormalities to further evaluate GB\n in setting of edema but no\ntrue\n cholecystitis and setting of gall\n stones\n - holding statin\n - f/u hepatitis serologies\n .\n ##. Anion Gap Acidosis: AG closed to 6 in setting of falling lactate\n suggesting source as lactic acidosis. No osmolar gap and negative tox\n screen.\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin and defer to Dr. \n - continue sotalol per Dr. \n .\n ##. Hypothyroidism: continue on home regimen of Levothyroxine.\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue on digoxin per Dr. as patient had prior\n reaction to amiodarone\n .\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:26 AM\n Multi Lumen - 06:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388392, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "General", "chartdate": "2159-08-25 00:00:00.000", "description": "Generic Note", "row_id": 388381, "text": "MICU ATTENDING ADDENDUM\n 9:50a\n I saw and examined Mr. with the ICU team for the key portions\n of the services provided. I agree with the ICU team note from today,\n including the assessment and plan. I would emphasize and add the\n following points:\n 61 y/o man with complex cardiac disease presented with AFib with RVR\n complicated by hypotension and profound lactic acidosis. He reports\n feeling MARKEDLY improved, particularly with his dyspnea.\n 97.4 68 100/59 15 98% on nasal cannula. CVP 19. Distant\n heart. Course breath sounds. Looks chronically but not acutely ill.\n Abdomen is soft. Left TMA is dressed.\n Meds: SQH, H2B, bupropion, celexa, digoxin, levothyroxine, sotalol.\n CXR shows improved pulmonary edema.\n Labs show markedly decreased lactate; creatinine is slightly improved;\n bili and transaminases improved.\n A/P\n 61-year-old man with resolved/resolving global hypo\n 61M DCM, AG acidosis with markedly elevated lactate, abnormal LFTs and\n ARF. Agree with plan to r/o infection (pancx, monitor off abx), run\n meds for interactions (no obvious culprits), and give IV thiamine. No\n compelling evidence for dead bowel, occult infection, compartment\n syndrome, malignancy, mitochondrial or glycogen storage disease though\n hypoglycemia may contribute - will check CO / CN levels as well as tox\n screen and osm gap, and will ask family about possible exposures.\n Suspect he is recovering from a low flow state d/t poor forward flow,\n possibly precipitated by episodic AF c RVR. For AF c RVR - consult EP\n re interrogation and continue sotalol, not an anticoag candidate; will\n also check TFTs. Will trend LFTs and consider HIDA - possibly passed\n stone? ARF somewhat better, not far off baseline, hold diuretics today,\n likely resume in AM, check sed for calcium oxalate crystals. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388385, "text": "Chief Complaint: 61 yo male hx of CAD s/p CABG, CHF with AICD and EF of\n 20 %, hypothyroidism and afib admitted to the ICU with dyspnea, concern\n for run of V-tach and elevated lactate.\n 24 Hour Events:\n - lactic acidosis workup\n -osmolar gap = 1\n -lactic acid trending down = 13.7 -> 11.2 -> 9.0 -> 4.8\n -serum tox = negative\n -co-ox = 2\n -CN = pending\n - EP consult: pacer interrogation reveals no evidence of ventricular\n arrythmias, recommend switching to amiodarone from sotalol.\n - emailed Dr. re: use of Sotalol with EF of 20% - reports\n patient had reaction to amiodarone and recs continuing Sotalol until\n f/u with him next week\n - lactate trend: 13.7 -> 11.2 -> 9 -> 4.8 -> 3.4\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:07 AM\n Furosemide (Lasix) - 06:20 PM\n Heparin Sodium (Prophylaxis) - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (68 - 83) bpm\n BP: 100/59(69) {79/38(48) - 105/79(84)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 112 kg (admission): 113 kg\n Height: 72 Inch\n CVP: 19 (2 - 26)mmHg\n CO/CI (Fick): (10.1 L/min) / (4.3 L/min/m2)\n SvO2: 78%\n Total In:\n 340 mL\n PO:\n 240 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 2,008 mL\n 820 mL\n Urine:\n 1,758 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,668 mL\n -820 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.39/33/106/31/-3\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 130 K/uL\n 10.0 g/dL\n 103 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 29 mg/dL\n 99 mEq/L\n 136 mEq/L\n 33.1 %\n 8.5 K/uL\n [image002.jpg]\n 05:44 AM\n 07:23 AM\n 09:45 AM\n 12:49 PM\n 12:59 PM\n 07:31 PM\n 03:34 AM\n WBC\n 11.5\n 10.0\n 8.5\n Hct\n 38.0\n 32\n 34.4\n 33.1\n Plt\n 182\n 138\n 130\n Cr\n 1.4\n 1.3\n 1.4\n 1.4\n TropT\n 0.05\n TCO2\n 21\n Glucose\n 90\n 98\n 99\n 75\n 103\n Other labs: PT / PTT / INR:43.7/42.5/4.7, CK / CKMB /\n Troponin-T:90//0.05, ALT / AST:, Alk Phos / T Bili:192/3.3,\n Lactic Acid:3.4 mmol/L, Albumin:3.5 g/dL, LDH:986 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.8 mg/Dl\n Micro\n - Legionella \n negative\n - HCV \n pending\n - MRSA, Blood Urine \n pending\n Imaging\n - CXR -\n Assessment and Plan\n ##. Elevated Lactate: patient initially noted to have lactate to 13.7\n at admission with unclear etiology. Workup showed negative tox screen,\n normal carboxy hemoglobin, absence of osmolar gap and no signs or\n symptoms concerning for infection. Lactate rapidly trended down\n throughout day. SVO2 continued to drop suggesting adequate O2\n extraction by peripheral tissues making septic shock less likely.\n - continue to trend lactate\n rapid fall with transaminitis may suggest\n episode of SVT with aberrancy and poor forward flow\n - f/u initial blood and urine cultures in setting of possible infection\n .\n ##. Dyspnea: likely do to fluid overload associated with prolonged SVT\n with abberancy. Cardiac enzymes cycled and stable which are below his\n prior baseline. AICD interrogated by EP and found no ventricular\n arrhythmias and only evidence of SVT with aberrancy and patient\n subjectively improved after resolution of arrhythmia.\n - f/u CXR for interval improvement s/p diuresis\n - hold off on lasix today and signout to floor team that I/O\ns must be\n strictly followed so that patient is negative\n ##. Transaminitis/hyperbilirubinemia: patient with initial\n transaminitis at presentation now resolving, likely suggest hepatic\n congestion vs. shock liver from prolonged hypoperfusion. Imaging\n showed no evidence of cholecystitis or hepatitis.\n - continue to trend LFTs\n resolving\n - consider HIDA scan if continued abnormalities to further evaluate GB\n in setting of edema but no\ntrue\n cholecystitis and setting of gall\n stones\n - holding statin\n - f/u hepatitis serologies\n .\n ##. Anion Gap Acidosis: AG closed to 6 in setting of falling lactate\n suggesting source as lactic acidosis. No osmolar gap and negative tox\n screen.\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin and defer to Dr. \n - continue sotalol per Dr. \n .\n ##. Hypothyroidism: continue on home regimen of Levothyroxine.\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue on digoxin per Dr. as patient had prior\n reaction to amiodarone\n .\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ - discontinue\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:26 AM\n Multi Lumen - 06:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388357, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt with crackles in his lung bases bilaterally, upper lobes clear. SpO2\n 97-100% on 2L NC, pt states no SOB or DOE.\n Action:\n CXR took this morning, pt encouraged to cough and deep breath. Daily\n weight taken.\n Response:\n Venous PH 7.42, pt states being comfortable with breathing and shows no\n signs of distress. Pt\ns weight is 112kg.\n Plan:\n Titrate supplemental O2, encourage pt to deep breath, and encourage pt\n to use IS. Daily weights, pt is on a heart healthy low sodium diet \n to his Heart Failure.\n Impaired Physical Mobility\n Assessment:\n Pt at times with a flat affect and slow to manage ADL\ns on own.\n Action:\n Pt helped with turns however lower extremities unable to move tem as\n well as upper extremities.\n Response:\n Pt is a min assist X 1 for turns/\n Plan:\n Pt could benefit from a PT and OT consult. Encourage pt to be OOB.\n" }, { "category": "Radiology", "chartdate": "2159-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099870, "text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated lactate, diastolic heart failure, shortness of\n breath\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diastolic heart failure. Evaluate for change.\n\n COMPARISON: .\n\n FINDINGS:\n\n AP radiograph of the chest demonstrates decreased pulmonary edema and\n decreased bilateral pleural fluid. There is no focal consolidation. The\n cardiomediastinal silhouette is stable, again noting mild cardiomegaly, median\n sternotomy wires, and ICD as well as a pacemaker. Right central venous\n catheter remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1099695, "text": " 1:26 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? CHOLECYSTITIS ELEVATED LFT'S\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CHF and elevated LFTs, jaundice\n REASON FOR THIS EXAMINATION:\n ?cholecystitis\n ______________________________________________________________________________\n WET READ: JXRl FRI 2:28 AM\n gallbladder partially decompressed, so difficult to assess for wall\n thickening, but GB wall appears edematous.\n cholelithiasis\n moderate ascites, new from \n cannot assess sign due to mental status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 61-year-old male with CHF, elevated LFTs and jaundice.\n\n COMPARISON: None.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic, without\n focal lesions identified. The right kidney is similarly echogenic. There is\n no intra- or extra- hepatic biliary ductal dilation. The common duct measures\n 3 mm. Flow through the portal vein is anterograde. There is a small amount of\n ascites. The gallbladder is contracted with multiple shadowing stones. The\n right kidney appears echogenic. The pancreas is suboptimally visualized,\n although is suboptimally visualized. Son sign cannot be\n assessed due to clincal status of the patient.\n\n IMPRESSION:\n 1. Ascites.\n\n 2. Cholelithiasis in a contracted gallbladder.\n\n 3. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n 4. Probable echogenic right kidney incidentally noted, which may suggest\n medical renal disease.\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099690, "text": " 12:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with VT\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with V-tach.\n\n COMPARISON: Multiple prior chest radiographs, most recently .\n Chest CTA . CT abdomen/pelvis .\n\n CHEST, UPRIGHT PORTABLE FRONTAL VIEW: Lung volumes are low. There is\n heterogeneous opacification of the right with effusion and dense left lower\n lobe consolidation. The heart is markedly enlarged, increased in size from\n portable chest radiograph .\n\n Radiographic findings correspond to unusual pleural fluid collections and mild\n pulmonary edema as demonstrated on subsequent CT abdomen/pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1099697, "text": " 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abdominal catastrophe\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 50 Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated LFTs and lactate 13.7\n REASON FOR THIS EXAMINATION:\n r/o abdominal catastrophe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl FRI 4:33 AM\n small b/l pleural effusions, fluid along fissures\n cardiomegaly\n small amount of ascites, free pelvic fluid\n cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from \n no secondary signs of bowel ischemia (no pneumatosis, free air, or dilation)\n\n pt received a 30mL prebolus of contrast\n WET READ VERSION #1 JXRl FRI 4:33 AM\n small b/l pleural effusions, fluid along fissures\n cardiomegaly\n small amount of ascites, free pelvic fluid\n cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with elevated LFTs and a lactate of 13.7.\n\n COMPARISON: Abdominal ultrasound, one hour prior and CT torso .\n Chest CTA .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases through the\n pubic symphysis without administration of IV contrast. The study was\n protocoled as noncontrast. However, 50 ml prebolus of IV contrast was\n administered. Multiplanar reformatted images were generated.\n\n CT ABDOMEN: The pleura is thickened and hyperdense, which could reflect some\n enhancement in this patient who received a small amount of IV contrast, vs.\n precontrast hyperdensity. The appearance is similar to . There are\n small bilateral pleural effusions and bibasilar atelectasis. The heart is\n enlarged. There are dense mitral annular calcifications. Pacer/ICD wires are\n incompletely imaged. Calcifications of the cardiac apex likely represent\n calcified apical infarct.\n\n The relative lack of IV contrast limits evaluation of abdomen for focal\n lesions. There is a small amount of ascites. The liver is homogeneous. The\n gallbladder is decompressed, with numerous gallstones. The spleen is normal\n in size. The pancreas is unremarkable. The adrenals are unremarkable. There\n is a small amount of contrast in the renal collecting systems bilaterally.\n There are no enlarged mesenteric or retroperitoneal lymph nodes. The stomach,\n (Over)\n\n 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abdominal catastrophe\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 50 Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n duodenum, small bowel, and colon are nondilated. There is no pneumatosis and\n no free intraperitoneal air.\n\n The abdominal aorta is densely calcified, with a focal ulcerated plaque or\n small saccular aneurysm (2:57).\n\n CT PELVIS: The urinary bladder is decompressed with a Foley catheter in\n place. The rectum and sigmoid are within normal limits. The prostate and\n seminal vesicles are unremarkable. There is a small amount of free pelvic\n fluid.\n\n There are multilevel degenerative changes of the thoracic spine. Compression\n deformity of L1 is of age indeterminate, new from . Grade 2\n anterolisthesis of L5 on S1 with a large bridging anterior ostephyte and\n endplate sclerosis has progressed from . There are bilateral pars\n defects.\n\n IMPRESSION:\n 1. No secondary signs to suggest bowel ischemia. Vessel patency on this\n study cannot be evaluated due to lack of a full contrast bolus.\n 2. Thickened and hyperdense pleura bilaterally, similar to .\n Clinical correlation with history of possible prior infection or known\n pleural disease is recommended. This is incompletely imaged on this\n examination.\n 3. Small bilateral pleural effusions. Fluid tracks along the pleural\n fissures.\n 4. Calcified cardiac apex suggestive of chronic apical infarct.\n 5. Small amount of ascites.\n 6. Cholelithiasis.\n 7. Atherosclerotic vascular calcifications. Ulcerated plaque or small\n saccular aneurysm of the infrarenal abdominal aorta (2:57).\n 8. L1 compression deformity, new from the most recent prior study of .\n Severe L5-S1 degenerative changes. Bilateral L5 pars defects.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1099699, "text": " 3:24 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement r ij\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypotension, tachycardia, fever new line placement please\n confirm line placement\n REASON FOR THIS EXAMINATION:\n confirm line placement r ij\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:37 A.M. :\n\n HISTORY: Hypotension, tachycardia and new line in place.\n\n IMPRESSION: AP chest compared to at 12:16 a.m.:\n\n Tip of the new right jugular line is partially obscured, but beyond the upper\n SVC. No pneumothorax. A small right pleural effusion was present prior to\n line placement. Severe cardiomegaly is unchanged. In addition to right\n pleural effusion collected in fissures in the right lower lung, there is a\n suggestion of new consolidation, possibly pneumonia, since the upper lobes do\n not show progression of pulmonary edema. Transvenous right atrial and two\n transvenous right ventricular pacer defibrillator leads emanate from the right\n axillary pacemaker and one ventricular lead exiting from the left chest could\n be connected to an abdominal or temporary pacemaker. No pneumothorax.\n\n" } ]
22,310	127,984	Patient was admitted for concern of meningitis, brainstem encephalitis to General Neurology Service. . 1. Neurology: Upon admission, patient had copius oral secretions, minimal alertness, worsening spasticity, and ophthalmoplegia with left 3rd nerve involvement and bilateral 6th cranial involvement. Lumbar puncture on admission showed WBC 150 wbc, 160 rbc with diff of 77%polys, 12% lymphs, 11% monos with TP 52, glucose 49; gram stain with 2+PMNs. He was kept in ICU for concern of poor handling of secretions and was stable for step-down unit the next day. MRI brain on admission showed new enhancement of the posterior pons and mid brain with new swelling of the left cerebral peduncle since scan. There was resolution of the prior enhancement of the lower pons, left inferior and middle cerebellar peduncles, and the left internal capsule/thalamus. MRI C-spine was normal. was making some mouthing movements that were concerning for seizure. However, a routine EEG showed occasional bursts of theta slowing in a random distribution, suggesting a mild encephalopathy. . Over the first week of his hospital course, his opthalmoplegia worsened and he developed facial diplegia. He had increased tone in all extremities and had extensor posturing to minimal stimulation. He had a hyperactive gag and jaw jerk indicative of pseudobulbar palsy. He was treated with 5 day course of Solumedrol without improvement. He was then started on 5 day course of IVIG and was noted to be more alert and improved extraocular movements by day 3 of this treatment. Patient started on Ampicillin, Ceftriaxone, Vancomycin, Acyclovir upon admission for concern of bacterial meningitis/HSV encephalitis. Acyclovir was discontinued once HSV PCR negative. Though CSF bacterial cultures were negative, he continued on course of ceftriaxone/vancomycin/ampicillin for 13 days. Patient had repeat lumbar puncture for further work-up of brainstem findings. . Work-up of his condition included 2 lumbar punctures, muscle/nerve biopsy by neurosurgery and small bowel biopsy by GI for concern of Whipple's disease. Differential diagnosis of etiology included 1. infection (though Serum Toxoplama IgM and IgG Ab Neg, Serum Cryptococcal Ag Neg, Serum Mycoplasma Ab IgM neg, IgG pos (1.7), Serum EBV Ab panel Neg, Serum Lyme Neg, RPR non-reactive and CSF EBV PCR negative, CSF Enterovirus PCR negative, CSF cx negative, CSF HHV6 negative, CSF Lyme negative, CSF VZV negative; CSF TB-PCR and GQ1B IgG Ab PENDING), 2. inflammatory, eg demyelinating disease ( Neg, ANCA Neg, Anticardiolipin IgG 17 (nl 0-15), Anticardiolipin IgA 8.2 (nl 0-12.5), ACE 15, ESR 20, CRP 37.8, CSF-PEP No oligoclonal banding, CSF IgG index and synthesis rate normal, CSF Whipple's PCR negative; work-up for Behcet's including ophthamological exam for uveitis and skin test with subcutaneous injection of saline negative) and 3. neoplastic (cytology sent, CT torse negative for adenopathy, scrotal US negative for mass). . A repeat lumbar puncture on showed 3 wbc, 0 rbc, TP 26, glucose 81; gram stain was negative. Cytology sent was sent and showed atypical lymphocytes but flow studies will have to be repeated at later date becuase poor sample. A MRS was done on and showed improvement in the enhancement seen within the posterior pons and mid brain on examination from . No new areas of abnormal enhancement were identified and there was normal MR spectrographic analysis of the midbrain and pons. Tissue samples of small bowel was within normal limits. Tissue of left gastrocnemius showed mild myopathy, chronic and active and no inflammatory findings on sural nerve pathology. Review of old medical records from of () indicated that midbrain was biopsied during a similar presentation of illness with T2 bright lesions in midbrain and pons. This biopsy revealed only gliotic changes in grey and white matter. No evidence of tumor or inflammatory changes. There were rare "rod cells" and lymphocytes associated with disorganized fragment of leptomeninges suggestive of encephalitis. A metabolic work-up had not been initiated at and patient had very long chain fatty acids (within normal limits), MMA (80 with normal range 87-318) sent on this admission. Further metabolic work-up may be considered in future. . Final results of muscle/nerve biopsy are pending. . On discharge, his bulbar function has improved, as has his strength. He is now, however, showing signs of pseudobulbar affect (mainly inappropriate laughter). He continues to have difficulty with speech and swallowing, as well as sitting up without support. . 2. CV/Resp: Patient was initially admitted to ICU for concern of poor handling of secretions. He developed an oxygen requirement several times during his hospitalization, which usually improved with suctioning. He was stable on room air at the time of discharge. . 3. FEN/GI: Mr. was fed via NG tube until he was more alert. During a speech and swallow evaluation on , it was determined that patient should remain NPO. A PEG tube was inserted. His AST/ALT were elevated on . GI was consulted and it was thought that his transaminitis was most likely drug-induced due to ceftriaxone. Labs were sent for possible infectious causes: HCV ab neg, HBsAg neg, HBsAb pos, HBcAb neg; HCV and CMV viral loads pending. A liver ultrasound was normal. On , his AST/ALT began to trend downwards. Patient was also noted to have constipation and was kept on an aggressive bowel regimen. . 4. Heme: Patient noted to have an anemia of chronic disease. Hct decreased from 36 to 29 on . DIC labs, coags, stool guaics were normal. . 5. ID: See Neuro. Patient had low grade fevers for which he was cultured on . BCX and UCX were negative. He had an episode of hematuria on with the Foley inserted. Blood cultures were negative. Foley was removed. . 6. Rehab: Patient worked with PT for concern of spasticity. . 7. Rheum: Rheum service consulted for concern of vasculitis who suggested angiogram in future. . 8. Ophthalmology: An ophthamologic exam was done to look for signs of uveitis which may be consistent with Behcet's disease. Exam was negative for uveitis but was found to have an increased cup-to-disc ratio and increased intraocular pressure. Follow-up was recommended in 6 mos to evaluate for glaucoma, especially given treatment with steroids.	Then after the uneventful intravenous administration of 130 cc of nonionic contrast, imaging was obtained through the chest, abdomen, and pelvis. Normal MR spectrographic analysis of the midbrain and pons. TECHNIQUE: Axial imaging was obtained of the abdomen without intravenous contrast. TECHNIQUE: Sagittal pre- and post-gadolinium T1; axial and post-gadolinium T1, T2, FLAIR, GRE, DWI, DTI; and coronal post-gadolinium T1-weighted images of the head were obtained. With the exception of a nasogastric tube placement, there has not been a substantial change in the appearance of the chest. Bowel is of normal caliber. The bowel is of normal contour. FINAL REPORT STUDY: MR of the head with and without contrast, including MR spectroscopy. Spectral analysis of the mid brain and pons reveal no abnormalities in the choline, creatine, and NAA peaks. UpdateSee careview for details...Neuro: Pt remains lethargic, follows simple commands at times, MAE, opens eyes to verbal, making some sounds but unable to understand themCV: VSS, afebrileResp: lungs coarse to clear, prod cough, sats 96-98%, mild sleep apnea noted, O2 3lncGI: abd soft, no BM, NPOGU: incont urine, adult diaper onSkin: dry and intact, LP site clean with band aid intactPlan: neuro assess There are no increased lactate or lipid levels in the area of original abnormality. FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable. FINDINGS FOR CT OF THE CHEST WITH IV CONTRAST: There is no mediastinal, hilar, or axillary lymphadenopathy. INDICATION: Nasogastric tube placement. FINDINGS FOR CT OF THE PELVIS: There is no ascites, lymphadenopathy, or free intraperitoneal gas. Pt put on 2Liters NC and sats have remained 94-98%.CV: Pt ST with HR 100-108, BP 110s-130s.GI/GU: Pt NPO, abdomen is large but soft with positive BS. No new areas of abnormal enhancement identified. The visualized orbits and major flow voids are normal. INDICATION: Patient with recurrent cranial nerve dysfunction and previously identified midbrain and pontine lesions. No new areas of abnormal enhancement are identified. There is no sizeable pleural effusion. 6:58 AM MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # MR SPECTROSCOPY Reason: Patient has midnrain and pontine lesions on T2. (Over) 6:58 AM MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # MR SPECTROSCOPY Reason: Patient has midnrain and pontine lesions on T2. A nasogastric tube is seen in place coursing throughout the esophagus. LS improved slightly after suctioning. Nasogastric tube terminates within the stomach. There is no shift identified of normally midline structures or hydrocephalus. present but minimal on today's examination. Portable AP chest radiograph compared to . MR spectroscopy was performed of the mid brain and pons. Patient post-steroid treatment with no clinical improvement. The paranasal sinuses are otherwise clear. (Over) 3:06 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for granulomatous disease, mass lesions Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) A large retention cyst is seen within the right maxillary sinus. There is no pleural or pericardial effusion. There is bilateral perihilar haziness which might represent volume overload or pulmonary edema. Needs MRS perfusion scans. The and white matter differentiation is maintained with no areas of slowed diffusion. Left pupil at 5mm and sluggishly reactive. Review of bone windows demonstrates no suspicious lytic or blastic lesions. NG tube tip is within the stomach. The distal tip of the nasogastric tube is seen within the body of the stomach. There is no pneumothorax. ?position REASON FOR THIS EXAMINATION: NGT placement FINAL REPORT REASON FOR EXAMINATION: Recurrent oxygen requirement. Received 5 d Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) There is bibasilar atelectasis. Nursing admit notePt arrived from 5 with assessment as follows:NEURO: Pt lethargic. There is no ascites, lymphadenopathy, or free intraperitoneal gas. 3:06 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for granulomatous disease, mass lesions Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 21 year old man with recurrent brainstem lesions concerning for sarcoid vs. lymphoma REASON FOR THIS EXAMINATION: assess for granulomatous disease, mass lesions No contraindications for IV contrast FINAL REPORT CT TORSO WITH CONTRAST, COMPARISON: CT torso, . Pt follows commands and can MAE. There is no evidence of intracranial hemorrhage. No evidence of mass or lymphadenopathy within the chest, abdomen, or pelvis. Discussed with Dr. Bibasilar atelectasis. NGT shifted. IMPRESSION: 1. The tip of PICC line is not well demonstrated as overlying external monitoring leads limit assessment. LUE able to lift and hold, and other extremities with generalized weakness but an move on bed. Continue IV antibiotics as ordered.	6	[ { "category": "Radiology", "chartdate": "2199-01-25 00:00:00.000", "description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS", "row_id": 943761, "text": " 6:58 AM\n MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n MR SPECTROSCOPY\n Reason: Patient has midnrain and pontine lesions on T2. Received 5 d\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with recurrent cranial nerve dysfunction, ataxia and slurred\n speech, MRI abn\n REASON FOR THIS EXAMINATION:\n Patient has midnrain and pontine lesions on T2. Received 5 days steroids, no\n clinical improvement. Needs MRS perfusion scans. Discussed with Dr. \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MR of the head with and without contrast, including MR spectroscopy.\n\n INDICATION: Patient with recurrent cranial nerve dysfunction and previously\n identified midbrain and pontine lesions. Patient post-steroid treatment with\n no clinical improvement. Assess for progression of underlying lesions.\n\n COMPARISONS: MR from .\n\n TECHNIQUE: Sagittal pre- and post-gadolinium T1; axial and post-gadolinium\n T1, T2, FLAIR, GRE, DWI, DTI; and coronal post-gadolinium T1-weighted images\n of the head were obtained. MR spectroscopy was performed of the mid brain and\n pons.\n\n FINDINGS: The enhancement seen on the previous examination from within\n the pons and central mid brain is significantly improved, i.e. present but\n minimal on today's examination. No new areas of abnormal enhancement are\n identified.\n\n There is no evidence of intracranial hemorrhage. There is no shift identified\n of normally midline structures or hydrocephalus. The and white matter\n differentiation is maintained with no areas of slowed diffusion.\n\n Spectral analysis of the mid brain and pons reveal no abnormalities in the\n choline, creatine, and NAA peaks. There are no increased lactate or lipid\n levels in the area of original abnormality.\n\n The visualized orbits and major flow voids are normal. A large retention cyst\n is seen within the right maxillary sinus. The paranasal sinuses are otherwise\n clear.\n\n IMPRESSION: Significant improvement in the enhancement seen within the\n posterior pons and mid brain on examination from . No new areas of\n abnormal enhancement identified. Normal MR spectrographic analysis of the\n midbrain and pons.\n\n\n (Over)\n\n 6:58 AM\n MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n MR SPECTROSCOPY\n Reason: Patient has midnrain and pontine lesions on T2. Received 5 d\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2199-01-14 00:00:00.000", "description": "Report", "row_id": 1554269, "text": "Nursing admit note\nPt arrived from 5 with assessment as follows:\nNEURO: Pt lethargic. Pt follows commands and can MAE. LUE able to lift and hold, and other extremities with generalized weakness but an move on bed. Left pupil at 5mm and sluggishly reactive. Right pupil at 3mm and reactive to light. Pt intermittently attempts to verbalize although words are garbled.\nRESP: LS congested, pt suctioned for large amts of thick yellow secretions. LS improved slightly after suctioning. Pt put on 2Liters NC and sats have remained 94-98%.\nCV: Pt ST with HR 100-108, BP 110s-130s.\nGI/GU: Pt NPO, abdomen is large but soft with positive BS. Pt incontinent of urine in large amounts. Attends placed on pt.\nSOCIAL: Pt lives at in group home setting at baseline.\nID: Tmax 100.1, continue to monitor\nPLAN: Monitor neuro status closely. Pt to receive methylprednisone 1000mg X 5 days. Continue IV antibiotics as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2199-01-15 00:00:00.000", "description": "Report", "row_id": 1554270, "text": "Update\nSee careview for details...\n\nNeuro: Pt remains lethargic, follows simple commands at times, MAE, opens eyes to verbal, making some sounds but unable to understand them\n\nCV: VSS, afebrile\n\nResp: lungs coarse to clear, prod cough, sats 96-98%, mild sleep apnea noted, O2 3lnc\n\nGI: abd soft, no BM, NPO\n\nGU: incont urine, adult diaper on\n\nSkin: dry and intact, LP site clean with band aid intact\n\nPlan: neuro assess\n" }, { "category": "Radiology", "chartdate": "2199-01-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 943743, "text": " 10:04 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with mental status changes and recurrent oxygen\n requirement. NGT shifted. ?position\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Recurrent oxygen requirement.\n\n Portable AP chest radiograph compared to .\n\n NG tube tip is within the stomach. The heart size is enlarged with some\n dilation of the azygos vein. There is bilateral perihilar haziness which\n might represent volume overload or pulmonary edema. There is no sizeable\n pleural effusion. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-01-19 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 942999, "text": " 3:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with mental status changes\n\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: at 7:33.\n\n INDICATION: Nasogastric tube placement.\n\n Nasogastric tube terminates within the stomach. The tip of PICC line is not\n well demonstrated as overlying external monitoring leads limit assessment.\n With the exception of a nasogastric tube placement, there has not been a\n substantial change in the appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2199-01-17 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 942606, "text": " 3:06 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for granulomatous disease, mass lesions\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with recurrent brainstem lesions concerning for sarcoid vs.\n lymphoma\n REASON FOR THIS EXAMINATION:\n assess for granulomatous disease, mass lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH CONTRAST, \n\n COMPARISON: CT torso, .\n\n INDICATION: 21-year-old male with recurrent brainstem lesions concerning for\n sarcoid versus lymphoma, assess for granulomatous disease, mass lesions.\n\n TECHNIQUE: Axial imaging was obtained of the abdomen without intravenous\n contrast. Then after the uneventful intravenous administration of 130 cc of\n nonionic contrast, imaging was obtained through the chest, abdomen, and\n pelvis. Patient also received oral contrast.\n\n FINDINGS FOR CT OF THE CHEST WITH IV CONTRAST: There is no mediastinal,\n hilar, or axillary lymphadenopathy. There is no pleural or pericardial\n effusion. There is bibasilar atelectasis. A nasogastric tube is seen in\n place coursing throughout the esophagus.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The liver,\n gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable.\n The distal tip of the nasogastric tube is seen within the body of the stomach.\n There is no ascites, lymphadenopathy, or free intraperitoneal gas. The bowel\n is of normal contour.\n\n FINDINGS FOR CT OF THE PELVIS: There is no ascites, lymphadenopathy, or free\n intraperitoneal gas. There is a Foley with balloon inflated within the\n bladder. Bowel is of normal caliber. There is no evidence of mass.\n\n Review of bone windows demonstrates no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. No evidence of mass or lymphadenopathy within the chest, abdomen, or\n pelvis.\n 2. Bibasilar atelectasis.\n\n (Over)\n\n 3:06 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for granulomatous disease, mass lesions\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]
19,371	144,959	77 year old female yo female h/o severe COPD (on 2L NC at home), T3 lung cancer s/p R pneumonectomy 4 years ago, admitted with COPD flare, found to have new liver, lung, and T6 lesions concerning for metastases. 1) COPD exacerbation: The patient received high dose steroids, bronchodilators, and 5 days of azithromycin. Her respiratory status gradually improved, and she was transferred from the ICU to the general medical floor . There, she was continued on a steroids, which will gradually taper until she follows up with Dr. next week, who will decide whether to continue steroids. At time of discharge, she was close to her baseline respiratory status and was on her home O2 requirement (2 liters). 2) Liver/lung/spine masses: A Chest CT revealed new left pulmonary and right hepatic masses, along with a new T6 sclerotic lesion (see result section). These findings are concerning for metastases, most likely lung CA, although pt also has h/o breast CA and a known cystic lesion near the duodenum (noted on a prior admission). The patient underwent an ultrasound-guided liver biopsy on , the results of which are pending at time of discharge. The patient will follow-up with Dr. and her PCP . to discuss the results and potential treatment. 3) Type II diabetes poorly controlled with complications: The patient was continued on Lantus with a Humalog sliding scale while in-house. As her prednisone dose was tapered, her glucose control improved and she was discharged on her home Lantus regimen (8 units). 4) Thyroid function test abnormalities: The patient's TSH was noted to be depressed at 0.1, although her free T4 was normal at 0.94. These should be repeated as an outpatient in 6 weeks. 5) Hypertension: The patient was continued on diltiazem. 6) Disposition: The patient was discharged home with VNA and PT to follow-up with her PCP and CT surgeon.	Recieved atrovent neb Tx q 6 hrs w/improvement in wheezes. Tmax 99.3po.Pain: Denies.Activity: Steady on feet. NS lock.A/P: exacerbation of COPD vs spread of lung CApossible bronch after Sx abatepossible call out today D/C'ed it. UA, C&S sent for c/o urgency & frequency. Felt better w/4 L NP @ that time for a few minutes. R side more diminished than L. Audibly wheezy when atrovent Tx due. Pt may have re-occurance in L lung now. Sinus rhythm with PACsPossible right atrial abnormalityPoor R wave progression - possible inferior myocardial infarctionLeft axis deviationSince previous tracing of , no significant change Induced for sputum for cytology & pneumocystis. Will try albuterol neb if needed. Atrovent nebs Q 6 hrs Tachypnea noted when patient got up to commode. Resp Care NotePt admitted within past 24 hrs. Wears 2 L O2 continuously. Able to move all limbs s difficulty & equally.CV: HR:80's SR no ectopy, cuff BP: 120's-170's/60's-80'sResp: Upper lungs clear. New R post forearm #20 started . Got up to commode several times w/assist of 1 person to help w/lines. Induced sputum sent for cytology and PCP. C/o that albuterol neb Tx gives a jittery feeling & nausea. Uses home O2 @ 2-3L NP.GI: LBM @ home. RR 22-38 O2sat 95-100% on 3L NP. She has hx COPD and lung ca R lung which resulted in pneumonectomy some years ago. Soft mildly distended abdomen. NPN 1900-Neuro: A&OX3. 4 NURSING PROGRESS NOTE 0700-1500FOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN "NURSING TRANSFER NOTE " SECTION OF CAREVIEW. THANK YOU. + bowel sounds.GU: Voids clear yellow urine. Lower lung fields diminished. Patient normally independent. Maintained O2 sat >90% even without increase in delivered O2. Has significant other who visits patient in her home, but just left to go to .Access: L ant forearm #20 () painful even w/blood return. is alert and oriented. Supportive family: stayed w/patient over last 3 weeks to help her w/ADL's. Tachypnea w/activity.Coping: Pleasant woman who enjoys talking.	4	[ { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517939, "text": " 4 NURSING PROGRESS NOTE 0700-1500\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE \" SECTION OF CAREVIEW. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517937, "text": "Resp Care Note\n\nPt admitted within past 24 hrs. She has hx COPD and lung ca R lung which resulted in pneumonectomy some years ago. Pt may have re-occurance in L lung now. Induced sputum sent for cytology and PCP. is alert and oriented. Wears 2 L O2 continuously. Atrovent nebs Q 6 hrs\n" }, { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517938, "text": "NPN 1900-\nNeuro: A&OX3. Able to move all limbs s difficulty & equally.\n\nCV: HR:80's SR no ectopy, cuff BP: 120's-170's/60's-80's\n\nResp: Upper lungs clear. Lower lung fields diminished. R side more diminished than L. Audibly wheezy when atrovent Tx due. RR 22-38 O2sat 95-100% on 3L NP. Tachypnea noted when patient got up to commode. Felt better w/4 L NP @ that time for a few minutes. Maintained O2 sat >90% even without increase in delivered O2. Recieved atrovent neb Tx q 6 hrs w/improvement in wheezes. Induced for sputum for cytology & pneumocystis. Coughing up nothing to clear secretions. C/o that albuterol neb Tx gives a jittery feeling & nausea. Will try albuterol neb if needed. Uses home O2 @ 2-3L NP.\n\nGI: LBM @ home. Soft mildly distended abdomen. + bowel sounds.\n\nGU: Voids clear yellow urine. UA, C&S sent for c/o urgency & frequency. Tmax 99.3po.\n\nPain: Denies.\n\nActivity: Steady on feet. Got up to commode several times w/assist of 1 person to help w/lines. Tachypnea w/activity.\n\nCoping: Pleasant woman who enjoys talking. Supportive family: stayed w/patient over last 3 weeks to help her w/ADL's. Patient normally independent. Has significant other who visits patient in her home, but just left to go to .\n\nAccess: L ant forearm #20 () painful even w/blood return. D/C'ed it. New R post forearm #20 started . NS lock.\n\nA/P: exacerbation of COPD vs spread of lung CA\npossible bronch after Sx abate\npossible call out today\n\n\n" }, { "category": "ECG", "chartdate": "2196-05-17 00:00:00.000", "description": "Report", "row_id": 298918, "text": "Sinus rhythm with PACs\nPossible right atrial abnormality\nPoor R wave progression - possible inferior myocardial infarction\nLeft axis deviation\nSince previous tracing of , no significant change\n\n" } ]
60,579	135,143	76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement who presented for total right hip revision with significant intra-operative bleeding and DIC requiring ICU transfer. ICU COURSE: # Hypotension: Shock most likely due to hypovolemia/hemorrhage given visible, significant bleeding in the OR. Patient was complicated by DIC and profuse bleeding (EBL 3000cc+) requiring 12L lactated ringers, 1.4L normal saline, 4 units pRBC, two units FFP and 2100cc of cell . Phenylephrine was started, but was weaned off within a day of the operation with stable BPs. Also on the differential were sepsis and cardiogenic process, both less likely. The patient has recent history of hip joint infection but presumably adequately treated; likewise, he had hemoptysis and cough in for which he was evaluated by pulmonary and treated with Z-pack. CXR currently possibly concerning for developing retrocardiac/right middle lobe infiltrate but not overwhelming. He was instrumented, though, today with new leukocytosis. Given empiric vancmycin, cefepime and ciprofloxacin, however changed to ciprofloxacin and cefazolin POD #2. Blood, urine and tissue cultures without growth. For cardiogenic processes, the patient has no known cardiac disease and good functional capacity previously. EKG also unchanged from prior. Coagulopathy management as below. Once stabilized, without further evidence of bleeding, patient was transferred to orthopedic surgery.	Status post right total hip long stem revision arthroplasty with constrained liner. INDICATION: Postoperative evaluation, status post revision right total hip arthroplasty. IMPRESSION: Expected postoperative change from right total hip long stem revision arthroplasty with constrained liner. Subcutaneous edema. Significantly since , gaseous distention of the stomach has resolved. Recently intubated. Low lung volumes with bilateral areas of atelectasis and borderline size of the cardiac silhouette. The endotracheal tube is in unchanged position. FINDINGS: As compared to the previous radiograph, the patient has undergone surgery. FINDINGS: Lateral skin staples. Getting significant amounts of fluid resuscitation, intubated. Sinus tachycardia. The patient is now intubated, the tip of the endotracheal tube projects 4.5 cm above the carina. FINDINGS: As compared to the previous radiograph, the image is unchanged. The lung volumes are low, there are bilateral areas of basal atelectasis. Degenerative changes of the knee. Borderline size of the cardiac silhouette without evidence of pulmonary edema. REASON FOR THIS EXAMINATION: s/p R THR revision FINAL REPORT HISTORY: THR revision. Surgical drain is present. Severe intraoperative bleeding. IMPRESSION: AP chest compared to and 5: Opacification at both lung bases is probably a combination of persistent atelectasis, moderate on the right and moderate to severe on the left. 7:45 PM FEMUR (AP & LAT) RIGHT Clip # Reason: post op eval patient in . Compared to the previous tracing of the rate hasincreased. FINDINGS: In comparison with the study of , there is little overall change in the appearance of the long stem total hip replacement that appears to be well seated and without evidence of hardware-related complication. REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT AP CHEST, 6:04 A.M., HISTORY: Osteoarthritis. 9:44 PM CHEST (PORTABLE AP) Clip # Reason: acute cardiopulm processes Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with right hip revision today s/p significant blood loss in OR REASON FOR THIS EXAMINATION: acute cardiopulm processes FINAL REPORT CHEST RADIOGRAPH INDICATION: Hip revision, significant blood loss, rule out cardiopulmonary process. No newly appeared focal parenchymal opacities. 5:43 AM CHEST (PORTABLE AP) Clip # Reason: acute cardiopulm processes - patient remains intubated Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with osteoarthritis s/p total hip replacement complicated by salmonells joint infection now s/p total hip revision with significant intraoperative bleeding REASON FOR THIS EXAMINATION: acute cardiopulm processes - patient remains intubated FINAL REPORT CHEST RADIOGRAPH INDICATION: Osteoarthritis, status post total hip replacement, joint infection, rule out cardiopulmonary process. There also is minimal blunting of the left costophrenic sinus, so that the presence of a small left pleural effusion cannot be excluded. There is also at least a small and a moderate volume of left pleural fluid. PLEASE CAPTURE FROM KNEE TO Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man s/p revision R THA REASON FOR THIS EXAMINATION: post op eval patient in . PLEASE CAPTURE FROM KNEE TO PELVIS (extra long revision prosthesis) FINAL REPORT STUDY: Two views of the right femur . No pulmonary edema. 5:07 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement who presented for total right hip revision with significant intra-operative bleeding. COMPARISON: . COMPARISON: . COMPARISON: . 10:02 AM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: s/p R THR revision Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with Revision Right Hip Replacement.	6	[ { "category": "Radiology", "chartdate": "2188-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222408, "text": " 9:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulm processes\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right hip revision today s/p significant blood loss in OR\n REASON FOR THIS EXAMINATION:\n acute cardiopulm processes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hip revision, significant blood loss, rule out cardiopulmonary\n process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n surgery. The patient is now intubated, the tip of the endotracheal tube\n projects 4.5 cm above the carina.\n\n The lung volumes are low, there are bilateral areas of basal atelectasis.\n There also is minimal blunting of the left costophrenic sinus, so that the\n presence of a small left pleural effusion cannot be excluded. Borderline size\n of the cardiac silhouette without evidence of pulmonary edema. No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222449, "text": " 5:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulm processes - patient remains intubated\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with osteoarthritis s/p total hip replacement complicated by\n salmonells joint infection now s/p total hip revision with significant\n intraoperative bleeding\n REASON FOR THIS EXAMINATION:\n acute cardiopulm processes - patient remains intubated\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Osteoarthritis, status post total hip replacement, joint\n infection, rule out cardiopulmonary process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the image is unchanged.\n The endotracheal tube is in unchanged position. Low lung volumes with\n bilateral areas of atelectasis and borderline size of the cardiac silhouette.\n No newly appeared focal parenchymal opacities. No pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222591, "text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old male with past medical history of osteoarthritis s/p right total\n hip arthroplasty in complicated by Salmonella septic joint requiring\n multiple wash outs and antibiotic spacer placement who presented for\n total right hip revision with significant intra-operative bleeding. Getting\n significant amounts of fluid resuscitation, intubated.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:04 A.M., \n\n HISTORY: Osteoarthritis. Recently intubated. Severe intraoperative\n bleeding.\n\n IMPRESSION: AP chest compared to and 5:\n\n Opacification at both lung bases is probably a combination of persistent\n atelectasis, moderate on the right and moderate to severe on the left. There\n is also at least a small and a moderate volume of left pleural fluid.\n Significantly since , gaseous distention of the stomach has resolved.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-12-01 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1223015, "text": " 10:02 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: s/p R THR revision\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with Revision Right Hip Replacement.\n REASON FOR THIS EXAMINATION:\n s/p R THR revision\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: THR revision.\n\n FINDINGS: In comparison with the study of , there is little overall change\n in the appearance of the long stem total hip replacement that appears to be\n well seated and without evidence of hardware-related complication.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-26 00:00:00.000", "description": "R FEMUR (AP & LAT) RIGHT", "row_id": 1222399, "text": " 7:45 PM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: post op eval patient in . PLEASE CAPTURE FROM KNEE TO\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p revision R THA\n REASON FOR THIS EXAMINATION:\n post op eval patient in . PLEASE CAPTURE FROM KNEE TO PELVIS (extra long\n revision prosthesis)\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Two views of the right femur .\n\n COMPARISON: .\n\n INDICATION: Postoperative evaluation, status post revision right total hip\n arthroplasty.\n\n FINDINGS: Lateral skin staples. Surgical drain is present. Subcutaneous\n edema. Status post right total hip long stem revision arthroplasty with\n constrained liner. The hardware appears intact. No evidence for\n peri-hardware lucency. No fracture or dislocation. Degenerative changes of\n the knee.\n\n IMPRESSION: Expected postoperative change from right total hip long stem\n revision arthroplasty with constrained liner.\n\n\n" }, { "category": "ECG", "chartdate": "2188-11-26 00:00:00.000", "description": "Report", "row_id": 128983, "text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n" } ]
88,523	184,337	83-year-old female with hx of CAD s/p 5v CABG, COPD, ESRD on HD, chronic diastolic CHF (EF 45-50%), DM, and PVD presenting with dyspnea, productive cough and chills and found to have left mid/lower PNA. Hospital course complicated by hyperglycemia, CHF exacerbation, and elevated troponins suggestive of ?NSTEMI vs. demand ischemia. . #. Hypoxic Respiratory Distress: Respiratory distress likely multifactorial in nature, most influenced by PNA and acute on chronic CHF exacerbation. Patient also has history of COPD which was probably a less important factor in current status. CXR showed left mid/lower consolidation as well as rapidly evolving right sided consolidation. She was treated for Hospital Acquired Pneumonia given recent hospital admission and dialysis sessions with vancomycin and cefepime (day 1 = ); coverage was later broadened to include levofloxacin (day 1 = ). PICC was placed on for continued antibiotics at LTAC; plan was to complete a ten day course. She should get a CXR in weeks after completion of treatment to confirm resolution of her PNA. Pulmonary edema from acute on chronic CHF was also likely contributing to her respiratory distress. She was given 80mg iv lasix on the floor and 120mg IV lasix at ICU on day of admission. She had subsequent removal of fluid via HD on three consecutive days. In terms of her oxygen requirements, she had been on NC on the floor and then transitioned to NRB when she desated to the 70s at which point she was transferred to the ICU. At the ICU, she was kept for the majority of time on high flow face mask. She briefly required BiPAP and NRB at one point but was stable by the time of discharge to the floor. She was sating consistently in the 90s. She continued to breath well on room air on re-admission to the floor and was discharged to rehab saturating >93% on Room Air, having completed total antibiotic therapy for ten days. - Repeat CXR 4-6 weeks after discharge recommended to assess resolution of pna . #. Elevated troponins: Pt with ST depressions on V4-6 on EKG. Troponin at admission was at baseline of 0.04 but uptrended, peaking at 6. She was started on a heparin and nitroglycerin gtt. Cardiology consult was obtained. TTE showed preserved EF and without focal wall motion abnormalities. Per cardiology, elevated troponin was likely due to demand ischemia secondary to pneumonia and volume overload as well as metabolic derangements (hyperglycemia). Troponin subsequently downtrended to 5.8. She was continued on her aspirin, plavix, beta blocker, acei, and statin throughout hospital admission. . # Atrial Fibrillation: While in the MICU, she had an episode of tachycardia which was atrial fibrillation on EKG. After a one time dose of intravenous metoprolol she quickly reverted back into sinus. Her metoprolol was uptitrated to 50mg three times a day and she was in sinus rhythm with good rate control for the remainder of her stay. After discussion with Cardiology consult that a single episode of atrial fibrillation in the setting of hypoxic respiratory distress, CHF exacerbation, demand ischemia and pneumonia not indication for chronic anticoagulation as she was perisistently in sinus for duration of her hospital stay. If she has further episodes of tachycardia or is noted to be in atrial fibrillation, she should discuss with her PCP or cardiologist future anticoagulation. - Metoprolol 50mg TID . #. Hyperglycemia: Pt presented with critically high blood glucose levels while on the floor. Urinalysis showed glucose and trace ketones. Anion gap was elevated to 15. Hyperglycemia was believed to be secondary to infection (PNA) or steroids she had received in the ED for COPD. She was given IV fluid boluses while on the floor. She was given insulin boluses and BS was in 400s upon arrival to ICU. It downtrended to 100s with insulin sliding scale during her stay here. . #. ESRD: Patient had history of ESRD and was on HD three times a week. Cr 4.6 on admission. She received three consecutive days of dialysis to remove fluid as volume overload was contributing to her respiratory distress. She was continued on her sevelamer throughout hospital stay. . #. Acute on chronic diastolic CHF: TTE performed showed preserved EF of > 55% and grossly no focal abnormalities. BNP was elevated to 13K on admission and CXR was consistent with pulmonary edema. She was given 80mg lasix iv on the floor and 120mg lasix x 1 on admission to the ICU. She was continued on her cardiac medications, including metoprolol, acei, and nifedipine. Her metoprolol was titrated up to 50 mg tid, her nifedipine was titrated down to 30mg daily, and her lisinopril was increased to 40mg daily and her isosorbide was discontinued per recommendations of cardiology and renal. She was instructed to follow up with her PCP and cardiologist regarding these changes. - Nifedipine, metoprolol and lisinopril dose changes. - Isosorbide discontinued.	There is an anterior space which most likely represents a prominentfat pad.IMPRESSION: Mild-moderate mitral regurgitation. There is mild regional left ventricular systolicdysfunction with hypokinesis of the basal inferior wall. The estimated pulmonary artery systolic pressure isnormal. Trace aorticregurgitation is seen. ST-T wave abnormalities withprolonged QTc interval are non-specific but clinical correlation is suggested.Since the previous tracing of atrial fibrillation has been replaced bysinus rhythm, ventricular ectopy is seen, precordial lead QRS voltage is lessprominent, ST-T wave changes are less prominent and the QTc interval may belonger. Mild regional LVsystolic dysfunction. Since the previoustracing of atrial fibrillation has replaced sinus rhythm and furtherST-T wave changes are seen.TRACING #1 Normal PAsystolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. Left ventricular function. Considermyocardial ischemia. Sinus rhythm with ventricular premature beat. Non-specific inferior and lateral ST-T wave changes. Consider leftventricular hypertrophy. Sinus tachycardia. Very mild regional systolicdysfunction c/w CAD.Compared with the prior study (images reviewed) of , regional andglobal left ventricular systolic function is improved and the estimatedpulmonary artery systolic pressure is now lower.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Mild to moderate (+) mitralregurgitation is seen. Myocardial infarction. Inferolateral lead ST-T wave abnormalities suggestmyocardial ischemia. Since the previoustracing of same date sinus tachycardia and further ST-T wave changes are bothnow present. ST-T wave abnormalities. Mild [1+] TR. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg).Right ventricularchamber size and free wall motion are normal. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.MITRAL VALVE: Normal mitral valve leaflets. Sinus rhythm. Sinus rhythm. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3)are mildly thickened but aortic stenosis is not present. Right ventricular function.Height: (in) 62Weight (lb): 160BSA (m2): 1.74 m2BP (mm Hg): 125/44HR (bpm): 71Status: InpatientDate/Time: at 16:10Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness and cavity size. No resting LVOTgradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Clinical correlation is suggested. Clinical correlation is suggested. Since the previous tracing of the rate is slower. Probable atrial fibrillation with rapid ventricular response. Diffuse ST-T wave abnormalities may be due tomyocardial ischemia. Coronary artery disease. Compared to the previous tracing of the lateralST-T wave changes are similar to previous tracing. Congestive heart failure. Left ventricular wall thicknesses andcavity size are normal. Q-T interval is longer. No AS. PATIENT/TEST INFORMATION:Indication: Chronic lung disease. The mitral valve leaflets are structurally normal.There is no mitral valve prolapse. Clinical decisions regarding the needfor prophylaxis should be based on clinical and echocardiographic data. No MVP. TDI E/e' >15, suggesting PCWP>18mmHg.	6	[ { "category": "Echo", "chartdate": "2200-11-17 00:00:00.000", "description": "Report", "row_id": 102373, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Congestive heart failure. Coronary artery disease. Myocardial infarction. Left ventricular function. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 125/44\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 16:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferior wall. The remaining\nsegments contract normally (LVEF >55 %). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg).Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is an anterior space which most likely represents a prominent\nfat pad.\n\nIMPRESSION: Mild-moderate mitral regurgitation. Very mild regional systolic\ndysfunction c/w CAD.\nCompared with the prior study (images reviewed) of , regional and\nglobal left ventricular systolic function is improved and the estimated\npulmonary artery systolic pressure is now lower.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2200-11-19 00:00:00.000", "description": "Report", "row_id": 294804, "text": "Probable atrial fibrillation with rapid ventricular response. Consider left\nventricular hypertrophy. Diffuse ST-T wave abnormalities may be due to\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of atrial fibrillation has replaced sinus rhythm and further\nST-T wave changes are seen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2200-11-17 00:00:00.000", "description": "Report", "row_id": 294805, "text": "Sinus rhythm. ST-T wave abnormalities. Since the previous tracing of \nthe rate is slower. Q-T interval is longer.\n\n" }, { "category": "ECG", "chartdate": "2200-11-16 00:00:00.000", "description": "Report", "row_id": 294806, "text": "Sinus tachycardia. Inferolateral lead ST-T wave abnormalities suggest\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of same date sinus tachycardia and further ST-T wave changes are both\nnow present.\n\n" }, { "category": "ECG", "chartdate": "2200-11-16 00:00:00.000", "description": "Report", "row_id": 294807, "text": "Sinus rhythm. Non-specific inferior and lateral ST-T wave changes. Consider\nmyocardial ischemia. Compared to the previous tracing of the lateral\nST-T wave changes are similar to previous tracing.\n\n" }, { "category": "ECG", "chartdate": "2200-11-20 00:00:00.000", "description": "Report", "row_id": 294803, "text": "Sinus rhythm with ventricular premature beat. ST-T wave abnormalities with\nprolonged QTc interval are non-specific but clinical correlation is suggested.\nSince the previous tracing of atrial fibrillation has been replaced by\nsinus rhythm, ventricular ectopy is seen, precordial lead QRS voltage is less\nprominent, ST-T wave changes are less prominent and the QTc interval may be\nlonger.\n\n" } ]
6,176	151,348	Pt was admitted and taken to the OR on for a left upper lobectomy via left thoracotomy complicated by an avulsion of the PA branch which was repaired. Trach was also changed intraoperatively. An epidural was placed for pain control. Pt was admitted to the ICU post-operatively d/t hypotension requiring neo gtt and IVF boluses. Cardiac enzymes were neg. Two left pleural chest tubes were to sxn and draining mod amt serosang fluid. POD#1 extubated and trach mask. hemodynamically stable off neo. chest tubes cont'd to sxn w/ persistant air leak. POD# 3 failed bedisde swallow exam -kept NPO. Persistant air leak. Epidural removed on PCA POD#4 chest tubes to water seal. POD#5 Chest tubes clamped. POD#6 purulent sputum on po levo. Breathing comfortably but did not clamping trial- back to water seal w/ perisistant air leak. POD# 7, 8 kept on water seal. progressing w/ post recovery. ambulating. reg diet and po pain med. one chest tube d/c'd. remaining chest tube w/ residual air leak. POD# persistant air leak on water seal. progressing w/post recovery. POD#12 chest tube clamping trial- tolerated trial and chset tube removed. post pull CXR unremarkable. POD#13 d/c'd to home .	IMPRESSION: New left effusion with air fluid level consistent with pneumothorax. Small apical pneumothorax on the left is again noted with unchanged amount of left subcutaneous emphysema. Stable left apical pneumothorax. 2nd to ..soc; family into visit and updated with pts current conditiona/p improved hemodynamics, off epidural. plan to wean ventilator when temperature increased.gi/gu: abd soft, obese. There is stable moderate left subcutaneous emphysema. pt turned and encouraged to cdb and chest pt done. For evaluation of the smali serial changes, a PA upright chest x-ray is recommended. Slight herniation of the right lung to the left. remains intubated via trach, see carevue for ventilator settings, abg wnl. The two left chest tubes are in place. 3p-7p:neuro: sedated on propofol gtt, light, opened eyes to stimuli. A tracheostomy tube is seen in a standard position. Elevation of left hemidiaphragm and atelectases in the left lower zone, unchanged. REASON FOR THIS EXAMINATION: evaluate lung field s/p h2o seal FINAL REPORT INDICATION: Left upper lobe lobectomy with low-grade fever. CHEST Comparison is made to the prior chest x-ray of . Moderate left lower lobe atelectasis. npn 0700-1900;events hypotension given fluid bolues with transient improvement. 11:30 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval any change in swallowing ability form exam Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA FINAL REPORT INDICATION: Status post supraglottic laryngectomy and chemotherapy and radiation therapy. done.skin; drsg to chest tubes due to around site, thoracotomy drsg and noted with marker.plan: transfer to floor for cont. Portable AP chest x-ray was compared to the previous film from . lytes wnlid: afebrile, post antib. REASON FOR THIS EXAMINATION: eval ptx FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after left thoracotomy and left upper lobe lobectomy with low grade fever. npnvery pleasan woman admitted for lul thoracotomy r/t HX of to lung CA. There is a persistent small left apical pneumothorax. lopressor 5mg iv q 6 hours.resp: lungs clear. REASON FOR THIS EXAMINATION: evaluate lung field s/p chest tube removal r/o effusion /ptx FINAL REPORT CHEST TWO VIEWS, PA AND LATERAL. A small left apical pneumothorax is again demonstrated. INDICATION: Status post left upper lobectomy. FINDINGS: There has been interval removal of the left chest tube. CHEST: Left upper lobectomy has been performed. IMPRESSION: PA and lateral chest compared to and 12: Tiny left apical pneumothorax and minimal layering pleural effusion unchanged. Stable small left apical pneumothorax. A small apical pneumothorax on the left is again noted with unchanged. There is a persistent tiny left apical pneumothorax. IMPRESSION: Tiny left apical pneumothorax. IMPRESSION: Tiny left pneumothorax. IMPRESSION: Persistent tiny left apical pneumothorax. There is a tiny left apical pneumothorax. There is a small left apical pneumothorax. There is a small left apical and lateral pneumothorax which is similar in appearance to the film prior to chest tube removal earlier the same day. Herniation of the right lung to left, unchanged. FINDINGS: Compared with , the right upper lobe collapse has now resolved and the right lung appears well aerated. Tracheostomy tube in standard placement. Heart mildly enlarged and shifted to the left reflecting lung resection. Subcutaneous emphysema is again demonstrated in the left chest wall. Subcutaneous emphysema is noted. There is elevation of the left hemidiaphragm and atelectasis in the left mid and lower zones. AP ERECT CHEST: Leftward shift of mediastinal structures has decreased as well as moderate consolidation reflecting improving left lower lobe atelectasis. Chest tube is present in left upper hemithorax. The two left chest tubes appear unchanged, with a slight increase in the amount of soft tissue emphysema along the lateral left chest wall. The chest tubes are present in the left upper hemithorax. A small amount of left chest wall subcutaneous emphysema remains unchanged. A right upper mediastinal density is seen which is thought to represent a collapsed right upper lobe with elevation of the minor fissure. IMPRESSION: Mild pharyngeal dysphagia. ptx or recurrent collection Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA MEDICAL CONDITION: 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p chest tube d/c. Subcutaneous emphysema is present in the left chest wall and ill-defined opacities consistent with atelectasis in the left lower zone with slight elevation of the left hemidiaphragm. effusion FINAL REPORT TWO-VIEW CHEST X-RAY OF COMPARISON: . There is elevation of the left hemidiaphragm and atelectases in the left lower zone. There is right apical slightly nodular pleural thickening that is unchanged. Subcutaneous emphysema is present in the left chest wall. Subcutaneous emphysema is present in the left chest wall and left neck. IMPRESSION: Interval resolution of right upper lobe collapse. Swallow initiation, velar elevation, laryngeal valve closure and pharyngeal transit time were within normal limits.	24	[ { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343772, "text": "Resp Care\nPt was taken off the vent and currently on 50% trach collar, with good abgs, sats >97. Suctioned for mod. amount of thick blood tinged, pt is able to cough fairly well on her own through the trach.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343773, "text": "npn 0700-1900;\n\nevents hypotension given fluid bolues with transient improvement. epidurual off since 330 pm with bp 110-120.70. awaiting pain service for new orders .denied pain until 530 pm when c/o of severe pain in lt side more towarrds back. given 2 mgs morphine with min effect.\n\nneuro; aoox3 mae to command oob tochair with min assist. perla 3mm asking appropriate questions. lethargic at times voice quiet and difficult to understand occassionallly.\n\nresp; lungs coarse rhonchi upper diminished at bases. strong productive cough of thick yellow secretions pt removes plug from trach. and coughs with good strength. sometimes sound stridorous but settles without treatment. sats 93-97% on 4ln/c rr14-22.\n\ncvs; tmax 99.4 po nsr 65-90 iso pac.bp 64/19-120/70 with maps 52-70.given 750 mls ns in 250 ml increments with transient effect. bp improved with d.c epidural at 330 pm remained pain free until 530 pm given mso4 2mgs i.v repeated at 620 pm with some improvent in pain awaiting new mix of dilaudid for epidural.\n\ngu; poor urine output responding to fluid bolus remianed 15 mls/hr for last 3hours team aware and will treat if u/o remains below 20 mls/hr for next hour.following lytes.\n\ngi; hypoactive bs taking mod amounts fluids some vanilla pudding c/o of nausea with low bp improved when bp increased. bs wnl. toadvance diet to house.pt states takes normal food able to swallow. normally. burping no stool no flatus.\n\nct x2 lt pleural, both with h persistent airleak team aware. draining mod amounts serosanguinious drainage.dsd unchanged no further staining noted.\n\n fem aline and 3llremoved this am. pt with ecg and cardiac enzymes sent.troponins nml ck high ? 2nd to ..\n\nsoc; family into visit and updated with pts current condition\n\na/p improved hemodynamics, off epidural. low urine output, responds to fluid boluses.\n continue to obtain better pain control.continue with pulmnary toilet encourage use of is .offer emotional support to pt and family.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343774, "text": "C/O of surgical site pain, epidural off at start of shift waiting for new bag and changing solution to meperidine, notified Dr. , 2 mg MSO4 ordered and given with some effect, meperidine epidural started with good effect\n\nPlan: repeat labs, keep MAP >60 and UO > 15cc/hr per Dr. \n" }, { "category": "Nursing/other", "chartdate": "2121-05-28 00:00:00.000", "description": "Report", "row_id": 1343775, "text": "npn\nvery pleasan woman admitted for lul thoracotomy r/t HX of to lung CA. Has receive chemo and raditation in past,\n\nneuro: aox3, voice is very soft but easily makes needs known, follows commands, somewhat frustrated with stay but overall very pleasant, has been dozing off and on thru night. arousable\n\npain: see previous nursing note, at 12mn pt stating she was more comofrtable at a 3 raange,increase discomfort with activity but pt willing to help. demerol epidural remains at 6ml /hr with no additional boluses given. pain level seems acceptable at present time. pt resting comfortably\n\ncad hr 70-80's sr no ectopy noted, nbp 133/67 to 91/50 when sleeping.no issues\n\nresp rr teens remains on 4l nc, sats 97 to 100%, ls rhonchi RUl all other lobes dimished, chest tube 1 20 to 15cc/hr of ss output total of 140 since mn, ct 2 no output since mn. pt turned and encouraged to cdb and chest pt done. pt is able to handle her own secretions thru her trach.\n\ngi: obese , bs+ no bm this shift, pt had two small bites of jello and on second bite was choking, no difficulty with swallowing water noted,\n\ngu: uo 20 to 40 cc/hr, remainson d51/2 ns at 50cc/hr, creat 1.3 up from baseline of .8 on admission. overall negative 500cc since admission. lytes wnl\n\nid: afebrile, post antib. done.\n\nskin; drsg to chest tubes due to around site, thoracotomy drsg and noted with marker.\n\nplan: transfer to floor for cont. of care, continue to monitor uo, and pain issues, encourage cdb and use of IS\n" }, { "category": "Nursing/other", "chartdate": "2121-05-26 00:00:00.000", "description": "Report", "row_id": 1343770, "text": "3p-7p:\nneuro: sedated on propofol gtt, light, opened eyes to stimuli. temperature 94.5, bair hugger on. dilaudid and bupivicaine epidural at T3-T4 at 6 cc/hr. APS 20 concentration, to change to APS 10 concentration.\n\ncv: sb 50-sr 60, no ectopy. neo gtt on/off intermittently to maintain sbp >90. easily palpable pedal pulses bilaterally. lopressor 5mg iv q 6 hours.\n\nresp: lungs clear. remains intubated via trach, see carevue for ventilator settings, abg wnl. ct to 20 cm sxn, small airleak. team aware. moderate sanguinous drainage. plan to wean ventilator when temperature increased.\n\ngi/gu: abd soft, obese. bs hypoactive. foley to gravity, autodiuresing. cr wnl.\n\nendo: fs wnl.\n\nplan: monitor hemodynamics, pulmonary status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343771, "text": "Neuro: weaned propofol to off, pt awoke angry amd upset because this writer was not able to read her lips as she attempted to speak, once extubated pt was able to write down her questions and needs, she is currently calm and cooperative with care, MAE's well\n\nCardiac: NSR, rare PVC, replaced calcium and magnesium as orderd with good results, neo weaned to off, goal to keep SBP > 90\n\nResp: see flow sheet for details, currently on FM at 50%, SPO2 >92%, CT's have an air , MD aware, minimal amount of bloody sputum pre extubation, zero sputum post extubation, pt has good cough and good lung volumes, pt has own trach and would like to know when she can have it put back in so she can talk again\n\nGI: sluggish BS, no flatus no BM, NPO\n\nGU: foley to gravity drainig clear yellow urine, quantity sufficient\n\nSocial: dtr called and updated, pt aware\n\nPlan: increase diet and activity as tolerated, follow labs and vitals and treat as orderd and as indicated\n" }, { "category": "Radiology", "chartdate": "2121-06-06 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 911652, "text": " 11:30 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval any change in swallowing ability form exam\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post supraglottic laryngectomy and chemotherapy and\n radiation therapy.\n\n VIDEO OROPHARYNGEAL FLUOROSCOPIC SWALLOWING EVALUATION:\n\n There has been no significant change in swallow since prior study. Trace\n aspiration is again noted of nearly all consistencies. Status post\n supraglottic laryngectomy and resection of epiglottis. For additional\n details, please refer to the swallow evaluation note in CareWeb from .\n\n" }, { "category": "Radiology", "chartdate": "2121-06-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911086, "text": " 1:16 PM\n CHEST (PA & LAT) Clip # \n Reason: chest tube clamped- plaese eval for PTX. OBTAIN CXR AT 1pm.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy\n\n REASON FOR THIS EXAMINATION:\n chest tube clamped- plaese eval for PTX. OBTAIN CXR AT 1pm.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left upper lobe lung cancer, status post left upper\n lobectomy.\n\n CHEST\n\n Comparison is made to the prior chest x-ray of . Pleural fluid is\n now present with an air fluid level which was not present on the prior chest\n x-ray. This indicates the presence of a pneumothorax. It does appear\n slightly smaller than on the prior chest x-ray.\n\n The right lung remains clear.\n\n IMPRESSION: New left effusion with air fluid level consistent with\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910936, "text": " 8:33 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: evaluate lung field s/p chest tube removal r/o effusion\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p chest tube removal r/o effusion /ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL.\n\n History of left upper lobectomy and fever.\n\n Chest tube is present in left upper hemithorax. There is a persistent small\n left apical pneumothorax. The second chest tube present on the prior study\n has been removed. There is subcutaneous emphysema in the left chest wall and\n neck. Elevation of left hemidiaphragm and atelectases in the left lower zone,\n unchanged. Slight herniation of the right lung to the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910753, "text": " 9:28 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate lung field s/p h2o seal\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p h2o seal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left upper lobe lobectomy with low-grade fever.\n\n COMPARISONS: Comparison is made to prior study of earlier the same day at\n 0553 hours.\n\n Small apical pneumothorax on the left is unchanged.\n\n A tracheostomy tube is seen in a standard position. Two left apical chest\n tubes remain unchanged in position. There is stable moderate left\n subcutaneous emphysema. Left retrocardiac opacification is unchanged. There\n is otherwise no significant change in the appearance of the chest from\n approximately 5 hours prior.\n\n IMPRESSION:\n 1. Stable left apical pneumothorax.\n 2. Moderate left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910595, "text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for atelectasis and pneumo hemo thorax\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n\n REASON FOR THIS EXAMINATION:\n Eval for atelectasis and pneumo hemo thorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for atelectasis and pneumothorax.\n\n Portable AP chest x-ray was compared to the previous film from .\n\n There is left lower lobe consolidation with prominent mediastinal shift to the\n left representing left lower lobe atelectasis which is new. The two left\n chest tubes are in place. Small apical pneumothorax on the left is again\n noted with unchanged amount of left subcutaneous emphysema.\n\n The right lung is clear. These findings were discussed with Dr. during\n reporting of this exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911629, "text": " 9:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after left thoracotomy and left\n upper lobe lobectomy with low grade fever.\n\n Portable AP chest radiograph compared to the previous film from done in\n upright position.\n\n FINDINGS: There is no sizable hydropneumothorax on the current chest x-ray\n which might be explained by difference in x-ray technique. The left-sided\n chest tube remain in place. The right lung remains clear. For evaluation of\n the smali serial changes, a PA upright chest x-ray is recommended. The\n mediastinal shift to the left is stable.\n\n" }, { "category": "Radiology", "chartdate": "2121-06-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911224, "text": " 10:35 AM\n CHEST (PA & LAT) Clip # \n Reason: ? effusion\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy\n\n REASON FOR THIS EXAMINATION:\n ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST X-RAY OF \n\n COMPARISON: .\n\n INDICATION: Status post left upper lobectomy. Evaluate effusion.\n\n A left-sided chest tube remains in place. A small left apical pneumothorax is\n again demonstrated. The previously reported loculated hydropneumothorax is no\n longer evident, but there remains a component of pneumothorax anteriorly on\n the lateral view in the retrosternal region in addition to the apical\n component. Subcutaneous emphysema is again demonstrated in the left chest\n wall. With the exception of resolution of the air-fluid level related to the\n loculated hydropneumothorax, there has not been a significant change from the\n recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910892, "text": " 10:52 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate lung field for effusion progression\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field for effusion progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of left upper lobectomy and fever.\n\n The chest tubes are present in the left upper hemithorax. There is a small\n left apical pneumothorax. There is elevation of the left hemidiaphragm and\n atelectasis in the left mid and lower zones. Subcutaneous emphysema is\n present in the left chest wall and left neck. The right lung remains clear.\n\n IMPRESSION: Tiny left pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910344, "text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Recent left upper lobectomy. Assess for pneumothorax/lung\n collapse.\n\n FINDINGS: Compared with , the right upper lobe collapse has now\n resolved and the right lung appears well aerated. The two left chest tubes\n appear unchanged, with a slight increase in the amount of soft tissue\n emphysema along the lateral left chest wall. No sizable left pneumothorax is\n identified. The residual left lung appears grossly clear. The position of\n the new tracheostomy tube appears unremarkable.\n\n IMPRESSION: Interval resolution of right upper lobe collapse.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910278, "text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PTX and chest tube placement\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n REASON FOR THIS EXAMINATION:\n Eval for PTX and chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left upper lobectomy.\n\n CHEST: Left upper lobectomy has been performed. Two chest tubes are present\n on the left side. No pneumothorax is seen. Subcutaneous emphysema is noted.\n\n Tracheostomy tube is present. A right upper mediastinal density is seen which\n is thought to represent a collapsed right upper lobe with elevation of the\n minor fissure.\n\n IMPRESSION: Probable collapse of right upper lobe. No left-sided\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910967, "text": " 9:13 AM\n CHEST (PA & LAT) Clip # \n Reason: evalaute lung field r/o ptx/effusion progression\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evalaute lung field r/o ptx/effusion progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of left upper lobectomy with fever.\n\n Chest tube is present in left upper hemithorax. There is a persistent tiny\n left apical pneumothorax. Subcutaneous emphysema is present in the left chest\n wall. There is elevation of the left hemidiaphragm and atelectases in the\n left lower zone. Surgical fracture, left sixth rib. Herniation of the right\n lung to left, unchanged.\n\n IMPRESSION: Persistent tiny left apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911772, "text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for ptx. Please do at Noon\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy with\n persistent air leak. CT to clamp. please do at Noon\n REASON FOR THIS EXAMINATION:\n Please eval for ptx. Please do at Noon\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: Squamous lung carcinoma, left upper lobectomy.\n\n IMPRESSION: PA and lateral chest compared to and 12:\n\n Tiny left apical pneumothorax and minimal layering pleural effusion unchanged.\n Heart mildly enlarged and shifted to the left reflecting lung resection.\n Right lung clear. Tracheostomy tube in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911841, "text": " 7:49 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval pneumo\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p\n d/c chest tube with sm pneumo\n REASON FOR THIS EXAMINATION:\n re-eval pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 07:41.\n\n INDICATION: LUL lobectomy - followup film after chest tube removal.\n\n COMPARISON: at 16:56.\n\n FINDINGS: Compared to the prior study, there is no significant interval\n change with a persistent small left apical pneumothorax and increased density\n projecting over the left lower lung field. Right lung remains clear.\n Pulmonary vascular markings are normal.\n\n IMPRESSION: Persistent left apical PTX and no interval change versus prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911800, "text": " 4:56 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx or recurrent collection\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p\n chest tube d/c. pelase do at 5pm\n REASON FOR THIS EXAMINATION:\n ? ptx or recurrent collection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS ON .\n\n HISTORY: Lung cancer status post left thoracotomy and left upper lobectomy\n with removal of chest tube.\n\n FINDINGS: There has been interval removal of the left chest tube. There is a\n small left apical and lateral pneumothorax which is similar in appearance to\n the film prior to chest tube removal earlier the same day. There continues to\n be scarring and patchy areas of volume loss in the left lung. The right lung\n is clear. There is right apical slightly nodular pleural thickening that is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911343, "text": " 9:28 AM\n CHEST (PA & LAT) Clip # \n Reason: eval interval change of L PTX.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy with\n persistent air leak. CT to water seal.\n REASON FOR THIS EXAMINATION:\n eval interval change of L PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old, squamous cell cancer and left upper lobectomy,\n assess pneumothorax.\n\n PA and lateral radiograph. Comparison is made to one day earlier.\n\n There is a persistent hydropneumothorax with new air-fluid levels seen\n posteriorly in lower lung. Left-sided chest tube remains in place. The right\n lung remains clear. The extent of hydropneumothorax is largely unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 910609, "text": " 9:12 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess swallowing capability\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with chronic trach, now with failed bedside swallow\n\n REASON FOR THIS EXAMINATION:\n assess swallowing capability\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old female with dysphagia.\n\n VIDEO ORAL AND PHARYNGEAL SWALLOW EXAMINATION:\n\n An oral and pharyngeal swallowing videofluoroscopy was performed today in\n collaboration with the Speech and Language Pathology Division. Various\n consistencies of barium including thin liquid, nectar thickened liquid, puree,\n and a cookie coated with barium were administered.\n\n The oral phase was within functional limits without significant residue or\n premature spillover. The pharyngeal phase was notable for mild-to-moderate\n pharyngeal residue. Swallow initiation, velar elevation, laryngeal valve\n closure and pharyngeal transit time were within normal limits. Vocal cord\n adduction and symmetric pharyngeal contraction were observed. There was mild\n penetration into the vestibule during the swallow with all consistencies due\n to anatomic changes, status post supraglottic laryngectomy. Mild aspiration\n occurred immediately after the swallow with nectar thick and puree due to\n spillover of penetrated material. Mild aspiration with thin liquids was also\n observed due to slightly reduced valve closure.\n\n IMPRESSION: Mild pharyngeal dysphagia. Mild aspiration.\n\n For greater detail and for treatment recommendations, please see the dedicated\n Speech and Language Pathology Division report of the same date.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910904, "text": " 1:13 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate lung field s/p clamping of chest tube\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p clamping of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n History of left upper lobectomy and fever.\n\n Two chest tubes are present in the left upper hemithorax. There is a tiny\n left apical pneumothorax. Subcutaneous emphysema is present in the left chest\n wall and ill-defined opacities consistent with atelectasis in the left lower\n zone with slight elevation of the left hemidiaphragm.\n\n IMPRESSION: Tiny left apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910736, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow-up pneumothorax.\n\n COMPARISON: .\n\n AP ERECT CHEST: Leftward shift of mediastinal structures has decreased as\n well as moderate consolidation reflecting improving left lower lobe\n atelectasis. Two left chest tubes are unchanged in position. A small apical\n pneumothorax on the left is again noted with unchanged. A small amount of left\n chest wall subcutaneous emphysema remains unchanged. The right lung is\n grossly clear. No pleural effusion is present.\n\n IMPRESSION:\n 1. Stable small left apical pneumothorax.\n 2. Improving left lower lobe moderate atelectasis.\n\n" } ]
3,237	110,358	Respiratory, the infant was admitted to the Newborn Intensive Care Unit with significant grunting, flaring and retracting, placed on nasal prong CPAP. Nasal prong CPAP was weaned within a few hours and infant weaned to room air with oxygen saturation greater then 95%, grunting, flaring and retracting quickly resolved. The infant has continued to be on room air for the remainder of her hospitalization. The patient has occasional bradycardic spells, no Methylxanthine have been required. Cardiovascular, the patient's blood pressure has been stable throughout her hospitalization. No saline boluses or pressor support has been required. A soft intermittent murmur has been noted during her hospitalization felt to be a PPS murmur. Fluids, electrolytes and nutrition, upon admission to the Newborn Intensive Care Unit, the patient was started on intravenous fluids of D10W at 80 cc per kg per day. D sticks have been within normal range throughout her hospitalization. Enteral feeds were initiated on day of life two and she quickly advanced to full volume feeds by day of life five. The patient is currently receiving feeds of premature Enfamil enriched to 26 calories with ProMod. Feeds are partially by bottle and partially by gavage. Last set of electrolytes on day of life four, sodium of 147, potassium of 5.3, chloride of 117 and a total carbon dioxide of 16. The patient is voiding and stooling without difficulty. The patient's weight at the time of transfer is gms (4 lbs 5.5 oz), length 45 cm, head circumference 32.5 cm. Gastrointestinal, peak bilirubin on day of life three was 8.2 with a direct bilirubin of 0.3. Phototherapy was started at that time. Phototherapy was discontinued on day of life six and rebound bilirubin on day of life seven was 5.2 with a direct bilirubin of 0.2. There have been no issues with feeding intolerance during her hospitalization. Hematology. The infant has not received any blood products during her hospitalization. Hematocrit at the time of admission was 43.5. Infectious Disease. A complete blood count and blood culture were drawn upon admission to the Newborn Intensive Care Unit. White blood cell count 10,000, platelet count of 284,000, hematocrit of 43.5 with 19% neutrophils and 2% bands. The patient received forty-eight hours of Ampicillin and Gentamicin. The blood culture drawn on admission was negative. Neurology, head ultrasound was not indicated for this 32 6/7 weeks infant. Sensory, a hearing screen was performed with automated, auditory brain stem responses. The patient passed in both ears. Ophthalmology, eye examination was not indicated for this 32 6/7 weeks. Psychosocial, a social worker has been involved with the family. The contact social worker can be reached at .	Minbenign asps. NPO for now with maintenance IVF. Passed hearing screen.Maturing breathing control. Currently on CPAP. abd soft,stable, voiding and passing very sm stool A: starting to pofeed P: continue present care.4. Baby stable, all VS WNL, see flow sheet for details. Infantoffered bottle x2 this shift. Serologies: A+, ab neg, RPR NR, hep BsAg neg, RNI. Offer bottle as interestedqof-qtf. Transfer isolette prepared with buld syrine, O2, monitor. Abd exam benign. Abd soft, bs +. of anterior anus.Impression:1. Med spitx1. P: Cont to supportand update. Will transfer to for futher level II care. 2 full po yest. Alt po/pg. visiting.A: Stable. A:AGA P:Cont to supportdev needs.#5: in this am, update given. Bottled entirevolume x's 1. UE=LE. +BS. A: AGA. Active, alert in an open cirb, AFOF, sutures opposed, good tone. Stooling (heme neg). Stool x2 trace. diddiscuss tranferring to Hosp. Both updated. Respiratory support as needed for RDS. +2 pulses noted. Sutures slightly seperated and mobile. Mucous membranes pink, moist.CV: HR 150's. On PE26 with Promod. Will f/u Blood cx results. Nospits or asp. Fontssoft/flat. Follow wt and exam. Both asking appropr. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. G3P0 now 2 mother. Ag stable. AG stable. Nostool thus far in shift. Passing heme negative stool. Alternating po/pg feeds. Alternating po/pg feeds. Dextrose level 63-104. AF flat, clear BS, soft murmur, abd soft, MAE. Bottling qof- took 29cc this am,with good coordination. Equal chest rise. RRR, without murmur, pulses 2+ and symmetrical. bely benign, abd soft, +, med spitx1. belly benign,voiding/stooling, abd soft, & +. Abd exam stable. Temp stable. A: Stable in RA P: Continue tomonitor#2 O: TF=140cc's/k/d of BM/PE 26 with promod. 1lg spit/minimal aspirates. BP stable. Temp stable.Active/alert w/ cares. A/G stable. A/G stable. Update given. Abdomen bneign.. AG stable. LS clear and =. Mild subcostal retractions. Gavaged TF at8a.m. Minimal aspirates. remains in RA. A: Toleratingfeeds. Cord care done. Voidingand stooling guiaic neg. Tempstable. Abdomen benign. Voiding/stooling, guiac neg. Passed hearing screen. Swaddled with boundaries in place. visual analfissure noted. Benign abdomen. Benign abdomen. Temp stable in off isollette.Wt 1665 up 10. On BM/PE 26 with Promod. asking appropriatequestions. Asking appropriatequestions. P: Continuew/ plan.4. Noretractions. A: , invested P: Continue to support andupdate Voiding/stooling, hem neg. Swaddled. AF , clear BS, no murmur, abd soft, MAE. A: Tol feeds, gaining wt. NPN 0700-1900#1 O: Infant remains in RA. NeonatologyDoing well. Abdomenbenign. Abdomenbenign. for4p.m. Active bowel sounds. Bellybenign. COmfortable appearing.No murmur.Last sepll on 24th. Stool x2. AG 23CM. for cares. Cont to monitor. Passed hearing test. Awake andalert with cares. Stools heme negative. A: Involved, P: Continue tosupport and update. P: supportfamily's needs. Neonatology-NNP Physical ExamInfant remains stable in RA. Stable girth. Gr murmur over ULSB, pulses +2, pink, CRT < 3 secs. Infant with nml pulses and brisk cap refill. one sm spit. VOIDING WELL; SMALL GREENSTOOL X1. cares. A: Involved, P: Continue tosupport and update Gavaged feed at8a.m. updatesgiven. Wean isolette as tolerated. helped with cares andfed pt. LS c+=. COnsolable with pacifier and bounderies. NPN Days#1 Pt received and cont in RA. P/ Cont. mild S/Cretrac. Neonatology attending note6 d.oresp: in RA, clear. Update given. In isolette, RA. Gaining wt. A: Tol feeds so far. Apgars . sounds clear with mild retractions.#2O: Wt. abd benign. Abd benign. Amp and gent as ordered. P: Consider d/cphototx. BBS =/clear. A/g stable. Nobrady's. Mild subcostal retractions. Mild retractions. Min. pt po qshift. Herbili was 4.9/0.3. LS clear. 1 sm. Br. NPN 7A-7P#1 Remains in RA w/o desat's or brady's. Resting well.BILI: Phx dc'd . Abd is benign,she is voiding and having trace stools, g-. asking approp ques. RR 40-60s, ls clear, nospells. sl jaund.eyeshields on. asp. Nursing Progress Note#1 RESPStable on RA with good sat. Remains in RA. P-Will cont to monitor FEN.#4 G&D- Temp stable nested in air mode isolette. Neonatology Attending remains in RA, isolette. of Pe20. A: Stable in RA. A: Stable in RA. F/n: O: Infant is on TF = 140cc/k/d, delivered mostly viagavage. Clear equal BS with mildretraction. Mottles with cares. P- Will obtain bili in am.See flowsheet for further details. Inital DS on arrival: 63/72. Rebound bili this am 5.2/0.2 from 4.9/0.3. P: Continue w/plan.4. AFOF. P- Will cont to monitor resp status.#2 FEN- TF= 140cc/kg/d of BM or PE22. ag- 24cm. PO's 1x shift; takes ~ of total volume po. max asp 4cc partially digestedformula, refed. LSclear/=, mild subC retractions present. Temps stable onwarmer/isolette. LSclear/=, mild IC retractions present. and ampi and gent d/c.#4O: In heated isolette with stable temp. Mild subcostal retractionsnoted. Single desat, self resolved.CV: Good HR, perfusion. Pt cont under singlephototherapy. nested insheepskin. Lytes andbili done, see flow sheet, d-s 61.#3O: Bld. Lungs clear, = bilat, mild SC retractions. helped with cares andheld pt. updatesgiven. able towean x2 for temps 98.8 and 99.1. alert and awake with cares.fontanelles soft and flat. lsc and equal. sounds clear and =.#2O: Wt. FunctionO: In RA, RR 30's-60's with mild SC retractions. Rebound bili to bedrawn in am. NEONATOLOGY ATTENDINGDay 2 for .RESP: RA, good sats. abd benign. in Resp. Transient soft bowel loops palpated. Neonatology - NP Physical ExamAwake and alert with cares, temp stable in air isolette. P- Willcont to monitor FEN.#4 G&D- Temp stable in air mode isolette. Sleeps well betwen cares.Tone is wnl- actions are appropriate for gestational age.FESO4 ordered. Voiding and stooling.4 DevTemp stable in air controlled isolette. mild scretractions noted. sounds clear with very mild retractions.#2O: Total fluids presently at 80cc/kg/d. Belly benign. Girth stable. Becoming independent with cares. cx neg. Lytes 145/5.2/112/19. thendiscarded. breath sounds clear and equla. BS +. NPN Days#1 Pt received in RA and cont in RA. cx. Belly soft, voiding and passingmec. Lytes and bili done, see flow sheet.#3O: Ambi and gent given, bld. RRR, without murmur, pulses 2+ and symmetrical. Advanced to 24 cals.	79	[ { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725716, "text": "Progress Note: Nurse \n32 week infant now DOL 1. Admission wt 1740.\n\nSkin: Intact, no breakdown, no rashes, no lesions. Skin pink/slightly ruddy.\n\nHEENT: Moulding to head noted. Fontanels soft, flat. Sutures slightly seperated and mobile. Eyes free of reddness and drainage. Symmetrical facial features with grimace/cry when disturbed. No masses noted. Mucous membranes pink, moist.\n\nCV: HR 150's. S1S2. No murmur. +2 pulses noted. UE=LE. BP 64/36 (48).\n\nRespiratory: On room air. O2 saturations 99-100%. Breath sounds clear and equal. Equal chest rise. Mild subcostal retractions.\nRR 30-50.\n\nGI/GU: Abdomen soft, round, no loops. +BS. No masses noted.\n\nMetabolic: Skin slightly ruddy. Checking bilirubin level with 24hr labs.\n\nFEN: TF 80cc/kg/d. Starting feeds today PE20cal/oz- 20cc/kg. Dextrose level 63-104. Assessing 24hr electolytes.\n\nID: On Ampicillin and Gentamicin for 48hr rule out sepsis. Will f/u Blood cx results. Initial CBC benign.\n\nImpression: Premature infant doing well since self extubating from CPAP to room air. Continue close monitoring clinically in overall status, including respiratory, toleration to newly initiated feeds and pending blood cultures.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-17 00:00:00.000", "description": "Report", "row_id": 1725712, "text": "Neonatology Attending Admit Note\n\nInfant is a 32 week, 1740 gm, female twin I, who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 30 y.o. G3P0 now 2 mother. Serologies: A+, ab neg, RPR NR, hep BsAg neg, RNI. Pregnancy complicated by:\n1. PTL - cerclage placed at 12 weeks gestation\n2. admitted to for \"failing cerclage\", cervical changes, and bulging membranes\n3. borderline hypertension\n4. insulin-dependent gestational diabetes mellitus\n\nBetamethasone complete. Today with progressive spontaneous labor to vaginal delivery.\n\nIn DR - neonatology present. Apgars 7,8. Facial CPAP given.\n\nPhysical exam:\nWt 1740g = < 50%\nL 42.5 cm = 25-50%\nHC 31.5 cm = 50-75%\n\nVS per CareView. Complete exam documented on \"newborn summary form\". Notable for respiratory distress on CPAP, hypotonia, and ? of anterior anus.\n\nImpression:\n1. AGA, premature female, twin 1\n2. Respiratory distress syndrome - most likely RDS. Also consider TTN, neonatal pneumonia\n3. r/o sepsis - risks include prematurity, multiples, GBS unknown\n4. IDM\n5. hypotonia - c/w prematurity and current degree of illness. Expect to improve with time.\n\nPlan:\n1. Respiratory support as needed for RDS. Currently on CPAP. Will follow gases, if symptoms/support progresses will initiate additional evaluation including CXR and consider intubation with surfactant delivery.\n2. Monitor for development of apnea of prematurity.\n3. Monitor BP. Follow for development of PDA.\n4. NPO for now with maintenance IVF. Consider initiating enteral feedings once respiratory status stabilizes.\n5. IDM - hypoglycemia protocol.\n6. r/o sepsis - check CBC with blood cx. Initiate ampicillin, gentamicin pending lab results and clinical course.\n7. Monitor tone, neurological exam.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725713, "text": "1 Alt in resp status\n2 FEN\n3 Sepsis\n4 Alt in development\n5 Alt in parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in resp status; added\n Start date: \n 2 FEN; added\n Start date: \n 3 Sepsis; added\n Start date: \n 4 Alt in development; added\n Start date: \n 5 Alt in parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-03 00:00:00.000", "description": "Report", "row_id": 1725787, "text": "NPN 7a-7p\n\n\n#2: TF: 150cc/k/d. Conts on PE26 with Promod, tol feeds\nq4hrs gavaged over 1hr15mins. Few sm spits today. Min\nbenign asps. Abd soft, +, no loops. Voiding qs. No\nstool thus far in shift. Bottling qof- took 29cc this am,\nwith good coordination. Does tire toward end. A: tol feeds\nwell, conts to work on bottling skills P:Cont with current\nfeeding plan. Follow wt and exam. Monitor tol to feeds.\n\n#4: conts to maintain stable temps while swaddled in\nan open crib. Alert and active with cares. Not yet waking\non own for feeds. MAE. Fonts soft/flat. Brings hands to\nface. Enjoys sucking on pacifier. A:AGA P:Cont to support\ndev needs.\n\n#5: in this am, update given. did\ndiscuss tranferring to Hosp. did tour\nfacility this am and are agreeable to transfer. Aware that\ntenatively will happen tomorrow. Dad gave sponge bath to\ninfant. Did well, good positioning. Needed verbal\ninstruction and guaidance. Mom bottled infant. A: Involved\n, awaiting transfer. P:Cont to support and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725788, "text": "NPN 1900-0700\n\n\n2 FEN\nCurrent weight 1.970 kg, up 35 grams. TF remain at\n150cc/kg/day of PE 26 with pm. Alt po/pg. Bottled entire\nvolume x's 1. Tolerating feedings well. Abd soft, bs +. No\nspits or asp. Voiding and stooling.\n\n4 Dev\nTemp stable in open crib. Awake and active with cares.\nSleeps well between cares. Brings hands to face.\n\n5 Parenting\nSpoke to Mom at start of shift. Phone consent given for\ntransfer to . Mom will call in am for updated\nplan.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725789, "text": "Neonatology Attending\n\nDay 18\n\nRemains in RA. RR 30-60s. No bradycardia. Intermittent murmur. HR 130-160s. Weight gms (+35). On PE26 with Promod. Alternating po/pg feeds. No spits. Passing heme negative stool. Stable temperature in open crib. Passed hearing screen.\n\nImproving breathing control, feeding. Gaining weight on current nutritional regimen. Will transfer to for futher level II care. Primary pediatrician is Dr. Pediatrics.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725790, "text": "Nursing Transfer Note\nBaby #1 to be transferred to Special Care Nursery. Report called to RN, Ambulance scheduled for 1030am. notified of transfer time, phone consent sheet shigned in chart. eager for transfer. Baby stable, all VS WNL, see flow sheet for details. ID Tags on. Transfer isolette prepared with buld syrine, O2, monitor. This RN will be accompanying baby on trip. Order for transfer obtained.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725781, "text": "2. TF 150cc/k/d of Bm/PE26 with promod, 47cc q4h. offering\npo when awake, took 52cc po well ~12n for Mom. abd soft,\nstable, voiding and passing very sm stool A: starting to po\nfeed P: continue present care.\n4. starting to wake for some feedings and take po, temps\nstable in open crib, active and alert with cares P: continue\nto support needs for growth and development.\n5. Mom here for 12/1230 feedings, has decided to stop\npumping, held and fed babies, planning to be here for next\ncares A: concerned and involved P: continue to inform and\nsupport.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725782, "text": "NPN NIGHTS\n\n\nFEN: Weight 1940gm up 50. TF 150cc/kg/day PE26 or BM26 with\npromod. Alternating po/pg feeds. No spits, max aspirate 4cc\npartially digested formula. Belly soft and round with active\nbowel sounds, no loops noted. Stool x1, heme negative. Will\ncontinue with current feeding plan.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares. Sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725775, "text": "NPN 0700-1900\n\n\n#2 O: TF= 150cc/kg/d. Infant taking 46cc's of BM/PE26 with\npromod q 4h via po/pg. Bottled 42cc's at 1200 for mom.\nAbdomen benign; voiding and stooling guaic neg x1. Med spit\nx1. Minimal aspirates. Feeding time increased to 1h 20\nminutes with no spit after. AG stable. A: Tolerating feeds.\nP: Cont to monitor.\n\n#4 O: Maintaining temp in oac. Awake and alert with cares;\nsleeping well between. Swaddled in blanket; brings hands to\nface for comfort. A: AGA. P: Cont to support development.\n\n#5 O: Both in to visit this afternoon. Mom feeding\nthis infant and very independent with cares. Grandparents in\nto visit as well. Asking appropriate questions. plan\nto come in for 1600 cares. A: Involved. P: Cont to support\nand update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725776, "text": "Neonatology Attending Progress Note\n\nNow day of life 14.\nCardiorespiratory status stable in RA.\nRR 40-50s.\nNo apnea and bradycardia.\nHR - 140-180s.\nBP 73/40 57\nWt. 1840gm up 40gm on 150cc/kg/d of MM or PE26 with Promod\nFeedings well tolerated by bottle or gavage.\nHas history of emesis.\n\nPO feedings are improving gradually.\n\nAssessment/plan:\n2 week old 32 week gestation infant with immaturity of feeding skills.\nWill continue with current management.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725783, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. In room air, BS clear and equal with symmetrical chest movement, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Hemangioma on right knee. Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725784, "text": "Neonatology Attending\n\nDOL 16 CGA 35 1/7 weeks\n\nStable in RA. No A/B.\n\nSoft murmur, intermittent. BP 67/33 mean 40.\n\nOn 150 cc/kg/d PE 26 with promod with feeds over 1 hr 15 min. 2 full po yest. Voiding. Stooling (heme neg). Wt grams (up 50).\n\nHemangioma on R knee.\n\n visiting.\n\nA: Stable. Minimal A/B. Tolerating feeds. Growing.\n\nP: Monitor\n Encourage pos as tolerated\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725785, "text": "NPN 7a-7p\n\n\n#2: TF: 150cc/k/d, conts on PE26 with Promod. Infant\noffered bottle x2 this shift. Bottled 18-30cc tiring easily\nand slow to feed. Decent coordination using yellow nipple.\nSm spit noted. Abd exam benign. Ag stable. Voiding qs.\nStooled. A: tol feeds well, working on bottling skills.\nP:Cont to follow wt and exam. Offer bottle as interested\nqof-qtf. Monitor tol to feeds.\n\n#4: conts to maintain stable temps while swaddled in\nan open crib. Alert and active with cares. MAE. Fonts\nsoft/flat. Sucks on fingers and pacifier intermittently.\nDoes spend ~30mins of quiet awake time after feed. A: AGA\nP:Cont to support dev needs.\n\n#5: in for 12care. Both updated. Mom with\ntemp, diaper and bottling. Both asking appropr. questions.\nA: Involved P:Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-03 00:00:00.000", "description": "Report", "row_id": 1725786, "text": "Newborn Med Attending\n\nDOL#17. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. Wt= down 5. On 150 cc/kg PE26 with PM, mostly PG.\nA/P: Growing premie working up on PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725777, "text": "NNP Physical Exam\n\nPE: pale pink, AFOF, breath sounds clear/equal with easy wOB, soft high pitched murmur mid LSB, +2/= pulses, abd soft, non distended, nevus simplex right knee, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725778, "text": "NPN NIGHTS\n\n\nFEN: Weight 1890gm up 50. TF 150cc/kg/day BM26 or PE26 with\npromod. Took 50cc po x1 this shift. Attempting bottling\nevery other feed. No spits. Belly soft and round with active\nbowel sounds, no loops. Stool x2 trace. Will continue with\ncurrent feeding plan.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares, sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: No contact so far this shift.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725779, "text": "Neonatology Attending\n\nDay 15\n\nRemains in RA. RR 40-50s. No bradycardia. Clear breath sounds. HR 140-150s. Soft, intermittent murmur. Pink. BP mean 52. Weight 1890 gms (+50). TF at 150 cc/kg of BM/PE 26 with Promod. Most feeds by gavage. Passing stool. Stable temperature in open crib. Passed hearing screen.\n\nMaturing breathing control. Monitoring cardio-respiratory status closely. Gaining weight well. Will continue to encourage po feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725780, "text": "Neonatology-NNP Physical exam\n\nInfant remains stable in RA. Active, alert in an open cirb, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, CRT < 3 secs. Abdomen soft, non-distended with active bowel sounds, no HSM, hemangioma on right knee. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725769, "text": "1900-0700 NPN\n\n\n#2F/E/N\nO:TF AT 150CC/KG BM/PE26 45CC Q4HR GAVAGE OVER 1HR 10\".\nABDOMEN SOFT, FULL WITH GOOD B.S. NO SPITS AND MINIMAL\nASPIRATES. VOIDING AND STOOLING (SMALL AMTS) OVERNIGHT. WT\nUP 35GM\nA:TOLERATING FEEDS WELL; IMPROVED SPITTING\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR FOR SPITS\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES.\nBOTTLED 29CC TONIGHT--BABY ROOTING, LATCHED ON AND SUCKED\nVERY WELL TONIGHT. WELL COORDINATED S/S/B WITHOUT A/B'S OR\nDESATS DURING BOTTLING.FONTANEL SFOT AND FLAT; SUTURES\nSMOOTH\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT, OFFER BOTTLE QSHIFT AND\nADVANCE AS TOLERATED\n\n#5PARENTING\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TOD ATE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725770, "text": "Neonatology Attending\n\nDay 13\n\nRemains in RA. Oximeter discontinued. No bradycardia. RR 40-50s. Intermittent murmur. HR 140-160s. Pale, pink. Weight 1800 gms (+35). TF at 150 cc/kg/d. On BM/PE 26 with Promod. Receiving po/pg feeds. Offered po feed once per shift. Took one ounce with one feed overnight. Stable temperature in open crib.\n\nAdequate breathing control. Will continue to monitor closely. Gaining weight well. Encouraging po feeds.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725771, "text": "Clinical Nutrition:\nO:\n34 wks CGA, BG now on DOL #13\nWt: 1800g (+35g)-(10-25th%ile); gained an average of 14 g/kg/day over the last week.\nLN: 44cm (42.5)-(25-50th%ile)\nHC: 32cm (31.5)-(~50th%ile)\nLabs: none recent\nMeds: Iron (~4.0-4.1 mg/kg/day from feeds+suppl.)\nNutrition: BM/PE26 w/ promod @ 150 cc/kg/day\n3 day average intake: ~143 cc/kg= ~124 Kcals/kg & ~3.8-4.2 g/kg of protein\nGI: benign\n\nA/goals:\nTolerating feeds well, noted decrease number of spits. Alternates PO/PG, offered a bottle Qshift. Gavage feeds over 1hr 10min d/t h/o spits. Voiding & stooling. Wt gain slightly below goal range over the last week. Current feeds+supplements meeting recommendations to support cont'd growth. Due for nutrition labs. No changes to nutritional plan today, will cont. to follow w/team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725772, "text": "NPN 0700-1900\n\n\n#2 O: TF=150cc's/k/d of BM/PE 26 w/ promod. Gavaged feed at\n8a.m. and 4p.m. Bottle fed at 12p.m. Infant took 44 cc's. 1\nlg spit/minimal aspirates. Voiding/stooling, hem neg. AG=\n23cm. Abdomen benign. Active bowel sounds. A: Tolerating\nfeeds. P: Continue to monitor and encourage PO feeds.\n\n#4 O: Infant remains in OAC. Swaddled. Temp stable.\nActive/alert w/ cares. A: AGA P: Continue to support G&D.\n\n#5 O: Mom called this morning. She came at 3:30p.m. for\n4p.m. cares. A: , invested P: Continue to support and\nupdate\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725773, "text": "Agree with above assessment and plan written by , coworker.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725774, "text": "NPN NIGHTS\n\n\nFEN: Weight 1840gm up 40. TF 150cc/kg/day BM 26 with pm or\nPE26 with pm. Took 45cc po x1 so far this shift. Remainder\nof feeds gavaged over 1hr 10mins. No spits. Stool x2. Belly\nbenign. Will continue to offer bottle every other feed.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares. Swaddled with boundaries in place. Will\nsend PKU this am.\n\nAlt in Parenting: No contact so far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725764, "text": "1900-0700 NPN\n\n\n#2F/E/N\nO:TF AT 140CC/KG BM/PE 26 41CC Q4HR GAVAGE OVER 1HR 10\".\nABDOMEN SOFT, FULL WITH GOOD B.S. NO SPITS, MINIMAL\nASPIRATES AND NO LOOPS. AG 23CM. VOIDING WELL; SMALL GREEN\nSTOOL X1. WT UP 20GM. OFFERED BOTTLE WITH ABSOLUTELY NO\nINTEREST--UNABLE TO GET BABY TO ROOT TO, ON TO OR SUCK\nFROM NIPPLE\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANE TO FEEDS, ENCOURAGE PO/BF\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERTURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. SWADDLED AND NESTED ON SHEEPSKIN.\nFONTANEL SOFT AND FLAT; SUTURES SMOOTH. POOR PO'ER--UNABLE\nTO GET BABY TO ON, ROOT TO OR SUCK FROM BOTTLE\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nSEE SIBLINGS NOTE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725765, "text": "Neonatology-NNP Physical Exam\n\nInfant remains stable in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur over ULSB, pulses +2, pink, CRT < 3 secs. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, strawberry hemangioma near right knee. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725766, "text": "Neonatology Attending\n\nDay 12\n\nRemains in RA. RR 40-60s. Mild subcostal retractions. Soft murmur. Pale, pink. BP mean 45. Weight 1765 gms (+20). Tf at 140 cc/kg/d of PE 26 with Promod. Had one small spit yesterday. Poor bottling- offered once per shift. Minimal aspirates. Benign abdomen. Stable girth. Passing stool. Stable temperature in open crib.\n\nAdequate control of breathing. Will continue to monitor cardio-respiratory status closely. Gaining weight but will increase feeding volume to 150 cc/kg/d. Will continue to encourage po feeding. Eye exam next week.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725767, "text": "coworker \n\n\n#2 FEN: TF increased to 150cc/k/d of BM/PE 26 with promod\ngavaged over 1hr and 10 min. offerred bottle and took 5\ncc's. bottled with no interest. bely benign, abd soft, +\n, med spitx1. A/G stable. no asp. thus far on shift.\nA: tol feeds well P: monitor infant/encourage infant to PO\nfeeds.\n\n#4 DEVE: temp remains stable with infant swaddled in an open\ncrib. alert and active with cares. poor suck and on.\nMAE. fontanels are soft/flat. infant has strawberry\nhemangioma on inner right knee. eye exam scheduled for the\n. A: AGA P: continue to monitor and support the\ninfant.\n\n#5 PARENTING: Mom, mom's sister, and grandmother were in\nfor afternoon care. Mom ind with temp, diaper, dressing,\nand cord care. A: and caring family. P: support\nfamily's needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725768, "text": "NPN 7a-7p\nAssessed infant and agree with co-worker noted.\n\nInfant conts to show little to no interest in bottling. Not really latching onto nipple. Abd exam stable. Voiding and stooling.\n\nSoft intermittent murmur noted. Infant with nml pulses and brisk cap refill. BP stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725758, "text": "Newborn Med Attending\n\nDOL#10. Cont in RA, no spells. AF , clear BS, no murmur, abd soft, MAE. WT=1715 up 50, TF=140 cc/kg/d. BM26 with PM mostly PG\nA/P: Growing premie working up on PO feeds. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725759, "text": "NPN 0700-1900\n\n\n\n\n#2 O: TF= 140cc's/k/d of PE/BM 26 with promod. Gavaged\nentire feed at 8a.m. and 12p.m. 2 large spits/minimal\naspirates. Will increase gavage time to 1h 10 min. for 4p.m.\nfeed. Voiding/stooling, guiac neg. AG= 23 cm. Abdomen\nbenign. A: Tolerating feeds P: Continue to monitor and\nencourage PO feeds.\n\n#4 O: Infant remains in OAC. Swaddled with hat on. Temp\nstable. Alert with cares. A: AGA P: Continue to support\ndevelopment.\n\n#5 O: will be in at 4p.m. for cares. They will\nattempt to bottle feed. A: Involved, P: Continue to\nsupport and update\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725760, "text": "2. F/n: O: Infant is on 140cc/k/d of 26cal BM/PE + promod,\ndelivered mostly via gavage q 4 hours over one hour and 10\nmin. Abd is benign, she is voiding and stooling g- stools,\neven though an anal fissure is visible. (A & D and vaseline\nointments applied.) No spits, Min asps. She gained 30g and\nis just above BW now. A: Tol feeds, gaining wt. P: Continue\nw/ plan.\n\n4. G/d: O: Temp is stable in the open crib and infant sucks\nwell on a binkie. She is alert and active w/ cares. A/P:\nContinue to support infant needs.\n\n5. : No contact from the family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725761, "text": "Neonatology Attending\n\nDay 11\n\nRemains in RA. RR 30-50s. Clear breath sounds. No bradycardia. Intermittent murmur not heard this morning. BP mean 44. HR 140-160s. Weight 1745 gms (+30). TF at 140 cc/kg/d on PE/BM 26 with Promod. Gavaged over 70 minutes. Stable abdominal girth. Benign abdomen. Stools heme negative. Small fissure. Passed hearing screen. Stable temperature. in currently.\n\nDoing well overall with adequate breathing control. Will continue to monitor closely. Gaining weight well. Will stay with this regimen for now.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725762, "text": "coworker p\n\n\n#2 FEN: TF remains at 140/cc/k/d of BM/PE 26 w/promod over\n1hour and 10 min. A/G stable. one sm spit. belly benign,\nvoiding/stooling, abd soft, & +. A: Tol feeds well P:\nmonitor infant.\n\n#4 DEVE: Temp remains stable with infant swaddled in open\ncrib. alert and active with cares. MAE. visual anal\nfissure noted. strawberry hemangioma also noted on inner rt\nknee. Passed hearing test. A: AGA P: Continue to support\ninfant.\n\n#5 PARENTING: were in for care. both are indep\nwith diaper, temp, and cord care. asking appropriate\nquestions. A: and caring family P continue to support\nthe family's needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725763, "text": "NPN 7a-7p\nAssessed infant and agree with note by co-worker .\n\nInfant attempted to bottle x1 for Dad. Infant took 4cc and tired out. Anal fissure noted. No bleeding noted. Vaseline oint applied. Cont to monitor.\n\n in for visit. Update given.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725751, "text": "NPN 7A-7P\n\n\n#1 In RA, no brady's or desat's, maintaining sao2's >96%. LS\n= and clear, con't to have mild intercostal/subcostal\nretractions. Monitor.\n\n#2 TF at 140cc/k/d, cal's increased to 26 (2 more cal's via\nMCT oil). No interest in bottlng today though alert and\nactive. Had mod spit x 1 this AM but none further. Voiding\nand stooling guiaic neg. Cord care done. Monitor\nwt/tolerance.\n\n#4 Maintaining 98.0 temp in off isolette, no brady's,\ndisinterested bottler. Con't to monitor and assess for\nfeeding cues to PO.\n\n#5 visit daily, do cares with minimal assistance.\nCon't to update/teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725752, "text": "NPN\n\n\n#1-O: in RA sats 99-100, pink RR 40's-50's, comfortable, no\nissues.\n\n#2-O: TF at 140cc/k enteral feeds of BM26/PE26 41cc q 4 hrs\nover 1 hour PG, poor po attempts, one sm. spit. abd soft,\nbenign, voiding and stooling soft yellow. wt up 10gms today.\n\n#4-O: alert and active with cares, AFOF, no spells, wrapped\nin off isolette, temp stable this shift 98.6-98.3 ? trial in\ncrib.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725753, "text": "Neonatology\nDoing well. remains in RA. No spells. COmfortable appearing.\nNo murmur.Last sepll on 24th. Temp stable in off isollette.\n\nWt 1665 up 10. Tolerating feeds at 140 cc/k/d of 26 cal. Will add Promod today and monitor tolerance. Abdomen bneign.. Still requiring mainly gavage.\n\nSlightly jaundiced. Bili 5 several days ago.\n\nContinue current resp montioring and nutritional rx.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725754, "text": "NPN 0700-1900\n\n\n#1 O: Infant remains in RA. Resp rate 40's-50's. O2 sats\n100%, O2 sat monitor d/c at 1p.m. LS clear and =. No\nretractions. No spells. A: Stable in RA P: Continue to\nmonitor\n\n#2 O: TF=140cc's/k/d of BM/PE 26 with promod. Gavaged TF at\n8a.m. Dad attempted to bottle feed at 12p.m., infant took\n12cc's. No spits, minimal aspirates. AG stable. Abdomen\nbenign. voiding/stooling. A: Tolerating feeds P: Continue to\nmonitor and encourage PO feeds.\n\n#4 O: Infant was changed from Off-Isolette to OAC. Swaddled\nwith hat on. Temp stable. Awake/Alert during cares. Sucks on\npassifier. A: AGA P: Continue to monitor.\n\n#5 O: Mom and Dad came to visit from 11a.m.-2p.m.\nIndependent with temp and diapering. Each parent held\ninfant. Dad attempted to bottle infant. Asking appropriate\nquestions. A: Involved, P: Continue to\nsupport and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725755, "text": "NNP Physical Exam\n\nPE: pale pink, mottled, AFOF, sutures approximated, lungs clear/equal with easy wOB, no murmur, abd soft, non distended, bowel sounds active, \"birth mark\" right leg by knee, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725756, "text": "Agree with above assessment and plan written by , Coworker. Infant passed hearing screen this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725757, "text": "1. Resp: O: Infant is in RA w/ no spells so far tonight. She\nis on no resp meds. RR 30-50s, ls clear. She is no longer on\na pulse oxymeter. A: Stable in RA. P: D/c problem.\n\n2. F/N: O: Infant is on 140cc/k/d of 26cal PE/BM w/ promod,\ndelivered via gavage q 4 hours over one hour. Abd is benign,\nshe is voiding and having trace stools, g-. A/g stable. She\ngained 50g. A: Tol feeds so far. Gaining wt. P: Continue w/\nplan.\n\n4. G/d: O: Temp is stable in the open crib. Infant is active\nw/ cares and sucks on a binkie. She sleeps well otherwise.\nA/P: Continue to support infant needs.\n\n5. : No contact from the family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725714, "text": "NPN admission note\nInfant arrived to NICU from L&D. Apgars . BBO2 and facial CPAP in DR. MD note for further DR and OB hx.\n\nResp: Infant GFR on arrival. Placed on CPAP of 6 at 21%FiO2 x2hrs until Infant pulled out NP tube. Remains in RA. LS clear. RR 30-50's. Mild retractions. No increase WOB noted. O2 sats 99-100%. No spells. A/P: Continue to monitor resp status.\n\nCV: Pink, perfused. HR 130-160's. No murmur. BP means: 41-47. A/P: Continue to monitor.\n\nFEN: BW 1740. NPO. TF at 80cc/kg of D10W. Inital DS on arrival: 63/72. DS remain stable thru shift at 91/104. Large mec stool. Void x1. Abdomen soft with active bowel sounds. A/P: Continue to monitor. Start feedings today?\n\nID: CBC with diff benign. Blood culture pending. Amp and gent as ordered. VSS. A/P: Continue with plan, f/U with blood cx results.\n\nDEV: Temp stable on servo warmer. Nested with boundaries in place. Initially on admission, infant hypotonic. Infant more active, moving all extremities-hypertonic. Active with cares. AFOF. A/P: Continue to support dev. needs.\n\nPARENTING: Parents in to visit shortly after admission. Update given. Asking appropriate questions. Have named this baby . A/P: Continue to update daily and offer support.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725715, "text": "Neonatology attending note\nborn last night at 32 wks GA, brief episode of CPAP, now in RA.\nAFOF.\nmild retraction, clear lungs.\nAbdomen aoft no mass palpable.\nNO murmur.\nnormal tone.\nwt= 1740 gm, TF= 80 cc/kg/d.\nA: 32 wks GA, resolved initial transitional respiratory distress, sepsis evaluation.\nP: continue antibiotics, consider starting feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725738, "text": "NPN Days\n\n\n#1 Pt received and cont in RA. LS c+=. mild S/C\nretrac. no spells. P- Will cont to monitor resp status.\n#2 FEN- TF= 140cc/kg/d of BM or PE22. abd benign. voiding\nand stooling. no spits. max asp 4cc partially digested\nformula, refed. ag- 24cm. pt po qshift. Pt took 27cc po. P-\nWill cont to monitor FEN.\n#4 G&D- Temp stable nested in air mode isolette. alert and\nactive with cares. sucking on pacifier. putting hands to\nface. Mottles with cares. P- Will cont to monitor G&D.\n#5 Parenting- in this shift. helped with cares and\nfed pt. loving and caring. asking approp ques. updates\ngiven. P- Will cont to encourage parental visits and calls.\n#6 Pt cont under single phototherapy. sl jaund.\neyeshields on. P- Will obtain bili in am.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725739, "text": "1. Resp: O: Infant is in RA, no O2. RR 40-60s, ls clear, no\nspells. She is on no resp meds. A: Stable in RA. P: Monitor.\n\n\n2. F/n: O: Infant is on TF = 140cc/k/d, delivered mostly via\ngavage. She is on 22cal. Abd is benign, she is voiding and\nstooling g- stools. She took 15cc via the bottle w/ the\nyellow nipple, taking a few strong sucks. D/s was 104. She\nlost 5g. A: Mostly gavage fed, tol feeds, still losing wt.\nP: Monitor. Consider adding cals.\n\n4. G/D: O: Infant is weaning the heat in her isolette. She\nis under phototx. She is active w/ cares and sucks well on a\nbinkie. A/P: Continue to support infant needs.\n\n5. : O: Mom called for an update. A: Mom. P:\nContinue to support.\n\n6. Bili: O: Infant is under single phototx w/ her eyes\ncovered. She is jaundiced. She is also stooling well. Her\nbili was 4.9/0.3. A: Hx Hyperbilirubinemia. P: Consider d/c\nphototx.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725740, "text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy wOB, no murmur, abd soft, nondistended, bowel sounds active, no rashes, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725741, "text": "Neonatology attending note\n6 d.o\nresp: in RA, clear. no spells.\nno murmur.\nabdomen soft.\nwt= 1625 gm -25, 140 cc/kg/d with EBM 2, 1 bottle /shift, tolerated well.\njaundice, bili= 4.9\n\nA: 32 wks GA, jaundice, growing preemie.\nP: f/u bili, advance calorie to 24 cal/oz.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725742, "text": "Social Work\n\n\n of twins well known to me from mother's lengthy antepartum course on antepartum service.\n seen today, doing very well, mother tired, but coping with demands of hospitalization, and very invested and involved in infant cares.\n integrating well into nicu environment, adapting and learning about needs of preterm infant.\nWill follow as needed.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725736, "text": "Clinical Nutrition\nO:\n32 wk gestational age BG, AGA, now on DOL 5.\nBirth wt: 1740 g (~25th to 50th %ile); current wt: 1630 g (down ~6% from birth wt)\nHC at birth: 31.5 cm (~50th to 75th %ile)\nLN at birth: 42.5 cm (~25th to 50th %ile)\nLabs noted.\nNutrition: Started on EN on DOL 1. TF @ 140 cc/kg/d PE 20, increasing now to PE 22. PO's 1x shift; takes ~ of total volume po. Projected intake for next 24 hrs from EN ~103 kcal/kg/d, ~3.4 g pro/kg/d.\nGI: Infant had 11 cc aspirate last night; feeds not increased until this morning. Currently abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems except aspirate as noted above. Labs noted and within acceptable range. Initial goal for feeds is ~150 cc/kg/d PE 24, providing ~120 kcal/kg/d and ~3.6 g pro/kg/d. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~1 cm/wk for LN gain, and ~0.5 to 1.0 cm/wk for HC gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725737, "text": "Progress Note: Neonatal Nurse \n32 wkr now 6do. Wt 1630(- 30gm)\n\nSkin: Jaudiced, slightly mottled. Skin intact- no rash, no lesions, no breakdown noted.\n\nHEENT: Fontanels soft, flat. Sutures overlap slightly. Eyes free from drainage and reddness. Alert when bili mask removed and lights off. No masses noted. Facial symmetry noted with facial expressions. Mucous membranes pink, moist.\n\nCV: s1s2. No murmur noted. HR 120-150. +2 pulses- UE=LE.\n\nRespiratory: Room air. RR 30-60. Mild subcostal retractions. Breath sounds clear and equal. No apenic or bradycardic spells.\n\nGI/GU: Abdomen soft, round, no loops. No masses. Voiding and stooling.\n\nFEN: Tolerating feeds PE20cal/oz. TF 140cc/kg/day. Increasing calories to 22cal/oz today.\n\nMetabolic: Under phototherapy x1. Checking bilirubin level in am.\n\nSocial: Spoke with at bedside. Updated to status and plan of care. verbalize understanding of information. No questions verbalized when encouraged.\n\nImpression: Premature infant with issues of hyperbilirubinemia. Tolerating feeds but requires an increase in calories. Respiratory status stable at this time on room air and no spells. Plan as discussed by systems and with Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725745, "text": "NPN:\n\nRESP: Sats 98-99% in RA. RR=40-60 w/SC retraction. BBS =/clear. No A&Bs over past 24 h.\n\nCV: Soft murmur audible at LUSB, lt axilla. Color pink w/good perfusion.\n\nFEN: Wt=1640g (+ 15g). TF=140cc/kg/d; 41cc PE-24 q 4 h via NG/PO. Gavaged tonight; tolerated fdgs well. Abd benign. Voiding & stooling. FeS04 supp.\n\nG&D: CGA~34 wk. Temp stable in off isolette. Active w/cares; good tone. Beginning to bottle feed. Resting well.\n\nBILI: Phx dc'd . Rebound Bili 5.2/0.2/ 5.0 (up from 4.9).\n\nSOCIAL: Father in to visit. He took temp and changed diaper of twin #2; attempted to bottle feed her but she was uninterested. Handles babies well.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725746, "text": "Neonatology Attending\n is 7do, 33 wks corrected. In isolette, RA. No a/b. Wt up 15 to 1640 on TF140 MM/PE 24 pg>po. Rebound bili this am 5.2/0.2 from 4.9/0.3. Soft murmur noted L axilla/?LSB.\n\nMeds Fe\n\nImp/former 32wk twin doing well. Feeding & thermoreg immaturity appropriate for GA. physiologic hyperbilirubinemia resolving s/p phototherapy. Asymptomatic murmur most c/w PPS.\n\nPlan/ continue to monitor cvr status, feeding tolerance & abilities, growth. Wean isolette as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725747, "text": "NPN 7A-7P\n\n\n#1 Remains in RA w/o desat's or brady's. LS = and clear,\ncon't to have intercostal retractions, but RR appear\nunlabored. Murmur audible x 1 this AM, is pink with quick\n refill. Monitor.\n\n#2 Bottled 15cc's well but got tired, remainder gavaged. No\nspits, voiding and stooling. On FIS. Con't to attempt PO\nfeeds.\n\n#4 Maintaining temp borderline in off isolette. Very alert\nand active for cares and resting comfortably b/t feeds. No\nbrady's. Working on bottling. Con't present interventions.\n\n#6 Bili this AM:5.2. No further checks ordered. Problem\nd/c'd.\n\n#5 in to hold x 2, do cares with minimal assistance.\nWill con't to update/support/teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725748, "text": "Nursing Progress Note\n\n\n#1 RESP\nStable on RA with good sat. Clear equal BS with mild\nretraction. No acute distress. No spells P/ Cont to assess\nCVR status\n#2 FEN\nWt 1.655 (up 15gm) On TF 140cc/k/d of BM24 or PE24cal.Due to\nmod spit feeding time increased, gavaged over 1 hour. Benign\nnon-tender abdomen.Girth stable at 23-24cm. NGT in place.\nVoiding and stooling heme neg stool. P/ Cont to assess\nfeeding intolerance.\n#4 G/D\nStable temp on unheated isolette. Alert and active with good\ntone. COnsolable with pacifier and bounderies. P/ Cont. to\nsupport G/D\n#5 Parenting\nNo contact with family this shift\n#6Problem of hyperbili resolved\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725749, "text": "6 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725750, "text": "Neonatology Attending\n remains in RA, isolette. No a/b.\nWt up 15g to 1655 on TF140 MM/PE24 pg>po; occ spits.\nMeds Fe\n\nPE active, appropriate, pink; AFOF. lungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n\nImp/ former 32+wk twin now 34 weeks corrected. immature feeding & thermoregulatory skills as expected for GA. Wt stabilizing but not yet back to Bwt.\n\nPlan/ continue to monitor cvr status, feeding tolerance, wt gain. Will increase to 26cal/oz feeds but keep TF at 140 given spits.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725729, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > 98% with no desats or\nbradys. Br. sounds clear with mild retractions.\n#2O: Wt. up 10 g on total fluids of 120cc/kg/d Feeds\nincreased to 100cc/kg, q 4 hrs. of Pe20. Belly soft, occ.\nsoft loops, voiding and stooling. Min. asp. 1 sm. spit. IV\nof D10W with lytes at 20cc/kg Lytes pnd., d-s 84.\n#4O: In heated isolette with stable temp. Active with\ncares.\n#5O: Mom called to check on the girls. Will visit later\ntoday.\n#6O: Under single phototherapy with eyes covered. Bili\nlevel done, see flow sheet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725730, "text": "Neonatology attending note\n4 d.o\nAFOF.\nin RA, no spell, clear.\nCV: no murmur.\nAbdomen soft.\nbili= 7.8\nwt= 1660 gm +10, TF= 120 cc/kg/d with feeding at 100 cc/kg/d with PE20.\nA: 32 wks GA, jaundice.\nP: observe for possible immaturity of breathing, f/u bili in 2 days, advance feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725731, "text": "NNP Physical Exam\n\nPE: pink, mild jaundice, AFOF, sutures approximated, moveable, lungs clear/equal with comfortable WOB, no murmur, abd soft, non distended, bowel sounds present, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725732, "text": "NPN Days\nIV infiltrated, puffy DC'd. Pt to reach goal of 140cc/kg/d @MN.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725733, "text": "NPN Days\n\n\n#1 Pt received in RA and cont in RA. mild S/C retrac.\nNo spells so far this shift. P- Will cont to monitor resp\nstatus.\n#2 FEN- TF=140cc/kg/d. Enteral feeds=120cc/kg/d of BM or\nPE20. abd benign. voiding and stooling. min asp no spits. po\n20cc x1. ag-23cm. IV fluids= 20cc/kg/d of D10W with 2NaCl\nand 1KCl. IV fluids to be DC this evening NNP. P- Will\ncont to monitor FEN.\n#4 G&D- Temp stable in air mode isolette. nested in\nsheepskin. alert and active with cares. PKU consent signed.\nP- Will cont to monitor G&D.\n#5 Parenting- in this shift. helped with cares and\nheld pt. asking approp ques. loving and caring. updates\ngiven. P- Will cont to encourage parental visits and calls.\n#6 Pt sl jaund. Pt cont under single\nphototherapy. eyeshields on. Bili to be drawn on wed am. P-\nWill cont to monitor hyperbili.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725734, "text": "NPN 1900-0700\n\n\n1 Resp\nSats remain 95-100% in RA. RR 40-60's. Lung sounds\nclear/=. Mild retractions, no increased work of breathing\nnoted.\n\n2 FEN\nCurrent weight 1.630 kg, down 30 grams. TF remain at\n140cc/kg/day. Enteral feedings currently at 120cc/kg/day,\ndue to advance to 140cc/kg/day at midnight but held d/t\nincreased asp. Abd soft, flat. Girth stable. BS +. No\nspits, 11cc asp x's 1. Voiding and stooling.\n\n4 Dev\nTemp stable in air controlled isolette. Awake and alert\nwith cares. Sleeps well between cares.\n\n5 Parenting\nNo contact thus far this shift.\n\n6 Bili\ncontinues under single phototherapy. Goggles in place.\nLevel to be checked .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725735, "text": "Neonatology attending note\n5 d.o\nin RA, clear, mild IC retraction, no spell.\nno murmur\njaundice, under phototherapy\nAbdomen soft.\nwt =1630 -30, 140 cc/kg/d with feeding PE 20, some aspirate noted yesterday.\nA: 32 wks GA, jaundice.\nP: monitor for episodes, motnitor tolerance feeding and may consider advancing calorie density if tolerated, f/u bili.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725743, "text": "NPN 0700-1500\n\n\nRESP: Infant remains in room air with sats>95%. Breath\nsounds are clear and equal. Mild subcostal retractions\nnoted. RR 30-40's. No apnea or bradycardia noted.\nA/P: Stable- monitor for spells.\n\nF&N: Tf-140cc/kg/d. Advanced to 24 cals. Tolerating feeds\nwell. Abd is flat and soft with active bowel sounds.\n Voiding and stooling. Infant bottled well at noon for\nDad, taking 27/41cc.\nA/P: Learning to po feed- Bottling once/shift- advance as\ntolerated. Monitor weight.\n\nDEV: Temp is stable in an air-controlled isolette. Infant\nis alert and active with cares. Sleeps well betwen cares.\nTone is wnl- actions are appropriate for gestational age.\nFESO4 ordered.\n\n: Mom and Dad and grandmother in to visit. Dad did\ncares- very eager to participate. Dad also bottled \nand was very much in tune with her cues and responded\nappropriately.\nA/P: Involved/ - cont to teach and support\nthem.\n\nBILI: Single phototherapy d/c'd at noon for a bili of\n4.9/.3/4.6. Infant is ruddy/jaundiced. Rebound bili to be\ndrawn in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725744, "text": "NPN 1500-2300\n\n#1 Alt. in Resp. Function\nO: In RA, RR 30's-60's with mild SC retractions. Breath sounds are clear. Sats 99-100. No spells.\nA: Doing well in RA\nP: Continue to monitor and observe. Document any spells.\n\n#2 Alt. in Nutrition\nO: TF=140cc/kg=41cc PE24 or BM24 Q 4 hrs. Abd. is round, soft with active BS, stable girth. Small aspirates, no spits. Voiding and passing green stool. Feeds given by gavage over 45 min.\nA: Tolerating feeds well at present, gaining wt.\nP: Continue with present feeding plan. Close observation for feeding tolerance and follow daily wts.\n\n#4 Alt. in Development\nO: Isolette turned off tonight and temp remains stable. Infant is swaddled, nested in sheepskin, positioned supine with boundaries in place. Not waking for feeds, but alert with cares. Sucks for short periods on pacifier. No spells.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs. Transfer to crib tomorrow if temp okay and no phototherapy needed.\n\n#5 Alt. in Parenting\nO: Mom in for 1600 feeding. Changed diaper and took temp. Held infant during gavage. Dad called later in shift. Plans to visit later tonight.\nA: Involved, \nP: Keep informed, support and teach.\n\n#6 Hyperbilirubinemia\nO: Color remains ruddy. Off phototherapy. Adequate hydration and passing stool.\nA: Resolving hyperbilirubinemia\nP: Check rebound bili in AM.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725726, "text": "Neonatology Attending\n\nDay 3\n\nRemains in RA. SA-O2 99-100%. Has had three bradycardic episodes- all mild- over last 24 hours. HR 120-130s. BP mean 55. Bilirubin 8.2/0.3. Weight 1650 gms (-55). TF at 120 cc/kg/d. Half volume is enteral. Bottle fed this morning. Increasing feeds by 20 cc/kg/ twice daily. Transient soft bowel loops palpated. Lytes 145/5.2/112/19. Stable temperature in air-controlled incubator.\n\nDoing well overall with mild apnea of prematurity. Will continue to monitor closely. Feeding well. Likely exaggerated physiologic hyperbilirubinemia. Will continue to treat with phototherapy and follow bilirubin. Continuing feeding advance. Metabolically fine. Family meeting held yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725727, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in air isolette. In room air, BS clear and equal with mild subcostal/intercostal retractions, color pink/jaundiced. RRR, without murmur, pulses 2+ and symmetrical. Slightly hypoactive bowel sounds, without loops, without HSM, tolerating advancing feeds well at present. Peripheral IV infusing well via left hand, without reddness or swelling at site.Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725728, "text": "0700- NPN\n\n6 Hyperbilirubinemia\n\nRESP: Infant is in RA with RR 30s-60s and sats 99-100%. LS\nclear/=, mild IC retractions present. Brady x1 without\ndesat, QSR. A: pot alt in resp r/t prematurity P: Cont to\nmonitor resp status.\n\nFEN: TF 120cc/k/d; IVFs D10w with 2NaCl+1KCl running at\n40cc/k/d via PIV, enteral feedings increased to 80cc/k/d\nPE20, po/pg. Infant bottled for the first time this a.m. and\ntook 15cc using yellow nipple. Good pacing and coordination\nnoted. No spits, min asp with small specs of brown, old\n present, NNP aware. Abd is soft and round with soft\ntransient loops present (NNP aware), active BS. Abd girth\n25cm, stable. Voiding and mec stooling (old also\npresent in stool). A: pot alt in feeding tolerance r/t\nprematurity P: Cont to monitor feeding tolerance, support\nand encourage po feedings.\n\nG&D: Temps stable in air iso, nested with sheepskin (under\nphotothx). MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping b'twn cares. Brings hands to midline,\nsucks on pacifier for comfort. A: AGA P: Cont to support\nG&D.\n\nPARENTING: in to visit today. Updated by RN, asking\nappropriate questions. Becoming independent with cares. Mom\nis being discharged today. A: loving and invested P: Cont to\nsupport and educate.\n\nBILI: Started on single photothx this a.m. for a bili of\n8.2-0.3-7.9. A: hyperbilirubinemia P: Recheck bili in a.m.\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725720, "text": "NEONATOLOGY ATTENDING\n\nDay 2 for .\n\nRESP: RA, good sats. RR 40-60. Mild retractions, no bradys. Single desat, self resolved.\n\nCV: Good HR, perfusion. MAP 39.\n\nBILI: Bili 5.2 last night. Repeat this AM pending.\n\nFEN: 1705 -35. 100/kg. 80/kg of D10 with lytes. 20/kg of HBM 20 gavage q4h. No spits, minimal aspirates. Belly benign. Urine 3.4/k/h. 145/5.1/113/21. Mec stools. Advance 20/kg .\n\nDVLP: Air-mode incubator.\n\nPARENTS: Parents happy.\n\nSee exam note below.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725721, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equla. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSm. active bowel sounds. ifnant alert and active.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725717, "text": "NPN 1430\n\n\n#1 Resp: remains in RA w/ O2sats 97-100%, no desats\nor bradys. Lungs clear, = bilat, mild SC retractions. Color\npink. A: Stable in RA. P: Cont to assess for change in resp.\nstatus.\n#2 F/N: Total fluids at 80cc/kg/d; feedings started at\n20cc/kg/d PE20 6cc q 4 hrs. PIV at 4.3cc/hr D10. Lytes and\nbili at 10pm tonight. Glucose= 114. Abd soft and flat w/ AG\n22.5cms, bowel snds present. Infant is voiding and stooling.\n#5 NG tube placed in the right nares to 17cms.\nA: Feedings initiated.\nP: Monitor for feeding intolerance.\n#3 ID: Remains on Ampi/Gent as ordered. Temps stable on\nwarmer/isolette. Behavior appropriate for age, moving\nall extremities. A: Stable on antibiotics. P: Cont as\nordered, monitor culture results.\n#4 Dev.: was moving to a 33.0C heated isolette this\nAM. Boundaries in place, sheepskin under baby. Baby is\nswaddled. Infant awake and alert w/ cares. A: AGA 33 wks.\nP: Cont dev. supports.\n#5 Parents: Mom and Dad up this AM. Held for a while.\nAsking appropriate questions. Mom is planning to attempt br.\nfeeding. Parents will try to locate a pediatrician in their\narea. A: Invested parents. P: Cont parent support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725722, "text": "0700- NPN\n\n\nRESP: Infant is in RA with RR 40s-60s and sats 99-100%. LS\nclear/=, mild subC retractions present. No bradys or desats\nat this time. A: stable in RA P: Cont to monitor resp\nstatus.\n\nFEN: TF 100cc/k/d; enteral feedings increased today to\n40cc/k/d BM20/PE20 pg, IVFs D10w with 2NaCl+1KCl running at\n60cc/k/d via PIV. No spits, min asp with small specs of\nbrown old- present, NNP aware. Abd soft, flat, no\nloops, active BS. Girth 22-22.5cm, stable. Voiding, no stool\nat this time. Dstick 73. A: tolerating feedings P: Cont to\nincrease enteral feedings 20cc/k/d as tolerated.\n\nSEPSIS: Cont on Amp and Gent x48hr r/o. VSS per flowsheet.\nA: no sx of sepsis at this time P: Cont to monitor.\n\nG&D: Temps stable in air control iso, dressed and swaddled.\nMAE, fontanels soft and flat. Alert and active with cares,\nsleeping b'twn cares. Brings hands to face, somewhat\ninterested in pacifier. A: AGA P: Cont to support G&D.\n\nPARENTING: Parents in to visit throughout the day, updated\nby RN. Both Mom and Dad taking temp and changing diaper with\nminimal assistance. A: loving and invested P: Cont to\nsupport and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725723, "text": "0700- ADDENDUM TO NPN\n\n\nInfant had a brady to 96 with desat to 78%, mild stim given.\nNo apnea noted.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725724, "text": "NNP On-Call/Family Meeting\nFamily meeting held with both , RN, myself, Dr. . All issues addressed per family meeting checklist. to chose primary pediatrician, are not interested in transfer to . All questions answered.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725725, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > than 98% with no desats or\nspells. Br. sounds clear and =.\n#2O: Wt. down 55g on total fluids of 100cc/kg. IV of D10W\nwith lytes presently at 40cc/kg. Feeds of Pe20 increased to\n60cc/kg, q 4 hrs. Belly soft, occ. soft loops and sm. asp.,\nno spits. Voiding qs, and passing mec stool. Lytes and\nbili done, see flow sheet, d-s 61.\n#3O: Bld. cx. neg. and ampi and gent d/c.\n#4O: In heated isolette with stable temp. Active and\nresponsive with cares, some mild sucking on pacifier.\n#5O: visited and updated. Mom will be d/c from the\nhospital later today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725718, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > than 96% with no desats or\nspells. Br. sounds clear with very mild retractions.\n#2O: Total fluids presently at 80cc/kg/d. Will be\nincreased with new IV fluid. IV of D10W at 60cc/kg and\nenteral feeds at 20cc/kg. Belly soft, voiding and passing\nmec. stool. Had a partially digested asp. with flecks of\nblood at 20:00 feed. to NNP, and asp. then\ndiscarded. Lytes and bili done, see flow sheet.\n#3O: Ambi and gent given, bld. cx neg. to date.\n#4O: In heated isolette with temp weaned 2 degrees. Alert,\nvery mellow with cares.\n#5O: Parents up and shown how to take temp, change diaper\nand swaddle. Both parents pleased that daughters are doing\nwell.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725719, "text": "nursing progress note 2400-0700\n\n\n#1 resp\no: pt in r/a with sats 99-100%. lsc and equal. mild sc\nretractions noted. rr40-60's. no spells. one drift to 84\nqsr. a: stable P: continue to monitor for changes and\nsupport as needed..\n#2 fen\no: tf 100cc/kg. ivf infusing via piv @ 80cc/kg. enteral\nfeeds of pe20 @ 20cc/kg. wt 1.705kg (-35gms). abd benign.\nmax aspir of 1.2cc brown in color, nnp aware. aspirate\ndisgarded and feed continued. ag stable 22.5-24.5cm. no\nspits. voiding 3cc/kg with trace mec stools. a: stable,\ntolerating feeds well. reported of infant swallowing large\namt of blood during delivery. p: continue to monitor for\nchanges and support as needed.\n#3 sepsis\nO: pt with stable temps in air controlled isolette. alert\nand awake with cares. remains on double abx til bc complete.\na: stable P: continue to monitor for changes and support as\nneeded.\n#4 g&d\nO; pt in air controlled isolette with stable temps. able to\nwean x2 for temps 98.8 and 99.1. alert and awake with cares.\nfontanelles soft and flat. sucking on pacifier. maew. a:\nstable P: continue to monitor for changes and support as\nneeded.\n#5 parenting\no: mom in for 12am cares. asking appropriate questions.\nconcerned. a; loving and caring mom P: continue to update\nwith new information when available and support as needed.\n\n\n" } ]
68,177	131,184	82 yo WF w PMHx of Lung adeno ca sp lobectomy, HTN, GERD, Hx of cerberal aneurysm presents w septic shock cholangitis, needing ICU stay, fluids, pressors, brief intubation 1. Septic shock - cholangitis from choledocholithiasis w + bacteremia w Strep and Ecoli. Now resolved. SP on w removal of sludge/pus and stent placement. Repeat Blood Cx NGTD. Initially placed on Vanc/Zosyn, abx narrowed to Rocephin based on sensi. PICC placed for a total of 14 day course. Repeat in 4 weeks 2. Mild hypoxia - to fluid overload from aggressive fluid resuscitation. Repeat CXR shows improvement in fluid overload, continue to monitor. Incentive spirometer to avoid pna. 2liters Oxygen prn to keep sats >90% 3. Incidental finding of L adnexal cyst - pt and daughter informed that PCP will need to do an outpt FU w pelvic ultrasound 4. Recent episode of SVT vs afib - no such episodes on floor, tele discontinued 5. Anemia - mild anemia w stable HCT. PCP to follow up at discharge 5. GERD - continued on ppi 6. Hx of depression - continued on effexor 7. HTN - switched to outpatient meds which included atenolol, triamterene/hctz . FEN - regular diet . Code status - full . VTE prophylaxis - sq heparin . Disposition - Discharged to Epic of Nursing home	-supplementary O2 PRN -low index of suspicion to repeat ABG for mental status changes # Cholangitis: Vanco / Zosyn as above. Now she has had return to pressor requirement despite optimized volume status--this is in the absence of significant fever but with persistent bandemia. Response: Have been able to wean levophed gtt down to 0.03mcg/kg/hr. Will continue gentle diuresis and get OOB given volume overload in the setting of massive resuscitation. # Cholangitis: Vanco / Zosyn as above. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. - Pipercillin/tazobactam -Vancomycin for GPC - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. - Pipercillin/tazobactam -Vancomycin for GPC - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. - Vanc/Zosyn - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. -monitor serial abdominal exams # Hypertension: hold antihypertensives except BB for the moment until longer w/o hypotension # Lung Cancer: not active issue, outpatient follow up # Cerebral Aneurysm: low tolerance for hypertension # Depression: continue antidepressents # Hypercholesterolemia: hold statin for now, restart when LFTs trendign toward normal # Access: Right IJ, Aline, also 2 PIVs # FEN: NPO # PPx: PPI, heparin SQ # Dispo; ICU # CODE: FULL ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:50 PM Prophylaxis: DVT: Hep SC Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: COMPARISON: at 05:06 FINDINGS: The patient has been extubated and the NGT has been removed. HPI: 24 Hour Events: -Patient with PSV wean across yesterday to minimal settings--A/C required with decreased drive and sedatin lightened this mornign -Norepinephrine weaned to off History obtained from Medical records Allergies: Meperidine Unknown; Percocet (Oral) (Oxycodone Hcl/Acetaminophen) Lightheadedness Codeine Constipation; Last dose of Antibiotics: Piperacillin/Tazobactam (Zosyn) - 04:00 AM Vancomycin - 08:02 AM Infusions: Other ICU medications: Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Constitutional: No(t) Fever Respiratory: Tachypnea Gastrointestinal: No(t) Abdominal pain Genitourinary: Foley Flowsheet Data as of 09:27 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.9C (98.5 Tcurrent: 36.9C (98.5 HR: 69 (59 - 75) bpm BP: 171/67(107) {92/34(58) - 171/76(107)} mmHg RR: 21 (15 - 21) insp/min SpO2: 96% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch CVP: 13 (2 - 13)mmHg Total In: 1,524 mL 579 mL PO: TF: IVF: 1,479 mL 579 mL Blood products: Total out: 1,152 mL 580 mL Urine: 1,152 mL 580 mL NG: Stool: Drains: Balance: 372 mL -1 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: CPAP/PSV Vt (Set): 0 (0 - 500) mL Vt (Spontaneous): 471 (446 - 562) mL PS : 5 cmH2O RR (Set): 0 RR (Spontaneous): 21 PEEP: 5 cmH2O FiO2: 50% RSBI: 80 PIP: 16 cmH2O Plateau: 17 cmH2O Compliance: 42.7 cmH2O/mL SpO2: 96% ABG: 7.32/41/89.//-4 Ve: 8.9 L/min PaO2 / FiO2: 178 Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 9.8 g/dL 70 K/uL 79 mg/dL 1.1 mg/dL 19 mEq/L 4.4 mEq/L 15 mg/dL 119 mEq/L 140 mEq/L 30.9 % 4.1 K/uL [image002.jpg] 12:39 PM 01:04 PM 04:55 PM 09:25 PM 09:47 PM 04:10 AM 06:08 AM 12:28 PM 04:36 PM 08:25 AM WBC 5.9 3.1 4.1 Hct 33.8 27.9 30.9 Plt 72 53 70 Cr 1.0 1.1 1.1 TCO2 20 20 21 17 21 21 22 Glucose 86 81 79 Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos / T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %, Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:2.3 mg/dL Fluid analysis / Other labs: 7.32/41/89 Microbiology: GNR's with pan-sensitive Assessment and Plan 82 yo female admit with biliary obstruction and ascending cholangitis and now with excellent stability of blood pressure following Rx with decompression and drainage. There is a small amount of hypodensity adjacent to the shunt catheter which may represent adjacent edema, which is unchanged from the prior study. Also noted is a stable appearing hypodensity within the right internal capsule, which is likely attributed to chronic ischemic changes. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line placement via the right basilic venous approach. Limited evaluation of the lung bases is unchanged with basilar atelectasis and right pleural thickening noted. IMPRESSION: Endotracheal tube in satisfactory position. ETT placment PFI REPORT Endotracheal tube in satisfactory position. CT ABDOMEN: There is mild-to-moderate intra- and extra-hepatic biliary dilatation which is new compared to the prior study dated . FINDINGS: Again noted is a right posterior ventriculostomy shunt catheter with the tip terminating in the frontal of the left lateral ventricle. The visualized paranasal sinuses and mastoid air cells are normally aerated. Endotracheal tube in satisfactory position. Right PICC tip is in the SVC. IMPRESSION: Right central venous catheter with tip at the cavo-atrial junction. There is a stable appearing region of hypoattenuation within the right frontal periventricular white matter which may represent the sequelae of microvascular angiopathy. There is unchanged positioning of the endotracheal tube whose tip terminates approximately 4 cm from the carina. 10:57 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: PE?	69	[ { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440839, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440909, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440989, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500. ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440990, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440994, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n back on CMV 500/18/50%/5 PEEP\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 440995, "text": "Chief Complaint: s/p ERCP, sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin - 07:56 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 59 (55 - 68) bpm\n BP: 114/54(76) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 65 Inch\n CVP: 10 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 712 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 667 mL\n Blood products:\n Total out:\n 2,707 mL\n 312 mL\n Urine:\n 2,707 mL\n 312 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 400 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, occasional)\n Abdominal: Soft, No(t) Bowel sounds present, Distended, Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2116-03-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440848, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440969, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym.\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440970, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains on vent settings,\n sedated with Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 440972, "text": "Chief Complaint: Sepsis\n Cholangitis\n respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n -2 liters overnight for hypotension and despite this Levophed\n restarted.\n History obtained from Medical records\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 07:56 AM\n Piperacillin/Tazobactam (Zosyn) - 10:03 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 60 (55 - 68) bpm\n BP: 94/50(68) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 9 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 897 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 852 mL\n Blood products:\n Total out:\n 2,707 mL\n 417 mL\n Urine:\n 2,707 mL\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 96%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n Diffuse\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 70 K/uL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Imaging: CVL, ETT, OGT in good position, persistent LLL opacity--no\n change\n Assessment and Plan\n 82 yo female admit with cholangitis and now s/p ERCP. She had\n significant sepsis and with stent relieving obstruction rapid wean of\n pressors was performed. Now she has had return to pressor requirement\n despite optimized volume status--this is in the absence of significant\n fever but with persistent bandemia.\n 1)Respiratory Failure\nPatient with intubationin the setting of sepsis\n and cholangitis. She has had substantial improvement in her\n oxygenation and ventilation with good preservation of aeration on CXR-\n -Will move to PSV today\n -Will trial RSBI and 1 hour SBT prior to extubation to consider\n possible successful extubation today\n -If mental status and CVP/fluid status favorable will move to\n extubation\n 2) SHOCK, SEPTIC\n -Vanco/Zosyn\n -Move to diuresis today as tolerated today\n ICU Care\n Nutrition: NPO given possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440978, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440979, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440984, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 441053, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: RSBI-80. Pt placed on\n CPAP/PS @5am. Plan is to extubate today.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440906, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 440964, "text": "Chief Complaint: s/p ERCP, sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin - 07:56 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 59 (55 - 68) bpm\n BP: 114/54(76) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 65 Inch\n CVP: 10 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 712 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 667 mL\n Blood products:\n Total out:\n 2,707 mL\n 312 mL\n Urine:\n 2,707 mL\n 312 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 400 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, occasional)\n Abdominal: Soft, No(t) Bowel sounds present, Distended, Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Hopefully\n she will do well. Continues to demonstrate septic physiology with\n pressor requirment.\n - mixed venous 02\n - titrate CVP to 12 w/fluid bolus\n - wean levophed as tolerated with CVP ~12\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Interestingly, however, is her elevated\n bicarbonate which could be from a higher level at baseline or from a\n contraction alkalosis. Currently intubated on Assist control 500 x 14\n w/5 peep and oxygenating well on 60%.\n - wean Fi02 to 40%\n - check ABgs to see if pH treding toward normal. Would not\n overventilate as I suspect her pCO2 is somewhat elevated given her age\n and elevated bicarbonates in the past (~30). Maintain current minute\n ventilation and monitor PH. Woudl expect as sepsis resolves her pH\n trends towards normal.\n - If pH normal then could change to pressure support and begin weanign\n process. Do not expect her to be intuabed long as her lungs were ok\n prior to admission\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - plans per ERCP\n - NPO for now\n - stent removal in future\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Rihgt IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: famotidine, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 441284, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 82F cholangitis c/b GNR sepsis, respiratory\n failure, and AF vs AVNRT.\n Exam notable for Tm 99.9 BP 130/50 HR 72 RR 17 with sat 98 on FM. WD\n woman, mildly confused. Coarse BS bases. RRR s1s2. Soft +BS. 2+ edema.\n Labs notable for WBC 5K, HCT 31, Cr 0.8.\n Agree with plan to continue vanco/zosyn for cholangitis / GNR sepsis;\n recent cx are negative. Will continue gentle diuresis and get OOB given\n volume overload in the setting of massive resuscitation. AF/AVNR is\n likely mediated by fluid shifts and critical illness. Will continue\n metoprolol and d/c CVL as able, but will hold off on anticoagulation\n for now. Will need PICC for longterm abx. PT eval, wean oxygen for sat\n goal >92%, OOB today. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:29 ------\n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441194, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on\n po lopressor TID,\n CV\n Pt continues in rapid rhythm. Lopressor IV 5mg given x2 with good\n response. BP stable. Afebrile. After pt received vicadin for leg\n pain- pt converted to NSR and PAC\ns. Rate in the 60\ns-70\ns. At\n midnight\ns HR suddenly increased to 150 and then spont went into a\n very slow brady and then broke into a regularly irregular rhythm in the\n 60\ns. Pt did not seem to have any adverse affects from this and this\n rhthym has not been seen again.\n Resp\n At beginning of shift pt was very restless\n BS with insp and\n exp wheezes and requiring more FIO2. Given an atrovent treatment and\n the wheezes decreased and her resp became less labored. She is\n presently on Face tent at 70% and her sats have been stable all night.\n Neuro\n Pt was very restless the entire evening but was unable to\n verbalize why. Attempted mult repositions and even trazodone with min\n response. Continued to try to get legs over the side of the bed.\n Daughter called to check in on mother and stated that her mother has\n restless leg syndrome and does very well with vicadin. Med given x1\n with remarkable response\n pt able to sleep in long naps and much more\n coherant and cooperative. Continues to kick blankets off but is not\n attempting to get out of bed as much.\n GI\n pt had small stools x2.\n GU\n Pt did not receive any more lasix\n UO has been adequate at\n 50-80/hr.\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441277, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Vanc/Zosyn\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441278, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Social Work", "chartdate": "2116-03-23 00:00:00.000", "description": "Social Work Admission Note", "row_id": 441280, "text": "Family Information\n Next of : , (Daughter) (H) \n Health Care Proxy appointed: It appears to this writer that there is no\n HCP. In in Profile under HCP there is the following comment:\n does not yet have a proxy. Would prefer Dtr: .\n Family Spokesperson designated: Same\n Communication or visitation restriction: None known.\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: This admission is the\n seventh at for Ms. , with her first computer accessible\n admission date being .\n Past psychiatric history: Per pt's daughter, Ms. has a HX of\n depression.\n Past addictions history: None known\n Employment status: Retired\n Legal involvement: None known.\n Additional Information:\n Patient/Family HX: A doctor admitted this widowed 82 y/o woman with\n sepsis. This worker spoke with her daughter, ; there is a\n second younger daughter. of the interview focused on Ms. and\n her stress and concern. She has two adult children, a son and a\n daughter, who live in housing for people who are developmentally\n challenged.\n Assessment:\n Although there were reported concerns about pt\ns two daughters being\n extremely anxious when pt was in the ED and being admitted, that was\n not this worker\ns experience of Ms. , or her sister whom this\n worker met in later in the day. Ms. \ns concerns for her children\n and mother consume much of her time and emotional energy. She works as\n a dental hygienists, primarily with special needs children. There was\n little relevant HX re Ms. .\n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n 1. To be available to family for support while pt is in the .\n Page \n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441322, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on po lopressor TID,\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR throughout shift. Per report overnight pt had bursts of afib\n with HR up into 140\ns. Throughout shift, pt\ns HR remained in 60\n NSR. Received pt on Lopressor 50mg PO TID.\n Action:\n Lopressor dose lowered to 25mg TID as pt was normotensive and\n experienced no episodes of afib.\n Response:\n Pt remains in NSR with HR in 60\ns. Some PVC\n Plan:\n Continue to monitor for afib. Continue to give Lopressor as ordered.\n Pt started to become very agitated around 1800. Denied pain and was\n ripping O2 mask off. Given 0.5mg Haldol IV x 1 and soft limb\n restraints applied to wrists. Good effect with Haldol as pt is calm\n and resting in bed.\n" }, { "category": "Physician ", "chartdate": "2116-03-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 440693, "text": "TITLE:\n Chief Complaint: Lethargy\n HPI:\n 82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status. The history was\n obtained from review of the notes as the patient was intubated and\n sedated at the time of admission to the ICU.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72. She was taken to the .\n On arrival to the her blood pressure was in the 60s systolic. She\n was given further fluid resussication (4 liters, for 8 liters total)\n and started on levophed. She was then taken emergenctly to the ERCP\n suite where a stent was placed in the common bile duct and frank pus\n was expressed.\n She returned to the on AC 500 x 14, 100%Fi02 and 5peep. Her Fi02\n was weaned. She was continued on levophed.\n ROS was not able to be obtained as the patient was intubated and\n sedated.\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Propofol - 45 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n # Adenocarcinoma of the lung,\n nonmetastatic, status post resection, Grade T2N0M0. She is\n status post Carboplatin and Taxol on ,\n status post right upper lobectomy on .\n # Cerebral Aneursym, s/p coiling @ in \n # Hypertension.\n # Hypercholesterolemia.\n # Diverticulosis.\n # Hiatal hernia.\n # Gastroesophageal reflux disease.\n # Status post cholecystectomy, appendectomy, total abdominal\n hysterectomy with bilateral salpingo-oophorectomy.\n n/c\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient lives in . She has a positive tobacco\n history. She smokes two packs per day for 52 years; she quit ten years\n ago. 2 very involved daughters, and .\n Review of systems:\n Flowsheet Data as of 10:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 69 (66 - 81) bpm\n BP: 140/53(84) {113/51(78) - 185/68(110)} mmHg\n RR: 16 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 26 Inch\n CVP: 8 (8 - 22)mmHg\n Total In:\n 8,798 mL\n PO:\n TF:\n IVF:\n 4,598 mL\n Blood products:\n Total out:\n 0 mL\n 1,820 mL\n Urine:\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,978 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/44/219//-4\n Ve: 7.1 L/min\n PaO2 / FiO2: 365\n Physical Examination\n General Appearance: intubated and sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/5/ 09:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 23\n Other labs: Lactic Acid:1.4 mmol/L\n Imaging: CT TORSO:\n 1) No evidence of pulmonary embolism or aortic dissection.\n 2) Emphysema and left lower lobe air space disease which may represent\n aspiration versus pneumonia versus atelectasis. Clinical correlation is\n recommended.\n 3) New intra- and extra-hepatic biliary dilatation with a probable\n filling\n defect noted within the common bile duct, which could represent stones,\n sludge, or neoplastic process. An MRCP is recommended for further\n evaluation.\n 4) 2.8-cm left adnexal cyst which appears larger compared to the prior\n study.\n A pelvic ultrasound is recommended for further characterization given\n the\n patient's post-menopausal status.\n Assessment and Plan\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Hopefully\n she will do well. Continues to demonstrate septic physiology with\n pressor requirment.\n - mixed venous 02\n - titrate CVP to 12 w/fluid bolus\n - wean levophed as tolerated with CVP ~12\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Interestingly, however, is her elevated\n bicarbonate which could be from a higher level at baseline or from a\n contraction alkalosis. Currently intubated on Assist control 500 x 14\n w/5 peep and oxygenating well on 60%.\n - wean Fi02 to 40%\n - check ABgs to see if pH treding toward normal. Would not\n overventilate as I suspect her pCO2 is somewhat elevated given her age\n and elevated bicarbonates in the past (~30). Maintain current minute\n ventilation and monitor PH. Woudl expect as sepsis resolves her pH\n trends towards normal.\n - If pH normal then could change to pressure support and begin weanign\n process. Do not expect her to be intuabed long as her lungs were ok\n prior to admission\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - plans per ERCP\n - NPO for now\n - stent removal in future\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Rihgt IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: famotidine, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:54 PM\n 20 Gauge - 05:57 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440758, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440854, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n" }, { "category": "Nursing", "chartdate": "2116-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441057, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Resp\n Pt weaned from propofol slowly starting at 0400 and stopped at\n 0530. RSBI was 80 so changed to CPAP 10/5 at 0500.\n Tolerating this well. BS cl bilat and suctioned for scant amt\n secretions.\n Plan is to wean and extubated this morning.\n CV\n Able to wean levo off at 0300 and BP stable. HR has been in the\n 70\ns most of the night with no ectopy. Pt has been afebrile.\n GU\n foley cath draining adequate amt cl yellow urine.\n GI\n Pt had one very small brown soft stool. OGT clamped.\n Social\n Daughter in visiting last evening\n updated on plan of care\n and anxious to have mother make forward progress.\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441420, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night , HO obtained ABG\n this am at 0630\n Plan:\n Continue to monitor, f/u ABG results\n" }, { "category": "Physician ", "chartdate": "2116-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441423, "text": "Chief Complaint: 82 y/o woman with history of lung Ca and cerebral\n aneuysym admitted to the ICU with cholangitis, septic shock, and\n respiratory failure\n 24 Hour Events:\n \n -Quiet day, maintained on shovel mask O2 (nasal cannula 3L this a.m.)\n and mainly had concerns regarding some minor intermittent confusion,\n presumed post infectious\n -Attempted nurse and weren't able to place so ordered for\n IR placed\n -Blood Cx finally positive for two isolates of E. Coli (relatively\n sensitive) and one bottle with Strep angionosus (usually pen\n sensitive). Nothing positive since ED blood cx.\n -Agitation at night and received haldol w/ good effect.\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Haloperidol (Haldol) - 03:52 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 62 (60 - 75) bpm\n BP: 113/47(62) {90/44(59) - 154/74(86)} mmHg\n RR: 14 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 7 (7 - 9)mmHg\n Total In:\n 798 mL\n 185 mL\n PO:\n TF:\n IVF:\n 798 mL\n 185 mL\n Blood products:\n Total out:\n 2,570 mL\n 580 mL\n Urine:\n 2,570 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,772 mL\n -395 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.43/50/64/33/7\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 169 K/uL\n 10.2 g/dL\n 84 mg/dL\n 0.9 mg/dL\n 33 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 31.9 %\n 6.5 K/uL\n [image002.jpg]\n 08:33 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n 02:45 AM\n 06:48 AM\n WBC\n 5.6\n 7.1\n 5.8\n 6.5\n Hct\n 35.0\n 34.0\n 31.5\n 31.9\n Plt\n 89\n 113\n 126\n 169\n Cr\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 24\n 27\n 26\n 26\n 29\n 34\n Glucose\n 23\n 85\n 83\n 84\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:73.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:8.0 %, Eos:1.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441141, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on\n po lopressor TID,\n Sepsis without organ dysfunction\n Assessment:\n Off pressors since 3am, extubated at 10am, CVP went from 10 up to high\n of 18, BP up to 160/80\ns I&O\ns show LOS +11 liters, rapid afib, 160\n BP ranged 90-120/60\ns ABGs done, blood culture x 1,\n Action:\n Atrovent nembs, lopressor 5mg x2 given, po started, cont to have short\n bursts of Afib during the day, lasix given 20mg , CVP down to 6-8 in\n the evening.\n Response:\n ABg slightly metabolic acidotic with improvement after lasix dose.\n Output 3.2 liters to lasix,\n Plan:\n Cont to follow ABG, closely monitor I&O\ns ?more lasix tonight,\n antibiotics as ordered. Awaiting culture results for isolation of\n bacteria, follow labs/electrolytes due to large output\n Social: son and two daughters in to visit updated by this RN and Dr.\n .\n" }, { "category": "General", "chartdate": "2116-03-19 00:00:00.000", "description": "ICU Event Note", "row_id": 440674, "text": "Clinician: Attending\n 83 yo female who has h/o HTN and is s/p lap ccy who presented with\n evidence of abdominal pain, fever and chills with associated N/V and\n now with evaluation had, in the ED-->\n -Pt with persistent lethargy patient had evolution of inability to\n maintain airway patency and patient intubated\n -Patient had elevation of T. Bili, CBD dilation and concern for\n obstruction on CT scan\n -Paitient to ICU for admission with CVL placed and 7 liters IVF given\n and Levophed started.\n Upon arrival-->\n Pt responsive to voice and follows commands\n BP-123/76 with levophed\n Bilateral Breath Sounds'\n Distant Heart sounds noted.\n 83 yo female with presentation consistent with cholangitis and bilary\n obstruction now with plans for acute ERCP to relieve obstruction. In\n the interim will-->\n -Place A-line for monitoring during procedure closely\n -Levophed to titrate to MAP >65\n -Will continue Antibiotics-Vanco/Zosyn\n -Continue with CMV support and FIO2=1.0 for now\n -Will continue evaluation following this initial stabilization\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441298, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on po lopressor TID,\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR throughout shift. Per report overnight pt had bursts of afib\n with HR up into 140\ns. Throughout shift, pt\ns HR remained in 60\n NSR. Received pt on Lopressor 50mg PO TID.\n Action:\n Lopressor dose lowered to 25mg TID as pt was normotensive and\n experienced no episodes of afib.\n Response:\n Pt remains in NSR with HR in 60\ns. Some PVC\n Plan:\n Continue to monitor for afib. Continue to give Lopressor as ordered.\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440833, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440835, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis and is intubated\n and sedated with propofol gtt.\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440722, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Respiratory ", "chartdate": "2116-03-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440713, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 40.9 None\n Ideal tidal volume: 163.6 / 245.4 / 327.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440719, "text": "Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440940, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp in 90s-100s with map 57 at beginning of shift with cvp 11 then down\n to 8. lactate 1.1. pt remains intubated on ac with no vent changes:\n .5x500x18+8. hct down to 27.9 from 33.8, plt down to 53 from 72.\n continues with gm negative sepsis ( bld cx + for gm negative rods).\n The source of pt\ns septic shock is most likely r/t cholangitis. Pm k\n 3.1.\n Action:\n Given 1 liter ns with transient increase in map to low 60s and cvp to\n 12 but back down again to high 50s with cvp back down to 8. given\n another 1 liter ns bolus again with only transient increase of map to\n low 60s and cvp back up to . levophed restarted at .03mcg/kg/min\n and titrated down to .01 mcg/kg.min. mixed venous 02 sat 74%. Pt given\n iv zosyn and also ordered vanco iv qd, next due at 8am . repleted\n with 40 meq po kcl via ogt and an additional 40meq iv kcl.\n Response:\n Sbp in 100s with map in low to mid 60s, unable to wean levophed further\n d/t map down to high 50s with levophed off. Am k 4.4. am hct 30 from\n 27.\n Plan:\n Continue to wean levophed as tolerated with map goal >60, sbp >90, cvp\n >12. monitor lactate. Continue iv abx. replete lytes prn. f/u with am\n wbc, plt.\n Sepsis without organ dysfunction\n Assessment:\n Gm negative rods in blood cx bottles from . afebrile, wbc down\n to 5.6. sepsis most likely biliary source. s/p ercp and no stone was\n visualized. Source of infection still unknown.\n Action:\n Temp monitored. Surveillance bld cx drawn x2 with am labs.\n Response:\n Afebrile, still requiring minimal dose of levophed. Am abg with\n improved acidosis: 7,35.29/102.\n Plan:\n Continue to monitor temp, abx as ordered, , f/u with culture results.\n Change vent to psv now that his ph has normalized.\n" }, { "category": "Physician ", "chartdate": "2116-03-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 441100, "text": "Chief Complaint: Sepsis\n Respiratory Failiure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Patient with PSV wean across yesterday to minimal settings--A/C\n required with decreased drive and sedatin lightened this mornign\n -Norepinephrine weaned to off\n History obtained from Medical records\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 69 (59 - 75) bpm\n BP: 171/67(107) {92/34(58) - 171/76(107)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 13 (2 - 13)mmHg\n Total In:\n 1,524 mL\n 579 mL\n PO:\n TF:\n IVF:\n 1,479 mL\n 579 mL\n Blood products:\n Total out:\n 1,152 mL\n 580 mL\n Urine:\n 1,152 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 372 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 471 (446 - 562) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.32/41/89.//-4\n Ve: 8.9 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 70 K/uL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n 12:28 PM\n 04:36 PM\n 08:25 AM\n WBC\n 5.9\n 3.1\n 4.1\n Hct\n 33.8\n 27.9\n 30.9\n Plt\n 72\n 53\n 70\n Cr\n 1.0\n 1.1\n 1.1\n TCO2\n 20\n 20\n 21\n 17\n 21\n 21\n 22\n Glucose\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos /\n T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0\n mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Fluid analysis / Other labs: 7.32/41/89\n Microbiology: GNR's with pan-sensitive\n Assessment and Plan\n 82 yo female admit with biliary obstruction and ascending cholangitis\n and now with excellent stability of blood pressure following Rx with\n decompression and drainage. She has been able to wean off pressors and\n maintained stable BP through to this morning. In addition, patient has\n had excellent tolerance of minimal ventilatory settings across the\n night and with sedation weaned to off patient with excellent mental\n status, able to follow commands and with minimal secretions.\n RESPIRATORY FAILURE\nPatient with initial intubation with altered mental\n status with sepsis and now has excellent alertness, sepsis (GNR\n improved, Ve requirement <10 and able to follow commands clearly and\n with CVP <10 has excellent control of volume status.\n -Extubation today given favorable RSBI, improvement in reasons for\n intubation\n -Check cuff leak prior to extubation\n -OOB to chair\n -Incentive spirometry\n SHOCK, SEPTIC\n -Vanco/Zosyn\n -IVF as needed\n -Continue to follow culture results\n ICU Care\n Nutrition: npo this morning\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "General", "chartdate": "2116-03-22 00:00:00.000", "description": "ICU Event Note", "row_id": 441110, "text": "Clinician: Attending\n Patient with extubation this am. She had favorable RSBI, excellent\n mental status but had evolution of paroxysms of tachycardia and\n significant pulmonary ocngestion and bronchospasm following extubation.\n She had excellent response to IV Lasix with 1.3 liters urine out.\n She has reasonable response to IV Lopressowith stabilization of HR to\n <90.\n She had some decrease in SB to 83 following diuresis whichi will limit\n capacity to prvide further diuresis.\n Patient exam shows substantial improvement in air movement and decrease\n in wheezing.\n Will need to-->\n Continue with rate control\n Lopressor po tid\n Hold on further diuresis\n No role for CPAP at this time as patient had significant diuresis and\n rate control will be primary mode for maintenance of extubated status.\n Plan described to housestaff/family and nursing.\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440929, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments No RSBI/no spont respiratory efforts at this time.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441015, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n back on CMV 500/18/50%/5 PEEP\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Physician ", "chartdate": "2116-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441084, "text": "Chief Complaint: 82 y/o woman with history of breast Ca and cerebral\n aneuysym admitted to the ICU with cholangitis, septic shock, and\n respiratory failure\n 24 Hour Events:\n :\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n ______________________________________________________\n \n - Trial of pt CO2 progressively rose and pH dropped with Minute\n Ventilation. ? if sedation interfering with resp drive. Expect to d/c\n sedation in am and retry PS for possible extubation tomorrow\n -Tried to wean levo but still requires between 0.01 and 0.02. Weaned\n off this a.m.\n - Blood cultures from growing pan-sensitive GNR.\n -d/c omeprazole- now on IV Famotidine only\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 07:56 AM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 75 (59 - 75) bpm\n BP: 111/62(83) {92/34(58) - 119/76(91)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (2 - 10)mmHg\n Total In:\n 1,524 mL\n 349 mL\n PO:\n TF:\n IVF:\n 1,479 mL\n 349 mL\n Blood products:\n Total out:\n 1,152 mL\n 320 mL\n Urine:\n 1,152 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 372 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 446 (446 - 562) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.29/42/94.//-5\n Ve: 8.5 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n 12:28 PM\n 04:36 PM\n WBC\n 5.9\n 3.1\n 4.1\n Hct\n 33.8\n 27.9\n 30.9\n Plt\n 72\n 53\n 70\n Cr\n 1.0\n 1.1\n 1.1\n TCO2\n 21\n 20\n 20\n 21\n 17\n 21\n 21\n Glucose\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos /\n T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0\n mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ, pneumoboots\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2116-03-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 440777, "text": "Chief Complaint: Sepsis\n Cholangitis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with abdominal pain and fever and to ED with those complaints\n and was found to have bile duct obstruction and dilitation which when\n combined with fever and abdominal pain was felt to be consistent with\n cholangitis.\n Upon arrival in ICU patient given 4 liters IVF and started on NE gtt.\n ERCP was performed last evening with stent to CBD with drainage of\n purulent fluid noted but no stone visualized. Stent was placed.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Lung Cancer-_Stage I--s/p resection\n Cerebral Aneurysm\n S/p CCY\n S/P APPY\n Occupation: Lives in \n Drugs: None\n Tobacco: 100 py hx\n Alcohol: None\n Other:\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.6\nC (96\n HR: 63 (57 - 81) bpm\n BP: 131/52(81) {84/33(51) - 185/68(110)} mmHg\n RR: 19 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 26 Inch\n CVP: 9 (4 - 22)mmHg\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 9,879 mL\n 2,676 mL\n PO:\n TF:\n IVF:\n 5,679 mL\n 2,676 mL\n Blood products:\n Total out:\n 2,200 mL\n 1,650 mL\n Urine:\n 1,200 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,679 mL\n 1,026 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 232 (232 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 51\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.27/43/116/20/-6\n Ve: 8.7 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 34.9 %\n 10.9 g/dL\n 89 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 20 mEq/L\n 120 mEq/L\n 3.6 mEq/L\n 142 mEq/L\n 5.5 K/uL\n [image002.jpg]\n 08:55 PM\n 09:20 PM\n 11:10 PM\n 03:22 AM\n 04:12 AM\n WBC\n 5.5\n Hct\n 34.9\n Plt\n 67\n Cr\n 1.1\n 1.1\n TC02\n 23\n 19\n 21\n Glucose\n 99\n 89\n Other labs: PT / PTT / INR:17.7/28.9/1.6, ALT / AST:169/76, Alk Phos /\n T Bili:352/6.2, Differential-Neuts:64.0 %, Band:21.0 %, Lymph:9.0 %,\n Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.4 g/dL,\n LDH:186 IU/L, Ca++:7.1 mg/dL, Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR--OGT, ETT, CVL in good position. MIld per-hilar fullness\n noted but no frank pulmonary edema.\n Microbiology: BC--GNR's in blood cultures\n Assessment and Plan\n 82 yo female admitted with sepsis and with severe compromise and\n significant bandemia consistent with septic shock.\n 1)Sepsis\nClearly most likely biliary source. She is now s/p ERCP but\n without stone seen raising the question of what the source of\n obstruction was. This may be stone not visualized or narrowing at the\n level of the ampullla\nfor now stent has provided decompression.\n Abdomen with mild tenderness. Of note CVP is 7, HCT is >30. Will\n -Utilize Fluid bolus as needed\n -Will continue with Levophed and wean as possible today\n -Vanco/Zosyn to continue\n -Will consider addition of Vasopressin if unable to wean Levophed\n rather than additional fluid if CVP remains elevated\n 2)Cholangitis-_Will follow up ERCP results with team\n -Continue ABX\n -NPO today\n -Stent in place\n 3)Respiratory Failure-Patient with persistent and significant elevation\n in required FIO2 in the setting of sepsis and fluid resuscitation\n dose have excellent compliance\nwith Pplat=18 in the setting of\n PEEP=8 and Vt=500. This is reassuring that if once we have PEEP\n optimized we shuld be able to decrease FIO2.\n -Wean FIO2-0.5 today\n -Up-titrate PEEP to 10 if decrease in PaO2 seen\n 4)Thrombocytopenia-\n -Will check DIC labs ongoing\n -Would consider likely related to Sepsis\n -Is decreased from baseline quite rapidly\n 5)Metabolic Acidosis\nNon gap and likely related to saline and volume\n expansion required.\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition: NPO today\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:54 PM\n 20 Gauge - 05:57 PM\n Arterial Line - 06:20 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2116-03-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 440795, "text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 81.2 kg\n ~4kg in ~6 mths\n 30\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 144\n 63\n 77.7kg \n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:22 AM\n BUN\n 15 mg/dL\n 03:22 AM\n Creatinine\n 1.1 mg/dL\n 03:22 AM\n Sodium\n 142 mEq/L\n 03:22 AM\n Potassium\n 3.6 mEq/L\n 03:22 AM\n Chloride\n 120 mEq/L\n 03:22 AM\n TCO2\n 20 mEq/L\n 03:22 AM\n PO2 (arterial)\n 116 mm Hg\n 04:12 AM\n PCO2 (arterial)\n 43 mm Hg\n 04:12 AM\n pH (arterial)\n 7.27 units\n 04:12 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 04:12 AM\n Albumin\n 2.4 g/dL\n 03:22 AM\n Calcium non-ionized\n 7.1 mg/dL\n 03:22 AM\n Phosphorus\n 2.8 mg/dL\n 03:22 AM\n Magnesium\n 1.8 mg/dL\n 03:22 AM\n ALT\n 169 IU/L\n 03:22 AM\n Alkaline Phosphate\n 352 IU/L\n 03:22 AM\n AST\n 76 IU/L\n 03:22 AM\n Total Bilirubin\n 6.2 mg/dL\n 03:22 AM\n WBC\n 5.5 K/uL\n 03:22 AM\n Hgb\n 10.9 g/dL\n 03:22 AM\n Hematocrit\n 34.9 %\n 03:22 AM\n Diagnosis: Sepsis\n PMH : Lung CA s/p RUL rxn with adjuvant chemo, cerebral aneurysm s/p\n coiling ', HTN, >chol, diverticulosis, hiatal hernia, GERD, s/\n ccy/appy, TAH.\n Food allergies and intolerances: none noted.\n Pertinent medications: norepinephrine, propofol.\n Current diet order / nutrition support: NPO.\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: dx, hx of CA, age\n Estimated Nutritional Needs\n Calories: 1386 - 1764 (BEE x or / 22 - 28 cal/kg)\n Protein: 70 - (1.1 - 1.488 g/kg)\n Fluid: per team.\n Specifics:\n 82 YO female p/w abdominal pain, N/V/D & found to have sepsis,\n cholangitis & respiratory failure & currently intubated. s/p ERCP on\n with stent to CBD w/ drain but stone not visualized. Per team NPO\n for today. Recommend nutrition support if remains intubated or NPO in\n the next 24-48hrs. TPN vs TF. If TF: FS Fibersource HN at goal 55mL/hr,\n providing 1584kcals & 70g protein. If TPN\nwill need central access &\n start with Day /Starter TPN & adjust lytes per labs. Goal TPN would\n be 60kg 3-in-1 STD solution: 1500mL(255g Dex/90g AA/30g Fat), providing\n 1500kcals.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If remains NPO or intubated in the next 24-48hrs: Consider TF:\n Fibersource HN; start at 10mL/hr, advance by 10-15mL/hr to goal 55mL/hr\n via OGT/NGT\n 2. Check residuals Q 4hrs & hold TF X1hr if >150mL\n 3. If TPN; obtain central access & start Day /starter & adjust\n lytes per labs\n 4. Check Triglycerides\n 5. start RISS; check FSBG Q 6hrs\n 6. Check chem. 10 daily\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 441463, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3. Sleeping this morning. Very restless even while asleep.\n Recived small dose of Haldol 0.5mg IV x1 overnight.\n Action:\n Family in to visit and Pt. more calm. Cont. on Effexor.\n Response:\n Sleeping this morning after Pt.\ns daughter left. redirected.\n Plan:\n More family to visit later today. OOB to chair.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. in NSR now and has for at least past 24 hrs.\n Action:\n Lopressop PO as ordered.\n Response:\n HR 60\ns NSR with no ectopy. BP 100\ns systolic and stable.\n Plan:\n Cont. with PO Lopressor. Monitor VS.\n Pt. with R IJ TLC. Ordered for PICC in IR today. Will go down shortly.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 81.8 kg\n Daily weight:\n Allergies/Reactions:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: hypercholesteremia,diverticulosis, hiatal hernia\n gerd, s/p cholecystectomy, appendectomy, total abd hysterectomy,bil\n salpingo oopherectomy, cerebral artery aneurysm rupture\n Surgery / Procedure and date: cholecystectomy, appendectomy, total abd\n hystorectomy with bilat salpingo-oophectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:108\n D:47\n Temperature:\n 98.3\n Arterial BP:\n S:133\n D:72\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 505 mL\n 24h total out:\n 790 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:45 AM\n Potassium:\n 3.3 mEq/L\n 02:45 AM\n Chloride:\n 101 mEq/L\n 02:45 AM\n CO2:\n 33 mEq/L\n 02:45 AM\n BUN:\n 13 mg/dL\n 02:45 AM\n Creatinine:\n 0.9 mg/dL\n 02:45 AM\n Glucose:\n 84 mg/dL\n 02:45 AM\n Hematocrit:\n 31.9 %\n 02:45 AM\n Finger Stick Glucose:\n 120\n 12:00 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley cath,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 402\n Transferred to: 1181\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440871, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n ------ Protected Section ------\n Levophed gtt off and will continue to follow pt\ns hemodynamics. Fio2 on\n vent dropped to 50% and abg on these settings=7.31/38/95/-. will\n maintain these vent settings over noc and if Hemodynamically stable\n tonoc will wean vent as pt tolerates and hoperfulle extubate.\n Surveillance blood cultures sent off to microbiology.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:43 ------\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440918, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp in 90s-100s with map 57 at beginning of shift with cvp 11 then down\n to 8. lactate 1.1. pt remains intubated on ac with no vent changes:\n .5x500x18+8. hct down to 27.9 from 33.8, plt down to 53 from 72.\n continues with gm negative sepsis ( bld cx + for gm negative rods).\n The source of pt\ns septic shock is most likely r/t cholangitis. Pm k\n 3.1.\n Action:\n Given 1 liter ns with transient increase in map to low 60s and cvp to\n 12 but back down again to high 50s with cvp back down to 8. given\n another 1 liter ns bolus again with only transient increase of map to\n low 60s and cvp back up to . levophed restarted at .03mcg/kg/min\n and titrated down to .01 mcg/kg.min. mixed venous 02 sat 74%. Pt given\n iv zosyn and also ordered vanco iv qd, next due at 8am . repleted\n with 40 meq po kcl via ogt and an additional 40meq iv kcl.\n Response:\n Sbp in 100s with map in low to mid 60s, unable to wean levophed further\n d/t map down to high 50s with levophed off.\n Plan:\n Continue to wean levophed as tolerated with map goal >60, sbp >90, cvp\n >12. monitor lactate. Continue iv abx. f/u with am kcl results and\n replete prn. Monitor am wbc, hgb, hct.\n Sepsis without organ dysfunction\n Assessment:\n Gm negative rods in blood cx bottles from . afebrile, wbc down\n to 5.6. sepsis most likely biliary source. s/p ercp and no stone was\n visualized. Source of infection still unknown.\n Action:\n Temp monitored. Surveillance bld cx drawn x2 with am labs.\n Response:\n Afebrile, still requiring minimal dose of levophed.\n Plan:\n Continue to monitor temp, abx as ordered, f/u with abg results, f/u\n with culture results. Change vent to psv once his ph normalizes.\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441235, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441364, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night\n Plan:\n Continue to monitor, ?ABG if confusion persists, pt reporting hx of\n sundowning f/u with family\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440998, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2116-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 441148, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: pt extubated\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441362, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night\n Plan:\n Continue to monitor, ?ABG if confusion persists, pt reporting hx of\n sundowning f/u with family\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1061153, "text": " 8:41 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yo F with RUQ, increased LFTs, and dilated CBD. Cholangitis. Rule out\n choledocholithiasis.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated LFTs and dilated CBD. Evaluate for choledocholithiasis.\n ERCP.\n\n COMPARISON: CT torso from .\n\n FINDINGS: Twelve spot fluoroscopic radiographs were obtained during ERCP are\n provided for review. Scout images demonstrate surgical clips in the patient's\n right upper quadrant, likely related to prior cholecystectomy. A nasogastric\n tube appears positioned near the duodenum. Multiple additional tubing\n catheters overlie the patient. Injection of contrast into the biliary system\n demonstrates a dilated common bile duct with luminal filling defect. There is\n mild dilatation of the intrahepatic biliary ducts. Per the patient's ERCP\n report, a single 10-mm stone was present. A plastic stent catheter was\n positioned in the common bile duct. For full details, please refer to the\n patient's ERCP note from the same day.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061526, "text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for volume overload vs infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p ercp, s/p extubation now with wheezing\n and tachycardia\n REASON FOR THIS EXAMINATION:\n eval for volume overload vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 12:22\n\n INDICATION: Abnormal breath sounds.\n\n COMPARISON: at 05:06\n\n FINDINGS: The patient has been extubated and the NGT has been removed. The\n right CVL remains in place. Compared to the prior study, there is no\n significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-24 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1061935, "text": " 11:39 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC\n Admitting Diagnosis: SEPSIS\n ******************************* CPT Codes *****************************\n PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE \n US GUID FOR VAS. ACCESS \n ***************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with need for IV abx for cholangitis and failed attempt by IV\n nursing.\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for ABx.\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. , the\n Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right baslic vein\n was punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a PICC line measuring 41 cm in length was then placed through\n the peel-away sheath with its tip positioned in the SVC under fluoroscopic\n guidance. Position of the catheter was confirmed by a fluoroscopic spot film\n of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line\n placement via the right basilic venous approach. Final internal length is\n 41cm, with the tip positioned in SVC. The line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061350, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placment\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis, bacteremia, resp failure\n REASON FOR THIS EXAMINATION:\n ? ETT placment\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb SAT 9:11 AM\n Endotracheal tube in satisfactory position. No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n INDICATION: 82-year-old woman with cholangitis and bacteremia. Respiratory\n failure. Question endotracheal tube placement.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube is in satisfactory position, approximately 3 cm\n above the carina. Remainder of the support lines and tubes are in stable\n position. There is no significant interval change in the appearance of the\n left base opacity, possibly representing atelectasis or consolidation. There\n is no pneumothorax. Heart and mediastinal contours are unchanged.\n\n IMPRESSION: Endotracheal tube in satisfactory position. No significant\n interval change in the appearance of the lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061351, "text": ", S. MED 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placment\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis, bacteremia, resp failure\n REASON FOR THIS EXAMINATION:\n ? ETT placment\n ______________________________________________________________________________\n PFI REPORT\n Endotracheal tube in satisfactory position. No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1060974, "text": " 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hx of aneurysm w/ lobectomy and vp shunt w/ vomiting and\n altered ms.\n FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:14 AM\n No acute hemorrhage. rt ventriculostomy shunt catheter terminating in left\n ventricle. No change in ventricular size. No change from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD\n\n COMPARISON: .\n\n HISTORY: 82-year-old female with history of aneurysm with lobectomy and VP\n shunt now with vomiting and altered mental status.\n\n TECHNIQUE: Contiguous helical acquisition through the head was performed\n without intravenous contrast.\n\n FINDINGS: Again noted is a right posterior ventriculostomy shunt catheter with\n the tip terminating in the frontal of the left lateral ventricle. The\n ventricles are stable in size compared to the prior study. There is no\n evidence of intraparenchymal hemorrhage or mass effect identified. There is a\n small amount of hypodensity adjacent to the shunt catheter which may represent\n adjacent edema, which is unchanged from the prior study. There is a stable\n appearing region of hypoattenuation within the right frontal periventricular\n white matter which may represent the sequelae of microvascular angiopathy.\n Also noted is a stable appearing hypodensity within the right internal\n capsule, which is likely attributed to chronic ischemic changes. Aneurysm\n clips are noted at the skull base. Evaluation of the skull base is limited\n secondary to streak artifact from the clips. The calvarium is stable in\n appearance. The visualized paranasal sinuses and mastoid air cells are\n normally aerated.\n\n IMPRESSION:\n\n No evidence of acute abnormality or change compared to the prior study.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1060977, "text": " 10:57 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: PE? pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hx of aneurysm w/ lobectomy and vp shunt w/ vomiting and\n altered ms. hypoxic on RA.\n REASON FOR THIS EXAMINATION:\n PE? pna?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:04 PM\n NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE REPRESENT ASPIRATION VS\n PNEUMONIA VS ATELECTASIS.\n .\n CT abd/pelvis: mild to moderate biliary dilitation with probable soft tissue\n defect in CBD. CHD measures 17 mm. rec MRCP for further eval.\n\n left adnexal cyst, larger than prior. rec US for further eval.\n WET READ VERSION #1 11:54 AM\n NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE REPRESENT ASPIRATION VS\n PNEUMONIA VS ATELECTASIS.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO, \n\n COMPARISON: .\n\n HISTORY: 82-year-old female with history of aneurysm and lobectomy and VP\n shunt with vomiting and altered mental status.\n\n FINDINGS: Contiguous helical acquisition through the chest, abdomen and\n pelvis was performed with intravenous contrast.\n\n CT CHEST: The heart is normal in size. There is atherosclerotic disease of\n the coronary arteries and aorta. The pulmonary artery and branch vessel\n opacifies normally with no evidence of intraluminal thrombus. The aorta\n opacifies normally with no evidence of aortic dissection. There is no\n mediastinal or hilar lymphadenopathy identified. There is left basilar air\n space disease identified. The right lung is clear. A surgical clip is noted\n at the right lung base. Post-surgical changes within the lungs are noted\n status post right upper lobectomy. There are diffuse emphysematous changes\n identified. There are old right-sided rib fractures noted. The osseous\n structures are otherwise intact. There are degenerative changes of the\n bilateral shoulders and spine.\n\n CT ABDOMEN: There is mild-to-moderate intra- and extra-hepatic biliary\n dilatation which is new compared to the prior study dated . Also noted is\n a probable soft tissue-density filling defect within the mid/distal common\n bile duct. The common hepatic bile duct measures 17 mm in diameter. The\n patient is status post cholecystectomy. The pancreas is normal in appearance\n with no evidence of pancreatic ductal dilatation. The spleen, adrenal glands,\n (Over)\n\n 10:57 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: PE? pna?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and bowel are normal in appearance. There are multiple low-density lesions\n noted within the kidneys bilaterally which are too small to characterize but\n likely represent renal cysts. There is no free air or free fluid identified.\n There is atherosclerotic disease of the descending aorta. There is a\n ventriculostomy shunt catheter identified.\n\n CT PELVIS: There is a left adnexal cyst which appears somewhat larger\n compared to the prior study and currently measures 2.8 cm. There is\n diverticulosis of the sigmoid and descending colon without evidence of\n diverticulitis. No pelvic masses or lymphadenopathy is identified. The\n osseous structures are intact with degenerative changes noted within the\n lumbar spine.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary embolism or aortic dissection.\n\n 2) Emphysema and left lower lobe air space disease which may represent\n aspiration versus pneumonia versus atelectasis. Clinical correlation is\n recommended.\n\n 3) New intra- and extra-hepatic biliary dilatation with a probable filling\n defect noted within the common bile duct, which could represent stones,\n sludge, or neoplastic process. An MRCP is recommended for further evaluation.\n\n 4) 2.8-cm left adnexal cyst which appears larger compared to the prior study.\n A pelvic ultrasound is recommended for further characterization given the\n patient's post-menopausal status.\n\n\n DFDdp\n\n" }, { "category": "ECG", "chartdate": "2116-03-22 00:00:00.000", "description": "Report", "row_id": 196795, "text": "Sinus rhythm with atrial premature complexes\nLeft axis deviation\nIV conduction defect\nLateral T wave changes are nonspecific\nSince previous tracing of , atrial premature complexes are new,\ndecreased QRS voltages\n\n\n" }, { "category": "ECG", "chartdate": "2116-03-19 00:00:00.000", "description": "Report", "row_id": 196796, "text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. Left ventricular hypertrophy. Non-specific\nST-T wave changes. Compared to the previous tracing right bundle-branch block\nis new.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061009, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess et tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with\n REASON FOR THIS EXAMINATION:\n assess et tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess endotracheal tube.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The tip of the endotracheal tube terminates 3 cm from the carina.\n Nasogastric tube courses through the esophagus into the stomach and off the\n field of view of the radiograph. A VP shunt catheter courses along the right\n hemithorax and off the field of view of the radiograph. The cardiac\n silhouette is enlarged which may be reflective of cardiomegaly. There is\n slight prominence of the pulmonary vasculature which may be representative of\n pulmonary congestion in comparison to the prior examination. Lung volumes are\n low and there is bibasilar atelectasis. No areas of consolidation are seen.\n Surgical clips projecting over the patient's right upper quadrant are likely\n related to prior cholecystectomy. Thickening of the right pleura and old\n mulitple right sided rib fractures.\n\n IMPRESSION:\n 1. Endotracheal tube 3 cm from the carina.\n 2. Low lung volumes with mild prominence of pulmonary vasculature.\n 3. Nasogastric tube and VP shunt catheter as described.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1062122, "text": ", V. MED 11R 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent septic shock w aggressive fluid resuscitation,\n eval for interval change in pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Bilateral pleural effusions are small, greater on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "P PORTABLE ABDOMEN PORT", "row_id": 1061095, "text": " 10:11 PM\n PORTABLE ABDOMEN PORT Clip # \n Reason: pls assess position of OGT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p OGT.\n REASON FOR THIS EXAMINATION:\n pls assess position of OGT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb FRI 3:11 PM\n Satisfactory OG tube position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with cholangitis, status post OG tube placement.\n\n COMPARISON: CXR .\n\n FINDINGS: A radiograph positioned at the thoracoabdominal junction was\n obtained for evaluation of orogastric tube placement, which terminates in the\n expected region of the gastric pylorus. A biliary catheter and scattered\n abdominal surgical clips are noted. Limited evaluation of the lung bases is\n unchanged with basilar atelectasis and right pleural thickening noted.\n\n IMPRESSION: OG tube tip near gastric pylorus.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061123, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pna, position of ET tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p intubation.\n REASON FOR THIS EXAMINATION:\n assess for pna, position of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M. \n\n HISTORY: Cholangitis after intubation. Assess for pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Worsening opacification in left lower lobe, probably due to progressive\n atelectasis. Right lung and left upper lung clear. ET tube in standard\n placement. Nasogastric tube ends in the stomach. Right jugular line tip in\n the region of the superior cavoatrial junction. Shunt catheter traverses the\n right neck, chest and upper abdomen. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1062121, "text": " 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent septic shock w aggressive fluid resuscitation,\n eval for interval change in pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 10:34 AM\n Bilateral pleural effusions are small, greater on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Recent septic shock with fluid resuscitation.\n\n Comparison is made with prior study, .\n\n The small bilateral pleural effusions are largely on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload. Mild cardiomegaly is stable. Right PICC tip is in the SVC.\n There is no pneumothorax. A thin catheter projects over the right hemithorax\n medially and right neck.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061025, "text": " 2:14 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with intubation and central line placement. Please confirm\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation and central line placement. Confirm line position.\n\n PORTABLE AP CHEST RADIOGRAPH\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: Since the study from approximately one hour prior, there has been\n placement of a right-sided central venous catheter whose tip terminates\n slightly above the cavoatrial junction. There is unchanged positioning of the\n endotracheal tube whose tip terminates approximately 4 cm from the carina. The\n nasogastric tube and VP shunt catheter are unchanged. There is slight\n prominence of the pulmonary vasculature; however, this is likely due to low\n lung volumes. There is minimal pleural thickening along the right lateral\n pleura, and there is minimal left basilar atelectasis. Otherwise, the lungs\n are clear. The cardiomediastinal silhouette appears unchanged. There are old\n multiple right-sided rib fractures which are chronic.\n\n IMPRESSION: Right central venous catheter with tip at the cavo-atrial\n junction. Low lung volumes with left basilar atelectasis. Endotracheal tube\n in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061836, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis and known pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n slightly better inspiration. Indistinctness of pulmonary vessels is again\n consistent with elevated pulmonary venous pressure. Increased opacification\n at the left base is consistent with atelectasis and effusion, though\n supervening pneumonia cannot be excluded in the absence of a lateral view.\n There may well be some pleural fluid and atelectasis at the right base as\n well.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "P PORTABLE ABDOMEN PORT", "row_id": 1061096, "text": ", F. MED 10:11 PM\n PORTABLE ABDOMEN PORT Clip # \n Reason: pls assess position of OGT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p OGT.\n REASON FOR THIS EXAMINATION:\n pls assess position of OGT\n ______________________________________________________________________________\n PFI REPORT\n Satisfactory OG tube position.\n\n" } ]

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In summary, Ms is an 80 year-old woman with chronic systolic congestive heart failure, presenting with shortness of breath. . # Acute on chronic systolic congestive heart failure: History and presentation consistent with CHF exacerbation - LVEF 20%, BNP 26,000 on admission, lung exam with crackles, CXR w left pleural effusion/congestion. Unclear etiology of CHF exacerbation, possibly from upper respiratory infection vs uncontrolled hypertension (a few SBPs in 140s-150s). Dietary indiscretion and medication non-compliance are likely not causes given patient is presenting from Rehab. Cardiac ischemia ruled out with negative biomarkers. Pt was diuresed w furosemide 80mg IV at first for a goal of -1L/24hrs, then with furosemide with HCTZ 30 minutes prior, as pt stopped responding to furosemide only. Total net -2L in 2 days. Pt improved clinically. PICC line placement was deferred to Rehab. Was transferred back to Rehab on losartan, metoprolol, furosemide, HCTZ. She will need electrolytes checked every other day in the future to monitor. . # Shortness of breath: Pt required BiPAP on admission, transitioned to Venti mask within hours. Successfully weaned to O2 by NC with diuresis. Distress treated with morphine PRN. Now on 2L NC. . # Pneumonia: After diuresis, patient developed worsening productive cough and fevers. CXR notable for likely right lower lobe infiltrate. After discussion with family, decision was made to treat with oral levofloxacin but not to aggressively pursue blood cultures or intravenous access for antibiotics, which had been difficult. Pt is to continue to take levofloxacin through . . # Atrial fibrillation: Patient had a brief of atrial fibrillation with rapid ventricular rate that was controlled with beta blocker and returned to sinus after 4 hours. The decision was made not to anticoagulate with warfarin given that this was likely precipitated by her acute illness and she was already on Plavix and full-dose aspirin. . # CAD: History of MI in . Will continued aspirin, Lopressor, and losartan. . # Peripheral Vascular Disease: S/p bypass. Continued aspirin. Restarted Plavix per discussion with PCP. . # CVA: Patient with right-sided hemiparesis, right facial droop, expressive aphasia. Continued aspirations and fall precautions, as well as supportive measures. . # Hypertension: Lopressor and losartan were continued. . # Diabetes: Type 2 on insulin. Continued standing insulin in addition to sliding scale. . # Parkinson's disease: Continued carbidopa levodopa TID. As per family, pt's condition is progressively worse. She is often more lethargic. Has been refusing meds in hospital, but eventually took them with family. . # Depression: continued sertraline and bupropion. . # Goals of care: On admission, patient was DNR/DNI. After discussion with her family, the decision was made to not aggressively pursue infectious work-up for fever, but rather empiric tx for now with levo. Pt is to be discharge to the .

TITLE: Cardiology Physician Note History of Present Illness Date: Initial visit Events / History of present illness: -improved resp status -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg HCTZ 30minutes before with good result; will continue this now -changed losartan to -repeat CXR showed resolution of possible infiltrate on prior film Medications Unchanged Physical Exam BP: 125 / 47 mmHg HR: 65 bpm RR: 28 insp/min Tmax C last 24 hours: 37.4 C Tmax F last 24 hours: 99.4 F T current C: 36.2 C T current F: 97.2 F O2 sat: 93 % on Supplemental oxygen: 3L NC Previous day: Intake: 300 mL Output: 1,582 mL Fluid balance: -1,282 mL Today: Output: 480 mL Fluid balance: -480 mL VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti mask Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Jugular veins: Not visible) Respiratory: (Effort: WNL), (Auscultation: crackles at bases) Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass: No), (Hepatosplenomegaly: No) Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle strength and tone: right upper extremity flexed. patient was tachypnenic, tachycardic and hypertensive- CXR showed bilateral infiltrates- EKG showed LBBB w/ lateral depressions- Patient was transferred to CCU on mask ventilation for further management Heart failure (CHF), Systolic, Acute on Chronic Assessment: Recd pt wl hr 100 afib. Did receive ntg in EW for hypertension. #Hypertension: continue lopressor and losartan . #Hypertension: continue lopressor and losartan . ), (Dorsalis pedis artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+), (Edema: Right: 0, Left: 0) Skin: ( WNL) Labs ABG: 7.40 / 49 / 128 / / 4 Values as of 01:00 PM Tests ECG: (Date: ), NSR, LVH, LBBB, st depressions V4-V6. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. Date of service: Initial visit, Cardiology service: CCU Presenting complaint: Dyspnea History of present illness: 80 y.o. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. 80 yof tx from Rehab for sob, tachypnea, tachycardia and hypertension. # Depression: - continue sertraline and bupropion FEN: pureed diet, diabetic consistent carbohydrate ACCESS: PIV's; consider PICC line upon discharge for easier administration of furosemide PROPHYLAXIS: -DVT ppx with heparin sub q, pneumoboots -Pain managment with tylenol, morphine -Bowel regimen colace, senna milk of magnesia CODE: DNR/DNI DISPO: call out to floor later today if stable ------ Protected Section ------ Cardiology Teaching Physician Note On this day I saw, examined and was physically present with the resident / fellow for the key portions of the services provided. Heart failure (CHF), Systolic, Acute on Chronic Assessment: Hemodynamically stable- lung sounds w/ bibasilar crackles. The previously present marked perivascular haze has regressed and in the accessible lung fields of the right hemithorax. In the left hemithorax, a previously described pleural density that obliterates the diaphragmatic contour remains and probably has increased somewhat with major portions layering posteriorly with patient in semi-upright position. FINDINGS: There is interval development of a right-sided, mild-to-moderate pleural effusion, and slight interval decrease in moderate-to-severe left- sided pleural effusions. There is interval decrease definition of the right cardiac border. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. - aspirin, clopidogrel per discussion with PCP # CVA: patient with right sided hemiparesis, right facial droop, expressive aphasia. TITLE: Cardiology Physician Note History of Present Illness Date: Initial visit Events / History of present illness: -improved resp status -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg HCTZ 30minutes before with good result; will continue this now -changed losartan to -repeat CXR showed resolution of possible infiltrate on prior film Medications Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 , bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan 50 PO BID, Carbidopa levodopa Physical Exam BP: 125 / 47 mmHg HR: 65 bpm RR: 28 insp/min Tmax C last 24 hours: 37.4 C Tmax F last 24 hours: 99.4 F T current C: 36.2 C T current F: 97.2 F O2 sat: 93 % on Supplemental oxygen: 3L NC Previous day: Intake: 300 mL Output: 1,582 mL Fluid balance: -1,282 mL Today: Output: 480 mL Fluid balance: -480 mL VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti mask Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Jugular veins: Not visible) Respiratory: (Effort: WNL), (Auscultation: crackles at bases) Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass: No), (Hepatosplenomegaly: No) Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle strength and tone: right upper extremity flexed.

49

[ { "category": "Respiratory ", "chartdate": "2177-02-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 435592, "text": "Demographics\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n To ICU from ED\n 11:45\n Transport was without incident.\n Bedside Procedures:\n ABG puncture (13:00)\n Comments: Pt placed on NIV at 8:35a in ER secondary to increased SOB\n with RR 40\ns. Pt tolerated well\n with improved RR 25-30. ABG done\n once pt was transported to unit\n results - 7.40/49/128/31/4 on PSV\n with 50% FiO2. Pt taken off NIV and placed on 50% Venti-mask. Pt\n tolerating well with sats 98-100%. Pt\ns breathing seems more\n comfortable.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435645, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- ABG done- successfully weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-45cc/hr- no respiratory distress.\n Plan:\n monitor I&O- ? lasix dose tonight- trend cardiac enzymes- resume\n cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435823, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436200, "text": "80 yr old Rehab patient w/ significant PMH for chronic systolic\n CHF (EF 20%) who presented to EW w/ SOB. patient was tachypnenic,\n tachycardic and hypertensive- CXR showed bilateral infiltrates- EKG\n showed LBBB w/ lateral depressions- Patient was transferred to CCU on\n mask ventilation for further management\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Rec\nd pt wl hr 100 afib. Spontaneously converted to NSR w/ no vea. BP\n 90-110/.\n Action:\n Lopressor dose held at 0800, but administered at 10am. HCTZ 12.5mg f/b\n 80mg po lasix.\n Response:\n HR 80\ns nsr w/ no vea. u/o 30-60cc/hr\n Plan:\n Cont meds as above monitoring I/o\ns, possible decrease in lasix dose if\n pt overdiureses.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436204, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHFw/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR,\n however pt noted to be in afib for approx 2 hrs. Pt spontaneously\n converted.\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID -\n GU\n u/o 30-60cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance. Pt is aspiration\n risk. Taking nectar thickened liquids. Meds have been crushed and put\n in pudding or applesauce.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436137, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435945, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS +bibasilar crackles, diuresing well to additional lasix/ hctz. Cont\n w/ conjested cough, sats dropping <90% on 2L nc, RR> 30.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont to encourage c&db, ? chest pt if tol. ? PICC placement here or @\n NH.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436119, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435939, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz .\n Conts w/ conjested cough, given nebs w/ good effect. Increased 02 to 3L\n nc to maintain sats >92%. No c/o HA, sugars covered by RISS. CXR pa/lat\n showed resolution of RLL infiltrate.\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435940, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n HEADACHE\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435944, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS +bibasilar crackles, diuresing well to additional lasix/ hctz. Cont\n w/ conjested cough, sats dropping <90% on 2L nc, RR> 30.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont to encourage c&db, ? chest pt if tol\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436115, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated. Cont standing insulin & sliding scale.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436112, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated.\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435938, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz .\n Conts w/ conjested cough, given nebs w/ good effect. Increased 02 to 3L\n nc to maintain sats >92%\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436051, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- - EKG showed LBBB w/\n lateral depressions- She was Rx w/ 80mg ivp lasix @ nursing home prior\n to transport. In EW tx w/ Ntg and placed on Bipap- Patient was\n transferred to CCU on mask ventilation for further management. Able to\n wean off BIPAP almost immediately and eventually weaned to 2LNC.,\n maintaining sats >95%. ON Tuesday AM pt was given additional Diuresis\n and goal was to add HCTZ and increase Lasix to provide better\n diuresis. PT has frequent admits for failure, Lives at Rehab,\n Plan is for pt to get PICC so she can be treated In the nursing home.\n We are treating her by increasing her antihypertensive, additional\n lasix was given yesterday with HCTZ PT responded to lasix after several\n doses, she is down over 2 liters by weight, she has good/fair urine\n output and has been incontinent around the Foley as well. CXR PA and\n Lateral was done yesterday that showed Improved CHF, as well as and\n left pleural effusion, Atrovent Nebs were also started for wheezing.\n Pt has been stable today but lethargic, thought to be R/T Parkinsons\n and pt refusing her meds. We did have problems with her taking meds\n today but with help of family pt did eventually take them. She sleep\n most of today, but was awake and alert in the afternoon, fed herself\n lunch, visited with son. She sounded wheezy this morning, did respond\n to atrovent, HCTZ and lasix ~ 350 cc. She was apparently incontinent\n last night of urine. She had two IV infiltrate today with D5W, warm\n compress to left arm, area looks ok, somewhat swollen elevated on\n pillows. IV team placed a 22 right hand, pt has VERY poor access and is\n planned for PICC line in future at rehab ( they place piccs\n there). Team is aware, we are hydrating pt with D5 to treat\n hypernatremia and we are checking lytes at 6 PM. Pt did rec KCL\n replacement. She continues to have high glucose, She only likes to eat\n pudding, milk, apple juice.\n Has decreased appetite lately per son. She gets SS and 70/30\n Plan is to continue med regime of HCTZ, Lasix, follow I/o weight.\n Offer PO free water hydrate with D5, and follow lytes NA, U/O\n ? Dc to rehab from CCU.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435585, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435641, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- ABG done- successfully weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr- no respiratory distress.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435886, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n ------ Protected Section ------\n Rec\nd hctz, followed 30minutes later w 80mg iv lasix at 6pm. Has begun\n to diurese. Congested cough. Rr mid 20s to 30s. sats >95% on 2l nc. c/o\n HA, rec\nd 650mg Tylenol. Poor appetite. Ate pudding, refused\n potato,. Bs 190, covered per ss. Family visited and updated.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:25 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436110, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions.\n" }, { "category": "Physician ", "chartdate": "2177-02-10 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 435569, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Dyspnea\n History of present illness: 80 y.o. female with pmh significant for\n chronic systolic congestive heart failure, LVEF 20%, presenting to ED\n from nursing home after waking this morning acutely short of breath.\n The on-call physician at the nursing home gave the patient lasix 80mg\n IV, albuterol, and morphine prior to transfer. No foley was placed,\n however, upon arival to ED the patient's sheets were soaked with\n urine. In ED, patient was tachypneic with RR in 40's and had Oxygen\n saturaiton of 88% on NRB. BNP was 26,000, CXR showed bilateral\n infiltrates. She was also hypertensive with BP 160/100 and tachycardic\n to 120's. EKG showed LBBB with lateral depressions. She was given\n nitroglycerin and placed on Bipap. She responded with O2 saturation\n of 98%, respiratory rate of 16, and her blood pressure and heart rate\n decreased to 110/60 and 60-70's respectively. Her ekg changes returned\n to baseline. Attempts were made to wean her form Bipap to NRB and\n venti mask, and were unsuccessful secondary to O2 desaturation and\n tachypnea.\n .\n The patient has had multiple CHF exacerbations recently, which have all\n been handled at rehab. Per the patient's PCP, has been\n decompensating somewhat with diminished PO intake. The patient had an\n episode of shortness of breath at Rehab on which reoslved\n with lasix 90mg IV and morphine. She was \"Do Not hospitalize\" status 1\n week ago, however, given the difficulty of treating her CHF\n exacerbations overnight without doctors on , it was decided to\n revoke the \"DNH\" status for the purposes of transferring the patient to\n the hospital in the event that an exacerbation would occur overnight\n and no MD's were avaliable to push IV lasix.\n .\n Review of symptoms is answered by her son. has expressive\n aphasia.\n .\n review of systems is notable for absence of fever, chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Past medical history: HTN\n DM type 2 insulin-dependent\n PVD (s/p bypass)\n CAD (s/p MI in )\n h/o stroke (in w/ residual complete R sided hemiparesis,\n dysphagia, expressive aphasia)\n CHF (LVEF 20-25%)\n Depression\n Intraductal papillary mucinous tumor found on CT \n Parkinson's disease\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus, Hypertension\n CAD Risk Factors Absent\n Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: No)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Current medications: Aspirin 325 mg PO daily\n Cholecalciferol (Vitamin D3) 1000 units PO daily\n Senna 8.6 mg PO BID\n Calcium Carbonate 500 mg (1,250 mg) PO daily\n Sertraline 50 mg PO daily\n Carbidopa-Levodopa 25-100 mg Tablet. One tablet PO daily\n Omeprazole 20 mg Capsule, Delayed Release(E.C.) PO BID\n Bisacodyl 10 mg Tablet, Delayed Release PO BID\n Metoprolol Tartrate 50 mg PO BID\n Losartan 50 mg PO Daily\n Bupropion 100 mg Tablet Sustained Release PO QAM\n Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension\n Sig: Sixteen (16) units Subcutaneous qAM: Please continue\n sliding scale coverage as directed.\n Furosemide 80 mg Tablet PO Daily\n Milk of magnesia\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n SOB\n Cardiovascular ROS Signs and Symptoms Absent\n Chest pain, Edema\n Cardiovascular ROS Details: Review of symptoms is answered by her son.\n has expressive aphasia.\n .\n review of systems is notable for absence of fever, chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Review of Systems\n Organ system ROS normal\n Constitutional, Gastrointestinal, Genitourinary\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis\n Physical Exam\n Date and time of exam: \n General appearance: on BiPap. Breathing comfortably responsive to\n voice. overweight. Right upper extremity flexed.\n Vital signs: per R.N.\n BP right arm:\n 120/60 / mmHg\n HR: 65 bpm\n RR: 16 insp/min\n O2 sat: 100 % on Supplemental oxygen: 50%\n Vital sign details: Vent: CPAP PEEP 6, FiO2 50%, Frequency 20, TV 290\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n ABG: 7.40 / 49 / 128 / / 4 Values as of 01:00 PM\n Tests\n ECG: (Date: ), NSR, LVH, LBBB, st depressions V4-V6.\n Echocardiogram: (Date: ), : The left atrium and right\n atrium are normal in cavity size. Left ventricular wall thicknesses and\n cavity size are normal. There is moderate to severe global left\n ventricular hypokinesis (LVEF = 20-25 %). No masses or thrombi are seen\n in the left ventricle. The right ventricular cavity is mildly dilated\n with moderate global free wall hypokinesis. The aortic valve leaflets\n (3) are mildly thickened but aortic stenosis is not present. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n Moderate (2+) mitral regurgitation is seen. The pulmonary artery\n systolic pressure could not be determined. There is no pericardial\n effusion.\n IMPRESSION: Severe global left ventricular systolic dysfunction c/w\n diffuse process (multivessel CAD, toxin, metablolic, etc.). Right\n ventricular cavity enlargement with free wall hypokinesis. Moderate\n mitral regurgitation.\n Assessment and Plan\n ASSESSMENT AND PLAN\n 80 year old woman with pmh significant for chronic systolic congestive\n heart failure, presenting with shortness of breath.\n .\n # Acute on Chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, BNP 26,000 on\n admission. Lung exam with crackles. Unclear etiology, dietary\n indescretion and medicaiton non-compliance are likely not causes given\n patient is presenting from rehab. Possible upper respiratory\n infection, possible worsening valvular disease. Uncontrolled\n hypertension is also a possibility. Ischemia is also a possibility.\n -diurese with lasix 40mg IV\n -trend cardiac enzymes\n -goal I/O neg 1L\n -continue metoprolol\n -continue losartan\n -will place PICC, to allow easier lasix administration while at \n rehab.\n .\n #Respiratory Status: Patient is breathing comfortablky on CPAP, PEEP\n 5Oxygen saturation 98% on FiO2 50%. Per report in ED, attempts at\n weaning off CPAP to venti mask were unsuccessful secondary to marked\n tachypnea to 40's. recent ABG with adequate oxygenation, and CO2 49.\n need to increase pressure support.\n -trend ABG\n -wean off Bipap\n .\n #CAD: History of MI in . Will continue aspirin, lopressor, and\n losartan.\n .\n #Peripheral Vascular Disease: S/p bypass. will continue aspirin. Will\n restart plavix per discussion with PCP.\n .\n #CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia. Will continue with aggressive bowel regimen, soft\n diet.\n .\n #Hypertension: continue lopressor and losartan\n .\n #Diabetes: Type 2 on insulin. will continue standing insulin in\n addition to sliding scale.\n .\n #Parkinson's disease: Continue carbidopa levodopa TID.\n .\n #Depression:continue sertraline and bupropion\n .\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: CCU\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435632, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable- lung sounds w/ bibasilar crackles.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation- weaned to 40% venti-mask.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr- no respiratory distress.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435714, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to tnsport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%.\n Headache\n Assessment:\n Pt w/ expressive aphasia. Found to be restless & motioning w/ L arm to\n forehead indicating c/o headache. ? Received ntg in EW.\n Action:\n Given apap 650mg po.\n Response:\n After approx 1hr restlessness & gesturing stopped, back to sleep.\n Plan:\n Cont to monitor for s/s HA.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n While c/o headache, RR ^30s, BP^ 150s, HR 112.\n Action:\n Given 80 ivp lasix.\n Response:\n RR down into 20s, BPs 120s, HR 70s. Voided approx 700cc over 6hr period\n Plan:\n Cont to monitor for potential flash.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436225, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 49.1 kg\n Daily weight:\n 46.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Nsaids\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CAD s/p MI - CHF (EF20-25%)- family hx of\n sudden cardiac death- h/o stroke w/ residual complete R sided\n hemiparesis- PVD s/p bypass- dysphagia, (expressive aphasia)-\n depression- intraductal papillary mucinous tumor found on CT -\n parkinson's disease.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:92\n D:55\n Temperature:\n 101.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 31 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 845 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 05:00 AM\n Potassium:\n 3.6 mEq/L\n 05:00 AM\n Chloride:\n 100 mEq/L\n 05:00 AM\n CO2:\n 31 mEq/L\n 05:00 AM\n BUN:\n 30 mg/dL\n 05:00 AM\n Creatinine:\n 1.0 mg/dL\n 05:00 AM\n Glucose:\n 112 mg/dL\n 05:00 AM\n Hematocrit:\n 33.0 %\n 05:00 AM\n Finger Stick Glucose:\n 188\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 625\n Transferred to: 323\n Date & time of Transfer: 1530 pM\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435706, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n HEADACHE\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n 80 year old woman with pmh significant for chronic systolic congestive\n heart failure, presenting with shortness of breath.\n .\n # Acute on Chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, BNP 26,000 on\n admission. Lung exam with crackles. Unclear etiology, dietary\n indescretion and medicaiton non-compliance are likely not causes given\n patient is presenting from rehab. Possible upper respiratory\n infection, possible worsening valvular disease. Uncontrolled\n hypertension is also a possibility. Ischemia is also a possibility.\n -diurese with lasix 40mg IV\n -trend cardiac enzymes\n -goal I/O neg 1L\n -continue metoprolol\n -continue losartan\n -will place PICC, to allow easier lasix administration while at \n rehab.\n .\n #Respiratory Status: Patient is breathing comfortablky on CPAP, PEEP\n 5Oxygen saturation 98% on FiO2 50%. Per report in ED, attempts at\n weaning off CPAP to venti mask were unsuccessful secondary to marked\n tachypnea to 40's. recent ABG with adequate oxygenation, and CO2 49.\n need to increase pressure support.\n -trend ABG\n -wean off Bipap\n .\n #CAD: History of MI in . Will continue aspirin, lopressor, and\n losartan.\n .\n #Peripheral Vascular Disease: S/p bypass. will continue aspirin. Will\n restart plavix per discussion with PCP.\n .\n #CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia. Will continue with aggressive bowel regimen, soft\n diet.\n .\n #Hypertension: continue lopressor and losartan\n .\n #Diabetes: Type 2 on insulin. will continue standing insulin in\n addition to sliding scale.\n .\n #Parkinson's disease: Continue carbidopa levodopa TID.\n .\n #Depression:continue sertraline and bupropion\n .\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: CCU\n" }, { "category": "Nursing", "chartdate": "2177-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436043, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. We are treating her by increasing her\n antihypertensives additional lasix was given today with no\n Response, team aware she may be EUvolemic, CXR PA and Lateral was done\n this afternoon to R/O infiltrates and she was started on Atrovent Nebs.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Lungs now with slt crackles right base left posterior lung hollow\n sounding, pt HR stable and BP under control,\n Weaned to 2.5 L nc and does not appear to have resp distress, was spry\n today ate 90 percent of breakfast and shake for lunch. We need a\n weight to assess i/O as she had been incontinent\n Action:\n Weaned o2 gave po lasix and IV lasix.\n Response:\n No response to 80 mg IV and PO, team aware\n Plan:\n Follow BP, hr, anxiety level lytes , O2 sat.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436222, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 49.1 kg\n Daily weight:\n 46.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Sulfasalazine\n Unknown;\n Nsaids\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CAD s/p MI - CHF (EF20-25%)- family hx of\n sudden cardiac death- h/o stroke w/ residual complete R sided\n hemiparesis- PVD s/p bypass- dysphagia, (expressive aphasia)-\n depression- intraductal papillary mucinous tumor found on CT -\n parkinson's disease.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:92\n D:55\n Temperature:\n 101.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 31 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 845 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 05:00 AM\n Potassium:\n 3.6 mEq/L\n 05:00 AM\n Chloride:\n 100 mEq/L\n 05:00 AM\n CO2:\n 31 mEq/L\n 05:00 AM\n BUN:\n 30 mg/dL\n 05:00 AM\n Creatinine:\n 1.0 mg/dL\n 05:00 AM\n Glucose:\n 112 mg/dL\n 05:00 AM\n Hematocrit:\n 33.0 %\n 05:00 AM\n Finger Stick Glucose:\n 188\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 625\n Transferred to: 323\n Date & time of Transfer: 1530 pM\n" }, { "category": "Nursing", "chartdate": "2177-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435627, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SO patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hemodynamically stable.\n Action:\n Lasix 80mg IV given prior to arrival to EW- placed on mask\n ventilation.\n Response:\n Incontinent large amount prior to foley insertion in EW- U/O\n 15-30cc/hr.\n Plan:\n ? repeat lasix dose this evening- monitor I&O- trend cardiac enzymes-\n resume cardiac meds when able.\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436217, "text": "80 yof tx from Rehab for sob, tachypnea, tachycardia and\n hypertension. Pt known CHF w/ EF 20%, CVA w/ r sided hemiparesis and\n aphasia, parkinsons.\n CCU course\n CV - diuresed w/ lasix and hctz, dose changed from admit. HR in NSR\n 70-80\ns. however pt noted to be in afib for approx 2 hrs. Pt\n spontaneously converted. BP90-120/50\n Resp\n O2 on 2ln/p w/ sats 93-100%. Pt/ w/ bronchial/tubular bs.\n Productive cough noted, however pt will swallow sputum. CXR pa and\n lat done .\n ID\n Temp 101.6 at noon . Po levofloxacin started at 1400\n GU\n u/o 30-100cc/hr clear yellow urine via foley cath.\n GI\n Pt on pureed and requires feeding assistance for set up. Needs\n encouragement, but will feed herself. Pt is aspiration risk. Taking\n nectar thickened liquids. Meds can be crushed and put in pudding or\n applesauce, but pt able to swallow small pills without difficulty.\n MS\n pt is alert. Unable to assess orientation d/t aphasia. R sided\n hemiparesis.\n IV access\n piv #22 r hand placed by IV team.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Ls tubular/bronchial on 2ln/p w/ sats 97-99%. Productive cough, but pt\n swallows sputum. u/o 20-50cc/hr, temp up to 101.6 pr\n Action:\n CXR pa and lat, levofloxacin po started, urine cult sent. No blood\n cultures done, as pt is difficult access.\n Response:\n Plan:\n Monitor temp, hemodynamics and response to levofloxacin. Tylenol prn.\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435772, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435774, "text": "TITLE:\n History of Present Illness\n - transitioned off bipap within hours of admission-->on Venti face mask\n and breathing comfortably all day. No diuresis given.\n - overnight, pt SOB, tachycardiac, hypertensive, apparently\n distressed. UOP ~20cc/h for several hours, lungs sounded wheezy and\n crackly, EKG showed more prominent T waves vs yesterday but unchanged\n from prior in . Given 80 mg IV lasix and oral morphine (on this\n at nursing facility). Tachycardia improved, patient resting\n comfortably, UOP ~300 cc/3 hours after.\n - IV nurses recommend midline rather than PICC for access at NH; will\n place \n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 35.6 C\n Tmax F last 24 hours: 96.1 F\n T current C: 35.6 C\n T current F: F\n Previous day:\n Weight: 49.1 kg\n Output: 365 mL\n Fluid balance: -365 mL\n Today:\n Output: 370 mL\n Fluid balance: -370 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 270\n 11.2\n 161\n 1.0\n 30\n 3.1\n 32\n 105\n 146\n 32.6\n 13.4\n 06:03 PM\n 04:02 AM\n WBC\n 13.4\n Hgb\n 11.2\n Hct (Serum)\n 32.6\n Plt\n 270\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n K + (Serum)\n 3.7\n 3.1\n Cl\n 103\n 105\n HCO3\n 31\n 30\n BUN\n 33\n 32\n Creatinine\n 1.1\n 1.0\n Glucose\n 192\n 161\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 30 / Values as of 04:02 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - continue diuresing with furosemide IV prn; will give another 80 mg IV\n this morning. Will need to increase PO furosemide upon discharge\n - goal I/O negative 1L\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:41 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435674, "text": "Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435675, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/ Ntg\n and placed on Bipap- Patient was transferred to CCU on mask ventilation\n for further management.\n" }, { "category": "Nursing", "chartdate": "2177-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435676, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to tnsport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%.\n Headache\n Assessment:\n Pt w/ expressive aphasia. Found to be restless & motioning w/ L arm to\n forehead indicating c/o headache. Did receive ntg in EW for\n hypertension.\n Action:\n Given apap 650mg po.\n Response:\n After approx 1hr restlessness & gesturing stopped, resumed sleeping.\n Plan:\n Cont to monitor for s/s HA.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n While c/o headache, RR ^30s, BP^ 150s, HR 112.\n Action:\n Given 80 ivp lasix.\n Response:\n RR down into 20s, BPs 120s, HR 70s. Voided 200cc over 1hr period\n Plan:\n Cont to monitor potential flash PE\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436138, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n Cont on metoprolol, increased losartan to 50 mg for better BP\n control. Consider digoxin to reduce hospital admissions. Hypernatremia\n (Na+149) Given 1L D5W & increased free water intake. Blood sugars\n subsequently elevated, (475) obtained one time order for 12 units reg\n insulin. Repeat sugar 94. Conts on standing insulin & sliding scale.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Diuresing well to po lasix/ hctz. Conts w/ conjested cough.\n Action:\n Given alb/ atrovent nebs, encouraged to c/db, increased 02 to 3L nc.\n Response:\n Sats maintaining >95%, RR in 20s\n Plan:\n Cont plan of care tx CHF, ? discharge back to NH. ? PICC placement\n prior to d/c.\n ------ Protected Section ------\n Approx 0545 pt went into Afib w/ RVR in 140s-150s, BPs remained stable.\n HO made aware, ordered one time dose of po lopressor 50mg. Dose given @\n 0620, results pending.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:52 ------\n" }, { "category": "Physician ", "chartdate": "2177-02-13 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 436160, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - refusing meds in AM, but finally\n took them with family at bedsite\n - difficult IV access, has 1 PIV, plan for PICC at Rehab\n - 700cc of D5W for hypernatremia, Na 149 --> 146 --> 145; fluids\n stopped once glucose was elevated\n - diuresing: lasix 80mg PO BID and HCTZ 12.5mg \n - at 6 AM went into afib, rate to 120s, metoprolol 50mg given\n Medications\n Unchanged\n Physical Exam\n BP: 119 / 57 mmHg\n HR: 107 bpm\n Tmax C last 24 hours: 37.8 C\n Tmax F last 24 hours: F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 % on Supplemental oxygen: 3L NC\n Previous day:\n Weight: 46.5 kg\n Intake: 1,250 mL\n Output: 1,175 mL\n Fluid balance: 75 mL\n Today:\n Output: 640 mL\n Fluid balance: -640 mL\n VS: BP (88-129)/(40-77), HR(97-120s), RR 25, O2 Sat 95-98% on 3L NC\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), Auscultation: no crackles, but some\n bronchial breath sounds\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 287\n 11.1\n 112\n 1.0\n 31\n 3.6\n 30\n 100\n 145\n 33.0\n 13.1\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n 05:59 PM\n 05:00 AM\n WBC\n 13.4\n 7.8\n 13.1\n Hgb\n 11.2\n 10.1\n 11.1\n Hct (Serum)\n 32.6\n 29.4\n 33.0\n Plt\n \n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n 146\n 145\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n 4.3\n 3.6\n Cl\n 103\n 105\n 106\n 103\n 100\n HCO3\n 31\n 30\n 30\n 31\n 33\n 30\n 31\n BUN\n 33\n 32\n 32\n 32\n 30\n Creatinine\n 1.1\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 192\n 161\n 108\n 258\n 112\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 31 / Values as of 05:00 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam now without crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on lasix with HCTZ before doses\n - lasix 80 PO BID and HCTZ 12.2mg PO BID 30min prior.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n # Afib: new onset, started this AM, HR to 120s, asymptomatic\n - may need to increase BB for rate control\n .\n #Hypernatremia: Likely from restricted access to free water. Improved\n now after 700 D5W + oral water.\n -monitor lytes\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.1 this morning AM, differential pending. Tmax\n 100. No clear sign of infection., possible PNA?.\n - f/u diff\n - monitor for signs of infection\n -consider abx for CAP\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-13 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 436176, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - refusing meds in AM, but finally\n took them with family at bedsite\n - difficult IV access, has 1 PIV, plan for PICC at Rehab\n - 700cc of D5W for hypernatremia, Na 149 --> 146 --> 145; fluids\n stopped once glucose was elevated\n - diuresing: lasix 80mg PO BID and HCTZ 12.5mg \n - at 6 AM went into afib, rate to 120s, metoprolol 50mg given\n Medications\n Unchanged\n Physical Exam\n BP: 119 / 57 mmHg\n HR: 107 bpm\n Tmax C last 24 hours: 37.8 C\n Tmax F last 24 hours: F\n T current C: 36.6 C\n T current F: 97.8 F\n O2 sat: 95 % on Supplemental oxygen: 3L NC\n Previous day:\n Weight: 46.5 kg\n Intake: 1,250 mL\n Output: 1,175 mL\n Fluid balance: 75 mL\n Today:\n Output: 640 mL\n Fluid balance: -640 mL\n VS: BP (88-129)/(40-77), HR(97-120s), RR 25, O2 Sat 95-98% on 3L NC\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), Auscultation: no crackles, but some\n bronchial breath sounds\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 287\n 11.1\n 112\n 1.0\n 31\n 3.6\n 30\n 100\n 145\n 33.0\n 13.1\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n 05:59 PM\n 05:00 AM\n WBC\n 13.4\n 7.8\n 13.1\n Hgb\n 11.2\n 10.1\n 11.1\n Hct (Serum)\n 32.6\n 29.4\n 33.0\n Plt\n \n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n 146\n 145\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n 4.3\n 3.6\n Cl\n 103\n 105\n 106\n 103\n 100\n HCO3\n 31\n 30\n 30\n 31\n 33\n 30\n 31\n BUN\n 33\n 32\n 32\n 32\n 30\n Creatinine\n 1.1\n 1.0\n 1.0\n 1.1\n 1.0\n Glucose\n 192\n 161\n 108\n 258\n 112\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 31 / Values as of 05:00 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam now without crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on lasix with HCTZ before doses\n - lasix 80 PO BID and HCTZ 12.2mg PO BID 30min prior.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n # Afib: new onset, started this AM, HR to 120s, asymptomatic; converted\n spontaneously.\n - continue aspirin 325\n - may need to increase BB for rate control\n - no need for anticoagulation now\n .\n #Hypernatremia: Likely from restricted access to free water. Improved\n now after 700 D5W + oral water.\n - encourage PO free water intake\n - check Na every other day\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n - check CXR\n # Leukocytosis: WBC 13.1 this morning AM, differential pending. Tmax\n 100. No clear sign of infection., possible PNA?.\n - f/u diff\n - monitor for signs of infection\n -consider abx for CAP\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: transfer back to Rehab (likely today)\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435970, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 ,\n bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan\n 50 PO BID, Carbidopa levodopa\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - diuresis switched to lasix 80 PO BID and HCTZ 25mg PO BID.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n #Hypernatremia: Likely from restricted access to free water. Will give\n D5W 1000cc.\n -D5W 1000cc.\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n" }, { "category": "Physician ", "chartdate": "2177-02-12 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 435972, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness:\n -improved resp status\n -no response to 80 IV lasix in AM, in PM given lasix 80mg PO with 25mg\n HCTZ 30minutes before with good result; will continue this now \n -changed losartan to \n -repeat CXR showed resolution of possible infiltrate on prior film\n Medications\n Unchanged, aspirin 325, vit D, hep sc, tums, metoprolol 50 ,\n bupropion, protonix, zoloft, lasix 80 PO BID, HCTZ 25 PO BID,, losartan\n 50 PO BID, Carbidopa levodopa\n Physical Exam\n BP: 125 / 47 mmHg\n HR: 65 bpm\n RR: 28 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.2 C\n T current F: 97.2 F\n O2 sat: 93 % on Supplemental oxygen: 3L NC\n Previous day:\n Intake: 300 mL\n Output: 1,582 mL\n Fluid balance: -1,282 mL\n Today:\n Output: 480 mL\n Fluid balance: -480 mL\n VS: BP 118/55 (105-150/41-65), HR 76, RR 25, O2 Sat 98% on 40% Venti\n mask\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: crackles at bases)\n Cardiac: (Rhythm: Regular), (Auscultation: S1: WNL, S3: Absent, S4:\n Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Pulsatile mass:\n No), (Hepatosplenomegaly: No)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle\n strength and tone: right upper extremity flexed.), (Dorsalis pedis\n artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,\n Left: 1+), (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 250\n 10.1\n 108\n 1.0\n 33\n 3.5\n 32\n 106\n 149\n 29.4\n 7.8\n [image002.jpg]\n 06:03 PM\n 04:02 AM\n 12:02 PM\n 09:32 PM\n 04:01 AM\n WBC\n 13.4\n 7.8\n Hgb\n 11.2\n 10.1\n Hct (Serum)\n 32.6\n 29.4\n Plt\n 270\n 250\n INR\n 1.2\n PTT\n 33.5\n Na+\n 143\n 146\n 149\n K + (Serum)\n 3.7\n 3.1\n 4.4\n 4.0\n 3.5\n Cl\n 103\n 105\n 106\n HCO3\n 31\n 30\n 30\n 31\n 33\n BUN\n 33\n 32\n 32\n Creatinine\n 1.1\n 1.0\n 1.0\n Glucose\n 192\n 161\n 108\n CK\n 34\n 35\n Troponin T\n 0.09\n 0.08\n ABG: / / / 33 / Values as of 04:01 AM\n Assessment and Plan\n 80 year old woman with history of chronic systolic congestive heart\n failure, presenting with shortness of breath.\n # Acute on chronic systolic congestive heart failure: History and\n presentation consistent with CHF exacerbation. LVEF 20%, with MR. BNP\n 26,000 on admission. Lung exam with crackles. Unclear initiating\n factor: dietary indiscretion and medication non-compliance are likely\n not causes given patient is presenting from Rehab. Possible\n upper respiratory infection, possible worsening valvular disease.\n Uncontrolled hypertension is also a possibility. Ischemia is unlikely\n given negative CEs x 3. Sx improving on IV furosemide.\n - diuresis switched to lasix 80 PO BID and HCTZ 25mg PO BID.\n - continue metoprolol; increase losartan to 50 mg for better BP\n control\n - consider digoxin to reduce hospital admissions\n .\n #Hypernatremia: Likely from restricted access to free water. Will give\n D5W 1000cc.\n -D5W 1000cc.\n # Respiratory status: Patient is breathing comfortably after having\n been weaned off CPAP after diuresis.\n - continue to treat heart failure as above\n - supplemental O2 as needed\n # Leukocytosis: WBC 13.4 this morning from 7.8, differential pending.\n No fever. No clear sign of infection. ?reactive leukocytosis.\n - f/u diff\n - monitor for signs of infection\n # CAD: History of MI in .\n - continue aspirin, metoprolol, and losartan.\n # Peripheral vascular disease: S/p bypass.\n - aspirin, clopidogrel per discussion with PCP\n # CVA: patient with right sided hemiparesis, right facial droop,\n expressive aphasia.\n # Hypertension: episodes of hypertension yesterday.\n - continue metoprolol and increase losartan to 50 mg \n # Diabetes: Type 2 on insulin.\n - continue standing insulin in addition to sliding scale.\n # Parkinson's disease:\n - continue carbidopa/levodopa TID.\n # Depression:\n - continue sertraline and bupropion\n FEN: pureed diet, diabetic consistent carbohydrate\n ACCESS: PIV's; consider PICC line upon discharge for easier\n administration of furosemide\n PROPHYLAXIS:\n -DVT ppx with heparin sub q, pneumoboots\n -Pain managment with tylenol, morphine\n -Bowel regimen colace, senna milk of magnesia\n CODE: DNR/DNI\n DISPO: call out to floor later today if stable\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:39 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436088, "text": "This is an 80 yr old nursing home patient w/ significant PMH for\n chronic systolic CHF (EF 20%) who presented to EW w/ SOB patient was\n tachypnenic, tachycardic and hypertensive- CXR showed bilateral\n infiltrates- EKG showed LBBB w/ lateral depressions- She was Rx w/\n 80mg ivp lasix @ nursing home prior to transport. In EW tx w/ Ntg and\n placed on Bipap- Patient was transferred to CCU on mask ventilation for\n further management. Able to wean off BIPAP & placed on 40% venti mask,\n maintaining sats >95%. ON Tuesday AM pt was given additional Lasix and\n diuresed further, able to wean o2 down to 2.5 L NC by 0800 am. PT has\n frequent admits for failure, Lives at Rehab, Plan is for pt to\n get PICC so she can be treated\n In the nursing home. Diuresed well to additional 80 ivp lasix &\n 25mg po hctz. Started on po doses of lasix & hctz . No c/o HA,\n sugars covered by RISS. CXR pa/lat showed resolution of RLL infiltrate.\n" }, { "category": "Echo", "chartdate": "2177-02-11 00:00:00.000", "description": "Report", "row_id": 87849, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Valvular heart disease.\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 129/58\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 09:50\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic;\nanterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic;\nlateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR. LV inflow pattern c/w restrictive filling abnormality, with elevated LA\npressure.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thicknesses are normal. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is severely\ndepressed (LVEF= 20-25 %) with inferior, anteroseptal and apical\nakinesis/severe hypokinesis and hypokinesis elsewhere. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests a restrictive filling abnormality, with\nelevated left atrial pressure. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056222, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with severe CHF p/w resp distress\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with severe congestive heart failure, now presents\n with respiratory distress. Evaluate for acute cardiopulmonary process.\n\n TECHNIQUE: Chest radiograph, portable upright AP view only.\n\n COMPARISON: Chest radiograph on .\n\n FINDINGS: The study is limited by motion and patient's rotation to the left.\n Allowing these limitations, the enlarged cardiac silhouette is unchanged.\n Aortic tortuosity with vascular calification is unchanged. There is mild\n perihilar haziness and pulmonary vasculature prominence, also unchanged,\n compatible with mild CHF. There is interval decrease definition of the right\n cardiac border. The left hemidiaphragm is silhouetted out, consistent with\n left pleural effusion. The right effusion is slightly decreased. There is\n non-specific opacity seen in the right upper lung. There is no pneumothorax.\n There are underlying degenerative changes seen in the thoracolumbar spines.\n\n IMPRESSION:\n 1. Mild congestive heart failure.\n 2. Non-specific new opacity in the left upper lung. Recommend repeat PA &\n lateral views after diuresis to further assess as this study is technicall\n limited.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056939, "text": " 11:47 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with leukocytosis. Please r/o PNA\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:14 PM\n Interval development of mild-to-moderate right pleural effusion and slight\n interval decrease in moderate-to-severe left pleural effusion. Bibasilar\n atelectasis. Pleural effusions and atelectasis limit detection of pneumonia\n within the lower lung fields.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 80-year-old female with leukocytosis. Please\n evaluate for pneumonia.\n\n EXAMINATION: PA and lateral chest radiographs.\n\n COMPARISONS: Comparison to PA and lateral chest radiographs from .\n\n FINDINGS: There is interval development of a right-sided, mild-to-moderate\n pleural effusion, and slight interval decrease in moderate-to-severe left-\n sided pleural effusions. There is persistent bibasilar atelectasis.\n Evaluation of the lower lung fields for pneumonia is limited secondary to hazy\n increased opacification from pleural effusions and atelectasis. The upper\n lung zones are clear with no signs of pneumonia. The cardiomediastinal\n contours are stable with moderate cardiomegaly. The visualized osseous\n structures are unchanged.\n\n IMPRESSION: Interval development of mild-to-moderate right pleural effusion,\n and slight interval decrease in moderate-to-severe left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2177-02-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056940, "text": ", M. 11:47 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with leukocytosis. Please r/o PNA\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n PFI REPORT\n Interval development of mild-to-moderate right pleural effusion and slight\n interval decrease in moderate-to-severe left pleural effusion. Bibasilar\n atelectasis. Pleural effusions and atelectasis limit detection of pneumonia\n within the lower lung fields.\n\n" }, { "category": "Radiology", "chartdate": "2177-02-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056551, "text": " 3:15 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 6:45 PM\n Pulmonary vascular congestion improved since yesterday, sizable left-sided\n pleural effusion persists.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: CHF exacerbation. Evaluate for infiltrates.\n\n FINDINGS: The patient's condition required examination in sitting upright\n position with AP frontal and lateral view. Analysis is performed in direct\n comparison with a preceding AP single chest view obtained during the preceding\n day. Heart size remains significantly enlarged. The previously present\n marked perivascular haze has regressed and in the accessible lung fields of\n the right hemithorax. The vascular pattern is now unremarkable and no\n evidence of pleural effusion is present in the right lateral sinus. No acute\n infiltrates are present. In the left hemithorax, a previously described\n pleural density that obliterates the diaphragmatic contour remains and\n probably has increased somewhat with major portions layering posteriorly with\n patient in semi-upright position. There is no evidence of pneumothorax on\n either side. The lateral view suffers from the non-elevated arms, but one can\n identify and confirm the rather prominent left-sided pleural effusion reaching\n posteriorly up to the level of the fifth thoracic vertebra. A right-sided\n pleural effusion is rather limited and only mildly blunts the posterior\n pleural sinus.\n\n IMPRESSION: Regression of pulmonary vascular congestion during the last one\n day interval. Sizable left-sided pleural effusion persists. No evidence of\n pneumothorax or new localized infiltrates. As shown earlier, there is a\n moderately compressed vertebral body at level T12.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-02-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1056552, "text": ", M. 3:15 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Pulmonary vascular congestion improved since yesterday, sizable left-sided\n pleural effusion persists.\n\n\n" }, { "category": "ECG", "chartdate": "2177-02-13 00:00:00.000", "description": "Report", "row_id": 220869, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. Possible\nleft ventricular hypertrophy. Diffuse non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of multiple\nabnormalities as previously noted persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2177-02-12 00:00:00.000", "description": "Report", "row_id": 220870, "text": "Sinus rhythm\nConsider left atrial abnormality\nModest intraventricular conduction delay mat be incomplete left bundle branch\nblock\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of , rate faster, but otherwise probably no\nsignificant change\n\n" }, { "category": "ECG", "chartdate": "2177-02-10 00:00:00.000", "description": "Report", "row_id": 220871, "text": "Sinus rhythm\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to hypertrophy\nSince previous tracing of the same date, heart rate slower\n\n" }, { "category": "ECG", "chartdate": "2177-02-10 00:00:00.000", "description": "Report", "row_id": 220872, "text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , heart rate faster\n\n" } ]

6,713

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1. Diabetic ketoacidosis - The patient came in in florid diabetic ketoacidosis with a pH of 6.98 and a bicarbonate of 5. She was aggressively treated with 4 liters of normal saline and insulin. Her potassium was also elevated at 6.7. She was continued on an insulin drip with 1/2 normal saline and kept NPO. Her glucose responded relatively quickly dropping below 200 into the 100s. Her anion gap also corrected relatively rapidly and the patient did well from this standpoint. Attempts were then made to normalize the patient's sugars which varied widely from low sugars on Glargine 12 and insulin sliding scale to high sugars on Glargine 8 and a regular insulin sliding scale. The acidosis associated with her diabetic ketoacidosis once corrected remained corrected and the patient did not again have an anion gap. Fluid repletion continued through her stay and by approximately the fourth day the patient was beginning to take p.o. well. The day before admission the patient was eating a full diabetic diet. 2. Cardiac - During the course of the stay the patient ruled in for a non-ST elevation myocardial infarction with troponins in the range of .4 to .5 and creatinine kinases in the range of 300. The patient was effectively asymptomatic, however, her mental status was confused during this time. The patient was treated with conservative medical management, receiving Aspirin and beta blocker. The patient had an echocardiogram during the admission which showed preservation of left ventricular function with an ejection fraction greater than 55%. Plan was to start the patient on a statin drug, either at the end of this admission or as an outpatient for its cardioprotective effects. The patient had a total cholesterol during admission of 106, however, this can be artificially low around the time of a myocardial infarction. 3. Abdominal pain - On day #2 of admission, the patient complained of some abdominal pain and had an increased amylase and lipase. The patient underwent abdominal computerized tomography scan which showed no evidence of colitis, bilateral pleural effusions or uterine fibroids. The patient's increased amylase and lipase resolved fairly rapidly. The patient did not continue to have any abdominal pain. 4. Change in mental status - Initially the patient was quite confused and disoriented, oriented only to her name. Her mental status slowly improved over the course of the admission. She had a head computerized tomography scan that was negative for acute process. Her B12 and Folate levels were both normal. RPR was negative. Because of the patient's persistent change in mental status, the patient underwent a lumbar puncture during the admission. The results were consistent with an aseptic meningitis with cerebrospinal fluid showing 59 white blood cells, 9 red blood cells, protein 53 and glucose of 121. Cryptococcal antigen was negative, RPR was negative, herpes PCR was negative, fungal culture negative, blood culture negative, and urine cultures were negative. A neurology consult was obtained and this will be discussed below. The patient's mental status continued to improve. She was able to passive swallow on evaluation, and her mental status changes were felt simply related to severe extent of her illness. She did have an myocardial infarction of the head and cervical spine which was also negative for an intracranial process. 5. Bilateral proximal arm weakness - The patient began to complain of this as her mental status improved and she literally could not move her upper arms very much, several days after admission. On further investigation it was determined that this was a longstanding problem for the patient and as she recovered from the illness she actually regained strength and decreased pain in her upper arms. Neurology was consulted for this problem as she did receive a head computerized tomography scan and computerized tomography scan of the spine. Computerized tomography scan of the head showed reversible posterior encephalopathy possibly secondary to hypertension but no masses, no midline shift. Magnetic resonance imaging scan of the spine showed cervical spondylosis C5-C6 and C6-C7 with some narrowing of the spinal canal but no epidural abscess or other intraspinal process. At the time of this dictation, it was suggested that the patient follow up with Neurosurgery for the pain and the findings either as she remains in-house or as an outpatient. 6. Hypertension - The patient came in an extensive hypertensive regimen including Lisinopril, Hydrochlorothiazide, Diovan and Atenolol. The patient was treated in the hospital with Metoprolol 275 t.i.d. She was started on Losartan 100 initially. An ACE inhibitor was not used because of the patient's allergy to Univasc. Her regimen will likely change before discharge, but she did continue to be hypertensive to the 180s/approximately 80 to 90. 7. Glaucoma - After several days off of treatment, the patient was continued on a home glaucoma regimen. 8. Anemia - The patient's hematocrit did drop below 28 and the patient received 1 unit of packed red blood cells to good affect increasing her hematocrit to 34. The patient will have her hematocrit monitored for the remainder of her stay and should continue receiving her B12 shots. This dictation will be addended with the patient's discharge information at time of discharge. , M.D. Dictated By: MEDQUIST36 D: 14:37 T: 14:45 JOB#:

Physiologic mitral regurgitation is seen (withinnormal limits). Sinus tachycardiaSupraventricular extrasystolesST junctional depression is nonspecificSince previous tracing, sinus tachycardia, atrial premature complexes, and STdepression is present CT HEAD WITHOUT IV CONTRAST: The ventricles, basal cisterns and sulci are mildly prominent throughout, consistent with age appropriate involutional changes. BS clear decreased in bases bilaterally.GI: Please guiac all stool, -BM, +BS. INDWELLING FOLEY IN PLACE; PATENT WITH LG. tx with 2 gms ceftriaxone and flagyl.NEURO-was disoriented and incoherent upon arrival to EW-perked up with some care and is now oriented to person, answering simple questons.IV ACCESS-has #18 L antecube, #18 L wrist.a-stable DKAPadmit to MICU B for monitoring, care LS CLEAR TO DIMINISHED BILAT. Maint fluid of D5.45NS stopped. Sinus rhythm.Minor nonspecific lateral ST-T wave changesSince previous tracing of the same date: atrial ectopy not seen and ST-T wavechanges are decreased SOFT, NTND WITH +BS NOTED. The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. AND ORDERED FOR DOSE CEFTRIAXONE; AWAITING ID APPROVAL.C/V- HR 70S', NSR WITH NO ECTOPY NOTED. Slight pain in RUQ, my have an abd CT in near future.GU: Pt has f/c with marginal to adequate u/o. Pt reciving K phos currently. BP pt slightly hyertensive 140-160's sys. NGT INSERTED AND MED WITH ZOFRAN. ON ASPIRATION PRECAUTIONS FOR ALTERED MENTAL STATUS YEST. At C7-T1 and inferiorly to T4-5 disc degenerative changes are identified. NGT DC'D YEST. Con't to monitor MS. At times able to converse and other times completely lethergic.Cardiac: Pt in SR HR 80-90 no ectopy. 99.3 ORALLY. Been taking BG from ear lobes, I think the result from the edematous fingertips is skewed.Access: PT has PIV x3.Next labs, CK, lytes and PTT at 2230, con't to monitor MS. NGT PLACED TO LIS AND THE ZOFRAN HELPED WITH THE NAUSEA.NEURO: PT HAS BEEN INTERMITTENTLY ALERT AND ORIENTED X2. FINDINGS: AP supine view is compared to semi-upright view dated . There is mildmitral annular calcification. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 62Weight (lb): 138BSA (m2): 1.63 m2BP (mm Hg): 194/81HR (bpm): 76Status: InpatientDate/Time: at 10:12Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). Pt on q1 Hr BG, done via ear since pt very edematous.ID: Pt con't to have white count, LP done today, along wiht CT of abd. GIVEN X1 DOSE VANCO. Meds changed to IV for aspiration risk.GU: Pt has f/c with good u/o. MICU Nursing Progress NoteNeuro: Pt lethergic, arousible to voice, oriented x2 at times. FINDINGS: At the craniocervical junction and C2-3 and C3-4 mild degenerative changes are noted. T1 axial and coronal images were obtained following gadolinium. ON IVF D5 1/2NS @ 75/HR.RESP- ON 2L NC. PERIPHERAL PULSES PALPABLE. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The heart and mediastinum are within normal limits. LP YEST. Anion gap closed. BP 120-130 systolic. At C6-7 diffuse disc bulge and posterior ridging is identified with mild bilateral foraminal narrowing. Glargine @ HS. Well-defined radiopaque densities seen at the proximal humerus are unchanged from . 8:41 PM MR W& W/O CONTRAST Clip # Reason: r/o disk dz or epidural abscess ? MICU Nursing Progress NoteNeuro: Pt remains pleasently confused. NEGATIVE.SKIN - GROSSLY INTACT.SOCIAL - PTS. Soft-tissue changes are identified in the right maxillary and ethmoid sinuses. WITH TMAX. The uterus is otherwise unremarkable. Mild to moderate bilateral foraminal narrowing seen. TECHNIQUE: T1, T2 inversion recovery sagittal and gradient echo axial images were obtained following Gadolinium. Bilateral pleural effusions. Of concern is pt's persistent weakness of UE's, ?MRI. DID R/I FOR MI. Pt waxes and wanes in MS. Pt currently difficult to arouse, arouses to voice. Pt ruling in MI, EKG done, given and started on lopressor q4 for HR control, HR in low 80's is acceptable. STATUS AND CONT. NGT dc'd during a period of alertness, unable to place another NGT. NIBP 130'S-170'S/40'S-60'S. BP 185/66 @ 1200, so Labetolol IV started @ 1mg/hr. Uterine fibroids. IMPRESSION: Mild CHF cannot be excluded. IMPRESSION: 1. CT ABD. +MAE, THOUGH MINIMAL RUE. Pt is an aspiration risk!GI: Pt c/o LUQ pain, Abd soft distended, tenderness with palpation. Bowel sounds present, no stool since 1200.Endo: Initially receiving Insulin @ .5u/hr, D/C'd @ 1200. AND ONE THIS AM PER TEAM; RESULTS PENDING. NOTABLE FOR WBCS IN TUBE #1 & #4. MICU B Nursing Progress Note (0700-1100)Pt. bp has been 80-100/.RESP-wearing O2 2-3L nasal cannula.RR 28-30, unlabored.F/E- is on 5th litre of NS.voided 700 ccs in EW.please see labs in carevue.mucous membranes are dry.ENDO-sugar was 850 upon admit to the EW.was tx with 10u ivp insulin then started on a drip at 7u/hr. AMTS. CT of abd negative. Poor access for venapuncture. However, mild CHF cannot be excluded. UPDATED ON PT. ALERT AND ORIENTED X PERSON AND TIME T/O EVE., CONFUSED WITH PLACE. Patient is status post cholecystectomy. Urine yellow/clear.Plan: Called out to floor. UE weak bilat, to go to MRI this pm for spine and head scans.CV: HR stable 75-88NSR without ectopy, increasing to 108 with talking. Pts cardiac enzymes peaked, heparin stopped.Resp: Pt on 2L via NC, O2 sat 100%. However, FS @ 1400 292 and @ 1600 403. Pt must remain flat X multiple hours due to LP.Cardiac: Pt in SR occ Sinus arrythmia.

17

[ { "category": "Radiology", "chartdate": "2140-09-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 797563, "text": " 1:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above\n r/o bleed in setting of falls\n REASON FOR THIS EXAMINATION:\n change in mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 4:46 AM\n no bleed; no major CVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change and fall.\n\n COMPARISON: \n\n TECHNIQUE: Noncontrast axial images were obtained from the skull base to the\n vertex.\n\n CT HEAD WITHOUT IV CONTRAST: The ventricles, basal cisterns and sulci are\n mildly prominent throughout, consistent with age appropriate involutional\n changes. There is no mass effect, shift of normally midline structures, intra\n or extra-axial hemorrhage, or hydrocephalus. /white matter differentiation\n is preserved. There is mild low attenuation changes within the\n periventricular white matter, consistent with chronic microvascular\n infarctions. The osseous structures, paranasal sinuses and soft tissues are\n unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or edema.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797564, "text": " 2:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hyperglycemic coma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above\n r/o infiltrate\n REASON FOR THIS EXAMINATION:\n hyperglycemic coma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoglycemic coma.\n\n COMPARISON: .\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiomediastinal and hilar contours are\n unremarkable. The lungs are clear without focal opacities or effusions. The\n soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 797690, "text": " 9:34 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: ABDOMINAL PAIN, LOW GRADE FEVER, ELEVATED AMYLASE, R/O MESENTERIC ISCHEMIA\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with abdominal pain, low grade fever, mental status changes,\n elevated amylase and leukocytosis (24)\n REASON FOR THIS EXAMINATION:\n r/o mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Abdominal pain and fever.\n\n TECHNIQUE: CT of the abdomen and pelvis with contrast. 150 cc of Optiray were\n used for this examination. Optiray was used due to patient request.\n\n There are no prior studies for comparison.\n\n FINDINGS\n\n CT OF THE ABDOMEN WITH CONTRAST:\n There are bilateral pleural effusions in the lung bases. The liver, spleen,\n adrenals, kidneys, pancreas, and intra- abdominal vessels are unremarkable in\n appearance. Patient is status post cholecystectomy. Small and large bowels are\n normal in appearance. There is no evidence of bowel dilation. There is no fat\n stranding or fluid within the mesentery or surrounding the bowel. There is no\n mesenteric or retroperitoneal lymphadenopathy. There is no free air or free\n fluid within the abdomen. An NG tube is visualized within the stomach.\n\n CT OF THE PELVIS WITH CONTRAST:\n A Foley catheter is present within the bladder. The bladder, rectum, and\n sigmoid are otherwise unremarkable in appearance. There are fibroids within\n the uterus. The uterus is otherwise unremarkable. There is no free fluid or\n lymphadenopathy within the pelvis.\n\n The osseous structures are unremarkable.\n\n\n IMPRESSION:\n 1. No evidence of ischemic colitis.\n 2. Bilateral pleural effusions.\n 3. Uterine fibroids.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-10 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 798011, "text": " 12:07 PM\n HUMERUS (AP & LAT) RIGHT; SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHTClip # \n Reason: assess for trauma, fracture\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with dka, aseptic meningitis, s/p fall\n REASON FOR THIS EXAMINATION:\n assess for trauma, fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with aseptic meningitis.\n\n FINDINGS: There is no fracture or dislocation. Well-defined radiopaque\n densities seen at the proximal humerus are unchanged from . These are\n probably soft tissue calcifications.\n\n IMPRESSION: No fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-09 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 797955, "text": " 8:41 PM\n MR W& W/O CONTRAST Clip # \n Reason: r/o disk dz or epidural abscess ?? not sure if contrast need\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with MS changes w/ CSF pleocytosis w/ mildly elevated glucose\n & nrml protein now w/ UE weakness\n REASON FOR THIS EXAMINATION:\n r/o disk dz or epidural abscess ?? not sure if contrast needed???\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with mental status changes and CSF pleocystosis with\n mildly elevated glucose, r/o epidural abscess.\n\n TECHNIQUE: T1, T2 inversion recovery sagittal and gradient echo axial images\n were obtained following Gadolinium. There are no prior similar examinations\n for comparison.\n\n FINDINGS: At the craniocervical junction and C2-3 and C3-4 mild degenerative\n changes are noted. At C4-5 mild disc bulging and a broad based right sided\n disc herniation seen slightly indenting the thecal sac. At C5-6 diffuse disc\n bulging and posterior ridging is seen with mild narrowing of the spinal canal\n and indentation on the thecal sac. Mild to moderate bilateral foraminal\n narrowing seen. At C6-7 diffuse disc bulge and posterior ridging is\n identified with mild bilateral foraminal narrowing.\n\n At C7-T1 and inferiorly to T4-5 disc degenerative changes are identified. The\n spinal cord shows normal intrinsic signal.\n\n Following Gadolinium no evidence of abnormal intraspinal enhancement or\n evidence of epidural abscess is identified. No evidence of discitis or\n osteomyelitis is seen in the cervical and upper thoracic region. Prevertebral\n soft tissues are well maintained.\n\n IMPRESSION: Changes of cervical spondylosis with mild spinal canal narrowing\n at C5-6 and C6-7 with foraminal changes as above. No evidence of epidural\n abscess or abnormal intraspinal enhancement.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-09 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 797956, "text": " 8:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for evidence of encephalopathy\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with MS changes w/ CSF pleocytosis w/ mildly elevated glucose\n & nrml protein now w/ UE weakness\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of encephalopathy\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with mental status changes, rule out\n encephalopathy.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and susceptibility axial\n images of the brain were obtained before gadolinium. T1 axial and coronal\n images were obtained following gadolinium. Comparison was made with the\n previous MRI study of .\n\n FINDINGS: There are foci of T2 hyperintensity in bilateral posteroparietal\n and supero-occipital regions in the subcortical region extending to the\n cortex. These findings are new since the previous MRI study. Mild changes of\n small vessel disease are identified. No evidence of midline shift, mass\n effect or hydrocephalus is seen. No evidence of abnormal parenchymal,\n vascular or meningeal enhancement seen following the administration of\n gadolinium. Soft-tissue changes are identified in the right maxillary and\n ethmoid sinuses. Soft-tissue changes are also seen in both sphenoid sinuses.\n\n IMPRESSION: Foci of T2 hyperintensity in the subcortical and cortical region\n of parieto-occipital lobes could be secondary to posterior reversible\n encephalopathy from hypertension. Clinical correlation recommended. Further\n evaluation with a follow-up and diffusion-weighted images is recommended.\n Findings were discussed with Dr. at the time of interpretation\n of this study on at 11:30AM.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797748, "text": " 9:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: HYPERGLYCEMIC COMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with above r/o infiltrate\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n FINDINGS: AP supine view is compared to semi-upright view dated .\n The heart and mediastinum are within normal limits. The pulmonary vessels\n appear more prominent since the prior study, which may be appropriate for\n supine positioning. However, mild CHF cannot be excluded. There is no focal\n consolidation or pleural effusion. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION: Mild CHF cannot be excluded.\n\n" }, { "category": "Echo", "chartdate": "2140-09-09 00:00:00.000", "description": "Report", "row_id": 64154, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 138\nBSA (m2): 1.63 m2\nBP (mm Hg): 194/81\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 10:12\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\nnormal limits). The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-07 00:00:00.000", "description": "Report", "row_id": 1351046, "text": "NURSING PROGRESS NOTE:\nAT BEGINING OF SHIFT PT VOMITING SM AMT'S OF THICK GREEN BILIOUS LOOKING MATERIAL. PT GAGGING AND WRETCHING. NGT INSERTED AND MED WITH ZOFRAN. NGT PLACED TO LIS AND THE ZOFRAN HELPED WITH THE NAUSEA.\nNEURO: PT HAS BEEN INTERMITTENTLY ALERT AND ORIENTED X2. AT ONE POINT PT'S EYES WERE GLAZED OVER AND UNABLE TO RESPOND VERBALLY OR UNABLE TO RESPOND TO SIMPLE COMMANDS. AFTER AWHILE PT BECAME MORE RESPONSIVE BUT WAS VERY CONFUSED. PT TALKING RAGTIME ALL .\nBLOOD SUGARS HAVE BEEN CHECKED EVERY HOUR AND INSULIN DRIP TITRATED ACCORDINGLY. SEE FLOWSHEET FOR DATA.\nPTT AT 2230 150, HEPARIN DRIP TURNED OFF FOR 1HR AND RESTARTED AT 450UNITS. WILL RECHECK PTT IN AM.\nCV: PT'S HR IN HIGH 80'S WITH NO ECTOPY, PT GIVEN AN EXTRA DOSE OF LOPRESSOR, HR IN 70'S-80'S ALL NIGHT.\nPT C/O INTERMITTENT ABD PAIN THROUGHOUT THE NIGHT. WBC ELEVATED AND AMYLASE RISING, PT TO HAVE ABD CT SCAN WITH CONTRAST, HAS NOT BEEN DONE AS OF YET.\nIV FLUID HAS BEEN RUNNING AT 300CC/HR ALL . KPHOS FINISHED AND PHOS CAME UP SLIGHTLY BUT K CAME BACK TOO HIGH. IV FLUID CONT WITHOUT K.\nFOLEY CATH PATENT AND DRAINING SM AMT;S OF CLEAR YELLOW URINE..\nPT IS NPO, HYPOACTIVE BOWEL SOUNDS, NO STOOL AT THIS TIME.\nBROTHER NOTIFIED LAST THAT PT A BLOOD TRANSFUSION DUE TO LOW HCT. BROTHER GAVE CONSENT AT THAT TIME BUT CALLED BACK AT O500 AND\nTOOK BACK THE ORDER BECAUSE HE FELT HE SHOULD COME IN AND SEE HER AND TO SEE THAT SHE IS REALY CONFUSED AND UNABLE TO MAKE THIS DECISION HERSELF.\nPT IS AT THIS TIME.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-07 00:00:00.000", "description": "Report", "row_id": 1351047, "text": "MICU Nursing Progress Note\nNeuro: Pt remains pleasently confused. Pt OOB with great difficulty to chair. Pt waxes and wanes in MS. Pt currently difficult to arouse, arouses to voice. Pt must remain flat X multiple hours due to LP.\n\nCardiac: Pt in SR occ Sinus arrythmia. Pt on lopressor IV changed to PO and changed back to IV. BP pt slightly hyertensive 140-160's sys. Pts cardiac enzymes peaked, heparin stopped.\n\nResp: Pt on 2L via NC, O2 sat 100%. BS clear decreased in the bases. Pt is an aspiration risk!\n\nGI: Pt c/o LUQ pain, Abd soft distended, tenderness with palpation. Pt given 900cc baricat, via NGT. CT of abd negative. Pt had episodes of nausea. NGT dc'd during a period of alertness, unable to place another NGT. Meds changed to IV for aspiration risk.\n\nGU: Pt has f/c with good u/o. yellow in color and clear. Pt on D5 1/2 NS at 50cc/hr.\n\nEndo: Pt currently on 2U/hr of insulin, team does not want insulin turned off, please adjust IVF to maintain BG between 100-120. Pt on q1 Hr BG, done via ear since pt very edematous.\n\nID: Pt con't to have white count, LP done today, along wiht CT of abd. No head CT at this time for MS. cx drawn. No source of infection at this time. 2 sets of BS to be drawn with next sets of labs.\n\nLabs: Pt due for pm labs at 2100, with 2100 labs please send first set of BC, with am labs please draw the second set of BC.\n\nAccess: Pt has PIV x2. Poor access for venapuncture.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 1351044, "text": "pmicu nursing brief admit note\nmrs is an 84 yo woman admitted to the pmicu this am from the EW with DKA. her family called EMS because pt was having a change in her mental status, fell several times and felt \"off balance\".she does not have air conditioning in her apt.? if she's been compliant with her insulin.\nbrief review of systems\nCV-HR came down from 120's st to ~110 with IVF administration. bp has been 80-100/.\nRESP-wearing O2 2-3L nasal cannula.RR 28-30, unlabored.\nF/E- is on 5th litre of NS.voided 700 ccs in EW.please see labs in carevue.mucous membranes are dry.\nENDO-sugar was 850 upon admit to the EW.was tx with 10u ivp insulin then started on a drip at 7u/hr. last fingerstick=485.\nGI-abd is soft, nontender, positive bowel sounds.had some nausea and vomitting at home and in EW- tx with 10 mgs reglan with relief.\nID-2 sets blood cultures, urine sent from EW. tx with 2 gms ceftriaxone and flagyl.\nNEURO-was disoriented and incoherent upon arrival to EW-perked up with some care and is now oriented to person, answering simple questons.\nIV ACCESS-has #18 L antecube, #18 L wrist.\na-stable DKA\nP_admit to MICU B for monitoring, care\n" }, { "category": "Nursing/other", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 1351045, "text": "MICU Nursing Progress Note\nNeuro: Pt lethergic, arousible to voice, oriented x2 at times. Con't to monitor MS. At times able to converse and other times completely lethergic.\n\nCardiac: Pt in SR HR 80-90 no ectopy. BP 120-130 systolic. Pt ruling in MI, EKG done, given and started on lopressor q4 for HR control, HR in low 80's is acceptable. Heparin started at 750u/hr with 3700u bolus. Next PTT is 2300. goal PTT is 50-80.\n\nResp: Pt on 2L via NC. O2 sat 100%. BS clear decreased in bases bilaterally.\n\nGI: Please guiac all stool, -BM, +BS. Slight pain in RUQ, my have an abd CT in near future.\n\nGU: Pt has f/c with marginal to adequate u/o. Pt on D5 1/2 NS with 20mEq K at 300 cc/hr, after the L hanging, change to D5 con't at 300cc/hr.\n\nEndo: Pt on insulin gtt currently at 8u/hr. BG q1 hr, goal is <150. Anion gap closed. Lytes being repleated. Pt reciving K phos currently. Been taking BG from ear lobes, I think the result from the edematous fingertips is skewed.\n\nAccess: PT has PIV x3.\n\nNext labs, CK, lytes and PTT at 2230, con't to monitor MS.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351048, "text": "MICU-B NPN 1900-0700\nNEURO - PT. ALERT AND ORIENTED X PERSON AND TIME T/O EVE., CONFUSED WITH PLACE. VERY PLEASANT. +MAE, THOUGH MINIMAL RUE. C/O PAIN WITH MOVEMENT OF RUE, NO BRUISING NOTED. LP YEST. NOTABLE FOR WBCS IN TUBE #1 & #4. ?VIRAL MENINGITIS. GIVEN X1 DOSE VANCO. AND ORDERED FOR DOSE CEFTRIAXONE; AWAITING ID APPROVAL.\n\nC/V- HR 70S', NSR WITH NO ECTOPY NOTED. NIBP 130'S-170'S/40'S-60'S. CONT. ON Q4 HR. 10 MG. LOPRESSOR. PT. DID R/I FOR MI. PERIPHERAL PULSES PALPABLE. ON IVF D5 1/2NS @ 75/HR.\n\nRESP- ON 2L NC. O2SATS. 98-100% RR TEENS-20'S. LS CLEAR TO DIMINISHED BILAT. BASES. PRODUCTIVE COUGH NOTED; WILL SWALLOW OR SPIT OUT.\n\nGI/GU - PT. NGT DC'D YEST. ON ASPIRATION PRECAUTIONS FOR ALTERED MENTAL STATUS YEST. ABD. SOFT, NTND WITH +BS NOTED. NO STOOL THIS SHIFT. INDWELLING FOLEY IN PLACE; PATENT WITH LG. AMTS. LIGHT, YELLOW URINE OUT OVER/.\n\nENDO - REMAINS ON INSULIN GTT. @ 1U/HR T/O SHIFT PER TEAM. FS CHANGED TO Q2/HR; ALL WITHIN GOAL RANGE 100-200.\n\nID - PT. WITH TMAX. 99.3 ORALLY. WBC 15.5 THIS A.M. DOWN FROM 25.4 YEST. X2 SETS BLOOD CXS. SENT. ONE LAST EVE. AND ONE THIS AM PER TEAM; RESULTS PENDING. CT ABD. YEST. NEGATIVE.\n\nSKIN - GROSSLY INTACT.\n\nSOCIAL - PTS. SISTER AND CALLED OVER/. UPDATED ON PT. STATUS AND CONT. PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351049, "text": "MICU B Nursing Progress Note (0700-1100)_\n\nPt. awake, alert and interactive. She has started taking clear liqs and tolerating them well. Insulin gtt has been decreased from 1U/hr to .5U/hr after fingerstick of 89. Continues on D5.45NS at 75cc/hr. Insulin requirements to be re-evaluated later in the day...to be converted to sliding scale as her po intake increases. Of concern is pt's persistent weakness of UE's, ?MRI.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-08 00:00:00.000", "description": "Report", "row_id": 1351050, "text": "Nursing Progress Note 1200-1900\nReview of Systems:\n\nNeuro: Pt remains pleasant and cooperative but intermit confused. A&O X 3. UE weak bilat, to go to MRI this pm for spine and head scans.\n\nCV: HR stable 75-88NSR without ectopy, increasing to 108 with talking. BP 185/66 @ 1200, so Labetolol IV started @ 1mg/hr. After 1hr, bolused with 5mg and rate increased to 2mg/hr. No sig change in BP. At 1600 Labetolol D/C'd and pt given Lopressor 37.5mg crushed in applesauce. BP presently 167/66. Afebrile.\n\nResp: Pt has remained on NC @ 2l, sating @ 97% with RR 25-30 and easy. HOB up 30 degrees. Lungs clear, diminished bilat.\n\nGI: Eating erratically, difficulty with swallowing foods/liqs. Able to swallow Lopressor in custard @ 1600. Maint fluid of D5.45NS stopped. Bowel sounds present, no stool since 1200.\n\nEndo: Initially receiving Insulin @ .5u/hr, D/C'd @ 1200. Given 2uReg/1uHumalog insulin per SS before lunch when FS 251. However, FS @ 1400 292 and @ 1600 403. Sliding scale adjusted and pt received 12uReg @ 1600.\n\nGU: Good urine output per carevue. Presently -100ml for 24hrs. Urine yellow/clear.\n\nPlan: Called out to floor. Reassess BP to adjust Lopressor dose. FS Q2hr, with insulin per SS. Glargine @ HS. MRI to help assess neuro status.\n\n\n" }, { "category": "ECG", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 123155, "text": "Sinus rhythm.\nMinor nonspecific lateral ST-T wave changes\nSince previous tracing of the same date: atrial ectopy not seen and ST-T wave\nchanges are decreased\n\n" }, { "category": "ECG", "chartdate": "2140-09-06 00:00:00.000", "description": "Report", "row_id": 123156, "text": "Sinus tachycardia\nSupraventricular extrasystoles\nST junctional depression is nonspecific\nSince previous tracing, sinus tachycardia, atrial premature complexes, and ST\ndepression is present\n\n" } ]

4,474

106,798

Patient was admitted to the on , and underwent an aortic valve replacement with #25 valve. The patient also underwent coronary artery bypass grafting from the saphenous vein graft to the right coronary artery. The procedure was performed without complications, and the patient was as is routine, transferred to the Cardiac Surgery Intensive Care Unit while intubated. The patient was extubated awhile after arriving to the Intensive Care Unit. At the time, the patient was alert and moving all extremities. His blood gases were good and appeared in no distress. Within a few minutes after being extubated, however, the patient decompensated and became apneic with a decrease in his oxygen saturations. The patient required reintubation and was evaluated by the Neurology service. Following evaluation, the patient's event was believed to be secondary to respiratory arrest contributed by the need to be supine with his groin line as well as his previously undiagnosed history of sleep apnea. Patient showed no neurological deficits after the reintubation and quickly returned to baseline neurologic function. No immediate imaging was deemed necessary. A bronchoscopy was performed revealing minimal mucus and essentially clear airways. Patient underwent hemodialysis on postoperative day #1. Patient was ultimately extubated on postoperative day #2 without event. On postoperative day two, the patient underwent another session of hemodialysis, and was noted to have frequent premature atrial contractions subsequently changing to atrial fibrillation at a rate of 140. The patient was bolused with amiodarone and started on a drip. The patient returned to sinus rhythm shortly after. The patient remained on Levophed drip. The patient had been empirically started on levofloxacin antibiotic regiment for possible pneumonia given some thick copious mucus. This patient was afebrile and had a normal white count. Over the following few days, the patient had brief episodes of atrial fibrillation, though revert to sinus rhythm with amiodarone boluses. A Heparin drip was started and plans were made for anticoagulation with Coumadin. The patient remained on a Levophed drip to support his blood pressure with goal systolic blood pressures in the 90s-100s. Patient was ultimately weaned off of his Levophed on postoperative day #7. His systolic blood pressure remained low mainly in the 90s, but the patient seemed to tolerate this well. The patient was transferred out of the ICU on postoperative day #8. The patient remained on hemodialysis and ultrafiltration to try and offload some of the volume the patient had gained intraoperatively. Patient was ultimately started on Coumadin on . Within three days, the patient's INR was 2.5 following doses of 2 mg, 2 mg, and 1 mg. Patient completed a 14-day course of levofloxacin and was started on clindamycin for some lower extremity erythema. Patient was noted to have small Stage II decubitus ulcer on , and wound care consult was requested with the recommendation made for Duoderm gel and thin Duoderm wafer dressings to the wound as well as frequent positioning changes. Patient had remained in normal sinus rhythm with no further episodes of atrial fibrillation since transferred from the Intensive Care Unit. He was on amiodarone by mouth. By postoperative day 20, the patient was deemed ready for discharge to rehab facility. But by the time of discharge, the patient's pain was well controlled and his respiratory status was stable. His estimated dry weight was 87 kg, and on the day prior to discharge, had a predialysis weight of 94.1 kg. Four kg of fluid was taken off that day. Patient had been seen by Physical Therapy while in house and on ambulation remained somewhat unsteady and weak, requiring the assist of two people for safe ambulation. The patient's sternal incision was healing well with Steri-Strips in place. Patient also had some left lower extremity incisions, which appeared to be healing well with a few small blisters. A transthoracic echocardiogram had been performed on approximately to confirm the absence of thrombus in the patient's heart. The transthoracic echocardiogram revealed no such thrombus, and the decision was made to cease further anticoagulation on the patient and his Coumadin was discontinued. The benefits and risks of further Coumadin therapy had been reviewed, and further treatment was deemed unnecessary given that the patient had been in normal sinus rhythm for much of his hospitalization and that his atrial fibrillation could have been attributed to his significant fluid overload immediately after the surgery.

Lobulated, somewhat cystic-appearing collection of fluid in close continuity with the left glenohumeral joint. There is opacification in the retrocardiac region obscurring the hemidiapragm which may be postoperative in nature. There has been a right nephrectomy. There is a new patchy opacity at the right base adjacent to the hemidiaprhagm and acute infiltrate can't be excluded. There is calcification of the aortic knuckle. There issevere mitral annular calcification. Ground glass opacity in right upper lobe of uncertain chronicity. FINDINGS: MR WITH CONTRAST: There is abnormal intermediate and high signal involving the subcutaneous soft tissues of the anterior and lateral right , representing nonspecific soft tissue edema. IMPRESSION: The patient has been extubated. IMPRESSION: Noncompressible right lower extremity vessels. Probable residual LV decompinsation with bilateral pleural effusions, larger on the left. Mild (1+) mitralregurgitation is seen.4. IMPRESSION: Satisfactory post-operative findings on AP single chest view. There is evidence of left lower lobe collapse/consolidation, associated with a moderate sized left pleural effusion. There is mild mitral stenosis. There is mild mitral stenosis. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. There are bilateral pleural effusions with lower lobe atelectasis. The lungs are grossly clear with the exception of some ground glass opacity toward the right lung apex which may represent early or resolving infectious or inflammatory focus. Aorta is calcified and unfolded. MILD RESP ACIDOSIS INITIALLY-RESOLVED AFTER VENT CHANGES. There is again evidence of the recent CABG and AVR surgery. MRI OF THE RIGHT ANKLE WO/W IV CONTRAST: In the lateral aspect of the talar dome there is a subchondral area of high T2 signal with associated loss of the articular cartilage. Septalhypokinesis is present.2. Incompletely imaged at the inferior most aspect of the coronal images is a round lesion within the calcaneus that is high signal on STIR sequences and is isointense to muscle on T1W images. FINDINGS: Doppler evaluation was performed of the right lower extremity arterial system. A moderate sized left pleural effusion is present. expiratory wheezes c/ activity. + dopp pp bilat. Wean Neo gtt as bp tolerates. Encourage respitory hygeine. pp by dopplerresp: LS clear with dim bases. CONT ON PO AMIODORONE. heparin gtt for afib. Clinda and levo given. Pulm: remains vented with abg's per . right leg dressing changed, eschar intact, small amt serosang drainage. Bp 80's off neo gtt. ABG-sl alk- with pO2 71 on RA-Placed on 2l nc. cont abx. PAIN RELIEF AFTER 1 PERCOCET X 2. d/c a-line. rle dsg changed->silvadine &dsd applied.resp: lungs clear but diminished in bases. Tolerating po's. Last BM .Endo: Glucose 100-WNL.Incisions: Sternum-healing-C/D-OTA. Wean Levo if BP tolerates. anuric. CI 2.33-2.95. Started Linezolid per id. R calf- erythema-wound debrided. converted to a-fib rate 100's to 120's--bolused c/ amio c/ improvement in hr. change rle dsg . GU: Hemodialysis M/W/F, right av fistula with +T/B. passing flattus no bm.gu: aneuric. bedrest d/t femoral line->t&r q2h. PLAN TO HAVE DIALYSIS THIS AM... 100, tylenol given at beginning of shift, PP+ via doppler.RESP: Lungs clear, diminished at bases, resp. Pedal pulses are dopplerable.RESP: Lungs clear w/ diminished bases. Instituted Msra precautions. later converted back to nsr. Awaiting MRI.Resp: Lungs ess CTA except crackles L base. ?D/C SWAN TODAY AND GET OOB. W/ REMINDERS. levo gtt weaned to keep MAP > 60. svo2 69-72. L thigh with dry eschar-no erythema-OTA. pt into afib ~ 0945 am (pt became slighlty hypotensive with afib -> SBP in the 80's. ?dc femoral aline in am. Resite IV line. R: As above. bs q6h. breath sounds clear bilat, decreased at lll. Change RLL . MONITOR PTT. afebrile. Pt currently on norepi at 0.34mcg/kg/min with sbp 104/48 (65). ORIGINAL STERNAL DRSG , REMOVED.A/P: UNEVENTFUL NOC. Dialysis as ordered. gtt., able to wean down to .28, CI/CO WNL, SV02 62-67, occassional PVC's and PAC's noted, low grade temp. asymptomatic. + BOWEL SOUNDS.GU: ANURIC,?DIALYSIS TOMORROW. SINCE OR YET.G.U./RENAL: BUN/CR IMPROVED AFTER HD. d/c to . 1st degree AVB. 1st degree AVB. Pt. Compared to the previous tracing the mechanism is once again probably sinuswith first degree A-V block, rate 74. gtt., SV02 60-70, CI/CO WNL, continues on amio.gtt, PP+, afebrile.RESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. , COMPRESSIONS GIVEN FOR APPROX. PATIENT'SS K AT APPROX. RESPIRATORY CALLED FOR EXTUBATION, GIVEN THE OK BY TO EXTUBATE. Amio gtt started and second bolus given. NEURO GROSSLY INTACT.CV: LEVO WEANED OFF POST DIALYSIS. GIVEN 2MORE AMPS D50 AFTER INTIAL AMP, PLAN TO CHECK 630 AM.. K PENDING THIS AM. Probable sinus rhythm with first degree A-V delay and left atrial abnormality.Prolonged QTc interval. Probable sinus rhythm with first degree AV delay and left atrial abnormalityLow voltageLeft axis deviationRight bundle branch block and left anterior fascicular blockConsider prior anterolateral myocardial infarctDiffuse ST-T wave changes with prolonged Q-Tc interval - cannot exclude in partmetabolic/drug effectand/or ischemiaClinical correlation is suggestedSince previous tracing of , QRS voltage decreased and further ST-T wavechanges seen Sinus rhythmFirst degree A-V blockMarked left axis deviationRBBB with left anterior fascicular blockPossible old anterior infarctLateral T wave changes are nonspecificLow QRS voltages in precordial leadsNo change from previous PULSES DOPPLERABLE. GI NPO NGT DRAINING APPROX. Probable junctional rhythm, rate 68, with associated right bundle-branchblock/left anterior hemiblock. Percocet x 1 for pain control. GROIN LINES PATENT.RESP: LUNG SOUNDS CLEAR TO DIM AT BASES EPISODES OF WHEEZING C/ ACTIVITY. Levo gtt infusing. PASSING FLATTUS NO BM.GU: ANEURIC. Normal sinus rhythmMarked left axis deviationRBBB with left anterior fascicular blockLow QRS voltages in precordial leadsOld anterior myocardial infarctSince last ECG, no significant change 10SEC, , ANESTHESIA HAD BEEN CALLED TO BEDSIDE, CALLED TO BEDSIDE, BEGAN CAPTURING WITH SBP, INTUBATED WITHOUT DIFFICULTY, PROPOFOL 10CC GIVEN PER ANETHESIA FOR INTUBATION LEVO WEANED TO .3MCG/KG/MIND/T SBP 170'S. Potassium down to 3.9. CONTINUE C/ CURRENT PLAN OF CARE. BG WNL.SKIN: Dsgs CDI. CA/MAG WNL THIS AM. Air leak heard with cuff deflated ptior to extubation,labile BP @ time will continue to follow.

48

[ { "category": "Radiology", "chartdate": "2133-04-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 819089, "text": " 8:03 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with severe AS, CAD. For AVR/CABG. put Dr. \n as ordering MD.\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Aortic stenosis, coronary artery disease. AVR/CABG. R/O CHF.\n\n PA AND LATERAL CHEST: The views were obtained on the stretcher. Comparison is\n made to previous films from taken supine. There is again evidence of\n the recent CABG and AVR surgery. The heart again shows fairly marked\n enlargement, predominantly left ventricular. Aorta is calcified and unfolded.\n The pulmonary vessels show moderate upper zone redistribution. There is\n evidence of left lower lobe collapse/consolidation, associated with a moderate\n sized left pleural effusion. There is also evidence of a right sided effusion\n posteriorly. Allowing for postural differences these findings show slight\n improvement since the prior study.\n\n IMPRESSION:\n\n 1. Status post CABG/AVR surgery.\n 2. Probable residual LV decompinsation with bilateral pleural effusions,\n larger on the left.\n 3. Left lower lobe collapse/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 817988, "text": " 9:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Asses ETT placement\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr re intubated for resp distress\n\n REASON FOR THIS EXAMINATION:\n Asses ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE DATED .\n\n INDICATION: Assess position of ET tube.\n\n COMPARISON: at 5:55.\n\n FINDINGS: The heart is enlarged. There is widending of the mediastinum,\n unchanged from prior examinations. There is calcification of the aortic\n knuckle. The lungs are expanded and clear.\n\n The tips of the ET tube and Swan-Ganz catheter are in satisfactory position.\n There has been interval uncurling of the Swan-Ganz.\n\n IMPRESSION: Line positions as described. Otherwise no significant from prior\n examination.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-30 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 820130, "text": " 3:35 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: s/p AVR/CABG w/new onset calf tenderness-r/o DVT\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR/CABG w/new onset calf tenderness-r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG and AVR with bilateral calf tenderness.\n\n FINDINGS: Duplex and color Doppler demonstrate no DVT from the common femoral\n through to the proximal tibial veins bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 817961, "text": " 3:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW\n\n INDICATION: History of bypass surgery and aortic valve replacement, follow up\n examination.\n\n FINDINGS: AP single view obtained with patient in supine position\n demonstrates EGT in place terminating in the trachea approximately 4 cm above\n the carina. NG tube has been passed reaching far below the diaphragm. A\n Swan-Ganz catheter approaching from below curves in the right atrium but\n reaches the area of the main pulmonary artery. No evidence of pneumothorax.\n Metallic structures of a porcine aortic valve prosthesis in place. Moderate\n post-operative mediastinal widening is seen and perivascular haze exists\n without evidence of edema or new parenchymal infiltrates. The lateral pleural\n sinuses are free.\n\n IMPRESSION: Satisfactory post-operative findings on AP single chest view.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-01 00:00:00.000", "description": "RP TIB/FIB (AP & LAT) RIGHT PORT", "row_id": 820206, "text": " 12:11 PM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: r/o necrotizing fascitis\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with s/p AVR/CABG, with worsening leg wound\n REASON FOR THIS EXAMINATION:\n r/o necrotizing fascitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infected leg wound, evaluate.\n\n TECHNIQUE: Two views of the right tibia and fibula.\n\n No comparisons.\n\n FINDINGS: There are surgical clips overlying the soft tissues of the left\n medial thigh. There is soft tissue swelling in the upper thigh, no definite\n evidence of subcutaneous air. There are extensive vascular calcifications.\n There is an ill-defined lucency overlying the navicular and possibly the\n middle cuneiform.\n\n IMPRESSION:\n 1. Soft tissue swelling in the proximal thigh, no definite evidence of\n subcutaneous air.\n 2. Ill-defined lucency overlying the dorsum of the navicular bone, dedicated\n foot views are recommended for better characterization. Differential\n diagnosis includes osteomyelitis or degenerative changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 818155, "text": " 12:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cabg avr re intubated for resp distress\n\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 64-year-old man with CABG and AVR now reintubated for respiratory\n distress.\n\n AP SUPINE PORTABLE CHEST: at 1 p.m.: Compared to prior portable\n chest two days ago, the endotracheal tube has been pulled. The pulmonary\n artery catheter is unchanged. There is still marked widening of the superior\n mediastinum. Some of this may be due to supine positioning, but mediastinal\n hematoma cannot be entirely excluded. There is opacification in the\n retrocardiac region obscurring the hemidiapragm which may be postoperative in\n nature. In addition, there is patchy density at the right base which is new.\n\n IMPRESSION: The patient has been extubated. There is widened mediastinum and\n mediastinal hematoma can't be entirely excluded. There is a new patchy\n opacity at the right base adjacent to the hemidiaprhagm and acute infiltrate\n can't be excluded. Postoperative changes at the left base. The overall\n opacity of the chest is increased raising the question of congestive heart\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2133-04-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 819678, "text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pleural effusion\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with severe AS, CAD. For AVR/CABG. put Dr. \n as ordering MD.\n REASON FOR THIS EXAMINATION:\n assess for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Severe AS and CAD.\n\n PA AND LATERAL CHEST: When compared to the prior films of , cardiac size\n appears to have decreased. Some cardiac enlargement, however, is still\n present. The aorta remains calcified and unfolded.\n\n The right lung field is clear. A moderate sized left pleural effusion is\n present. Significantly altered in size since the prior chest x-ray.\n\n IMPRESSION: Decreasing cardiac size, left effusion. No significant failure.\n\n" }, { "category": "Echo", "chartdate": "2133-04-27 00:00:00.000", "description": "Report", "row_id": 70856, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/p AVR with 25 mm perimount Pericardial AVR.\nHeight: (in) 68\nWeight (lb): 200\nBSA (m2): 2.05 m2\nBP (mm Hg): 126/68\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 15:09\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: An aortic valve prosthesis is present.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nsevere mitral annular calcification. There is mild mitral stenosis. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function very difficult to asses but is probably normal. Septal\nhypokinesis is present.\n2. An aortic valve prosthesis is present.\n3. The mitral valve leaflets are moderately thickened. There is severe mitral\nannular calcification. There is mild mitral stenosis. Mild (1+) mitral\nregurgitation is seen.\n4. There is no pericardial effusion.\n5. Compared with the findings of the prior study (tape reviewed) of ,\nthe prosthetic aortic valve is new.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-07 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 820850, "text": " 8:10 AM\n ART EXT (REST ONLY) Clip # \n Reason: RLE full non-invasive studies please.\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with nonhealing saphenectomy wound s/p CABG, AVR.\n REASON FOR THIS EXAMINATION:\n RLE full non-invasive studies please.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with nonhealing saphenectomy site.\n\n FINDINGS: Doppler evaluation was performed of the right lower extremity\n arterial system. Doppler tracings are triphasic at all levels from the\n femoral to the dorsalis pedis artery. Ankle brachial index is falsely\n elevated due to noncompressible vessels. Pulse volume recordings are\n maintained to the ankle and show drop off of the metatarsal where they are\n approximately 7 mm.\n\n IMPRESSION: Noncompressible right lower extremity vessels. Mild flow deficit\n to the right forefoot.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-05 00:00:00.000", "description": "R MR ANKLE W&W/O CONTRAST RIGHT", "row_id": 820618, "text": " 10:00 AM\n MR ANKLE W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: r/o lateral malleolar osteo\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M, dialysis dependent PKD, POD #21 s/p CABG/AVR complaining of pain at\n , vein harvest incision somewhat macerated, no gross purulence or\n erythema. Afebrile but with WBC increased 10.4 to 13.2.\n REASON FOR THIS EXAMINATION:\n r/o lateral malleolar osteo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG, complaining of pain at at the site of vein harvest\n incision, no erythema or secretions, elevated white blood cells.\n\n TECHNIQUE: Axial, coronal, and sagittal images of the right ankle were\n obtained without and with IV contrast.\n\n Comparison with prior x-rays from .\n\n MRI OF THE RIGHT ANKLE WO/W IV CONTRAST: In the lateral aspect of the talar\n dome there is a subchondral area of high T2 signal with associated loss of the\n articular cartilage. There are multiple well-defined rounded lesions in\n multiple bones which have high T2 signal and are consistent with erosions. The\n largest ones are seen in the distal fibula, in the anterior aspect of the\n calcaneus and in the cuboid bone. The navicular bone is fragmented, there is\n joint space narrowing at the joint space between the navicular and the\n cuneiform with associated subchondral marrow edema. There is diffuse edema in\n the subcutaneous soft tissues without evidence of focal collections. There is\n no fluid within the joint space. The visualized tendons and ligaments about\n the ankle joint are preserved. There is generalized muscle edema.\n\n IMPRESSION:\n 1) Diffuse subcutaneous and muscle edema without evidence of focal\n collections.\n\n 2) Multiple large erosions in the distal fibula, calcaneus, and tarsal bones,\n differential diagnosis includes synovitis related to trauma, inflammatory\n arthropathy, gout and less likely amyloid.\n\n 3) Fragmentation and degenerative changes in the articulation between the\n navicular and the cuneiform could be related to neuropathic changes.\n\n 4) Osteochondral defect in the talar dome.\n\n The findings were discussed with Dr. at the time of the exam.\n (Over)\n\n 10:00 AM\n MR ANKLE W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: r/o lateral malleolar osteo\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2133-05-02 00:00:00.000", "description": "R MR CALF W&W/O CONTRAST RIGHT", "row_id": 820337, "text": " 8:11 PM\n MR W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: C/O PAIN @ RIGHT , VEIN HARVEST INCISION SOMEWHAT MACERATED. PT. IS AFEBRILE BUT W/ INCREASED WBC.\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M, dialysis dependent PKD, POD #21 s/p CABG/AVR complaining of pain at\n , vein harvest incision somewhat macerated, no gross purulence or erythema.\n Afebrile but with WBC increased 10.4 to 13.2.\n REASON FOR THIS EXAMINATION:\n Evaluate for deep infection along vein harvest incision.** Note allergy to\n iodinated contrast **\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P right lesser saphenous vein harvest. Complaining of right \n cellulitis at vein harvest site.\n\n TECHNIQUE: MR examination of the right was performed utilizing the\n following sequences: axial and coronal T1W images and T2W IR images, and\n axial PD weighted images with fat saturation following the IV administration\n of Gadolinium. Comparison is made to the radiographs obtained .\n\n FINDINGS:\n MR WITH CONTRAST: There is abnormal intermediate and high signal\n involving the subcutaneous soft tissues of the anterior and lateral right\n , representing nonspecific soft tissue edema. No fluid collection is\n demonstrated. No abscess is seen. There is abnormal, non-specific,\n intermediate signal involving the anterior cortex of the anterior tibia\n which is of uncertain etiology but which may reflect the presence of local\n hyperemia. No frank fracture line is identified.\n\n There is a round, well-circumscribed, lesion in the distal fibula metaphysis,\n measuring 15 mm. This lesion demonstrates uniform high signal on STIR\n sequences and is isointense to muscle on T1W images. Following Gadolinium,\n uniform high signal is seen on fat saturated proton density weighted images. A\n tract exiting through the anterior medial cortex of the distal fibula and\n communicating with the joint space is demonstrated. The signal within the\n lesion on post contrast imaging is isointense to enhancing joint fluid.\n\n Incompletely imaged at the inferior most aspect of the coronal images is a\n round lesion within the calcaneus that is high signal on STIR sequences and is\n isointense to muscle on T1W images.\n\n Several tiny foci of susceptibility artifact along the anterior and medial\n are consistent with the patient's history of surgery.\n\n There is a moderate ankle joint effusion.\n\n IMPRESSION:\n\n Cellulitis involving the soft tissues of the anterior and medial .\n Underlying signal abnormality in the anterior tibial cortex may represent\n (Over)\n\n 8:11 PM\n MR W&W/O CONTRAST RIGHT; MR CONTRAST GADOLIN Clip # \n Reason: C/O PAIN @ RIGHT , VEIN HARVEST INCISION SOMEWHAT MACERATED. PT. IS AFEBRILE BUT W/ INCREASED WBC.\n Admitting Diagnosis: CAD/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n reactive edema or local hyperemia. The finding is nonspecific, however, and\n infection is not excluded.\n\n Lesions within the lateral malleolus and calcaneus. These lesions are not\n well evaluated on this study, which was tailored to examine the . Further\n evaluation with contrast enhanced MR examination of the ankle is recommended.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 820899, "text": " 3:13 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVALUATE FOR POSSIBLE STERNAL COLLECTION\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with\n REASON FOR THIS EXAMINATION:\n r/o sternal collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for sternal infection. Postop 26 days from CABG.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast chest CT.\n\n FINDINGS: There is soft tissue and fluid attenuation surrounding the sternum\n and in the retrosternal space, but with no discernible fluid collection. There\n is leftward displacement of the most superior sternal wire. The sternum\n itself demonstrates rarefaction of bone with a moth-eaten permeative\n appearance which may be seen in the setting of osteomyelitis. There is\n extensive coronary and vascular calcification. There is no adenopathy. There\n is a small pericardial effusion. There is a lower right paratracheal lymph\n node which measures just under 1 cm. The upper abdomen reveals the presence\n of numerous low-density lesions within the liver and numerous cystic lesions\n and calcifications in the left kidney. There has been a right nephrectomy.\n The gallbladder is somewhat distended and contains several calcified stones\n towards the gallbladder neck. Two similar calcifications are noted in the\n region of the pancreatic head, perhaps representing common duct stones.\n Clinical correlation is suggested.\n\n There are bilateral pleural effusions with lower lobe atelectasis. The lungs\n are grossly clear with the exception of some ground glass opacity toward the\n right lung apex which may represent early or resolving infectious or\n inflammatory focus. The bones reveal, in addition to findings suspicious for\n sternal osteomyelitis, multiple bilateral anterior rib fractures. Has this\n patient had chest compressions?\n\n IMPRESSION:\n 1. Findings concerning for sternal osteomyelitis with adjacent peristernal\n infection/inflammation. This could be confirmed with either gallium or\n Indium-111 labeled white blood cell sanning. 2. Gallstones and probable\n choledocholithiasis. There is no definite biliary dilatation but correlation\n with liver function tests and clinical symptoms is suggested.\n 3. Numerous hepatic cysts and multicystic left kidney with multiple\n calcifications. Does this patient have polycystic kidney disease?\n 4. Large bilateral pleural effusions with atelectasis.\n 5. Ground glass opacity in right upper lobe of uncertain chronicity. If\n acute, this may be due to an early or resolving infection. If chronic,\n bronchoalveolar cell carcinoma would be a consideration. In the absence of\n infectious symptoms, a 3- month- old followup CT could be considered to insure\n (Over)\n\n 3:13 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVALUATE FOR POSSIBLE STERNAL COLLECTION\n Admitting Diagnosis: CAD/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n resolution.\n 6. Lobulated, somewhat cystic-appearing collection of fluid in close\n continuity with the left glenohumeral joint. This may represent a\n proliferative synovial process. Consider left shoulder MRI for further\n evaluation without and with gadolinium.\n 7. Multiple anterior rib fractures. Has this patient had chest compressions?\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320231, "text": "Resp Care\n\nFrom OR pt placed on full vent support of 800/10/100/5. Original abg slightly acidotic and rr increased to 12. Fio2 decreased to 50%\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320232, "text": "admission note\nPT FROM OR S/P CABG X 1 & #25 TISSUE AVR. SEDATED ON PROPOFOL AND HIGH DOSE LEVO GTT. ALSO AVP REPORTEDLY FOR PROLONGED PR.\n\nCV: LABILE SBP 70'S-130'S TX W/ 2L LR AND LEVO TITRATION. BP STABLE NOW THAT REVERSED, PROPOFOL AWAKE AND PROPOFOL OFF. SVO2 60'S-70'S W/ GD C.I.(SEE FLOW SHEET). SVO2 DID DROP TO 57% AFTER TURNING FOR BATH BUT RECOVERED SLOWLY. MINIMAL DRNG VIA SINGLE MED CT. 2ND U PRBC INFUSING FOR HCT 25. ALL LINES IN R FEM DUE TO OCCLUDED PROX VESSELS(SEE HX). RUA AVF W/ FAINT THRILL.\n\nNEURO: , FOLLOWING COMMANDS AND NODDING HEAD APPROPRIATELY TO QUESTIONS. REFUSING PAIN MED ;ACKNOWLEDGED THAT PAIN IS MINIMAL.\n\nRESP: MILD EXP WHEEZES INITIALLY. MILD RESP ACIDOSIS INITIALLY-RESOLVED AFTER VENT CHANGES. CURRENTLY EXCELLENT VT'S ON 10 IPS, 5 PEEP. FIO1 .50; SPO2 99%.\n\nG.I.: SM AMT BILIOUS DRNG VIA OGT.\n\nG.U./RENAL: NO FOLEY-DOES NOT MAKE URINE. CREAT=5, K+4.9. CA+2 REPLETED. PLAN FOR HD TOMORROW VIA AVF.\n\nSKIN: INTACT. DRSGS DRY. HAS BILAT LE ACES.\n\nSOCIAL: HAS LG FAMILY. WIFE TO BE SPOKESPERSON. ALL IN TO VISIT.\n\nA/P: BP STABILIZING. BEGINNING TO WEAN LEVO. NEURO INTACT. TOLERATING INITIAL VENT WEAN. PLAN TO EXTUBATE IF BP STABLE AND WEAN PROGRESSING WELL. WILL BE DIFFICULT TO RAISE HEAD DUE TO GROIN LINES. CHECK CXR. MONITOR LYTES AND HCT. HD TOMORROW. ASSESS FOR PAIN.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-13 00:00:00.000", "description": "Report", "row_id": 1320244, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative with care.\n\nCV: Junctional rthyem with rate of 63-66, BP tolerating well, continues on low dose levo., able to slowly wean, CI/CO WNL, Sv02 60-68, PP+, afebrile, A pacing wires not sensing and capturing 100%, switched over to V side for higher mA's, currently pacer turned to off.\n\nRESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. 100%, using IS, nonproductive cough.\n\nGI: Obese, BS+, taking sips of water.\n\nGU: Hemo. patient, to be dialyzed today, + bruit on RUE AVG but no palpable thrill.\n\nPAIN: no c/o pain.\n\nPLAN: Continue to monitor CV and RESP status, wean levo. as tolerated, wean 02, pulmonary toilet, increase activity once femerol lines out, continue to monitor electrolytes, increase po intake.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-13 00:00:00.000", "description": "Report", "row_id": 1320245, "text": "D: Please see data, MD notes/orders. Neuro: A&O x3 CV: Afib with hr 17eens-120s. Sbp 90's. CO/CI stable wnl. Pulm: 02 at 2L n/c, sats 98-100%. Lungs clear, decr at bases. GU: Dialized this am, see notes. Required levo titration to keep map >60. Pt recieved one unit prbc for hct 29.4. GI: Abd obese, bs+, pt taking fair po intake. Skin: Surfaces intact, peripheral pulses palpable. Soc: Wife/children visiting in two's q 1-2hrs. Access: Peripheral access unobtainable, pt remains with femoral cco swanganz/art line. Comfort: Has intermitent soreness at sternotomy site, mostly with turns. P: Monitor hr/rythm for now, titrate levo gtt down as bp tolerates. D/c art line when levo gtt off, change line to tlc over wire to allow pt to increase activity level. Prn pain meds, note response to same. Keep family updated on plan of care. R: Levo currently at 0.04mcg/kg/min with map of 61. Pt medicated for pain with one percocet x2 today with good effect. Questions from family answered satisfactorily.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-14 00:00:00.000", "description": "Report", "row_id": 1320246, "text": "UPDATE\nCV: ACCEL JUNCTIONAL HR IN 70'S. CONT ON PO AMIODORONE. IV HEPARIN GTT STARTED LAST EVE. PTT THIS A.M. 35 ON 700U/HR->UP TO 800U. LEVO INCREASED SL TO MAINTAIN MAP 60 OR>. C.I. CONSISTENTLY >2.5, SVO2 LOW-MID 70'S.\n\nRESP: USING I.S. W/ REMINDERS. C&R THICK, YELLLOW SPUTUM THIS A.M. SPO2 HIGH 90'S ON RA.\n\nNEURO: INTACT. PAIN RELIEF AFTER 1 PERCOCET X 2. SLEPT WELL ON&OFF.\n\nG.I.: THIRSTY-DRINKING LIQS O/N. NO B.M. SINCE OR YET.\n\nG.U./RENAL: BUN/CR IMPROVED AFTER HD. OTHER LYTES WNL. I&O +200 BY MN. PT STATES ARMS STILL FEEL HEAVY DUE TO FLUID.\n\nSKIN: INTACT. ORIGINAL STERNAL DRSG , REMOVED.\n\nA/P: UNEVENTFUL NOC. ?D/C SWAN TODAY AND GET OOB. REMAINS DEPENDANT ON PRESSOR FOR BP. CONT PULM TOILET. ENC NUTRITION. MONITOR PTT. PAIN MED PRN.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-12 00:00:00.000", "description": "Report", "row_id": 1320243, "text": "NEURO: INTACT.\nCARDIAC: MP JUNCTIONAL, ABLE TO WEAN LEVO TO .08M/K/M. KEEPING MAP ^ 6O. CO/CI ACCEPTABLE, SVO2 55-60+. AMIODORONE GTT DECREASED TO .5M/M.\nRESP: CPT Q 4, COUGHING RAISING THICK WHITE. CS COARSE DIMINISHED IN BASES.\nGI: ATTEMPTING TO EAT, POOR APPETITE. + BOWEL SOUNDS.\nGU: ANURIC,?DIALYSIS TOMORROW. BRUIT PRESENT.\nENDO: FOLLOWING PROTOCOL, NO NEED FOR TX.\nPAIN: MEDICATED WITH PERCOCET WITH RELIEF.\nFAMILY IN.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-05-04 00:00:00.000", "description": "Report", "row_id": 1320259, "text": "PATIENT WITH QUIET NIGHT, SLEEPING IN 2-3HR INTERVALS, THEN REPOSITIONED.. NO C/O PAIN TO LOWER EXTREMITY. SB P 80'S THRU THE NIGHT, AFEBRILE ,1ST DEGREE AVB NO ECTOPY..NO O2, BILATERAL BS CLEAR.PLAN TO DRAW AMLABS AFTER DSG CHANGE AT 6AM.. PATIENT ON LINEZOLID/LEVAQUIN FOR LEG WOUND..\n" }, { "category": "Nursing/other", "chartdate": "2133-05-04 00:00:00.000", "description": "Report", "row_id": 1320260, "text": "PATIENT'S WOUND IMPROVING PER CT SERVICE, SIVADENE DSG APPLIED. WILL RELAY TO RN COMING ON IN REGARDS TO EVALUATING DUODERM /COOCCYX DSG FOLLOWED BY RN... PATIENT BATHED, ORAL CARE DONE. PLAN TO GET OOB TO CHAIR IN AM, PLAN TO ENCOURAGE PATIENT TO TAKE PAIN PILL PRIOR OOB TO CHAIR. PLAN TO HAVE DIALYSIS THIS AM...\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320238, "text": "CSRU NOTE:\n\nNEURO: , , follows commands, able to communicate by mouthing words and nodding head to questions.\n\nCV: Apaced at rate of 88, underlying rythem accelerated junctional with subsequent decrease in BP, continues on levo. gtt., able to wean down to .28, CI/CO WNL, SV02 62-67, occassional PVC's and PAC's noted, low grade temp. 100, tylenol given at beginning of shift, PP+ via doppler.\n\nRESP: Lungs clear, diminished at bases, resp. alkalosis (see flowsheet), on Fi02 40%, PEEP 5, PS 5, 02 sat. 100%, suctioned for small to moderate amounts of thick tan secretions, sputum culture sent.\n\nGI: Obese, BS hypo, OGT in place, placement verified.\n\nGU: ESRD, on hemodialysis M,W,F. AVF to RUE, + bruit, (-) thrill, nonfunctional AVF to LUE.\n\nPAIN: Medicated with MS04 for incisional pain with good relief.\n\nENDO: RISS per unit protocol.\n\nPLAN: ? extubate today, HD today for fluid removal?, continue to monitor hemodynamics, continue to wean levo. if BP tolerates, pain management, monitor electrolytes.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320237, "text": "D: Please see data, MD notes/progess notes. Neuro: , following commands, communicating by mouthing words/gesturing. Mae with equal strength. CV: Pt initially asynchronously av paced at rate of 92. During hemodyalisis had bursts of afib and pacer was put on standby for brief period and then av pacing was resumed. Pacer was placed on pause after dialysis with junctional rythm noted. SBP in mid to high 80's at that time with pressors onboard. Pacing mode changed to asynchronous atrial pacing with improved sbp. Pt currently on norepi at 0.34mcg/kg/min with sbp 104/48 (65). Co/Ci stable. T max 101.7 with bc sent x2. Pulm: remains vented with abg's per . Lungs coarse, decr at bases. 02sats >95%. GU: Anuric, hemodialized today for hyperkalemia. Post dialysis K 4.5. Pt needed volume repletion for sustained hypotension not responsive to pressor support. See dialysis notes. GI: Abd obese, bs+, ogt to lws draining small amounts bile. Skin: surfaces intact, extremities w/d. All dressings per . Endo: Has not needed insulin coverage. Soc: Has many children/wife who have visited briefly each hour and were updated on pt condition/plan of care. Consults: Seen by neuro today as follow up from events last night, ?ing obstructive sleep apnea after obtaining hx from pts wife. P: Notify team of change in neuro status, ativan/mso4 prn. CV: titrate levo other pressors to keep map >60, monitor for further rythm changes.Continue vent support, ?extubation in am. Possible hemodialysis tomorrow to take off fluid as tolerated. Support family, clarify info prn. R: As above.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-01 00:00:00.000", "description": "Report", "row_id": 1320254, "text": "shift update:\n\nneuro: a&o x3. mae. turned & repositioned in bed. c/o numbness in rle when elevated on more than one pillow. denies pain.\n\ncardiac: 1st degree av block. hr 60-70's. sbp remains low 70-100's. asymptomatic. + dopp pp bilat. rle dsg changed->silvadine &dsd applied.\n\nresp: lungs clear but diminished in bases. sat's 99-100% on ra.\n\ngi/gu: +bs. tolerated po's for breakfast but at lunch pt c/o having congestion when eating. denied n/v & difficulty swallowing. food present in sputum. no uop. no hd today.\n\nendo: no ssri required per protocol.\n\nskin: duoderm changed to decub on coccyx. several small open areas noted. scant ss drainage.\n\nsocial: family into visit.\n\nplan: mri. cont abx. monitor hr/rhythm/bp. bedrest d/t femoral line->t&r q2h. bs q6h. monitor skin for further breakdown. change rle dsg .\n" }, { "category": "Nursing/other", "chartdate": "2133-05-02 00:00:00.000", "description": "Report", "row_id": 1320255, "text": "1900-0700\n\nC/O of right leg pain \"aching\" med with percoet with relief and elevated on pillow\nNeuro-intact\nCV-SBP 70's-90's Ct team aware pt asymptomatic CSM doppler pulses cap refill>3\nResp-LS clear dim at bases RA\nGI-renal diet/BS WNL\nGU-CRF hemodialysis ?sat/or sunday\nID-awaiting MRI of right leg ?fluid collection Positve BC +cocci pairs cluster cont on ABX afebrile\nskin-right leg incision site black areas tender to touch silvaden drsg to \nPlan-MRI/HD/ cont ABX and maintain pts comfort\n" }, { "category": "Nursing/other", "chartdate": "2133-05-02 00:00:00.000", "description": "Report", "row_id": 1320256, "text": "NEURO: A+Ox3, following commands. Medicated w/ 2 percocet tabs for pain.\n\nCV: Started on neo gtt post HD d/t sbp 60-80's asymtomatic. Notified . Maintained in 90's. 1st degree AVB. No ectopy. Pedal pulses are dopplerable.\n\nRESP: Lungs clear w/ diminished bases. Spo2 >96% 2L Np.\n\nRENAL: 500cc off via dialysis.\n\nID: Tmax 100. Instituted Msra precautions. Started Linezolid per id. VSS. No anaphylactic rxn.\n\nGI: Tolerating solids.\n\nSKIN: RLE eschar tissue intact. No drainage. DSD changed @ 1800. Last changed @0600.\n\nA/P Monitor for allergic rxn to Linezolid. Wean Neo gtt as bp tolerates. Drsg @ 0600.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-03 00:00:00.000", "description": "Report", "row_id": 1320257, "text": "ekg sr, first degree avb, no ectopy, rate 60s. sbp > 90 most of night, able to wean neo to 0.4 mcg, did not tolerate decrease to 0.2 mcg. anuric. afebrile. breath sounds clear bilat, decreased at lll. deep breathes well, occ nonproductive cough. maintaining spo2 94-99% on room air. abd soft, bowel sounds present, drinking small amts, no stool tonight. feet warm, palp pulses bilat. right leg dressing changed, eschar intact, small amt serosang drainage. chest and l leg incisions dry and intact. admitted to r leg discomfort at 0500, but wanted only tylenol. after dressing change was more uncomfortable and accepted 1 tylenol. and oriented, cooperative, sleeps when undisturbed.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-03 00:00:00.000", "description": "Report", "row_id": 1320258, "text": "A+OX3, pleasant, cooperative. Bp 80's off neo gtt. 1st degree AVB. No ectopy. Lungs are clear diminished bases. Tolerating po's. Small formed brn bm today. Dopplerable pedal pulses. Change RLL . Small amt serous drainage. Wound still necrotic w/ small areas of slough. Silvadine cream applied. DSD applied. A/P Stable. Contact precautions. . Keep leg elevated.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-16 00:00:00.000", "description": "Report", "row_id": 1320251, "text": "D: Neuro: A&O, intermitent incisional pain. Emotional day, recieved news that his 86yr old mother died this morning. CV: SR converted to afib with rate 106-120s this afternoon. BP remained stable, converted back to sr at 1600. Amiodorone bolus/increased po dose per med sheets. Levo gtt currently off, sbp 98-100/40's. Pulm: RA sats 96-97%. Lungs clear, exertional expiratory wheezes noted. GU: Hemodialysis M/W/F, right av fistula with +T/B. GI: Abd obese, bs+, passing flatus, no stool. Skin: Surfaces intact, bilateral leg incision dressings d&i. Pedal pulses weak but palpable. Act: 00B in chair for several hours today, tolerated well. Soc: Very supportive family, children/wife in for short visits every 1-2hrs. P: Attempt to keep levo gtt off, keep sbp>85. ?dc femoral aline in am. Encourage respitory hygeine. Dialysis as ordered. Increase act as tolerated, reconsult PT when pt able to ambulate. Offer emotional support for pt loss. R: As above, pt back in bed, sleeping in naps, no pain voiced. Pt able to speak with his brother on the phone re: loss of mother, wife will contact priest to come visit pt.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-17 00:00:00.000", "description": "Report", "row_id": 1320252, "text": "focus: status update\nneuro: and oriented x3 mae on command. perl. mildly anxious awaiting dialysis. perl.\n\ncv: nsr c/ no ectopyfor most of the noc. converted to a-fib rate 100's to 120's--bolused c/ amio c/ improvement in hr. later converted back to nsr. levo off ? d/c a-line. hep cont at 1100 c/ ptt within range.\n\nresp: lung sounds clear at top fields dim at bases. expiratory wheezes c/ activity. sats 97 to 100 ra.\n\ngi: tolerting po intake and fluid. abd obese c/ active bowel sounds. passing flattus no bm.\n\ngu: aneuric. pt to be dialyzed today.\n\nendo: riss.\n\npain: medicated c/ percocet c/ improved level of discomfort.\n\nsocial: family called for update on pt's status.\n\nplan: ? d/c to . to be dialyzed today.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-01 00:00:00.000", "description": "Report", "row_id": 1320253, "text": "Nursing Admission Note:\n\nPt is 64yo ESRD pt who underwent CABGX1/AVR on , now readdmitted to CSRU r/t hypotension assoc with c/o R leg pain and ?infection-monitor for sepsis.-Ruled out for DVT by US. Has R calf erythema, wound debrided on 2- Pt seen by plastics and ID.\n\nNeuro: and oriented X3. MAE. C/o feeling weak and tired.\nCV: HR-60-70's SR with 1st degree AV block. SBP 70-90/30-40's by cuff on L arm. Dr aware- Pedal pulses palp- 1+ ankle edema.\nID: BC X2 drawn-on via L fem arterial stick and 1 from R TLCL. Clinda and levo given. Attempted to place R fem line -unable- Will attempt again in am-If able to get further IV access will dc R TL and culture tip. Awaiting MRI.\nResp: Lungs ess CTA except crackles L base. Cough dry-non prod. ABG-sl alk- with pO2 71 on RA-Placed on 2l nc. O2 sats 98-100%.\nGU: Last HD -Renal to see this am-DNV.\nGI: NPO, Abd soft, NT, ND with +BS. Last BM .\nEndo: Glucose 100-WNL.\nIncisions: Sternum-healing-C/D-OTA. L thigh with dry eschar-no erythema-OTA. R calf- erythema-wound debrided. Betadine and DSD applied.\nComfort: Medicated with Percocet 1 X2 for R calf intermittent throbbing pain with good effect.\nActivity: On bedrest r/t low BP-leg.\nA: Low BP and R leg infection-Rule out sepsis\nP: ID following-Clinda and levo as ordered., Awaiting MRI. Renal following for HD-assess volume status. Resite IV line. BC pending.-Follow labs.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-14 00:00:00.000", "description": "Report", "row_id": 1320247, "text": "7am-7pm update\nNeuro: Pt and orientated x 3. MAE and able to follow commands.\n\nCV: pt initally in NSR, no ectopy. pt into afib ~ 0945 am (pt became slighlty hypotensive with afib -> SBP in the 80's. requiring increase in levo gtt). afib treated 150 mg amio bolus IV and pt remains on amio PO BID. pt on heparin gtt this am -> heparin gtt turned to off for line change. heparin gtt for afib. goal to keep PTT 40-60. pt continues on levo gtt. levo gtt weaned to keep MAP > 60. svo2 69-72. CI 2.33-2.95. PA line dc'd this afternoon. pp by doppler\n\nresp: LS clear with dim bases. becomes SOB/wheezing with activity. pt remains on room air. o2 sats 97-100%.\n\ngi/gu: pt with + bs. tolerting cardiac diet. no urine output\n\nrenal: HD yesterday. no HD today. lytes WNL\n\ncomfort: percocet for pain control.\n\nplan: wean levo gtt to keep MAP > 60, ? HD tomorrow, restart heparin gtt this evening at 900 u/hr, goal to keep PTT 40-60. monitor lytes/bs, pain control\ncomfort:\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-15 00:00:00.000", "description": "Report", "row_id": 1320248, "text": "Pt. flat in bed with slight reverse t- and hob @ 15 degrees until 2300 due to right fem. line oozing since line changed. Dsg changed and heparin resumed @ 2200. 900u/hr. Medicated for incisional pain with percocet. Sleeping in naps. Becoming slightly sob and wheezy with linen changes but improved when left alone. No o2; sao2 >95%.\nBP stable on current dose of Levophed.\nplan: hemodialysis today. Wean Levo if BP tolerates. OOB to chair. Continue pulm hygeine and advance diet as tol.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-15 00:00:00.000", "description": "Report", "row_id": 1320249, "text": " A:\n\nNeuro: and oriented x 3,mae, following commands correctly, oob to chair with slide board, hoya back to bed and tolerated well.\n\nCardiac: nsr in the 70's no ectopy, on levo gtt and weaning off, dopplerable pedial pulses, skin warm dry and intact, a-febrile, continues heparin gtt for old a/f.\n\nResp: lungs dim in bases, no o2 ra sats are 100%, is using i/s and is coughing and deep breathing.\n\nSkin: chest with staples is cdi, abd with old ct dsd's are cdi, bilat legs with dsd's that are draining a moderate amount of serosang drainage.\n\nGi/gu: tolerating po's abd soft and obese, good bowel sounds, is a hd pt and dnv, awaiting for dialisis later today.\n\nPlan: wean levo, monitor ptt's, monitor bp's durring dialisis, increase activity, encourage to cough and deep breath, monitor leg dsd's and change as needed.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-16 00:00:00.000", "description": "Report", "row_id": 1320250, "text": "FOCUS: STATUS UPDATE\nNEURO: AND ORIENTED X3, MAE ON COMMAND. PERL. NEURO GROSSLY INTACT.\n\nCV: LEVO WEANED OFF POST DIALYSIS. HEP INCREASED TO 1100 U/H TO MAINTAIN GOAL OF 50 TO 70. NSR C/ NO ECTOPY. PULSES DOPPLERABLE. GROIN LINES PATENT.\n\nRESP: LUNG SOUNDS CLEAR TO DIM AT BASES EPISODES OF WHEEZING C/ ACTIVITY. SATS 98 TO 100 RA.\n\nGI: AND OBESE C/ ACTIVE BOWEL SOUNDS. ABD SOFT AND NOT TENDER TO PALPATION. PASSING FLATTUS NO BM.\n\nGU: ANEURIC. DIALYZED 2L\n\nENDO: RISS.\n\nSOCIAL: FAMILY VISITED AND WIFE CALLED FOR UPDATE\n\nPLAN: ? D/C TO FLOOR. CONTINUE C/ CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 1320233, "text": "PATIENT'SS K AT APPROX. 6.5 TREATED WITH 10U REGULAR INSULIN IV, 1AMP D50, ALSO NABICARB IV AS WELL. APPROX. 10MIN AFTER TREATMENT. RESPIRATORY CALLED FOR EXTUBATION, GIVEN THE OK BY TO EXTUBATE. PATIENT MAE STRONG, ABG GOOD. HOB ELEVATED APPROX. 10DEGREES, BED IN REVERSE TRENDELBERG. PATIENT EXTUBATED TO 50% SHOVEL MASK, INTIALLY RESPONDING TO RN/RESP THERAPIST, BUT WITHIN A FEW MINUTES DECOMPENSATED, AMBU ON 100%, DROPPING SBP, PLACED IN REVERSED TRENDELBERG, INCREASED LEVOPHED TO.4 FROM .33, , NP PRESSURE. , COMPRESSIONS GIVEN FOR APPROX. 10SEC, , ANESTHESIA HAD BEEN CALLED TO BEDSIDE, CALLED TO BEDSIDE, BEGAN CAPTURING WITH SBP, INTUBATED WITHOUT DIFFICULTY, PROPOFOL 10CC GIVEN PER ANETHESIA FOR INTUBATION LEVO WEANED TO .3MCG/KG/MIND/T SBP 170'S. NEURO CALLED TO EVALUATE APPROX. 30MIN AFTER INTUBATION PATIENT AWAKE APPROPRIATELY RESPONDING TO NEUROLOGIST QUESTIONS MAE STRONGLY TO COMMAND. PLAN TO EVALUATE NEURO STATUS THRU THE NIGHT. SEDATED ON LOW DOSE PROPOFOL AT 10MCG/KG/MIN. GIVEN AMG MSO4 AT 2245 FOR INCISIONAL DISCOMFORT. K 5.4 AFTER INTERVENTIONS WITH MEDS WILL FOLLOW CLOSELY. BS DOWN TO 122, WILL RECHECK AT 2300, IF ELEVATED STILL PLAN TO START INSULIN DRIP , POSTTRANSFUSION HCT AT 31.. ICA 1.1 GIVEN 2GMCAGLUCONATE IV. SVO2 RECAL AT 69%.. DISCUSSED PATIENT'S STATUS WITH FAMILY. ALL FAMILY MEMBERS INTO VISIT PRIOR TO GOING HOME, FATHER RESPONSIVE TO FAMILY..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320234, "text": "AFTER PATIENT REINTUBATED, BRONCHSCOPY DONE AT BEDSIDE, SMALL PLUG REMOVED FROM AIRWAY, OTHERWISE ALL LOOKS GOOD. PATIENT CONTINUES TO MAE TOCOMMAND, WHEN ASKED, RESTING COMFORTABLE ON LOW DOSE PROPOFOL. K ELEVATED AGAIN, GIVEN 10UREGULAR INSULIN IV, ALSO 1/2D50GIVEN. PLAN TO WEAN TO FIO2 40%..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320235, "text": "AFTER INSULIN GIVEN, BS CHECKED 75, GIVEN AMP D50 AGAIN. APPROX. 1HR LATER K ELEVATED AT 5.9 GIVEN 10U REGUALR INSULIN IV, 1 AMP D50 GIVEN AS WELL.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-10 00:00:00.000", "description": "Report", "row_id": 1320236, "text": "AFTER INSULIN TO LOWER K BS HAS BEEN LOW RECEIVED 2AMPS D50 SEE FLOW SHEET PLAN TO CHECK BS AT 630 AM..PATIEN AVPACED THRU THE NIGHT AT 91, GOOD CI/SVO2 IN THE 69% RANGE, SBP SUPPORTED ON LEVOPHED .35-.4MCG/KG/MIN. RESP WEANED DOWN TO 40% WITH ABG PENDING THIS BS CLEAR BILATRELLY, NIL SECRETIONS, MINIMAL CT DRAINAGE FROM MEDIASTINAL CT..GU NO URINE MADE BASELINE. GI NPO NGT DRAINING APPROX. 150CC BILIOUS DRAINAGE, ABDOMEN DISTENDED.. K ELEVATED TREATED WITH INSULIN/DEXTROSE/BICARB. BS LOW AFTER INSULIN GIVEN. GIVEN 2MORE AMPS D50 AFTER INTIAL AMP, PLAN TO CHECK 630 AM.. K PENDING THIS AM. CA/MAG WNL THIS AM. NEURO PATIENT THIS AM DURING , TO COMMAND MOUTHING HIS NEEDS, ABLE TO LIFT ARMS.. I/D ON CLINDAMYCIN X 6DOSES, LEVOFLOXCIN NEEDS I/D APPROVAL THIS AN DRUG DUE AT 9AM!!!?? WEAN TO EXTUBATE THIS AM.??ACCESS IV.??/HEMODIALYSIS?? THIS AM. CONTINUE TO SUPPORT FAMILY DURING PATIENT'S ICU STAY..\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320239, "text": "Resp Care\n\nPt stable on current settings. Acid base relationship adequate with good oxygenation. RSBI 61 ? wean attempt this am. Suctioning sm to mod thick tan sputum.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320240, "text": "Patient extubated and placed on 70% open face mask. ,coop HR 76,BP 112/47,sat 100%. Air leak heard with cuff deflated ptior to extubation,labile BP @ time will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-11 00:00:00.000", "description": "Report", "row_id": 1320241, "text": "7a-7p\nCV: Apaced in morning with AAI 88, underlying rhythm switching between junctional and NSR 70s. Levo gtt infusing. Pacing wires began to not capture 100%, attempted to pace on v-side using higher ma's but still did not capture 100%. Pacer turned off. CI was >2 and SVO2 >60%. Frequent PACs started during dialysis, amiodarone bolus given with result of fewer PACs. Rhythm changed to afib with rate of 140. BP slightly lower but MAP still >60. Amio gtt started and second bolus given. Magnesium given. HR dropped to low 100s. Had to increase levo gtt slightly. Lopressor 5mg IV given. Pt later converted to junctional rhythm 60-70s. Attempted to apaced again, but still will not capture 100% and rhythm becoming more irregular with the intermittent pacing. Low grade temp.\n\nPULM: Weaned and extubated without difficulty. Pt was placed in reverse t- with HOB 30 degrees, and cuff leak checked before extubation. Currently on 4L/NC with 100% sats. Lungs clear. CTs draining very small amounts serosanginous fluid, no airleak.\n\nNEURO: Oriented. Percocet x 1 for pain control. Family in to visit several times during day.\n\nGU: Bilaral nephrectomies in past.\n\nGI: Bowel sounds present, NG tube was d/c'd after swallowing clears OK.\n\nRENAL: Hemodialysis done today, did not remove any fluid. Potassium down to 3.9. BG WNL.\n\nSKIN: Dsgs CDI.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-12 00:00:00.000", "description": "Report", "row_id": 1320242, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative with care.\n\nCV: Continues in junctional rthym at 63, BP stable and able to slowly wean levo. gtt., SV02 60-70, CI/CO WNL, continues on amio.gtt, PP+, afebrile.\n\nRESP: Lungs clear, diminished at bases, 02 @ 4L via NC, with sats. 100%, chest PT done, +cough but unable to expectorate any sputum, CT to 20 cm suction with scant drainage, pt. is a mouth breather.\n\nGI: Obese, BS+, tolerating sips of clears.\n\nGU: Hemo. patient, last dialyzed yesterday, no fluid removed, AVG to RUE with +bruit, but no palpable thrill.\n\nPAIN: Medicated with Percocets for incisional pain with good effect.\n\n\nPLAN: Pulmonary toilet, wean levo. as BP tolerates, continue to monitor CV and RESP. status, monitor electrolytes, pain management.\n" }, { "category": "ECG", "chartdate": "2133-04-30 00:00:00.000", "description": "Report", "row_id": 159592, "text": "Normal sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nLow QRS voltages in precordial leads\nOld anterior myocardial infarct\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2133-04-27 00:00:00.000", "description": "Report", "row_id": 159824, "text": "Probable sinus rhythm with first degree A-V delay and left atrial abnormality.\nProlonged QTc interval. Right bundle-branch block. Left axis deviation - left\nanterior fascicular block. Generalized low voltage. Consider prior\nanterolateral myocardial infarction. Clinical correlation is also suggested for\nmetabolic/drug effect and/or ischemia. Since the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2133-04-26 00:00:00.000", "description": "Report", "row_id": 159825, "text": "Sinus rhythm\nFirst degree A-V block\nMarked left axis deviation\nRBBB with left anterior fascicular block\nPossible old anterior infarct\nLateral T wave changes are nonspecific\nLow QRS voltages in precordial leads\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2133-04-21 00:00:00.000", "description": "Report", "row_id": 159826, "text": "Probable sinus rhythm with first degree AV delay and left atrial abnormality\nLow voltage\nLeft axis deviation\nRight bundle branch block and left anterior fascicular block\nConsider prior anterolateral myocardial infarct\nDiffuse ST-T wave changes with prolonged Q-Tc interval - cannot exclude in part\nmetabolic/drug effectand/or ischemia\nClinical correlation is suggested\nSince previous tracing of , QRS voltage decreased and further ST-T wave\nchanges seen\n\n" }, { "category": "ECG", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 159827, "text": "Compared to the previous tracing the mechanism is once again probably sinus\nwith first degree A-V block, rate 74. Otherwise, no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-04-09 00:00:00.000", "description": "Report", "row_id": 159828, "text": "Probable junctional rhythm, rate 68, with associated right bundle-branch\nblock/left anterior hemiblock. Possible old anteroseptal and lateral wall\ninfarction. Compared to the previous tracing of the mechanism is now\njunctional accelerated rhythm rather than sinus with first degree A-V block.\nTRACING #1\n\n" } ]

69,024

179,797

#vfib arrest - Pt developed post-operative anterior Q wave myocardial infarction on in setting of stopping aspirin followed by ventricular fibrillation arrest. He was defibrillated x5. Pt was pulseless for 20 minutes then got pulse back. Received 5 shocks first of which for vfib at 5:30 pm got 150j then got 1mg of epi for bradycardia 39-42, second shock at 5:39 with BP 102/63, received 300g amiodarone then in VF, shocks at 5:48, 5:49, 5:50 with pulse back at 120 with BP of 90/60 got 150 g lidocaine. His EKG (anterior Q waves)and TTE (akinesis of the anteroseptal segments, apical walls) were consistent with proximal LAD territory infarction stent thrombosis after stopping aspirin. Pt arrived at 18 hours after the event and was therefore out of the window for cooling or thrombolytics. Pt was started on a heparin drip and a lidocaine drip as his vfib arrest was in the setting of acute ischemia. Lidocaine was stopped on . Lactate was only 1.2 on transfer. EP was consulted and and pt was sent home with a lifevest per their recommendations with plan for repeat echo in roughly 1 month for re-assessment of EF and consideration of AICD. Pt had full return of neurologic function and was found to be an alert/oriented lively conversationalist. Also without any focal neurologic deficits on neuro exam. . # - In the PACU at following sphincterotomy pt c/o chest pain was found to have hyperacute T waves in V3-V6 and ~ depressions in I and II, and cardiac enzymes showed CK of 4270, CKMB of 610 and Tn-XX of 136. Pt then experienced Vfib arrest, see above, and was intubated/stabilized overnight and EKG on showed Q waves in V1-V5. Pt was transferred to where MB on presentation was >500 and troponin 11.21, enzymes subsequently trended down. Pt had been started on plavix at , which was continued along with aspirin, heparin gtt and atorvastatin 80. Pt's last documented cath was from and showed: left main: normal no disease. LAD: 85% proximal stenosis along with mild long mid area of disease, post stenosis. large diag branch noted within the ostia of 60% stenosis. Lcirc: normal vessel without disease. results of PCI: reduction of the initial 85% severe proximal/LAD stenosis to 0% and a reduction of the initial 60% ostial diagonal branch stenosis to less than 20%. Cath was performed at on which showed: 50% flow through stent, (likely thrombus that migrated distally) TIMI 3 flow, no intervention, no other lesions. Pt was sent home on crestor as he stated atorvastatin "did not work for him" in the past (likely was referring to myalgias). Also home with metoprolol, aspirin/plavix, lisinopril, and spironolactone. . #CHF - ECHO after vfib arrest/ showed: severely depresssed left ventricular systolic function with regional wall motion abnormalities. Moderate pulmonary artery systolic hypertension. EF 15-20%. prior to admission pts last TTEwas at hospital , showed: compared to study of no significant changes. left atrium borderline enlarge, normal LV fn, normal wall motion. Trace AI, trace MR, trace TR. LVEF 55%. Pt had been taking lasix 40 daily and metolazone 5mg m/w/f at home. On admission, pt was persistently tachycardic, likely as compensation for impaired contractility. Pt was aggressively diuresed with good resolution in respiratory status and cxr findings of improvement in pulmonary edema. Given his marked apical akinesis of LV with EF of 15-20% pt was sent home with warfarin lifelong anticoagulation, and bridged with enoxaparin. . #respiratory status - pt was intubated in setting of vib arrest, extubated on at without issues. Remained with O2 requirement (NC sufficient to maintain appropriate sats). Evidence of pulmonary edema on CXR secondary to , Vfib arrest responsible for decreased EF to 15-20%. hypoxia/dyspnea resolved with aggressive diuresis, see CHF above. . #hypotension - transferred on levophed for low blood pressures, likely cardiac injury s/p stent thrombosis. Pt was also on propofol for sedation while on ventilator and this was likely contributingg. Levophed was quickly weaned without issue. Propofol was changed to fentanyl/midazolam which were also weaned the day after transfer. . #fever/leukocytosis - on transfer pt was found to have dark cloudy urine. He had received 1g CTX on at OSH for WBC of 15 and concern for UTI. UA at OSH was cloudy, trace ketones, large blood, neg nit and leuks WBC RBC 4+ bacteria. Although cultures and UA were negative at , CTX was continued for 7 day course as these studies had been done after pt had received his first dose. WBC trended down to normal limits. It was also felt that /vfib arrest was contributing somewhat to leukocytosis. . #Atrial fibrillation - pt was newly with atrial fibrillation s/p Vfib arrest/. He was successfully cardioverted on . # (Cr of 1 --> 1.5): in setting of vfib arrest/ pt had an elevated creatinine to 1.5 on transfer from baseline 1.0. With extubation, pressor weaning, and diuresis creatinine quickly went back to baseline. . #transaminitis - LFTs considerably elevated with ALT of 131 AST 565 LD 1381 (alkphos 57, tbili 0.4). These elevations were felt to be poor perfusion during vfib arrest. LFTs trended down and on discharge ALT was 64 and AST was down to 150. Pt without jaundice,n/v/abd pain. . #tobacco use - pt longtime and current smoker. Was extensively counseled on the risks of smoking and was maintained on a nicotene patch throughout hospital stay. . #s/p sphincterotomy - contact at OSH who did the procedure to get recs for dressing. Pt was monitored closely as he was being anticoagulation but no signs of significant bleeding and remained hemodynamically stable.

Anterior ST segment elevation myocardial infarctionpattern, age indeterminate. Stable left basilar atelectasis with a possible small left pleural effusion. A right internal jugular central line ends in the upper SVC. A right internal jugular central line ends in the upper SVC. Right internal jugular catheter ends in the mid SVC. Trivial mitral regurgitation is seen. RV function depressed.AORTA: Normal aortic diameter at the sinus level. Trace aortic regurgitation is seen. FINDINGS: The endotracheal tube ends approximately 1.7 cm from the carina. Anteroseptal myocardial infarction, age indeterminate.Borderline low voltage. Endotracheal tube 1.7 cm from the carina. Hypokinesis of the basal and mid inferoseptal, anteriorand anterolateral walls. Anteroseptal myocardial infarction of indeterminate age. Non-specific inferiorST-T wave changes. Anterior wall myocardial infarction, age indeterminate withST segment elevations in the anterior precordial leads. Anterior ST segment elevation myocardial infarction, ageindeterminate. Anteroseptal wall myocardial infarction,age indeterminate. Q waves in leads V1-V5 with ST segment elevation.Anteroseptal myocardial infarction of indeterminate age. Mild [1+] TR. Low limb and precordial QRS voltage. FINDINGS: A right internal jugular central line overlies the SVC and ends at the level of the carina, approximately in the mid SVC. Compared to the previoustracing of the rhythm is now atrial flutter. Moderate pulmonaryartery systolic hypertension.Dr. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. A small left pleural effusion is likely present. FINDINGS: In comparison with the study of , the endotracheal tube has been removed. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Sinus rhythm. Sinus rhythm. Sinus rhythm. Noprevious tracing available for comparison. The patient appears to be in sinusrhythm. The cardiomediastinal silhouette is mildly enlarged and unchanged from the prior radiograph. Right IJ catheter tip remains in the upper portion of the SVC. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Improvement in left basilar atelectasis. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -akinetic; basal inferoseptal - hypo; mid inferoseptal - hypo; basalanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;septal apex- akinetic; lateral apex - akinetic; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size. Mild pulmonary edema. Mild pulmonary edema. The cardiac silhouette is mildly enlarged. The cardiac silhouette is moderately enlarged and unchanged. Endotracheal tube is too low and at the level of the carina pointing towards the main stem bronchus. There ismoderate pulmonary artery systolic hypertension. Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. ST segment elevation in the anteriorprecordial leads. Left hemidiaphragm is not well seen, consistent with small effusion and atelectasis. Trivial MR. (<140ms) transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There is mild pulmonary edema. Evaluate endotracheal tube. Generalized lowvoltage. A clip in the right upper lobe is noted. Compared to the previous tracing of nochange.TRACING #1 Suboptimalimage quality - poor suprasternal views. Compared totracing #2 the rhythm is now sinus.TRACING #3 ST segment elevation in leads V1-V4 with Q waves.ST segment depression seen in the inferior limb leads may be reciprocalchanges. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. FINDINGS: The endotracheal tube ends 3.5 cm from the carina. Mild enlargement of the cardiac silhouette with probable worsening of pulmonary vascular congestion. Atrial flutter with 3:1 conduction. A small amount of atelectasis persists. An endotracheal tube is too low and approximately 5 mm from the carina pointing towards the right main stem bronchus. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. ETT pulled back 3 cm. Endotracheal tube 3.5 cm from the carina. A small amount of left basilar atelectasis is unchanged. Reassess placement of ETT. There is no pericardialeffusion.IMPRESSION: Severely depresssed left ventricular systolic function withregional wall motion abnormalities as described above. Since the previous tracing of the rate is now slower. STEMI.Height: (in) 66Weight (lb): 242BSA (m2): 2.17 m2BP (mm Hg): 127/75HR (bpm): 100Status: InpatientDate/Time: at 15:08Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: OptisonTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LVsystolic dysfunction. Atrial flutter with 4:1 conduction. No AS. Bilateral perivascular haze reflects engorgement of the pulmonary vasculature with mild pulmonary edema. There is severe regional left ventricular systolicdysfunction with akinesis of the anteroseptal segments, apical walls (withrelative preservation of the apical inferior segment), and true apex(?near-aneurysmal). Chest radiograph at 1215. Compared to the previous tracing ST segmentelevations are slightly more prominent.TRACING #3 The left heart border is somewhat obscured, most likely due to underlying atelectasis, although an early or small pneumonia cannot be excluded. There is no right pleural effusion. A small left pleural effusion may be present, but is not definitely seen. ST segmentelevation is similar in appearance.TRACING #2 The mitral valveleaflets are mildly thickened. Rightward axis. Mild pulmonary edema is unchanged from the prior radiograph. 3. 3. 3. Left ventricular wall thicknesses andcavity size are normal. Left basilar hazy opacification is likely atelectasis, although early pneumonia cannot be excluded. Clinical correlation is suggested. ST segment elevation isslightly more prominent. 2. 2. 2. No LV mass/thrombus. COMPARISONS: Chest radiograph at 1320. Compared to tracing #1 conduction is now 4:1. No definite pleural effusions are seen. 1:22 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Reassess placement of ETT. ST segment elevation in leads V2-V5, cannot exclude ongoinginjury patern. REASON FOR THIS EXAMINATION: Reassess placement of ETT. The opacification at the left base has improved suggesting it was likely atelectasis. Compared to the previous tracing no change.TRACING #4 PATIENT/TEST INFORMATION:Indication: V-fib arrest. FINAL REPORT INDICATION: Status post STEMI and Vfib arrest.

14

[ { "category": "Radiology", "chartdate": "2163-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223639, "text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, pulmonary edema\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with large STEMI perioperatively, new onset CHF EF 15%\n REASON FOR THIS EXAMINATION:\n interval change, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MI with new onset of CHF.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has\n been removed. The patient has taken a much better inspiration. Mild\n enlargement of the cardiac silhouette with probable worsening of pulmonary\n vascular congestion. Left hemidiaphragm is not well seen, consistent with\n small effusion and atelectasis.\n\n Right IJ catheter tip remains in the upper portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223547, "text": " 1:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Reassess placement of ETT.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD s/p STEMI and VF arrest, now intubated. ETT pulled\n back 3 cm. Reassess placement of ETT.\n REASON FOR THIS EXAMINATION:\n Reassess placement of ETT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post STEMI and Vfib arrest. Evaluate endotracheal tube.\n\n COMPARISONS: Chest radiograph, at 12:15.\n\n FINDINGS: The endotracheal tube ends approximately 1.7 cm from the carina. A\n right internal jugular central line ends in the upper SVC. The opacification\n at the left base has improved suggesting it was likely atelectasis. A small\n amount of atelectasis persists. There is mild pulmonary edema. No definite\n pleural effusions are seen. The cardiomediastinal silhouette is mildly\n enlarged and unchanged from the prior radiograph. A feeding tube is in place\n within the stomach.\n\n IMPRESSION:\n 1. Endotracheal tube 1.7 cm from the carina.\n 2. Improvement in left basilar atelectasis.\n 3. Mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223555, "text": " 1:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p vfib arrest check for ETT plcment\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p vfib arrest\n REASON FOR THIS EXAMINATION:\n s/p vfib arrest check for ETT plcment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube placement, status post V-fib arrest.\n\n COMPARISONS: Chest radiograph at 1320. Chest radiograph\n at 1215.\n\n FINDINGS: The endotracheal tube ends 3.5 cm from the carina. A right\n internal jugular central line ends in the upper SVC. Mild pulmonary edema is\n unchanged from the prior radiograph. A small amount of left basilar\n atelectasis is unchanged. A small left pleural effusion may be present, but\n is not definitely seen. There is no right pleural effusion. There is no\n consolidation or pneumothorax. The cardiac silhouette is moderately enlarged\n and unchanged. A feeding tube is seen within the stomach.\n\n IMPRESSION:\n 1. Endotracheal tube 3.5 cm from the carina.\n 2. Mild pulmonary edema.\n 3. Stable left basilar atelectasis with a possible small left pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2163-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223536, "text": " 12:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pna, ards\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p vfib arrest, cardiogenic shock\n REASON FOR THIS EXAMINATION:\n please eval for pna, ards\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post V-fib arrest.\n\n COMPARISONS: None.\n\n FINDINGS: A right internal jugular central line overlies the SVC and ends at\n the level of the carina, approximately in the mid SVC. An endotracheal tube\n is too low and approximately 5 mm from the carina pointing towards the right\n main stem bronchus. A clip in the right upper lobe is noted. A feeding tube\n is seen within the stomach with the tip out of the field of view. Bilateral\n perivascular haze reflects engorgement of the pulmonary vasculature with mild\n pulmonary edema. The left heart border is somewhat obscured, most likely due\n to underlying atelectasis, although an early or small pneumonia cannot be\n excluded. A small left pleural effusion is likely present. There is no\n pleural effusion on the right. There is no pneumothorax. The cardiac\n silhouette is mildly enlarged.\n\n IMPRESSION:\n 1. Endotracheal tube is too low and at the level of the carina pointing\n towards the main stem bronchus.\n 2. Right internal jugular catheter ends in the mid SVC. No pneumothorax.\n 3. Left basilar hazy opacification is likely atelectasis, although early\n pneumonia cannot be excluded.\n\n The endotracheal tube position was discussed with the ICU team at 1:30 pm on\n by Dr. .\n\n" }, { "category": "Echo", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 93708, "text": "PATIENT/TEST INFORMATION:\nIndication: V-fib arrest. STEMI.\nHeight: (in) 66\nWeight (lb): 242\nBSA (m2): 2.17 m2\nBP (mm Hg): 127/75\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -\nakinetic; basal inferoseptal - hypo; mid inferoseptal - hypo; basal\nanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;\nseptal apex- akinetic; lateral apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. \n(<140ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. The patient appears to be in sinus\nrhythm. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is severe regional left ventricular systolic\ndysfunction with akinesis of the anteroseptal segments, apical walls (with\nrelative preservation of the apical inferior segment), and true apex\n(?near-aneurysmal). Hypokinesis of the basal and mid inferoseptal, anterior\nand anterolateral walls. No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size is normal with depressed free wall\ncontractility. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Severely depresssed left ventricular systolic function with\nregional wall motion abnormalities as described above. Moderate pulmonary\nartery systolic hypertension.\n\nDr. notified of the results by phone on at 6:25 p.m.\n\n\n" }, { "category": "ECG", "chartdate": "2163-12-20 00:00:00.000", "description": "Report", "row_id": 243759, "text": "Sinus rhythm. Rightward axis. Q waves in leads V1-V5 with ST segment elevation.\nAnteroseptal myocardial infarction of indeterminate age. Generalized low\nvoltage. Since the previous tracing of the rate is now slower.\n\n" }, { "category": "ECG", "chartdate": "2163-12-18 00:00:00.000", "description": "Report", "row_id": 243760, "text": "Sinus tachycardia. Anterior wall myocardial infarction, age indeterminate with\nST segment elevations in the anterior precordial leads. Non-specific inferior\nST-T wave changes. Low limb and precordial QRS voltage. Compared to\ntracing #2 the rhythm is now sinus.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-12-18 00:00:00.000", "description": "Report", "row_id": 243981, "text": "Atrial flutter with 4:1 conduction. ST segment elevation in the anterior\nprecordial leads. Compared to tracing #1 conduction is now 4:1. ST segment\nelevation is similar in appearance.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-12-17 00:00:00.000", "description": "Report", "row_id": 243982, "text": "Atrial flutter with 3:1 conduction. Anteroseptal wall myocardial infarction,\nage indeterminate. ST segment elevation in leads V2-V5, cannot exclude ongoing\ninjury patern. Clinical correlation is suggested. Compared to the previous\ntracing of the rhythm is now atrial flutter. ST segment elevation is\nslightly more prominent. The other findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-12-16 00:00:00.000", "description": "Report", "row_id": 243983, "text": "Sinus tachycardia. Anterior ST segment elevation myocardial infarction, age\nindeterminate. Compared to the previous tracing no change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2163-12-16 00:00:00.000", "description": "Report", "row_id": 243984, "text": "Sinus tachycardia. Anterior ST segment elevation myocardial infarction\npattern, age indeterminate. Compared to the previous tracing ST segment\nelevations are slightly more prominent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243985, "text": "Sinus tachycardia. ST segment elevation in leads V1-V4 with Q waves.\nST segment depression seen in the inferior limb leads may be reciprocal\nchanges. Compared to the previous tracing the rate is increased and ST-T wave\nchanges are new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243986, "text": "Sinus rhythm. Anteroseptal myocardial infarction, age indeterminate.\nBorderline low voltage. Compared to the previous tracing of no\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-12-15 00:00:00.000", "description": "Report", "row_id": 243987, "text": "Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age. No\nprevious tracing available for comparison.\n\n" } ]

24,105

142,549

Admitted on and underwent minimally invasive mitral valve repair with Dr. . Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Extubated that evening and started on amiodarone for brief non-sustained runs of SVT/VT. Swan removed on POD #1 and transferred to the floor to begin increasing his activity level. Chest tubes removed on POD #2 with slight right apical pneumothorax present, but asymptomatic. He made excellent progress on the floor and was cleared for discharge to home with VNA on POD #3.

Normal descending aorta diameter. IMPRESSION: Unchanged right pneumothorax and bilateral bibasilar discoid atelectasis. hypotension (SBP 80 mm Hg) and tachycardia(HR 110 bpm) there is with a posteriorly directed MR jet of moderateintesity and a maximalleft ventricular outflow tract gradient calculated to be70-80 mm Hg.With fluid boluses/HR and after load control the improved to Chordal only. Normal ascendingaorta diameter. Linear atelectasis overlies left hilum. There is no pericardial effusion.P2 segment of the mitral valve shows flail segment with anteriorly directed MRjet of severe intensity./PL ratio less than 1.5 and C- distance= 2.78cmMitral annulus diameter in the IC plane= 3.1 cm.POST CPB:Preserved biventricular systolic functionAnnuloplasty ring in mitral position.Posterior leaflet has been resected.There is chordal with any associated mitral regurgitation or significantleft ventricular outflow gradient at a SBP of 130 mm Hg and HR of 75 bpm..With provocative maneuvers, e.g. Mildmitral annular calcification. FINDINGS: There has been interval placement of an endotracheal tube, NG tube, and right-sided chest tube, which remain in satisfactory position. Additional Amiodarone bolus given and drip kept at 1mg. Severe (4+) MR. Eccentric MR jet.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. REASON FOR THIS EXAMINATION: r/o PTX, effusion. The small right apical pneumothorax, right subcutaneous emphysema partially overlying the right lower lung, the bilateral, more on the right, bibasilar discoid atelectasis are unchanged. Chest tube is present in right apical region. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is a small right apical pneumothorax (10%). Myxomatous mitral valveleaflets. The IVC is normal in diameterwith appropriate phasic respirator variation.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Sinus rhythmST-T wave configuartion suggests in part early repolarization pattern/normalvariant but clinical correlation is suggestedSince previous tracing of , early precordial QRS transition and T waveless prominent R/O PTX. IMPRESSION: Small right apical pneumothorax (10%). Comparison is made to the prior chest x-ray dated . 2:42 PM CHEST (PA & LAT) Clip # Reason: RT SIDED CHEST TUBE. Mitral valve prolapse.Status: InpatientDate/Time: at 10:49Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Pre CPB TEE performed to assess the mitral valve and placement of monitoringlines.Coronary Sinus canula and PA vent line placed under TEE guidance into theCoronary sinus and Pulmonary artery.Aortic perfusion wire placed under TEE guidance.Venous access cannula wire and venous cannnula positoned in the right atrimunder TEE guidance.LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Focal calcifications in aortic root. Overall normal LVEF (>55%).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. The ascending,transverse and descending thoracic aorta are normal in diameter and free ofatherosclerotic plaque. d/c swan if VEA continues. NP IN REGARDS TO 2ND AMIO BOLUS.. GU GREAT U/O. Linear and discoid atelectases are present at both lung bases, and there are probable small bilateral pleural effusions. Cutaneous and anterior mediastinal emphysema is noted in the lateral view. There is bibasilar atelectasis. Left ventricular wall thicknesses and cavity size arenormal. Neo started to keep SBP >100 in view of echo results "SAMS" when BP too low.Pulm: breath sounds dim at bases. ON KEFZOL . 1645 PATIENT WITH INCREASED MULTIFOCAL ECTOPY K INFUSING , APPROX. Bibasilar atelectasis. The right chest tube remains in place. Keep BSP > 100 up to 130.Encourage ADL's as tol. continues to have ventricular ectopy with one 24 beat run VT at 0120. Patchy atelectasis is seen at the lung bases. Neuro: Pt. The semi-rounded opacity projecting just lateral to the left of the spine most probably represents an inserted new mitral valve. Mitral valve disease. The endotracheal tube, nasogastric tube, and the Swan-Ganz catheter has been removed. There is partial mitral leafletflail. The previously identified mild congestive heart failure has been resolved. CT's now to water seal. IMPRESSION: 1. Severe (4+) mitral regurgitation is seen. Respiratory Care Note: received patient this shift s/p mrr and on ventilatory support. PATIENT/TEST INFORMATION:Indication: Left ventricular function. The cardiomediastinal contours are stable. COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared to previous study of yesterday. Rightventricular chamber size and free wall motion are normal. 10:15 AM CHEST (PORTABLE AP) Clip # Reason: r/o PTX, effusion. 's BP sagging to 90's after extubation. PATIENT ON PROPOFOL SR IN THE 80'S, PER ANESTHESIA D/T "" KEEP SBP GREATER THAN 100, WITH HR 80-80'S. Pt. No atheroma in descendingaorta.AORTIC VALVE: Normal aortic valve leaflets (3). SPO2 100%. Overall left ventricular systolic function is normal (LVEF>55%). The TEE probe was passedwith assistance from the anesthesioology staff using a laryngoscope.Conclusions:PRE-BYPASS: The left atrium is elongated. A cuff leak was noted prior to extubation. The mitralvalve leaflets are mildly thickened. palp pp.Plan: ? The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation.

9

[ { "category": "Nursing/other", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 1576788, "text": "PATIENT ON PROPOFOL SR IN THE 80'S, PER ANESTHESIA D/T \"\" KEEP SBP GREATER THAN 100, WITH HR 80-80'S. PATIENT HAS RECEIVED TOTAL OF 4000CCLR , BUT DESPITE THE VOLUME IS STILL NEGATIVE!! HCT SENT AT 1900 PLAN TO TRANSFUSE IF 30 OR LESS. PRESENTLY PROPOFOL AT 40MCG/KG/MIN WITH NEO AT .5MCG/KG/MIN. RSP AT 40% PLAN TO CHANGE TO SIMV AND EVENTUALLY CPAP ONCE MORE AWAKE. REVERSED AT 1845, MAE TO COMMAND AT 1900. AT APPROX. 1645 PATIENT WITH INCREASED MULTIFOCAL ECTOPY K INFUSING , APPROX. 20 BEAT RUN OF VT , BOLUSED WITH 150 MG AMIODARONE DRIP STARTED ON AMIODARONE DRIP AT 1MG/MIN, K/CA/MAG ALL REPLETED. K AT THIS TIME WAS 3.5. SINCE VT CONTINUES TO HAVE COUPLETS AS WELL AS MULTIFOCAL PVC, PLAN TO ?? NP IN REGARDS TO 2ND AMIO BOLUS.. GU GREAT U/O. GI OGT TO LCS, DRAINING BROWN TO BLOODY SECRETIONS, ON CARAFATE/RANITIDINE. PATIENT SEADTED WITH 2MG MORPHINE X2 , AS WELL RECEIVING TOTAL OF 25MG DEMEROL IV FOR SHIVERING. ON INSULIN DRIP SEE FLOW SHEET FOLLOWING CSRU INSULIN PROTOCOL. ON KEFZOL . PLAN TO DISCUSS WITH NP IN REGARDS TO MOTRIN ORDER. WIFE SEE PATIENT ALONG WITH MOTHER.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 1576789, "text": "Respiratory Care Note:\n received patient this shift s/p mrr and on ventilatory support. patient weaned and extubated to a 50% cool mist face tent. A cuff leak was noted prior to extubation. Patient able to vocalize and raise blood tinged sputum post extubation. SPO2 100%. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-08 00:00:00.000", "description": "Report", "row_id": 1576790, "text": "Neuro: Pt. extubated last evening. He was completely appropriate and alert.\nCV: Pt. continues to have ventricular ectopy with one 24 beat run VT at 0120. All electrolytes repleted. Additional Amiodarone bolus given and drip kept at 1mg. Pt.'s BP sagging to 90's after extubation. Neo started to keep SBP >100 in view of echo results \"SAMS\" when BP too low.\nPulm: breath sounds dim at bases. Otherwise clear. O2 weaned to cannula.\n\nGI/GU: taking ice chips without n/v. HUO continues to be > 100cc/hr and up to 450cc for earlier hours. K+ repleted.\n\nEndo: insulin drip off when BS in the 80's.SSRI started at BS 129.\n\nSkin: right lateral chest wall dsg d&i. palp pp.\n\nPlan: ? d/c swan if VEA continues. Keep BSP > 100 up to 130.\nEncourage ADL's as tol. Pain management prn.\n" }, { "category": "Echo", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 67896, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Mitral valve prolapse.\nStatus: Inpatient\nDate/Time: at 10:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPre CPB TEE performed to assess the mitral valve and placement of monitoring\nlines.\nCoronary Sinus canula and PA vent line placed under TEE guidance into the\nCoronary sinus and Pulmonary artery.\nAortic perfusion wire placed under TEE guidance.\nVenous access cannula wire and venous cannnula positoned in the right atrim\nunder TEE guidance.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler. The IVC is normal in diameter\nwith appropriate phasic respirator variation.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Focal calcifications in aortic root. Normal ascending\naorta diameter. Normal descending aorta diameter. No atheroma in descending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve\nleaflets. Elongated mitral valve leaflets. Partial mitral leaflet flail. Mild\nmitral annular calcification. Severe (4+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope.\n\nConclusions:\nPRE-BYPASS: The left atrium is elongated. No atrial septal defect is seen by\n2D or color Doppler. Left ventricular wall thicknesses and cavity size are\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. The mitral valve leaflets are myxomatous.\nThe mitral valve leaflets are elongated. There is partial mitral leaflet\nflail. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet\nis eccentric. There is no pericardial effusion.\nP2 segment of the mitral valve shows flail segment with anteriorly directed MR\njet of severe intensity.\n/PL ratio less than 1.5 and C- distance= 2.78cm\nMitral annulus diameter in the IC plane= 3.1 cm.\n\nPOST CPB:\nPreserved biventricular systolic function\nAnnuloplasty ring in mitral position.\nPosterior leaflet has been resected.\nThere is chordal with any associated mitral regurgitation or significant\nleft ventricular outflow gradient at a SBP of 130 mm Hg and HR of 75 bpm..\nWith provocative maneuvers, e.g. hypotension (SBP 80 mm Hg) and tachycardia\n(HR 110 bpm) there is with a posteriorly directed MR jet of moderate\nintesity and a maximalleft ventricular outflow tract gradient calculated to be\n70-80 mm Hg.\nWith fluid boluses/HR and after load control the improved to Chordal \nonly.\n\n\n" }, { "category": "ECG", "chartdate": "2163-06-07 00:00:00.000", "description": "Report", "row_id": 149285, "text": "Sinus rhythm\nST-T wave configuartion suggests in part early repolarization pattern/normal\nvariant but clinical correlation is suggested\nSince previous tracing of , early precordial QRS transition and T wave\nless prominent\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 913479, "text": " 6:30 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct d/c\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe MR, plans for MVR\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of pneumothorax after discontinuation of\n the right chest tube.\n\n PA and lateral upright chest radiograph compared to the previous film from the\n same day made at 13:49 a.m.\n\n The small right apical pneumothorax, right subcutaneous emphysema partially\n overlying the right lower lung, the bilateral, more on the right, bibasilar\n discoid atelectasis are unchanged. The lung volumes are relatively low. The\n heart size is top normal and stable, the mediastinal width is unchanged as\n well. The semi-rounded opacity projecting just lateral to the left of the\n spine most probably represents an inserted new mitral valve.\n\n IMPRESSION: Unchanged right pneumothorax and bilateral bibasilar discoid\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 913442, "text": " 2:42 PM\n CHEST (PA & LAT) Clip # \n Reason: RT SIDED CHEST TUBE. R/O PTX.\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe MR, plans for MVR\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n HISTORY: Mitral regurgitation with mitral valve repair and pneumothorax.\n\n Chest tube is present in right apical region. There has been no significant\n change in the size of the small right pneumothorax. Linear and discoid\n atelectases are present at both lung bases, and there are probable small\n bilateral pleural effusions. Linear atelectasis overlies left hilum.\n Cutaneous and anterior mediastinal emphysema is noted in the lateral view.\n\n IMPRESSION: No significant change in size of small right pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 913145, "text": " 3:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, tamponade, Pulmonary edema, pneumothorax\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MV Repair\n REASON FOR THIS EXAMINATION:\n Pleural effusion, tamponade, Pulmonary edema, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair.\n\n Comparison is made to the prior chest x-ray dated .\n\n FINDINGS: There has been interval placement of an endotracheal tube, NG tube,\n and right-sided chest tube, which remain in satisfactory position. There has\n also been placement of a right internal jugular catheter through which a Swan-\n Ganz catheter has been advanced. The tip of the catheter is not well seen due\n to motion artifact, probably in the outflow tract. There is bibasilar\n atelectasis. The cardiomediastinal contours are stable. There is no pleural\n effusion. No pneumothorax is identified.\n\n IMPRESSION:\n 1. Bibasilar atelectasis.\n 2. Interval placement of Swan-Ganz catheter with the tip not well seen due to\n motion artifact. A repeat film will be recommended to confirm position.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 913233, "text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, effusion.\n Admitting Diagnosis: MR\\MITRAL VALVE REPLACEMENT MINIMALLY INVASIVE APPROACH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MV repair. CT's now to water seal.\n REASON FOR THIS EXAMINATION:\n r/o PTX, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE:\n\n INDICATION: 45-year-old man status post MV repair.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n to previous study of yesterday.\n\n The right chest tube remains in place. There is a small right apical\n pneumothorax (10%). Patchy atelectasis is seen at the lung bases. There is\n continued cardiomegaly. The previously identified mild congestive heart\n failure has been resolved.\n\n The endotracheal tube, nasogastric tube, and the Swan-Ganz catheter has been\n removed.\n\n IMPRESSION: Small right apical pneumothorax (10%).\n\n\n" } ]

65,689

143,433

73M with h/o CVA on coumadin, CAD s/p DES->LCx , s/p L renal artery stent , infrarenal AAA s/p repair admitted with forearm, chest, and tooth pain (prior anginal equivalent) who went to cardiac catheterization for NSTEMI, s/p PCI complicated by mid vessel RCA dissection, followed by STEMI (distal RCA + RPL, felt to be secondary to dissection). . # NSTEMI and STEMI: The patient was admitted to the floor and his cardiac enzymes were trended peaking at 0.08 from <0.01 on admission. He was taken to cardiac catheterization, which revealed a RCA thrombus thought to be the culprit lesion that was treated with one DES. This was complicated by a distal RCA dissection requiring three overlaping BMS distal to and overlapping with the DES as well as one proximal BMS and overlapping with the DES with the final result being TIMI-3 flow. Bedside TTE was performed and was notable for the absence of pericardial effusion with normal wall motion. He was started on plavix 75mg, which he will take 75mg for one week and then change to 75mg daily. He was continued on aspirin 325mg daily. He was maintained on an integrillin drip for 18hours post catheterization. He was started on rosuvastatin, as he had a history of poor tolerance to other statins. He was pain-free until afternoon at which time he developed chest pressure, arm pain, and teeth pain. At that point he was noted to have ST-elevations in inferior leads and CODE STEMI was called. He was brought immediately to the cath lab at which time angiography showed occlusion of the RPL off the mid-distal RCA felt to be due to his prior dissection. The proximal PCA appeared patent. Given the dissection flap, a wire could not be passed into the vessel and no intervention was performed. He was chest pain free several hours later and remained so throughout the remainder of his hospital stay. Follow-up echocardiogram showed basal/midlateral akinesis/hypokinesis (although technically sub-optimal) that was new from priors. . # HISTORY OF CVA: Given his history of recent stroke, thought to be embolic, he was maintained on systemic anticoagulation with coumadin. Heparin was initiated while his INR was subtherapeutic. In consultation with his outpatient neurologist the goal INR is 1.8 to 2.5. The patient was discharge home with Lovenox injections twice daily until he began therapeutic again on his Coumadin. . # ATRIAL TACHYCARDIA: He was monitored on telemetry during the course of his hospitalization. He was primarily in sinus rhythm with a rate in the 80s although he did have asymptomatic episodes of atrial tachycardia to the 110s. His metoprolol dose was increased to 37.5mg q8hr. . # HAND CELLULITIS: This was thought to be due to an infiltrated IV site. There was a pustule that was lanced with culture growing MSSA. He was started on Keflex + Bactrim with plans for a 7 day course (Bactrim D/C'd once sensitivities available). He remained afebrile with a normal white count and site clinically improved prior to discharge. . # HYPERTENSION: He was continued on losartan and metoprolol. As above, metoprolol dose increased to 37.5 tid. Losartan held for ARF. . # ACUTE RENAL FAILURE: Creatinine trended up from baseline 1.2 -> 1.4 after cath . It rose again from 1.4 -> 1.6 after second cardiac cath. This was felt to be due to potential contrast nephropathy as he received substantial contrast load for both procedures. was held with some improvement in his renal function. Creatinine at baseline for this patient is 1.1-1.2 and 1.4 upon discharge. . # HYPERLIPIDEMIA: He was initially continued on niacin and cholestyramine. This was changed to rosuvastatin 10mg daily, however he developed myalgias and he was changed back to home cholestyramine.

Noaortic regurgitation is seen. There is moderatesymmetric left ventricular hypertrophy. There is amild resting left ventricular outflow tract obstruction. Mild regionalLV systolic dysfunction. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Consider left ventricular hypertrophy by voltagein lead aVL. Resting bradycardia (HR<60bpm).Conclusions:The left atrium and right atrium are normal in cavity size. The patientappears to be in sinus rhythm. PATIENT/TEST INFORMATION:Indication: Evaluate for pericardial effusion/ s/p coronary perforation, hypotensionHeight: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 123/90HR (bpm): 116Status: InpatientDate/Time: at 15:11Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Small LV cavity. Ectopic atrial tachycardia. Since the previous tracing of ST-T waveabnormalities are both prominent.TRACING #1 Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Inferoposterolateral myocardial infarction with ST-T waveconfiguration consistent with acute/recent/in evolution process. Myocardial infarction.Height: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 140/107HR (bpm): 58Status: InpatientDate/Time: at 09:58Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Moderate symmetric LVH. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow patternc/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , regional wallmotion abnormality is now detected but studies are technically suboptimal forcomparison. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Clinicalcorrelation is suggested. Compared to the previous tracing of therehas been further evolution of the findings of acute infero-posterolateralmyocardial infarction. The left ventricular cavity size isnormal. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Sinus rhythm with slowing of the rate as compared with prior tracingof . The left ventricular inflow patternsuggests impaired relaxation. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus bradycardia. Sinus bradycardia. There is further evolution of the findings of acuteinfero-posterolateral myocardial infarction. ST-T waveflattening in lead I with downsloping ST segment depression in lead aVL. Inferoposterolateral myocardial infarction with ST-T waveconfiguration suggesting acute/recent/in evolution process. Mild resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: No pericardial effusion.Conclusions:Focused study to exclude effusion: The left ventricular cavity is unusuallysmall. The mitral valve appears structurally normalwith trivial mitral regurgitation. Ectopic atrial rhythm. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The estimated pulmonary artery systolic pressureis normal. Earlyprecordial R wave transition. Tamponade.Height: (in) 69Weight (lb): 202BSA (m2): 2.08 m2BP (mm Hg): 161/102HR (bpm): 114Status: InpatientDate/Time: at 19:10Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Clinical correlation is suggested.TRACING #3 The aortic valveleaflets (3) are mildly thickened. ST segment elevation in leads II, III and aVF. The rate has increased and the findings are consistent withactive inferoposterior and lateral myocardial infarction. Followup andclinical correlation are suggested.TRACING #1 Since the previous tracing of ST-T wavechanges are less prominent.TRACING #4 Since the previous tracing of same date probably nosignificant change.TRACING #3 Left ventricular systolic function is hyperdynamic (EF>75%). Suboptimal image quality - patient unable to cooperate. Followup and clinical correlation are suggested.TRACING #2 No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. There is mild regional left ventricular systolic dysfunction withprobable basal to mid lateral akinesis/hypokinesis (LVEF ?45-50%) but viewsare technically suboptimal for assessment of regional wall motion. Right ventricularchamber size and free wall motion are normal. Normal LV cavity size. Compared to the previous tracing of voltage inleads I and aVL is now more prominent. Rightventricular chamber size and free wall motion are normal. Emergencystudy performed by the cardiology fellow on call. There is no significant pericardial effusion.Dr. Results were personallyreviewed with the MD caring for the patient.Conclusions:Very limited study. Since the previous tracing of same date there isprobably no significant change.TRACING #2 These findings are new as compared with priortracing of . Hyperdynamic LVEF >75%. No AS. There is no aortic valve stenosis. There is no pericardialeffusion.

11

[ { "category": "Echo", "chartdate": "2190-06-08 00:00:00.000", "description": "Report", "row_id": 93464, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 140/107\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 09:58\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mild regional\nLV systolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient\nappears to be in sinus rhythm. Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is moderate\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. There is mild regional left ventricular systolic dysfunction with\nprobable basal to mid lateral akinesis/hypokinesis (LVEF ?45-50%) but views\nare technically suboptimal for assessment of regional wall motion. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The left ventricular inflow pattern\nsuggests impaired relaxation. The estimated pulmonary artery systolic pressure\nis normal. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , regional wall\nmotion abnormality is now detected but studies are technically suboptimal for\ncomparison.\n\n\n" }, { "category": "Echo", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 93503, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade.\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 161/102\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 19:10\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Emergency\nstudy performed by the cardiology fellow on call. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nVery limited study. There is no significant pericardial effusion.\n\nDr. was notified in person of the results on at 7 p.m.\n\n\n" }, { "category": "Echo", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 93504, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for pericardial effusion/ s/p coronary perforation, hypotension\nHeight: (in) 69\nWeight (lb): 202\nBSA (m2): 2.08 m2\nBP (mm Hg): 123/90\nHR (bpm): 116\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%. Mild resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nFocused study to exclude effusion: The left ventricular cavity is unusually\nsmall. Left ventricular systolic function is hyperdynamic (EF>75%). There is a\nmild resting left ventricular outflow tract obstruction. Right ventricular\nchamber size and free wall motion are normal. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2190-06-05 00:00:00.000", "description": "Report", "row_id": 244067, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration suggesting acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of ST-T wave\nchanges are less prominent.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244068, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of same date probably no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244069, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of same date there is\nprobably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-06-04 00:00:00.000", "description": "Report", "row_id": 244070, "text": "Sinus bradycardia. Inferoposterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute/recent/in evolution process. Clinical\ncorrelation is suggested. Since the previous tracing of ST-T wave\nabnormalities are both prominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-06-02 00:00:00.000", "description": "Report", "row_id": 244071, "text": "Sinus rhythm with slowing of the rate as compared with prior tracing\nof . There is further evolution of the findings of acute\ninfero-posterolateral myocardial infarction. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 244072, "text": "Ectopic atrial tachycardia. Compared to the previous tracing of there\nhas been further evolution of the findings of acute infero-posterolateral\nmyocardial infarction. Followup and clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-06-01 00:00:00.000", "description": "Report", "row_id": 244073, "text": "Ectopic atrial rhythm. ST segment elevation in leads II, III and aVF. ST-T wave\nflattening in lead I with downsloping ST segment depression in lead aVL. Early\nprecordial R wave transition. These findings are new as compared with prior\ntracing of . The rate has increased and the findings are consistent with\nactive inferoposterior and lateral myocardial infarction. Followup and\nclinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-05-28 00:00:00.000", "description": "Report", "row_id": 244294, "text": "Sinus bradycardia. Consider left ventricular hypertrophy by voltage\nin lead aVL. Compared to the previous tracing of voltage in\nleads I and aVL is now more prominent.\n\n" } ]

52,593

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66 y/o male s/p segment III resection with Dr on who was discharged to rehab facility and now returns with abdominal incision wound infection. His other concerns are fluid overload and acute on chronic renal failure. He was initially admitted to 10 but was transferred to the SICU for worsening respiratory status, however he did not require intubation. Legionella culture was negative. Bubble study was negative for intracardiac shunt A wound VAC was placed to the abdominal incision after completely opening the incision and Vancomycin was started x 3 days. Blood cultures were negative. Right leg cellulitis was noted on admission and this improved with the Vancomycin. LENIs were obtained and negative for DVT. He was seen in consult by Nephrology and Hepatology. Per both their recommendations Midodrine and octreotide were added as was Rifaxamin. With mild volume expansion, the ARF appeared to be resolving and all diuretics continued to be held. On he underwent paracentesis for increasing abdominal pain. Ultrasound did indicate the presence of ascites. 1.7 liters of fluid was removed and the WBC was 955 with 79% polys. No organisms were seen on gram stain and the fluid culture was reported as no growth. He was started on Zosyn (6 days total) and the Vancomycin was added back in and dosed per trough levels. Nutrition consult was obtained and TPN was initiated via newly placed PICC line. He was transfused 2 units RBCs on HD 7 for Hct 28.2 which dropped 4% from previous day in setting of paracentesis. Hct remained stable thereafter. On a repeat paracentesis was performed and the WBC was now elevated to 3925 with 70% polys. As this occured while on Zosyn, the antibiotic was changed to Meropenem, this was per ID recommendation who was also consulted. Renal consult service was recommending the initiation of hemodialysis as his creatinine which initially decreased to 3.3 by HD 5 was increasing daily in the ensuing days. The patient was transferred to the medical service on with the hepatobiliary (West 1 team) following abdominal wound and VAC changes. On , the patient was in respiratory distress with tachypnea and sat-ing at 95% on 5 liters of oxygen. This was secondary to fluid overload secondary to liver and renal failure. Paracentesis with ultrasound was attempted at the bedside, but very little fluid could be removed. Fluid was sent for fungal cultures. To date, all blood, peritoneal, and urine cultures have been negative. Hemodialysis line was placed by IR in anticipation of hemodialysis for fluid overload. Hemodialysis did not provide any relief of respiratory symptoms and the patient remained in a great deal of pain with respiratory distress. Goals of care were discussed with the patient, his family, and the PCP (Dr. , as well as the attending of record, Dr. . The patient was made DNR/DNI on . Clinical status continued to deteriorate on . On , the family decided on comfort measures only and all medications/treatments were discontinued. Mr. at 15:42 on .

IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status Supplemental O2. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po Plan: Monitor resp status. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. HR 100-110 sinus tach & sbp 120-130 Action: Gentle IV hydration @ 75 cc/hour. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. IVF continue Response: Oxygen saturation stable >95% on 4Liters Tolerating scheduled/PRN nebs/discks Poor po PICC being placed this evening Plan: Monitor resp status. The aortic valve leaflets are mildlythickened (?#). There is a mildresting left ventricular outflow tract obstruction. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg). Moderate mitral annularcalcification. PROCEDURE: Placement of temporary hemodialysis catheter via the right IJ access. Mild restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (?#). A spot in the right upper quadrant was marked and prepped and draped in the usual sterile fashion. Drainage now serosang fluid. Drainage now serosang fluid. FINDINGS: As compared to the previous radiograph, the course of the right-sided PICC line is unchanged. FINAL REPORT CHEST RADIOGRAPH. Impaired Skin Integrity Assessment: Patients abdominal dressing oozing moderate amounts serous fluid. Impaired Skin Integrity Assessment: Patients abdominal dressing oozing moderate amounts serous fluid. Newly inserted central venous access line, the course is normal, the tip projects over the right atrium and should probably be pulled back by 3-4 cm. Assess for fluid collection or abscess. There is stable appearance of the anterior abdominal wound with wound VAC in place. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # Reason: Diagnostic paracentesis requested for today please. The right side of the neck was prepared and draped in the usual sterile fashion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right IJ was accessed with a micropuncture needle under ultrasound guidance. A 0.018 wire was then placed through the needle into the right IJ. (Over) 1:58 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Assess for fluid collection/abscess, eveidence of SBP Admitting Diagnosis: RENAL FAILURE FINAL REPORT (Cont) OR THERAPEUTIC; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # Reason: please do paracentesis. No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. A request was made to place a temporary hemodialysis catheter. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The dilators were removed. HR 100-110 sinus tach & sbp 100-120. HR 100-110 sinus tach & sbp 100-120. Poor R waveprogression, probably a normal variant. There are coronary artery calcifications. There is diverticulosis. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Action: Transplant team aware, vac dressing placed by Dr. . Action: Transplant team aware, vac dressing placed by Dr. . TECHNIQUE: CT through the abdomen and pelvis was performed after administration of oral contrast only. There is diffuse mesenteric stranding. A small incision was made over the needle and then the needle was removed.

31

[ { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688931, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 132.4 kg\n Daily weight:\n 132.1 kg\n Allergies/Reactions:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Precautions: None\n PMH: COPD\n CV-PMH:\n Additional history: HCV, cirrhosis, HCC, hepatocellular CA, (s/p liver\n resection ), osteroarthritis, COPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:71\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 2,056 mL\n 24h total out:\n 924 mL\n Pertinent Lab Results:\n Sodium:\n 131 mEq/L\n 02:58 PM\n Potassium:\n 5.4 mEq/L\n 02:58 PM\n Chloride:\n 96 mEq/L\n 02:58 PM\n CO2:\n 26 mEq/L\n 02:58 PM\n BUN:\n 55 mg/dL\n 02:58 PM\n Creatinine:\n 3.6 mg/dL\n 02:58 PM\n Glucose:\n 121 mg/dL\n 02:58 PM\n Hematocrit:\n 29.7 %\n 03:12 AM\n Finger Stick Glucose:\n 131\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: None\n Transferred from: SICU B\n Transferred to: 10\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688865, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill.\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Response:\n U/o remained stable\n Per\n No Vanco dose due today. Dose/Trough due prior dose\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688866, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688861, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688863, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team.\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n Plan:\n Monitor resp status\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous\n Foley to gravity w/ adequate u/o >30cc/hr\n BLE w/ generalized edema. Lasix d/c\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2151-07-07 00:00:00.000", "description": "Generic Note", "row_id": 688843, "text": "TITLE:\n Clinical Nutrition:\n 65 y.o. M s/p segment 3 resection for HCC readmitted from rehab\n with hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring. Patient started on calorie counts today . Patient\n reports a poor appetite and refused supplements at this time. Will\n follow up with calorie counts and po intake.\n #\n" }, { "category": "Physician ", "chartdate": "2151-07-07 00:00:00.000", "description": "Intensivist Note", "row_id": 688841, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n cellulitis\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy, obesity, osteoarthritis, COPD\n Current medications:\n 3. 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Bisacodyl\n 7. Docusate Sodium 8. Fluticasone-Salmeterol Diskus (250/50) 9. 10.\n Ipratropium Bromide Neb 11. Multivitamins 12. Senna 13. Sodium Chloride\n 0.9% Flush 14. Sodium Chloride 0.9% Flush 15. Thiamine 16. Vancomycin\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.1\nC (96.9\n HR: 106 (99 - 125) bpm\n BP: 120/59(73) {104/45(61) - 146/99(111)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132.1 kg (admission): 132.4 kg\n Total In:\n 2,515 mL\n 478 mL\n PO:\n 590 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,925 mL\n 358 mL\n Blood products:\n Total out:\n 945 mL\n 175 mL\n Urine:\n 945 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,570 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: R LE cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 155 K/uL\n 9.9 g/dL\n 111 mg/dL\n 3.9 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 97 mEq/L\n 132 mEq/L\n 29.7 %\n 10.5 K/uL\n [image002.jpg]\n 02:46 AM\n 05:57 PM\n 03:12 AM\n WBC\n 12.1\n 10.5\n Hct\n 29.7\n 29.7\n Plt\n 145\n 155\n Creatinine\n 4.1\n 3.9\n 3.9\n Glucose\n 89\n 146\n 111\n Other labs: PT / PTT / INR:19.8/33.2/1.8, ALT / AST:34/51, Alk-Phos / T\n bili:65/2.1, Amylase / Lipase:, Albumin:2.4 g/dL, Ca:8.0 mg/dL,\n Mg:2.0 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN INTEGRITY,\n ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neuro: oriented, interactive\n CVS: Stable, goal MAPS >60\n Pulm: for COPD Advair; albuterol atrovent neb q4, autoset CPAP,\n pulmonary following\n GI:reg diet, bowel regimen\n FEN: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: ATN (from lasix) vs HRS: elevated BUN/Cr reflecting decreased\n intravascular volume, pre-renal failure, nephro following, consider\n adding midodrine or octreotide, U/O 20-100, LOS +2.6L\n Heme: boots for proph, autoanticoagulation given liver disease\n Endo: cosyntropin stress test, cortisol 15.8 > 22.0 (> 3hrs later), ?\n adrenal insufficiency\n ID: had vanco on floor for cellulitis, F/U AM trough\n TLD:PIV, foley, PICC requested\n Wounds: abd w/ vac dressing, RLE with cellulitis\n Imaging: CXR P\n Prophylaxis: boots\n Consults: transplant \n Code: full\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:01 PM\n 22 Gauge - 03:15 AM\n Prophylaxis:\n DVT: Boots\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688907, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688908, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688909, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Pt fully alert and oriented x3. No c/o of SOB but positive\n DOE.\n Baseline ST 100\ns but up to 110\ns w/ exertion\n 5Liters via NC overnoc sating >95%. O2 sat best found on\n forehead per history\n LS clear in upper lobes and diminished at bases. No cough.\n Pulmonary following. Recommends Auto CPAP at HS but refused\n last evening.\n Initial eval done for PICC this am by PICC team. PIV x2\n Regular house diet on Calorie Count.\n NS @ 75cc/hr\n Action:\n Advair disk/Albuterol and Atrovent nebs PRN\n Weaned down to 4 Liters via NC and saturation >95%\n OOB and ambulated in w/ PT. Sats dipped to mid 80\ns w/\n ambulation\n OOB to chair for majority of day.\n Tolerating small amts of po\ns. IVF continue\n Response:\n Oxygen saturation stable >95% on 4Liters\n Tolerating scheduled/PRN nebs/discks\n Poor po\n PICC being placed this evening\n Plan:\n Monitor resp status. Pulm following\n Supplemental O2. Scheduled resp meds/nebs\n CPAP at night\n Enc OOB\n Continue calorie count on floor. Continue IVF\n Needs CXR and wire removal from PICC prior transfer to \n 10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Appearing generally chronically ill. ATN d/t ?lasix\n Todays BUN 57 Cr 3.9 K 5.2. Improved from previous.\n Foley to gravity w/ adequate u/o >30cc/hr\n TTE/bubble study negative\n BLE w/ generalized edema. Lasix d/c\n Right leg cellulits unchanged\n Abd wound w/ wound VAC to suction\n Renal US and BLE US down overnoc\n Vancomycin renal dosed Q48hrs for Cellulitis\n Action:\n Gentle hydration w/ IVF\n Borderline po\ns. Carlorie Count\n u/o monitored q 1hr and >20cc/hr.\n Wound Vac intact\n Elevate BLE\n Response:\n U/o remained stable\n Per Transplant Renal US and BLE US negative\n No Vanco dose due today. Dose/Trough due prior dose\n BM x2\n Plan:\n Monitor u/o\n Monitor labs\n Renal dose meds.\n Renal following\n Continue Calorie Count.\n Transfer to 10\n" }, { "category": "Rehab Services", "chartdate": "2151-07-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 688825, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt. is 65 y.o. male\n s/p liver resection for HCC, re-admitted from rehab with wound\n infection, SOB, LE cellulitis and hyponatremia.\n Past Medical / Surgical History: Chronic HCV, cirrhosis, HCC,\n hepatocellular CA s/p resectiion, peripheral neuropathy, obesity, OA,\n COPD,\n Medications: Vancoymycin, Albuterol, Thiamine\n Radiology: CXR: No significant interval change from earlier same day.\n Lungs remains clear.\n No large effusion and no pneumothorax. Cardiomediastinal contour is\n unchanged, as is elevation of the right hemidiaphragm.\n LE US: no evidence of DVT\n Labs:\n 29.7\n 9.9\n 155\n 10.5\n [image002.jpg]\n Other labs:\n Activity Orders: As tolerated\n Social / Occupational History: Lives alone. Family involved in care. +\n tobacco hx, +ETOH\n Living Environment: 3 STE, 1 level home\n Prior Functional Status / Activity Level: At rehab PTA, assistance with\n all ADLs\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3 impulsive at\n times\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 103\n 115/69\n 19\n 92 on 3L\n Sit\n /\n Activity\n 118\n /\n 85-92 on 4L\n Stand\n /\n Recovery\n 102\n 115/64\n 18\n 94 on 3L\n Total distance walked:\n Minutes:\n Pulmonary Status: BS dimished at bases\n Integumentary / Vascular: Abd vac attached, Foley catheter, L UE PIV,\n Telemetry, R Lower leg cellulitis\n Sensory Integrity: pt. reports sensation grossly intact to LT in LEs.\n Pain / Limiting Symptoms: no c/o pain\n Posture: obese\n Range of Motion\n Muscle Performance\n bilat. UEs/LEs: WLF throughout\n bilat. UEs/LEs: > throughout\n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. amb 200 ft pushing w/c with CGA, desatting to\n 85-88 % on 4L.\n Rolling:\n Received in sitting\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n Stand-pivot\n\n\n x\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n Pushing w/c\n\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: no LOB during ambulation\n Education / Communication: Pt. edu re: Role of PT, , d/c plan to\n home, RN comm re: pt. status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Transfers, Impaired\n Clinical impression / Prognosis: Pt. is 66 y.o. male s/p liver\n resection, admitted from rehab with wound infection, SOB, cellulitis,\n that p/w above impairments associated with pulmonary pump\n dysfunction/deconditioning. Pt. appears to be functioning close to his\n baseline and anticipate that pt. will progress towards d/c home in \n PT visits. Will f/u as appropriate to progress mobility, and endurance.\n Goals\n Time frame: 1 week\n 1.\n supine to sit indep.\n 2.\n sit to stand indep.\n 3.\n Amb 300 ft with RW indep\n 4.\n Maintain SpO2 > 92 % on 2L\n 5.\n Verbalize understandin of Role of PT\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: x/wk\n bed mobility, transfers, gait-training with RW, stairs, endurance\n training\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face time: 9:30-10:17 am\n Nsg recs: Amb with RW x/day\n" }, { "category": "Physician ", "chartdate": "2151-07-06 00:00:00.000", "description": "Intensivist Note", "row_id": 688507, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n SOB\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy , obesity, osteoarthritis , COPD\n PSH: Segement III Liver resection\n : Ascorbic acid 500\" , Keflex 500\"\" , Heparin SQ ''' , Dilaudid PRN\n Vac change , Advair diskus 1\" , Thiamine 100' , MVI , Zinc 220'\n ,Atrovent PRN , senna , Serax 15 PRN HS , Ambien 5' , Dilaudid PRN\n All: iodine, peanuts\n Current medications:\n 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Cosyntropin\n 7. Fluticasone-Salmeterol Diskus (250/50)\n 8. Ipratropium Bromide Neb 9. Multivitamins 10. Senna 11. Sodium\n Chloride 0.9% Flush 12. Sodium Chloride 0.9% Flush\n 13. Thiamine\n 24 Hour Events:\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 106 (96 - 118) bpm\n BP: 110/69(78) {102/50(62) - 138/69(78)} mmHg\n RR: 22 (16 - 26) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 920 mL\n 449 mL\n PO:\n 120 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 800 mL\n 329 mL\n Blood products:\n Total out:\n 140 mL\n 190 mL\n Urine:\n 140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 259 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), wet sounds bilat\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: cellulitis right leg, marked\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN\n INTEGRITY, ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neurologic: oriented, interactive\n Cardiovascular: Stable, goal MAPS >60\n Pulmonary: for COPD continue salmeterol + fluticasone; ipratropium +\n albuterol neb prn\n Gastrointestinal / Abdomen: reg diet\n Nutrition: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: elevated BUN/Cr , ?pre-renal failure, FENa 0.3%\n Hematology: boots for proph, autoanticoagulation given hx of liver\n disease\n Endocrine: F/U corsyntropin stress test as pt has low Na and elevated\n K, question adrenal insuficiency\n Infectious Disease: Check cultures, had vanco on floor for cellulitis,\n F/U AM trough\n Lines / Tubes / Drains: PIV, foley\n Wounds: leg, abd vac\n Imaging:\n Fluids:\n Consults: transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 08:01 PM\n 20 Gauge - 08:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2151-07-07 00:00:00.000", "description": "Intensivist Note", "row_id": 688751, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n cellulitis\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy, obesity, osteoarthritis, COPD\n Current medications:\n 3. 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Bisacodyl\n 7. Docusate Sodium\n 8. Fluticasone-Salmeterol Diskus (250/50) 9. 10. Ipratropium Bromide\n Neb 11. Multivitamins 12. Senna\n 13. Sodium Chloride 0.9% Flush 14. Sodium Chloride 0.9% Flush 15.\n Thiamine 16. Vancomycin\n 24 Hour Events:\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.1\nC (96.9\n HR: 106 (99 - 125) bpm\n BP: 120/59(73) {104/45(61) - 146/99(111)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132.1 kg (admission): 132.4 kg\n Total In:\n 2,515 mL\n 478 mL\n PO:\n 590 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,925 mL\n 358 mL\n Blood products:\n Total out:\n 945 mL\n 175 mL\n Urine:\n 945 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,570 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: R LE cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 155 K/uL\n 9.9 g/dL\n 111 mg/dL\n 3.9 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 97 mEq/L\n 132 mEq/L\n 29.7 %\n 10.5 K/uL\n [image002.jpg]\n 02:46 AM\n 05:57 PM\n 03:12 AM\n WBC\n 12.1\n 10.5\n Hct\n 29.7\n 29.7\n Plt\n 145\n 155\n Creatinine\n 4.1\n 3.9\n 3.9\n Glucose\n 89\n 146\n 111\n Other labs: PT / PTT / INR:19.8/33.2/1.8, ALT / AST:34/51, Alk-Phos / T\n bili:65/2.1, Amylase / Lipase:, Albumin:2.4 g/dL, Ca:8.0 mg/dL,\n Mg:2.0 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS), CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITHOUT ACUTE EXACERBATION, RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN INTEGRITY,\n ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neuro: oriented, interactive\n CVS: Stable, goal MAPS >60\n Pulm: for COPD Advair; albuterol atrovent neb q4, autoset CPAP,\n pulmonary following\n GI:reg diet, bowel regimen\n FEN: MVI, thiamine, regular diet, 1/2NS @75 ml/hr\n Renal: ATN (from lasix) vs HRS: elevated BUN/Cr reflecting decreased\n intravascular volume, pre-renal failure, nephro following, consider\n adding midodrine or octreotide, U/O 20-100, LOS +2.6L\n Heme: boots for proph, autoanticoagulation given liver disease\n Endo: cosyntropin stress test, cortisol 15.8 > 22.0 (> 3hrs later), ?\n adrenal insufficiency\n ID: had vanco on floor for cellulitis, F/U AM trough\n TLD:PIV, foley, PICC requested\n Wounds: abd w/ vac dressing, RLE with cellulitis\n Imaging: CXR P\n Prophylaxis: boots\n Consults: transplant \n Code: full\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:01 PM\n 22 Gauge - 03:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2151-07-06 00:00:00.000", "description": "Intensivist Note", "row_id": 688593, "text": "SICU\n HPI:\n 65M s/p segment 3 resection for HCC readmitted from rehab with\n hyponatremia, rising creatinine, hyperkalemia, lower extremity\n cellulitis, and SOB. On floor had desat and was transferred to ICU for\n monitoring.\n Chief complaint:\n SOB\n PMHx:\n chronic HCV infection, cirrhosis, HCC, Hepatocellular CA s/p segement\n III resection peripheral neuropathy , obesity, osteoarthritis , COPD\n PSH: Segement III Liver resection\n : Ascorbic acid 500\" , Keflex 500\"\" , Heparin SQ ''' , Dilaudid PRN\n Vac change , Advair diskus 1\" , Thiamine 100' , MVI , Zinc 220'\n ,Atrovent PRN , senna , Serax 15 PRN HS , Ambien 5' , Dilaudid PRN\n All: iodine, peanuts\n Current medications:\n 1000 mL 1/2NS 4. 500 mL NS 5. Albuterol 0.083% Neb Soln 6. Cosyntropin\n 7. Fluticasone-Salmeterol Diskus (250/50) 8. Ipratropium Bromide Neb\n 9. Multivitamins 10. Senna 11. Sodium Chloride 0.9% Flush 12. Sodium\n Chloride 0.9% Flush 13. Thiamine\n Allergies:\n Iodine\n Shortness of br\n Peanut\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 106 (96 - 118) bpm\n BP: 110/69(78) {102/50(62) - 138/69(78)} mmHg\n RR: 22 (16 - 26) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 920 mL\n 449 mL\n PO:\n 120 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 800 mL\n 329 mL\n Blood products:\n Total out:\n 140 mL\n 190 mL\n Urine:\n 140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n 259 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), wet sounds bilat\n Abdominal: Soft, Non-tender, Obese\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: cellulitis right leg, marked\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), IMPAIRED SKIN\n INTEGRITY, ELECTROLYTE & FLUID DISORDER, OTHER\n Assessment and Plan: 65 yo M s/p partial liver resection back in\n hospital from rehab for ARF, hyponatremia, cellulitis, and SOB, in SICU\n for desat on floor\n Neurologic: oriented, interactive\n Cardiovascular: Stable, goal MAPS >60\n Pulmonary: for COPD continue salmeterol + fluticasone; ipratropium +\n albuterol neb prn\n Gastrointestinal / Abdomen: reg diet\n Nutrition: MVI, thiamine, regular diet, NS @75 ml/hr\n Renal: elevated BUN/Cr , ?pre-renal failure, FENa 0.3%. Consult\n nephrology and discuss albumen\n Hematology: boots for proph, autoanticoagulation given hx of liver\n disease\n Endocrine: F/U corsyntropin stress test as pt has low Na and elevated\n K, question adrenal insuficiency\n Infectious Disease: Check cultures, had vanco on floor for cellulitis,\n F/U AM trough\n Lines / Tubes / Drains: PIV, foley\n Wounds: leg, abd vac\n Consults: transplant\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n 22 Gauge - 08:01 PM\n 20 Gauge - 08:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688682, "text": "Constipation (Obstipation, FOS)\n Assessment:\n c/o constipation..passing flatus\n Action:\n Digital exam for hard stool..given ducolax supp..fleets\n enema..disimpacted & ss enema given\n Response:\n Mod amt hard formed stool\n Plan:\n Continue with good bowel regiment..increase activity as tol..PT consult\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Placed on ofm @ fio2 100%\n Action:\n Sat\ns >95% when sitting up\n Response:\n Does drop sat\ns when flat or with exertion\n Plan:\n Continue with good pulmonary toilet..encourage deep breathing &\n coughing..increase activity as tol..oob as much as pt can tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat remains elevated but adequate huo\n Action:\n Urine lytes sent ..renal consult\n Response:\n No increase in renal failure\n Plan:\n Will try to remove fluid ? Lasix or albumin at this time awaiting renal\n consult suggestions..continue to follow huo\ns closely\n" }, { "category": "Nursing", "chartdate": "2151-07-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688737, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Breathing unlabored @ rest. Dyspneic with any activity. Sp02 mid 90\n on 5 L nasal cannula. Lung sounds clear but diminished.\n Action:\n Resp status monitored.\n Response:\n Unchanged overnight.\n Plan:\n CXR this am. Encourage pulmonary hygiene.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient making adequate hourly urine (> 20 cc/hour). HR 100-110 sinus\n tach & sbp 120-130\n Action:\n Gentle IV hydration @ 75 cc/hour.\n Response:\n Unchanged overnight.\n Plan:\n Awaiting AM labs. Patient to have renal ultrasound this AM.\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688547, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted to SICU from FA 10 due to recent increase in\n creatinine & worsening resp status. Patient s/p liver rsx .\n Patient arrived approx 7:30, oriented and appropriate. SOB with any\n activity, but otherwise unlabored. Lung sounds clear but diminished.\n Spo2 high 90\ns with NRB. Patient making borderline hourly urine 30-40\n cc. HR 100-110 sinus tach & sbp 100-120.\n Action:\n Fluid bolus given over 2 hours and IV maint fluid given. NRB changed\n to nasal cannula 5 liters.\n Response:\n Resp status remains unchanged. All vitals stable. AM creat still 4.1,\n patient continues to make urine. Patient slept minimally overnight.\n Remains oriented x3, but now occasionally making confused statements.\n Plan:\n ? Transfer back to Fa 10 today.\n Impaired Skin Integrity\n Assessment:\n Patient\ns abdominal dressing oozing moderate amounts serous fluid.\n Afebrile. No complaints abdominal/wound pain. Wound tissue pink,\n granulating.\n Action:\n Transplant team aware, vac dressing placed by Dr. . Drainage\n now serosang fluid.\n Response:\n Skin otherwise intact. Wound vac functioning well. Patient has area\n of cellulitis on RLE, no change since admission.\n Plan:\n Continue to monitor closely.\n" }, { "category": "Nursing", "chartdate": "2151-07-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688546, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted to SICU from FA 10 due to recent increase in\n creatinine & worsening resp status. Patient s/p liver rsx .\n Patient arrived approx 7:30, oriented and appropriate. SOB with any\n activity, but otherwise unlabored. Lung sounds clear but diminished.\n Spo2 high 90\ns with NRB. Patient making borderline hourly urine 30-40\n cc. HR 100-110 sinus tach & sbp 100-120.\n Action:\n Fluid bolus given over 2 hours and IV maint fluid given. NRB changed\n to nasal cannula 5 liters.\n Response:\n Resp status remains unchanged. All vitals stable. AM creat still 4.1,\n patient continues to make urine.\n Plan:\n Continue to follow closely.\n Impaired Skin Integrity\n Assessment:\n Patient\ns abdominal dressing oozing moderate amounts serous fluid.\n Afebrile. No complaints abdominal/wound pain. Wound tissue pink,\n granulating.\n Action:\n Transplant team aware, vac dressing placed by Dr. . Drainage\n now serosang fluid.\n Response:\n Skin otherwise intact. Wound vac functioning well.\n Plan:\n" }, { "category": "Echo", "chartdate": "2151-07-06 00:00:00.000", "description": "Report", "row_id": 98179, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. BUBBLE STUDY, respiratory failure.\nHeight: (in) 67\nWeight (lb): 290\nBSA (m2): 2.37 m2\nBP (mm Hg): 108/62\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 13:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient did not cooperate with the entirety of the study; therefore images\nwere incomplete.\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF >75%. TDI E/e' >15, suggesting PCWP>18mmHg. Mild resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No valvular AS. The\nincreased transaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). There is a mild\nresting left ventricular outflow tract obstruction. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are mildly\nthickened (?#). There is no valvular aortic stenosis. The increased\ntransaortic velocity is likely related to high cardiac output. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\ntricuspid valve leaflets are mildly thickened. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Hyperdynamic left ventricular function.\nNo intracardiac shunting by bubble study.\n\nCompared with the report of the prior study (images unavailable for review) of\n, no major change is evident.\n\n\n" }, { "category": "ECG", "chartdate": "2151-07-16 00:00:00.000", "description": "Report", "row_id": 277316, "text": "Sinus tachycardia with intermittent ventricular premature beats. Poor R wave\nprogression, probably a normal variant. Non-specific lateral ST-T wave\nchanges. Compared to the previous tracing of the overall rate has\ndecreased. The other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2151-07-09 00:00:00.000", "description": "Report", "row_id": 277317, "text": "Sinus tachycardia. Poor R wave progression. Non-specific low amplitude\nT waves. Low QRS voltage in the precordial leads. Compared to the previous\ntracing of T wave flattening is slightly more pronounced, especially\nin lead I.\n\n" }, { "category": "ECG", "chartdate": "2151-07-08 00:00:00.000", "description": "Report", "row_id": 277318, "text": "Sinus tachycardia. Poor R wave progression. Low QRS voltage in the precordial\nleads. Compared to the previous tracing of ventricular rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2151-07-05 00:00:00.000", "description": "Report", "row_id": 277319, "text": "Sinus tachycardia. Low QRS voltage in the precordial leads. Compared to the\nprevious tracing of there is no significant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-07-05 00:00:00.000", "description": "Report", "row_id": 277320, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2151-07-14 00:00:00.000", "description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)", "row_id": 1090883, "text": " 2:56 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: please do paracentesis. send fluid for gram stain, culture,\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with HCC s/p liver resection readmitted with incision\n cellulitis and worsening HRS\n REASON FOR THIS EXAMINATION:\n please do paracentesis. send fluid for gram stain, culture, cell count\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED PARACENTESIS\n\n COMPARISON: None.\n\n HISTORY: 66-year-old male with HCC status post liver resection with worsening\n ascites.\n\n FINDINGS/PROCEDURE: After the risks, benefits and alternative to the\n procedure were explained to the patient, written informed consent was\n obtained. Preprocedure timeout was performed using three patient identifiers.\n A spot in the right upper quadrant was marked and prepped and draped in the\n usual sterile fashion. Local anesthesia was obtained using buffered lidocaine\n solution 1%. Subsequently, a 5 French catheter was advanced into the\n pocket of ascites. 600 cc of clear yellow-brown fluid was obtained. Small\n amount of samples were sent to the laboratory as requested.\n\n There were no immediate post-procedure complications.\n\n The attending physician, . , was present and supervising\n throughout the entire procedure.\n\n IMPRESSION: Successful ultrasound-guided diagnostic and therapeutic\n paracentesis yielding 600 cc of clear yellow brownish fluid. Small amount of\n sample was sent to the laboratory as requested.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1091213, "text": " 4:24 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : Where is the line?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with dyspnea and question line location\n REASON FOR THIS EXAMINATION:\n Where is the line?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Line placement.\n\n COMPARISON: , 8:10 a.m.\n\n FINDINGS: As compared to the previous radiograph, the course of the\n right-sided PICC line is unchanged. Newly inserted central venous access\n line, the course is normal, the tip projects over the right atrium and should\n probably be pulled back by 3-4 cm. There is no evidence of complications such\n as pneumothorax. Otherwise, the radiograph is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-12 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1090551, "text": " 1:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Assess for fluid collection/abscess, eveidence of SBP\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with increasing WBC, + paracentesis\n REASON FOR THIS EXAMINATION:\n Assess for fluid collection/abscess, eveidence of SBP\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old man with increasing white blood count and suspicion of\n spontaneous bacterial peritonitis. Assess for fluid collection or abscess.\n\n COMPARISON: .\n\n TECHNIQUE: CT through the abdomen and pelvis was performed after\n administration of oral contrast only. The patient could not receive IV\n contrast due to elevated creatinine. Multiplanar reformats were performed.\n\n FINDINGS:\n\n ABDOMEN: There is increasing consolidation with air bronchograms in the right\n lower lobe, suspicious for pneumonia. There are coronary artery\n calcifications. The liver is shrunken and nodular, consistent with cirrhosis.\n There is an increasing amount of free flowing ascites in the abdomen and\n pelvis, compared to prior, but no focal fluid collection to suggest discrete\n abscess. The pancreas, spleen, and adrenal glands are unremarkable. There are\n two 1.0 cm stones in the lower pole of the left kidney. The right kidney\n appears normal. There is diffuse mesenteric stranding. The bowel loops are\n of normal caliber.\n\n PELVIS: Again seen is slightly increasing pelvic ascites. There is stable\n appearance of the anterior abdominal wound with wound VAC in place. There is\n no abscess in this location. There is diverticulosis. There are degenerative\n changes in the spine.\n\n IMPRESSION:\n\n 1. Increasing ascites without discrete focal fluid collection to suggest\n abscess.\n\n 2. Changes in the liver consistent with cirrhosis.\n\n 3. Increasing right lower lobe consolidation suspicious for pneumonia.\n\n 4. Two 1 cm nonobstructing left kidney stones.\n\n 5. Diverticulosis.\n\n\n (Over)\n\n 1:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Assess for fluid collection/abscess, eveidence of SBP\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 1091207, "text": " 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ********************************* CPT Codes ********************************\n * NON-TUNNELED US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESLD, hepatorenal syndrome, volume overload leading to\n dyspnea who needs initiation of HD for fluid removal\n REASON FOR THIS EXAMINATION:\n Please place a temporary HD catheter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 7:52 PM\n PFI: Placement of temporary hemodialysis catheter via the right IJ access\n with tip of the catheter in the right atrium and the catheter is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 66-year-old man with endstage liver\n disease, hepatorenal syndrome, volume overload, leading to dyspnea, who needs\n initiation of hemodialysis for fluid removal. A request was made to place a\n temporary hemodialysis catheter.\n\n OPERATORS: Dr. and Dr. , the attending\n radiologist who was present and supervised during whole procedure.\n\n PROCEDURE: Placement of temporary hemodialysis catheter via the right IJ\n access.\n\n ANESTHESIA: Lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After the risks and the benefits of procedure as well\n as local anesthesia were explained, informed consent was obtained. The\n patient was brought to the angiographic suite and placed on the stretcher. The\n head of the stretcher was raised in 45 degree to relieve the shortness of\n breath. The right side of the neck was prepared and draped in the usual\n sterile fashion. The right IJ was accessed with a micropuncture needle under\n ultrasound guidance. Hard copies of ultrasound were stored. A 0.018 wire was\n then placed through the needle into the right IJ. A small incision was made\n over the needle and then the needle was removed. A micropuncture sheath was\n then placed over the wire into the right IJ. The wire and the inner stiffener\n of the sheath were removed. A 0.035 wire was then placed through the\n sheath into the right IJ. The sheath was then removed. A 12 French and a 14\n French soft tissue dilators were sequentially used to dilate the soft tissue\n entrance into the right IJ. The dilators were removed. A 14 French, 15-cm\n AngioDynamics temporary hemodialysis catheter was then placed over the wire\n into the right IJ. The final position of the tip of the catheter was in the\n right atrium which was confirmed by a bedside chest x-ray. Both ports of\n catheter were aspirated and flushed easily. Both ports were capped. The\n catheter was sutured to skin and a sterile dressing was applied.\n\n The patient tolerated the procedure well, and there were no immediate\n (Over)\n\n 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n complications.\n\n IMPRESSION: Placement of a temporary hemodialysis catheter via the right IJ\n access with the tip of the catheter in the right atrium and the catheter is\n ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-16 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 1091208, "text": ", C. MED FA10 3:49 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary HD catheter\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESLD, hepatorenal syndrome, volume overload leading to\n dyspnea who needs initiation of HD for fluid removal\n REASON FOR THIS EXAMINATION:\n Please place a temporary HD catheter\n ______________________________________________________________________________\n PFI REPORT\n PFI: Placement of temporary hemodialysis catheter via the right IJ access\n with tip of the catheter in the right atrium and the catheter is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-08 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1090009, "text": " 2:32 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place double lumen PICC\n Admitting Diagnosis: RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man needing access and TPN\n REASON FOR THIS EXAMINATION:\n place double lumen PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for TPN and IV access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure under supervision of Dr.\n .\n\n TECHNIQUE: Using sterile technique and local anesthesia, the basilic vein was\n punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a dual lumen PICC line measuring 38 cm in length was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied. The patient tolerated\n the procedure well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double-lumen PICC line placement via the right basilic venous approach. Final\n internal length is 38 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2151-07-11 00:00:00.000", "description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US", "row_id": 1090380, "text": " 9:38 AM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Diagnostic paracentesis requested for today please.\n Admitting Diagnosis: RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG. OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ascites, ?SBP\n REASON FOR THIS EXAMINATION:\n Diagnostic paracentesis requested for today please.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 66-year-old male with ascites and abdominal pain, to\n assess for possible subacute bacterial peritonitis. Preliminary scans reveal\n moderate volume of ascites, particularly in the right flank.\n\n After obtaining written informed consent and performing a timeout procedure\n with three patient identifiers, an appropriate site in the right upper\n quadrant/right flank was selected for paracentesis. Under sterile conditions\n with local anesthesia (1% Xylocaine), a 5 French catheter was placed into\n the fluid and specimens were obtained for requested laboratory tests,\n including cell count and differential and culture. The catheter was then\n connected to vacuum bottles and 1.7 liters of fluid was removed without\n difficulty. There were no complications during the procedure.\n\n CONCLUSION: Successful ultrasound-guided paracentesis.\n\n\n" } ]

16,576

145,108

A/P: 85 yo female with h/o CHF, HTN and AFib who presents with CHF exacerbation. 1. CHF: Pt with echo in with EF>55%. Likely diastolic component of HF. Dose of diuretics recently adjusted by PCP as thought she was overdiuresed and now has had increased fluid overload. Started with iv lasix at 40mg IV bid with minimal response however good response with 80mg iv bid. Discussed mgmt with daily weights and adjust lasix dose based on this and may have to decrease ace/BB dose to tolerate excess diuresis. Also as vague left sided chest pain with clinical heart failure out of proportion to echo, re-reviewed nuclear stress in with attending and findings concerning for reversible defect of anterior wall and taken to catheterization to evaluate for ischemia contributing to worsening episodesof heart failure. Was continued on atenolol and lisinopril while in house, but following catheterization while on integrillin patient developed hematemesis and was transferred to ccu. She was also hypotensive after further diuresis in cath lab. She was monitored in the ccu and her blood pressures improved as diuresis was held. Her hematocrits remained stable and was transferred back to floor. Her diurretics were held with goal to keep her euvolemic. Then as blood pressure improved, she was restarted on low dose ace and changed to coreg from atenolol for heart failure. She was continued on asprin for life and plavix for 9months for recently placed stent. At time of discharge she was euvolemic with a weight of 81.3kgs. She will monitor her weights at rehab. She was started on 80mg lasix qd with goal to keep her weight stable within 1-2kg of 81.3kg. Her blood pressures should be monitored closely with adjustments in her lasix regemin. She was continued on oxygen and this can be continued to followed and titrated off as tolerated. Her CXRs confirmed cardiomegaly and bilateral pleural effusions. Her dyspnea was stable with ambulation, but will require continued physical therapy. If her weight increased by more than 2kg her lasix should be increased to twice a day and if she loses more than 2kg then her lasix dose should be halved. * 2. CAD: stable no previously known heart disease but after re-review of nuclear stress, pt went to cardiac cath as above and had a stent to her distal left circumflex. For which she will continue asprin for life and plavix for 9months at least. * 3. Afib: stable as she is s/p ablation with pacer and maintained on amiodarone, temporarily bridged with heparin during her stay and then restarted on her wafarin with good result. Her goal INR , but came in supratherapeutic INR and coumadin was held intiitally and for her catheterization. She is also continued on her beta-blocker with good rate control. * 3. HTN: stable after episode of hypotension after overdiuresis on floor and during catheterization. Slowly as her volume status improved, she was started on low dose lisinopril instead of enalapril and coreg instead of atenolol because of her heart failue. Even as she was re-started on lasix her blood pressure remained stable. * 4. Acute on chronic renal failure: her creatinine was 1.5 at baseline, the source of her chronic renal failure was unclear and she had bilateral renal ultrasounds with dopplers to assess for flow across renal arteries as she has a pacer and an MRA is not possible. Renal ultrasound was inconclusive for hypertensive nephropathy vs renal artery stenosis. During her catheterization, unfortunately her renal arteries were not assessed. Following catheterization she did have a slight creatinine bump which may have been secondary to contrast nephropathy, exacerbated by overdiuresis or ATN secondary to transient hypotension. However, by time of discharge her creatinine was 1.2 and stable even on ace and lasix. * 5. Hematemesis: patient developed hematemesis and melanotic stools following integrillin infusion post-stent. She was transfused and her hematocrit remained stable and she was eventually taken for EGD and colonoscopy with results as above. She was started on twice a day protonix, four times a day sucralfate and will plan to re-EGD in 3weeks. Her dysphagia improved and her diet is slowly being advanced as she tolerates. Her pain is improving as well with treatment. She also had a speech and swallow eval which assessed her swallow function to be normal and felt that her dysphagia was consistent with esophageal source as by EGD. Per nutrition they reccommended more frequent, smaller meals with Boost supplements. Of note her CMV IgM ws negative and IgG was posotive consitent with prior exposure to CMV. Her H.pylori serologies are still pending at time af discharge and is return positive she should be started on treatement for H.pylori. * 6. Pseudomonas bronchitis: patient continued to have productive cough, but negative chest xray, her sputum was sent and showed pan-sensitive pseudomonas and staph aureus. She was started on vanc/cipro/ceftaz empirically and then transitioned to cipro for discharge to complete 2week course which will be completed on .

BS: slight expiratory wheez RUL, which cleared with the RX. follow hct in am, fluid boluses as needed if bp drops. Prev BS's pnd. has pneumoboots on.ms- dtr interprets (pt speaks ). dtr pt's stent card and info brochure.a- s/p cath w/rising creatinine. pt to turn side to side, ?oob when bp staying up. Compared to the previous tracing of nodiagnostic interim change. Conitnue to monitor resp status and nebs tx. Pulses palpable.Resp: Pt LS coarse with exp wheezes noted at bases and at times throughout, neb tx given. APPEARS MORE COMFORTABLE SINCE TREATMENT.GI: ABD SOFT, + BOWEL SOUNDS NO BM OVERNIGHT. GIVEN ALB/ATR NEBS X3. GIVEN ALB/ATR NEB WITH SOME RELIEF FORM SOB. ccu npno-id- t max 99.2. c+s sputum shows pseudomonas and staph aureus coag pos. WILL NEED MED FOR CONSTIPATION.ID: AFEBRILE WBC 13.3 CONT ON LEVAQUIN PO.A: RESP DISTRESS, CONGESTED. C/O RIGHT LOWER ABD PAIN. DENIES CHEST PAIN, C/O INTERMITTENT ABDOMINAL CRAMPINESS, STATES FEELS LIKE SHE NEEDS TO MOVE BOWELSO. NT SUCTIONING DONE. extremities edematous except for r arm. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATAID: TEMP 98.9 -99.6 PO, CONTINUES ON LEVO - WBC 13RESP: SPUTUM FROM YESTERDAY 3+ GM NEG RODS - LUNGS COARSE W/EXP WHEEZES, DENIES SOB, RECEIVING ALBUTEROL NEBS, SATS ON R/A 89% - 92%, SATS ON 2L NC 95-98%; CONTINUES TO HAVE INTERMITTENT CONGESTED COUGH, LOOSE, MOSTLY NON-PRODUCTIVE, RECEIVED DELSYM X1, TYLENOL #3 X1CV: HR 60 AV PACED, BP REMAINS 70-80'S/SYSTOLIC - HCT 27.7 RECEIVED 1 UNIT PRBC'S - BP TO 90'S THEN DRIFTED BACK TO 70'S, 2ND UNIT HUNG AND INFUSING SLOWLY OVER 4 HOURSGI: ABDOMEN SOFT, INTERMITTENT CRAMPING DIET NPO TO CLEARS, TOLERATING SIPS H2O THUS FAR, NO STOOL BUT OCCAS STATES SHE FEELS CONSTIPATEDGU: FOLEY IN PLACE DRAINING CLEAR AMBER URINE IN SM AMTS DESPITE 2 U PRBC'S, BUN/CR RISING POST CATH AND WITH LOW BPNEURO/MS: A+O X3, SLEEPING IN NAPS THIS AFTERNOON, NO ISSUES W/ANXIETY THIS SHIFTSOCIAL: GRANDDAUGHTER IN MOST OF DAY, NOW DAUGHTER IN W/PT, FAMILY VERY INVOLVED IN CARE, UPDATED FREQUENTLY REGARDING PT CONDITIONA: REMAINS HYPOTENSIVE - ? urine lytes sent.po4 5.7, on tums.gi- abd soft w/bowel sounds. BECAME TRANSIENTLY HYPOTENSIVE SBP 60 (RESOLVED WITHOUT TREATMENT). neb rxs prn, none given.gu- creat up to 3.3. u/o inmproved to 15-23cc/hr. NURSING PROEGRESS NOTE 7P-7ANEURO: PT. Pt denies SOB, RR 12-21 O2 sats 93-99. pneumonia.p- follow resp status, creat. also s/b gi. a+o according to dtr. COOL NEB FOR 02 TO HELP LOOSEN SECRETIONS. S/P CVA ? Pt speaking, understands and speaks minimal English.CV: Pt HR 60 AV paced, NBP 71-87/32-38, MAPs 46-54, HO aware. assisted/encouraged to turn side to side with skin care q2-3hrs, does not stay far over on side hwever after repositioned. Tylenol with codeine given x 1.GU: Pt with poor u/o 6-35 cc/hr anber urine, HO aware, no increase in u/o see with fluid boluses. cooperative and pleasant.access- i iv leaking, 1 clotted off, unable to flush. Regular A-V sequential pacingSequence error: V2,V3 omittedPacemaker rhythm - no further analysisNo change from previous RIGHT GROIN C&D. ?swallowing eval. LUNGS WITH RALES IN UPPER AIRWAYS. A-V sequential paced rhythmNo change from previous A-V sequential paced rhythmNo change from previous A-V sequential paced rhythmNo change from previous S/P STENT PLACEMENT.P: MED FOR CONSTIPATION. ANXIOUS AT TIMES.CV: BP 64-78, GIVEN FLUID BOLUS 250 CC WITH MODERATE EFFECT. No dizziness, BP stable.Resp: sats 97% on 2L NC, LS with scattered rhonchi, congested cough, strong but not expectorating.ID: sputum with pseudomonas as well as staph auereous coag (+), placed on MRSA contact precautions. CCU NPN 7p-7aS: "Okay...Thank you. HCT 29.1GI: ABD SOFT HYPOACTIVE BOWEL SOUNDS, ATTEMPTED BM BUT NO RESULTS. send clot w/next bld draw. GIVEN TESSALON PERLESAND TYLENOL#3 FOR C/O HEADACHE AND GENERLIZED BODY PAIN. O2 SOURCE CHANGED TO COOL NEB 70% TO HELP LOOSE SECRETIONS. GIVEN LASIX 60 MG IVP WITH FAIR RESPONSE.A: S/P STENT TO LCX, POST PROCEEDURE CHEST DISCOMFORT WITH BLOODY EMESIS.P: FOLLOW HCT, LASIX IF NEEDED. MONITOR I/O. Attempted BM on commode without success.Soc: daughter, grandson in. c/o feeling of something stuck in esophagus. k-3.8, replaced with 40meq po x1. BUN/creat cont to rise from yesterday. "O: Please see careview for VS and additional data. Respiratory Care:The RN graciuosly said she will do NEBs today becauce of the high level of of RT activity elsewhere. AT TIMES DIFICULT TO COMMUNICATE WITH PT. DENIES C/O CP.RESP: C/O "UNABLE TO CATCH MY BREATH". Pt contines with non productive congested sounding cough. hct 31.2. no chest pain.resp- on 2l n/c sat 94-98. l/s coarse, few scat wheezes in am, none this pm. See careview for full assessment data, VS, and transfer note.pt alert and oriented times three. FOLLOW HCT. ETIOLOGY HYPOVOLEMIA VS INFECTION VS OTHER ETIOLOGYP: MONITOR BP - CONSIDER TRANSFUSION INSTEAD OF FURTHER FLUID BOLUSES W/HCT < 30, CONTINUE TYLENOL #3 FOR PLEURITIC TYPE CHEST PAIN/COUGH,CONT SUPPORT PT AND FAMILY. GIVEN DELSYM COUGH SYRUP WITH SOME RELIEF FROM COUGH.GU: URINE OUTPUT POOR. UO ~40cc/hr after fluid. A few minutes after the morphine pt states she feels much better. Updated by RN/MD.A/P: pt s/p cath with stent x2, worsening renal function post cath, choking episode, with hemoptysis, hypotension, now with MRSA, pseudomonas in sputum. Pt denies CP/SOB. CARDIAC VS GI. CCU NURSING 0700-1900 S/P CATH/STENTS. bp improved. FOLLOW LYTES. C/O MIDSTERNAL CHEST DISCOMFORT ? BUN 43 (was 33), creat 3.3 (was 2.7).Neuro: Pt denies pain, family at bedside for translation.GI: Pt abd soft, +BS x 4 no stool this shift. DAUGHTER IN ALL NOC. no bm.skin- butocks reddened, no breakdown. prob. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATAID: TEMP TO 101R - BC X2, SPUTUM SENT, WBC'S TO 15 FROM 5, LEVO IV STARTED, TYLENOL GIVENCV: PT CONTINUED TO C/O CHEST PAIN AS ABOVE THIS AM, STATS MSO4 DID NOT HELP - AM CPK FLAT, RECEIVED TYLENOL #3 1 TAB THEN REPEATED X1 AFTER PT TOLERATED IT WELL AND SYMPTOMS IMPROVED, PT SLEEPING THROUGHOUT AFTERNOON, WHEN WAKENED, A+O, DENIES FURTHER PAIN; HR REMAINS AV PACED AT 60, BP REMAINS LOW AT 75-107/30'S-60, RECEIVING MULTIPLE BOLUSES NS AND D5NS AT 100/HR, RESPONDING TO BOLUSES BRIEFLT THEN DECREASING TO 70'S AGAIN, PT BASELINE HYPERTENSIVE, W/BP 70/ PT W/O COMPLAINTS AND MENTATING WELL, BP CHECKED BY AUSCULTATION AND NBP BILATERALLY - ALL CORRELATE; NEGATIVE PULSUS PER CARDS FELLOWHEME: NO FURTHER WRETCHING OR HEMOPTYSIS; SERIAL HCTS 31.2 - 30.1 - 29.0, NO OBVIOUS SOURCE OF BLEEDING, NO ABDOMINAL PAIN OR BACK PAINRESP: LUNGS COARSE W/EXP WHEEZES, FREQUENT CONGESTED COUGHING IN AM - RECEIVED TYLNOL #3/TENSILLON PEARL THIS AM - NOW W/O COUGH WHILE ASLEEP, O2 AT 4L NC, SATS 96-100%, RR 12-14, RECEIVING Q 6HR NEBS W/GOOD RESULTSGI: GI FOLLOWING, CONTINUING PPI/NPO, NO STOOLGU: FOLEY DRAINING CLEAR YELLOW URINE ~ 20CC/HR, + 1750CC THUS FAR TODAYSOCIAL: DAUGHTER, GRANDDAUGHTER IN THROUGHOUT DAY, VERY ATTENTIVE TO PT, ASKING NUMEROUS QUESTIONS, RN ALSO SPOKE W/GRANDSON FROM STATE, ALL UPDATED REGARDING CONDITION AND PLAN OF CAREA: T SPIKE/^ WBC, CONGESTED COUGH, HX FOR POTENTIAL ASP PNEUMONIA NO EVIDENCE OF BLEED - HCT DECREASING W/^ FLUID INTAKE REMAINS HYPOTENSIVE - ?

20

[ { "category": "ECG", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 300940, "text": "A-V sequentially paced rhythm with capture. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 300941, "text": "A-V sequentially paced rhythm. Compared to the previous tracing of no\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300942, "text": "Regular A-V sequential pacing\nSequence error: V2,V3 omitted\nPacemaker rhythm - no further analysis\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300943, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 300944, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 300945, "text": "A-V sequential paced rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 300946, "text": "Regular A-V sequential pacing\nPacemaker rhythm - no further analysis\nSince previous tracing of same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 300947, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 300948, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479174, "text": "ccu npn\no-id- t max 99.2. c+s sputum shows pseudomonas and staph aureus coag pos. . pnd for staph aureus.\ncv- hr 60, 100%av paced, bp rarely 70s in early am, then 80s-low 90s, up to 108/ this pm. re'd 1 fluid bolus 500cc n/s in am over 1hr. k-3.8, replaced with 40meq po x1. hct 31.2. no chest pain.\nresp- on 2l n/c sat 94-98. l/s coarse, few scat wheezes in am, none this pm. no sob. neb rxs prn, none given.\ngu- creat up to 3.3. u/o inmproved to 15-23cc/hr. urine lytes sent.\npo4 5.7, on tums.\ngi- abd soft w/bowel sounds. taking meds ok, liquids ok. c/o heartburn/pain when tried to eat solids, unable to eat, ho informed. also s/b gi. no bm.\nskin- butocks reddened, no breakdown. has ecchymosis on r side from fall at home prior to admit and on arms esp. left. extremities edematous except for r arm. assisted/encouraged to turn side to side with skin care q2-3hrs, does not stay far over on side hwever after repositioned. has pneumoboots on.\nms- dtr interprets (pt speaks ). a+o according to dtr. cooperative and pleasant.\naccess- i iv leaking, 1 clotted off, unable to flush. ivs restarted x2 r hand and r lower arm, #20s, patent.\nsocial/teaching- dtr in all day, updated on pt's condition and plan, understands. dtr pt's stent card and info brochure.\na- s/p cath w/rising creatinine. bp improved. difficulty eating. prob. pneumonia.\np- follow resp status, creat. try soft diet. gi following, may need ugi. follow hct in am, fluid boluses as needed if bp drops. send clot w/next bld draw. enc. pt to turn side to side, ?oob when bp staying up.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479175, "text": "CCU NPN 3-11PM\nCV: HR 60 AV paced, BP 96-117/48, given 2 500cc NS fluid boluses this eve based on urine lytes showing dehydration and low UO. UO ~40cc/hr after fluid. Pt denies CP/SOB. transfer to chair, able to take a few steps, transferred from chair to commode and then back to bed. No dizziness, BP stable.\n\nResp: sats 97% on 2L NC, LS with scattered rhonchi, congested cough, strong but not expectorating.\n\nID: sputum with pseudomonas as well as staph auereous coag (+), placed on MRSA contact precautions. BC x 2 drawn prior to giving 1 gm Vanco IV. Prev BS's pnd. T 99.2-98.6.\n\nSkin: intact, bruise on lower R side of back d/t fall at home prior to adm.\n\nGI: ate few bites of pureed food, ice cream, taking fluids and pills without problem. c/o feeling of something stuck in esophagus. ?swallowing eval. Attempted BM on commode without success.\n\nSoc: daughter, grandson in. Updated by RN/MD.\n\nA/P: pt s/p cath with stent x2, worsening renal function post cath, choking episode, with hemoptysis, hypotension, now with MRSA, pseudomonas in sputum. Starting 14 day course Vanco, cont on Ceftaz and Cipro. Fluid bolused over past 24hrs for dehydration, BP improving. Cont to monitor, support pt/family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479167, "text": "NURSING PROGRESS NOTE\nS: \"I HAVE PAIN IN MY CHEST\"\n\nO: 85 Y/O RUSSIAN SPEAKING WOMAN ADMITTED FROM 3 S/P STENT PLACEMENT. AFTER EATING SMALL AMT OF DINNER SHE ? ASPIRAATED A PIECE OF AND STARTED A COUGHING FIT. SHE THEN VOMITED ~ 50 CC BRB. BECAME TRANSIENTLY HYPOTENSIVE SBP 60 (RESOLVED WITHOUT TREATMENT). SHE ALSO C/O MIDSTERNAL CHEST PAIN. TRANFERED TO CCU FOR CLOSE MONITORING. HCT STABLE AT 35.8. NO FURTHER EPISODES OF VOMITING.\n\nNEURO: PLEASANT AND COOPERATIVE, SPEAKS LITTLE ENGLISH, MAINLY RUSSIAN SPEAKING. DAUGHTER IN TO INTERPRET. MOVING ALL EXTREMITIES WELL. S/P CVA ? YEAR. NO DEFICIT NOTED.\n\nCV: AV PACED RATE 60. NO VEA NOTED. MAP DOWN TO 48-52. GIVEN 250 CC FLUID BOLUS. EKG SHOWS NO CHANGES. RIGHT GROIN C&D. + PEDAL PULSES. C/O MIDSTERNAL CHEST DISCOMFORT ? CARDIAC VS GI. GIVEN MSO4 3 MG IVP TOTAL AND 1 SL NTG WITH GRADUAL RELIEF FROM PAIN. COUGHING, C/O CHEST PAIN WITH COUGH.\n\nRESP; COUGHING AND RAISING THICK WHITE SPUTUM. LUNGS WITH RALES IN UPPER AIRWAYS. O2 SAT 96% ON 4L NC. GIVEN ALB/ATR NEB WITH SOME RELIEF FORM SOB. APPEARS MORE COMFORTABLE SINCE TREATMENT.\n\nGI: ABD SOFT, + BOWEL SOUNDS NO BM OVERNIGHT. NO FURTHER VOMITING.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE. GIVEN LASIX 60 MG IVP WITH FAIR RESPONSE.\n\nA: S/P STENT TO LCX, POST PROCEEDURE CHEST DISCOMFORT WITH BLOODY EMESIS.\n\nP: FOLLOW HCT, LASIX IF NEEDED. OFFER EMOTIONAL SUPPORT TO PT. AND FAMILY. KEEP POSTED ON PLAN OF CARE AS DISCUSSED WITH MEDICAL TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479168, "text": "Respireaotry Care:\nPatient treated with 2.5 mg albuterol/0.5 mg ipratropium bromide via aerosol mask. BS: slight expiratory wheez RUL, which cleared with the RX.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479171, "text": "CCU NURSING PROGRESS NOTE 0700-1900\nS. DENIES CHEST PAIN, C/O INTERMITTENT ABDOMINAL CRAMPINESS, STATES FEELS LIKE SHE NEEDS TO MOVE BOWELS\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP 98.9 -99.6 PO, CONTINUES ON LEVO - WBC 13\n\nRESP: SPUTUM FROM YESTERDAY 3+ GM NEG RODS - LUNGS COARSE W/EXP WHEEZES, DENIES SOB, RECEIVING ALBUTEROL NEBS, SATS ON R/A 89% - 92%, SATS ON 2L NC 95-98%; CONTINUES TO HAVE INTERMITTENT CONGESTED COUGH, LOOSE, MOSTLY NON-PRODUCTIVE, RECEIVED DELSYM X1, TYLENOL #3 X1\n\nCV: HR 60 AV PACED, BP REMAINS 70-80'S/SYSTOLIC - HCT 27.7 RECEIVED 1 UNIT PRBC'S - BP TO 90'S THEN DRIFTED BACK TO 70'S, 2ND UNIT HUNG AND INFUSING SLOWLY OVER 4 HOURS\n\nGI: ABDOMEN SOFT, INTERMITTENT CRAMPING DIET NPO TO CLEARS, TOLERATING SIPS H2O THUS FAR, NO STOOL BUT OCCAS STATES SHE FEELS CONSTIPATED\n\nGU: FOLEY IN PLACE DRAINING CLEAR AMBER URINE IN SM AMTS DESPITE 2 U PRBC'S, BUN/CR RISING POST CATH AND WITH LOW BP\n\nNEURO/MS: A+O X3, SLEEPING IN NAPS THIS AFTERNOON, NO ISSUES W/ANXIETY THIS SHIFT\n\nSOCIAL: GRANDDAUGHTER IN MOST OF DAY, NOW DAUGHTER IN W/PT, FAMILY VERY INVOLVED IN CARE, UPDATED FREQUENTLY REGARDING PT CONDITION\n\nA: REMAINS HYPOTENSIVE - ? HYPOVOLEMIA VS SEPSIS VS OTHER\n PROBABLE PNEUMONIA\n\nP: MONITOR BP, HR ASSESS HCT RESPONSE TO PRBC'S X2, INCREASE DIET TO CLEARS AND ASSESS TOLERATION, CONT MEDS FOR COUGH, NEBS AS NEEDED Q 6HR, FOLLOW BUN/CR, EMOTIONAL SUPPORT FOR PT/FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479172, "text": "Respiratory Care:\nThe RN graciuosly said she will do NEBs today becauce of the high level of of RT activity elsewhere. Thanks\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1479173, "text": "CCU NPN 7p-7a\nS: \"Okay...Thank you.\"\n\nO: Please see careview for VS and additional data. Pt speaking, understands and speaks minimal English.\n\nCV: Pt HR 60 AV paced, NBP 71-87/32-38, MAPs 46-54, HO aware. 500 cc NS boluses given x 2 with no effect in BP. Pt received 2 units PRBCs during day shift, Hct this am 31.2, K 3.8. Pulses palpable.\n\nResp: Pt LS coarse with exp wheezes noted at bases and at times throughout, neb tx given. Pt denies SOB, RR 12-21 O2 sats 93-99. Pt contines with non productive congested sounding cough. Tylenol with codeine given x 1.\n\nGU: Pt with poor u/o 6-35 cc/hr anber urine, HO aware, no increase in u/o see with fluid boluses. BUN/creat cont to rise from yesterday. BUN 43 (was 33), creat 3.3 (was 2.7).\n\nNeuro: Pt denies pain, family at bedside for translation.\n\nGI: Pt abd soft, +BS x 4 no stool this shift. Pt taking clear liquids with encouragement.\n\nA/P: 85 y/o female continues with hypotension, received 500 NS fluid boluses x 2 with no effect in BP and u/o, increasing BUN/creat with poor u/o. Continue to monitor renal func and u/o, continue to monitor BP. Conitnue to monitor resp status and nebs tx. Continue to increase diet as tol. Continue to provide emotional support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1479176, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 60-62 AV paced BP 87-114/39-50 no fluid boluses over night\n\nResp: coarse BS with junky cough,nonproductive sats 96-99 on 2l NP.\n\nID: afebrile,cont on cipro and ceftaz,vanco x1 given last evening\n\nGU/Volume: uo 25-60/hr -265 since midnight,+4l LOS\n\nNeuro: alert and oriented,did not want to be wakened for am labs,wanted to keep sleeping.\n\nA/P: hemodynamically stable\n draw am labs\n to have PICC placed today for long course of abx\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1479177, "text": "See careview for full assessment data, VS, and transfer note.\npt alert and oriented times three. speaking but understands and speaks some english. Family in to see pt and translated things that she found difficult to explain. Family very supportive. LS rhoncii throughout continues on RA O2Sat 95-100%. Around 1:30 pt was eating lunch and complained of pain in chest accompanied by SOB. Telephoned daughter due to pt's request. Daughter said this is exactly what happend before. Pt told family that She feels that something is stuck and it is causing her pain and trouble breathing. Because of this and he inability to communicate her exact feelings she gets panicy. O2 sat continues to be 100% nebulizer treatment given for pt complaints of SOB. MD in to evaluate and said that she responded well to morphine the other day and that this is how she presented before here episode with hemoptosis. A few minutes after the morphine pt states she feels much better. WIll continue to monitor VS and for pain closely. No EKG changes and BP stable.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1479169, "text": "CCU NURSING 0700-1900 S/P CATH/STENT\nS. C/O CHEST PAIN ACROSS CHEST, ^ W/COUGH, DEEP BREATHING\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP TO 101R - BC X2, SPUTUM SENT, WBC'S TO 15 FROM 5, LEVO IV STARTED, TYLENOL GIVEN\n\nCV: PT CONTINUED TO C/O CHEST PAIN AS ABOVE THIS AM, STATS MSO4 DID NOT HELP - AM CPK FLAT, RECEIVED TYLENOL #3 1 TAB THEN REPEATED X1 AFTER PT TOLERATED IT WELL AND SYMPTOMS IMPROVED, PT SLEEPING THROUGHOUT AFTERNOON, WHEN WAKENED, A+O, DENIES FURTHER PAIN; HR REMAINS AV PACED AT 60, BP REMAINS LOW AT 75-107/30'S-60, RECEIVING MULTIPLE BOLUSES NS AND D5NS AT 100/HR, RESPONDING TO BOLUSES BRIEFLT THEN DECREASING TO 70'S AGAIN, PT BASELINE HYPERTENSIVE, W/BP 70/ PT W/O COMPLAINTS AND MENTATING WELL, BP CHECKED BY AUSCULTATION AND NBP BILATERALLY - ALL CORRELATE; NEGATIVE PULSUS PER CARDS FELLOW\n\nHEME: NO FURTHER WRETCHING OR HEMOPTYSIS; SERIAL HCTS 31.2 - 30.1 - 29.0, NO OBVIOUS SOURCE OF BLEEDING, NO ABDOMINAL PAIN OR BACK PAIN\n\nRESP: LUNGS COARSE W/EXP WHEEZES, FREQUENT CONGESTED COUGHING IN AM - RECEIVED TYLNOL #3/TENSILLON PEARL THIS AM - NOW W/O COUGH WHILE ASLEEP, O2 AT 4L NC, SATS 96-100%, RR 12-14, RECEIVING Q 6HR NEBS W/GOOD RESULTS\n\nGI: GI FOLLOWING, CONTINUING PPI/NPO, NO STOOL\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE ~ 20CC/HR, + 1750CC THUS FAR TODAY\n\nSOCIAL: DAUGHTER, GRANDDAUGHTER IN THROUGHOUT DAY, VERY ATTENTIVE TO PT, ASKING NUMEROUS QUESTIONS, RN ALSO SPOKE W/GRANDSON FROM STATE, ALL UPDATED REGARDING CONDITION AND PLAN OF CARE\n\nA: T SPIKE/^ WBC, CONGESTED COUGH, HX FOR POTENTIAL ASP PNEUMONIA\n NO EVIDENCE OF BLEED - HCT DECREASING W/^ FLUID INTAKE\n REMAINS HYPOTENSIVE - ? ETIOLOGY HYPOVOLEMIA VS INFECTION VS OTHER ETIOLOGY\n\nP: MONITOR BP - CONSIDER TRANSFUSION INSTEAD OF FURTHER FLUID BOLUSES W/HCT < 30, CONTINUE TYLENOL #3 FOR PLEURITIC TYPE CHEST PAIN/COUGH,\nCONT SUPPORT PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1479170, "text": "NURSING PROEGRESS NOTE 7P-7A\nNEURO: PT. ALERT AND ORIENTED X3. AT TIMES DIFICULT TO COMMUNICATE WITH PT. DUE TO COMMUNICATION BARRRIER. DAUGHTER IN ALL NOC. MOVING ALL EXTREMITIES. ANXIOUS AT TIMES.\n\nCV: BP 64-78, GIVEN FLUID BOLUS 250 CC WITH MODERATE EFFECT. AV PACING RATE 60, NO VEA NOTED. DENIES C/O CP.\n\nRESP: C/O \"UNABLE TO CATCH MY BREATH\". O2 SAT ON 4L NC 97%, EXP WHEEZES NOTED THROUGHOUT. GIVEN ALB/ATR NEBS X3. O2 SOURCE CHANGED TO COOL NEB 70% TO HELP LOOSE SECRETIONS. C/O INCREASED MUCOUS AT BACK OF THROAT. NT SUCTIONING DONE. SUCTIONED FOR SCANT AMT OF THICK WHITE SPUTUM. HAS LOOSE NON-PRODUCTIVE COUGH. GIVEN TESSALON PERLES\nAND TYLENOL#3 FOR C/O HEADACHE AND GENERLIZED BODY PAIN. GIVEN DELSYM COUGH SYRUP WITH SOME RELIEF FROM COUGH.\n\nGU: URINE OUTPUT POOR. 10-15 CC/HR. URINE AMBER COLORED. ? COULD BENEFIT FROM PRBC TO INCREASE RENAL PERFUSION. HCT 29.1\n\nGI: ABD SOFT HYPOACTIVE BOWEL SOUNDS, ATTEMPTED BM BUT NO RESULTS. C/O RIGHT LOWER ABD PAIN. WILL NEED MED FOR CONSTIPATION.\n\nID: AFEBRILE WBC 13.3 CONT ON LEVAQUIN PO.\n\nA: RESP DISTRESS, CONGESTED. S/P STENT PLACEMENT.\n\nP: MED FOR CONSTIPATION. COOL NEB FOR 02 TO HELP LOOSEN SECRETIONS. FOLLOW LYTES. MONITOR I/O. FOLLOW HCT. UPDATE FAMILY ON PLAN OF CARE.\n" } ]

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1. Respiratory. He has had no issues. 2. Cardiovascular. He has had no issues. 3. Fluid and electrolytes. Initial D stick on admission was 27. Infant started on intravenous fluid of D10W at 80 cc/kg/day. Followup blood sugar was 127. Remainder of blood sugars throughout hospital course have been greater than 60. Infant was initially begun on 24 calorie formula, and weaned off of IVF by early morning on . On , infant was transitioned from Enfamil 24 to Enfamil 20, and continued with adequate intake and stable blood sugars. Infant is currently ad lib feeding Enfamil 20 formula. Birth weight was 3040 grams; weight at discharge is 2975 gm. 4. Gastrointestinal. Bilirubin on day of life 3 was 10.3/0.4; repeat on day of life 4, day of discharge, was 10.2/0.4. 5. Hematology. Initial hematocrit was 66.6. He was followed closely for concerns about symptomatic polycythemia. Hct gradually decreased, to 65 by day of life #3 and 64 on day of life #4, the day of discharge. With normalized blood sugars, stable hematocrit, and no other evidence of symptoms of polycythemia, no other intervention was pursued. 6. Infectious disease. WBC and blood culture were obtained prior to discharge because of maternal GBS colonization and less than 4 hours of antepartum antibiotics. Repeat CBC was obtained on admission to the newborn intensive care unit, and the infant has otherwise been without issues or concerns for infectious disease. WBC was unremarkable on both occasions. 7. Neurologic. The infant had toxicology screen in light of jittery presentation to the newborn intensive care unit. Toxicology screen was negative. Symptoms resolved. 8. Sensory. Audiology - Hearing screen was performed with automated auditory brainstem responses, and the infant passed both ears.

Taking E24.Dsticks AC, wnl this shift.. Abd exam benign. Belly benign, voiding and stooling heme neg.D/S 86 (4th Dstik in a row >60), notified NNP, advised toreduce frequency in monitoring to once per shift. Infant's ivf weaned this shift and are nowheplocked. Dstiks stable off IVF on E20 ad lib feeding. abd benign, +BS, noloops or distention, vdg/stlg qs. NO contact from overnight.Continue to support as they prepare for infant'sd/c. NPN 7p-7aFen: Rec infant on ivf 80cc/kg of d10w and po'ing adlib e24with 3hr minimum. Abdomen benign of 24 cal.Lytes in good range. NPN#1 Infant received on q3h feeds of Enf 24, ad lib vol. Piv initiated as well as infant po fed enfe 24 cal. A: DS stable this shift.P: ? I have placed EIP & VNA options in record. Updated at bedside. Cont to support andupdate. Hct stable, mildly elevated.PLANS:- Now on 20 cals, continue, monitor dstiks.- Repeat bili, Hct in am.- Possible d/c tomorrow if stable.- Discharge planning. To postpartum floor for further care; will be on service (primary care to be at Peds). Temps stable in OAC. ad lib E20, taking 75-95ccovernight. Comfortable appearing.Wt 2870 down 125. Nursing Progress Note1. NeonatologyDoing well. Last dstik 85 (on 24 cals). Voiding/stooling.GI: Bili 10.2/0.4 (unchanged).HEME: Hct 63.4 today.DEV: In crib.RHCM: Received Hep B, passed hearing screen, PKU sent.IMP: Former 37 wk infant with hx hypoglycemia, polycythemia, doing well. Neonatology-NNP Progress NotePE: Remains in room air, bbs cl=, rrr s1s2no murmur, abd sfot, nontender, V&S, afos, activeSee attending note for plan Crit this am: 63.4.Continue to support needs.3. Bili thisam: 10.2/0.4 (down from 10.3).Continue to monitor DS and, feeding tolerance and intake.2. Maternal abx given <4hrs PTD. P- Cont to assess for FEN needs.#2-O/A- Infant cont to be awake and active with clustercares q3hrs. Nursing Progress Note#1-O/A- Infant feeding ad lib volume q3hrs. Current wt 2975gms (+25). See ccc for am lytes. Blood glucose done @ 3hrpostparandial 61. Ad lib feeding, 75-95 cc E20 q feed. Feeding ad lib, switched from E24 to E20 this morning. Examined by MD, to transfer to NBN. EDC -- 38+ wks. Previous jitteriness most likely related to hypoglycemia or matrenal meds.COntinue as at present. Neuro exam non focal and age appropriate.Hct down to 65.7 this am. Appropriate & symmetric tone & activity. Fed and changed infant.P- Cont to enc parental calls and visits.See flowsheet for further details. Off IVF since 4 am yesterday.HEME: Hct 66 this am (stable).GI: Bili 10.8/0.4.IMP: Term infant with hx hypoglycemia and mild polycythemia, doing well. Dadfeed infant. Bottling 30-45ccq3hrs. Dsticks thus far were 78-120. HR 130s, RR 30s. Will follow closely.Parents updated fully on baby's status and treatment.cbc and blood culture from yesterday reassuring - risk of sepsis appears to be low. Alert/active, waking for feedsq4hrs. Cont tosupport developmental milestones.Parenting: Mom and Dad into visit. Dstiks stable on 24 cals, now trying 20 cals. Med-lg spit x2. Will need referral faxed to above # at d'c. Taking ad lib demand. Temp stable inopen crib. Hemodynamically stable, no murmur.FEN: Wt 2950, up 75 grams. P- Cont toassess for G&D needs.#3-O/ Dad in to visit with updates given. IV fluids to be weaned gradually as tolerated.Polycythemia is mild - will recheck Hct tomorrow or if blood sugars fall to determine potential need for parital exchange transfusion.Maternal treatment with Prozac noted - high pitched cry/initially noted irritability may be related. Baby took 45cc and was allowedto go to q4h feeds, at 01:00 feed, glucose 74, infant took50cc E24, and took 50cc at 05:00 feed. AFOF, molding, minimal caput. Called x1 for update. Active bs. Ca Nl.BS have been in good range.Clincally stable. Feeds changed to E20 @ 0900. Hemodynamically stable.FEN: Wt 2975, up 25 grams. Well coordinated with pofeeds. Bili appropriate.PLANS:- D/C today.- F/U with PMD later this week, VNA this week.- Continue ad lib E20 feeding. Not on abx.Not jittery this am. Remains in RA. Repeated in one hour 79 glucometer, 74serum sent to lab. VSS, D/S 55, had small spit of formula (confirmed feed on L&D with transferring nurse admission). Dstik 86 overnight. Tryingto obtain urine specimen.Dev: Temp stable on weaning servo warmer. Voiding with eachdiaper change. No other risk factors for sepsis; afebrile, ROM <2 hrs PTD. Hips stable. NeonatologyDOL #3, CGA 39 wks.CVR: Remains in RA, no spells, no desats. Loving andinvolved. Neonatology TriageAsked to evaluate pt by Dr for sepsis risk.Mom is 31yo G1 P0-1 with unremarkable PNS except GBS positive. Report of sepsis eval for gbs positive Mom. Apgars 8&9; BBO2 only.Baby is 3040g AGA male, well-appearing. P: cont to support and inform. NeonatologyDOL #4, CGA 37 wks.CVR: Remains in RA, no spells, no desats. SVD. Hct still generous but stable to decreasing. Infant's 02 sats 98-100%.Urine bag for toxic screen with no void as of this writing. NPN 1900-07001. Likes pacifier. IV was placed and IV dextrose was initiated at 80 ml/kg/day.Blood sugar from the lab was 45.PE - Alert, slightly high pitched cry but easily consoled.VS - T 98.1 HR 121 RR 42 BP 67/35 47Skin - area of erythema noted on chinHEENT - AF soft and flat, palate intact, Eyes - RR normal bilaterallyResp - lungs clear and equal, breathing very comfortablyCVS - S1 S2 normal intensity, no murmurAbd - soft flat, no distension or organomegalyGU - normal male, foreskin slightly incomplete - urethral opening appears to be normally placed, testes palpable bilaterallyNeuro - jittery on admission - less so on follow-up exam, tone movement symmetricalLabs - FU blood sugar 45, Hct 67.5% plat 198,000Assessment/plan:Term male infant with hypoglycemia and mild polycythemia.Will continue with close monitoring of blood sugar and treat with IV fluids. All in agreement w/plan. Abd soft. Dr. examined infant. At21:00 feed, glucose level 85. GU with testes down bilaterally, somewhat short foreskin. Both parents in for much of day, doing most of care.Discharge teaching done.

16

[ { "category": "Nursing/other", "chartdate": "2176-08-02 00:00:00.000", "description": "Report", "row_id": 1869449, "text": "Neonatology Triage\nAsked to evaluate pt by Dr for sepsis risk.\n\nMom is 31yo G1 P0-1 with unremarkable PNS except GBS positive. EDC -- 38+ wks. No other risk factors for sepsis; afebrile, ROM <2 hrs PTD. Maternal abx given <4hrs PTD. SVD. Apgars 8&9; BBO2 only.\n\nBaby is 3040g AGA male, well-appearing. HR 130s, RR 30s. Pink with minimal acrocyanosis. AFOF, molding, minimal caput. Lungs CTA, no rtx. Heart rrr without murmur. Abd soft without HSM or masses. Hips stable. GU with testes down bilaterally, somewhat short foreskin. Spine straight without defects. Appropriate & symmetric tone & activity. Passed meconium while in .\n\nImp/ asymptomatic term infant at risk for sepsis due to maternal GBS colonization with antibiotics given <4hrs prior to delivery.\n\nPlan/ CBC/diff, Bcx sent. To postpartum floor for further care; will be on service (primary care to be at Peds). No antibiotics unless indicated by CBC or Bcx results.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-03 00:00:00.000", "description": "Report", "row_id": 1869450, "text": "Nrsg Admission Note-0700-1900\nBaby admitted at 1740 for glucose of 27 at 1700. Report of sepsis eval for gbs positive Mom. Infant jittery with glucose (central sent to the lab) at 1750. D stix with no result from glucometer. Piv initiated as well as infant po fed enfe 24 cal. Dr. examined infant. Face with rash areas on chin. Infant's 02 sats 98-100%.Urine bag for toxic screen with no void as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-03 00:00:00.000", "description": "Report", "row_id": 1869451, "text": "Neonatology Attending Admission Note\n\nBaby - ( ) is a 38 week gestation infant admitted to the for evaluation because of hypoglycemia.\n\nPediatrician - Dr. - Pediatrics\n\nMother is 31 old G1 P0-1.\nPregnancy was uncomplicated with the exception of maternal medication with Prozac 30mg/d for depression.\n\nPNS - O pos, HBSAg neg, RPR NR, RI, GBS positive.\n\nRupture of membranes was less than 24 hours prior to admission.\n\nBaby was at 9:40 AM on so is now 34 hours of life.\nThe baby was admitted briefly to the for a sepsis evaluation after birth because of maternal GBS colonization and treatment with antenatal antibiotics only 2 hours PTD.\ncbc - wbc 16,700 diff 48P 2B 30L 15nrbcs Hct 66.6% Plat 228,000\nBlood sugar was 55 at that time.\nBaby was doing well in the Newborn Nursery - bottle feeding -\n1 oz every 2 hours. Baby was noted to be jittery at 5PM and was transferred to the after a heelstick Dstix was 27.\n\nOn admission to the baby was noted to be very jittery and a venous blood sugar was sent to the lab. IV was placed and IV dextrose was initiated at 80 ml/kg/day.\n\nBlood sugar from the lab was 45.\n\nPE - Alert, slightly high pitched cry but easily consoled.\nVS - T 98.1 HR 121 RR 42 BP 67/35 47\nSkin - area of erythema noted on chin\nHEENT - AF soft and flat, palate intact, Eyes - RR normal bilaterally\nResp - lungs clear and equal, breathing very comfortably\nCVS - S1 S2 normal intensity, no murmur\nAbd - soft flat, no distension or organomegaly\nGU - normal male, foreskin slightly incomplete - urethral opening appears to be normally placed, testes palpable bilaterally\nNeuro - jittery on admission - less so on follow-up exam, tone movement symmetrical\n\nLabs - FU blood sugar 45, Hct 67.5% plat 198,000\n\nAssessment/plan:\nTerm male infant with hypoglycemia and mild polycythemia.\nWill continue with close monitoring of blood sugar and treat with IV fluids. IV fluids to be weaned gradually as tolerated.\n\nPolycythemia is mild - will recheck Hct tomorrow or if blood sugars fall to determine potential need for parital exchange transfusion.\n\nMaternal treatment with Prozac noted - high pitched cry/initially noted irritability may be related. Will follow closely.\n\nParents updated fully on baby's status and treatment.\n\ncbc and blood culture from yesterday reassuring - risk of sepsis appears to be low.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869452, "text": "NPN 7p-7a\n\n\nFen: Rec infant on ivf 80cc/kg of d10w and po'ing adlib e24\nwith 3hr minimum. Infant's ivf weaned this shift and are now\nheplocked. Dsticks thus far were 78-120. Bottling 30-45cc\nq3hrs. Abd soft. Active bs. Yellow stool. Voiding with each\ndiaper change. Med-lg spit x2. See ccc for am lytes. Trying\nto obtain urine specimen.\n\nDev: Temp stable on weaning servo warmer. Infant is alert\nremains jittery with activity. Well coordinated with po\nfeeds. Likes pacifier. Sleeps well between cares. Cont to\nsupport developmental milestones.\n\nParenting: Mom and Dad into visit. Updated at bedside. Dad\nfeed infant. Called x1 for update. Cont to support and\nupdate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869453, "text": "1 Fen:\n2 Dev:\n3 Parents:\n\nREVISIONS TO PATHWAY:\n\n 1 Fen:; added\n Start date: \n 2 Dev:; added\n Start date: \n 3 Parents:; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869454, "text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 2870 down 125. Taking ad lib demand. Abdomen benign of 24 cal.\nLytes in good range. Ca Nl.\n\nBS have been in good range.\n\nClincally stable. Not on abx.\n\nNot jittery this am. Neuro exam non focal and age appropriate.\nHct down to 65.7 this am. Given asx nature will not require rx. Previous jitteriness most likely related to hypoglycemia or matrenal meds.\n\nCOntinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869461, "text": "NPN 1900-0700\n\n\n1. Current wt 2975gms (+25). ad lib E20, taking 75-95cc\novernight. Belly benign, voiding and stooling heme neg.\nD/S 86 (4th Dstik in a row >60), notified NNP, advised to\nreduce frequency in monitoring to once per shift. Bili this\nam: 10.2/0.4 (down from 10.3).\nContinue to monitor DS and, feeding tolerance and intake.\n\n2. Temps stable in OAC. Alert/active, waking for feeds\nq4hrs. AFSF. Crit this am: 63.4.\nContinue to support needs.\n\n3. NO contact from overnight.\nContinue to support as they prepare for infant's\nd/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869462, "text": "Neonatology\nDOL #4, CGA 37 wks.\n\nCVR: Remains in RA, no spells, no desats. Hemodynamically stable.\n\nFEN: Wt 2975, up 25 grams. Ad lib feeding, 75-95 cc E20 q feed. Dstik 86 overnight. Voiding/stooling.\n\nGI: Bili 10.2/0.4 (unchanged).\n\nHEME: Hct 63.4 today.\n\nDEV: In crib.\n\nRHCM: Received Hep B, passed hearing screen, PKU sent.\n\nIMP: Former 37 wk infant with hx hypoglycemia, polycythemia, doing well. Dstiks stable off IVF on E20 ad lib feeding. Hct still generous but stable to decreasing. Bili appropriate.\n\nPLANS:\n- D/C today.\n- F/U with PMD later this week, VNA this week.\n- Continue ad lib E20 feeding.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 1869463, "text": "Case Management Note\nReferral to Care Group VNA (/fax ) and have set up home visit for Wednesday . Will need referral faxed to above # at d'c. All in agreement w/plan.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-02 00:00:00.000", "description": "Report", "row_id": 1869448, "text": " Nursing Admission/Transfer Note:\n Admitted baby boy to warmer from L&D for sepsis evaluation (see MD note). Infant is pink, LS = and clear, no murmur heard. CBC w/diff and blood culture sent and is pending. VSS, D/S 55, had small spit of formula (confirmed feed on L&D with transferring nurse admission). Infant resting comfortably at present. Examined by MD, to transfer to NBN.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869455, "text": "Nursing Progress Note\n\n\n#1-O/A- Infant feeding ad lib volume q3hrs. Taking E24.\nDsticks AC, wnl this shift.. Abd exam benign. Voiding and\nstooling. P- Cont to assess for FEN needs.\n#2-O/A- Infant cont to be awake and active with cluster\ncares q3hrs. Sleeps well between cares. Temp stable in\nopen crib. Little to no jitteriness noted. P- Cont to\nassess for G&D needs.\n#3-O/ Dad in to visit with updates given. Loving and\ninvolved. Appropriate questions. Fed and changed infant.\nP- Cont to enc parental calls and visits.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-04 00:00:00.000", "description": "Report", "row_id": 1869456, "text": "Neonatology-NNP Progress Note\n\nPE: Remains in room air, bbs cl=, rrr s1s2no murmur, abd sfot, nontender, V&S, afos, active\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869457, "text": "NPN\n\n\n#1 Infant received on q3h feeds of Enf 24, ad lib vol. At\n21:00 feed, glucose level 85. Baby took 45cc and was allowed\nto go to q4h feeds, at 01:00 feed, glucose 74, infant took\n50cc E24, and took 50cc at 05:00 feed. abd benign, +BS, no\nloops or distention, vdg/stlg qs. A: DS stable this shift.\nP: ? decrease cals today.\n#2 stable in open crib, waking for feeds, calm with cares,\nsleeps well between, sucks some on pacifier. A: AGA P: cont\nto support development\n#3 mom and dad here for 21:00 and 05:00 feeds, dad handles\nbaby quite independently, mom sl less confident. asking many\nquestions about possible discharge, sugar levels etc. A:\nloving, involved family. P: cont to support and inform.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869458, "text": "Case Management Note\nChart has been reviewed and events noted. I have placed EIP & VNA options in record. I will be providing clinial updates to HMO Blue insurance and will cont to follow for any d'c planning needs along with family & team.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869459, "text": "Neonatology\nDOL #3, CGA 39 wks.\n\nCVR: Remains in RA, no spells, no desats. Hemodynamically stable, no murmur.\n\nFEN: Wt 2950, up 75 grams. Feeding ad lib, switched from E24 to E20 this morning. Taking 50-55 cc/feed. Last dstik 85 (on 24 cals). Off IVF since 4 am yesterday.\n\nHEME: Hct 66 this am (stable).\n\nGI: Bili 10.8/0.4.\n\nIMP: Term infant with hx hypoglycemia and mild polycythemia, doing well. Dstiks stable on 24 cals, now trying 20 cals. Hct stable, mildly elevated.\n\nPLANS:\n- Now on 20 cals, continue, monitor dstiks.\n- Repeat bili, Hct in am.\n- Possible d/c tomorrow if stable.\n- Discharge planning.\n" }, { "category": "Nursing/other", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 1869460, "text": "Nursing Progress Note\n\n\n1. Feeds changed to E20 @ 0900. Blood glucose done @ 3hr\npostparandial 61. Repeated in one hour 79 glucometer, 74\nserum sent to lab. Eating well q4 hr ad lib amounts taking\n50-105cc.\n\n2. Holding temp well in open crib. Awake and alert for\nfeeds, feeding well.\n\n3. Both parents in for much of day, doing most of care.\nDischarge teaching done. Circumcision being arranged.\nPediatrician appointment to be made by parents.\n\n\n" } ]

72,483

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Patient was admitted to the in the context of evolving dyspnea secondary to terminal cancer. The family immediately decided to make the patient's treatment priority comfort measures. The decision was accepted by the medical staff. The patient was made comfortable with Morphine and outpatient home hospice was arranged. It was the wish of the family to have the patient transferred home as soon as possible. The patient's discharge was accelerated once his comfort on Morphine was assured.

HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Hypotension/Acute Renal failure: Both have resolved. Support to family Renal failure, acute (Acute renal failure, ARF) Assessment: Creat 1.1, Action: Lasix 10 mg IV Response: >2L out but remains hypoxic Plan: Gaols of care comfort and gettinh Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Assessment and Plan HYPOTENSION (NOT SHOCK) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ANXIETY HYPOXEMIA ANEMIA THROMBOCYTOPENIA Patient's dyspnea is likely multifactorial with anemia, hypoxemia, acidemia, restrictive lung disease from pleural mets and probably lymphangitic tumor. 24 hr nursing Cont fentanyl patch.. Assess resp status/distress. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Respiratory failure, acute (not ARDS/) Assessment: Pt tachypneic in 30s, on 100% NRB, desats to 78-79% with turns/effort, anxious Action: Remains on NRB. - Tx plt if <20 - hct/plt - consider heme c/s if still low and concern for TTP 4. - Tx plt if <20 - hct/plt - consider heme c/s if still low and concern for TTP 4. - hepatitis serologies - repeat LFTs - Likely do CT torso ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 10:17 PM 20 Gauge - 10:17 PM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU Brought in with hypoxemia with altered mental status in the recent past and low-grade hemoptysis. Brought in with hypoxemia with altered mental status in the recent past and low-grade hemoptysis. Hold clonazapam & morphine for increased somnolence, MS changes, R <10 Renal failure, acute (Acute renal failure, ARF) Assessment: Creat 1.1, Action: Response: Plan: Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. Hypotensive, hyperkalemic in the ED: transfused, given IV abx for possible infection, IV insulin, D50 and Ca gluconate. HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. DNR/DNI 64M NSCLC (/) c/b metastasis and ? Hx lung ca S/P RUL resection with recurrence 7 restaged to IIIb. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. Hypotension/Acute Renal failure: Both have resolved. s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . s/p RUL resection at in and subsequent MRSA infxn, wedge resection of LL in , had been undergoing chemotx, last recd gemcytobine on . There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , the rightventricular cavity is more dilated with more prominent free hypokinesis.The estimated pulmonary artery systolic pressure is slightly higher.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal aortic diameter at the sinus level. RUQ us unremarkable per prelim read making concern for malignancy less likely. Mild to moderate [+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. HypoxiaHeight: (in) 73Weight (lb): 260BSA (m2): 2.41 m2BP (mm Hg): 117/74HR (bpm): 90Status: InpatientDate/Time: at 10:10Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Hypodensities in the periventricular and subcortical white matter reflect chronic microvascular ischemic change, not significantly changed from . Noresting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. Left-sided pleural disease is again noted with a dominant area of pleural thickening in the left upper hemithorax relatively unchanged from the previous examinations. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. FINAL REPORT CHEST RADIOGRAPH INDICATION: Worsening hypoxia. Hypoxia/Malignancy: Continues. The right atrial pressure is indeterminate.There is mild symmetric left ventricular hypertrophy with normal cavity sizeand global systolic function (LVEF>55%). Areas of fibrosis are again noted within the right lower lung laterally with unchanged area of pleural thickening in the right upper hemithorax. Pt now with Increased work of breathing and on SL morphine as pt has no IV access. Pt now with Increased work of breathing and on SL morphine as pt has no IV access. Pt has had worse hypoxia overnight.

49

[ { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429253, "text": "HX NSCLA P/W SOB, hypotension. Pt reports SOB 7-10 days PTA, worse\n 2days PTA.\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429256, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die.\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n Plan:\n Clonapin 0.5mg started\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. Repeat\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429239, "text": "Chief Complaint: Respiratory distress, hypoxemia, acute renal failure,\n hypotension, acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n In MICU, dyspnea has persisted. Patient has required NRB mask to\n maintain O2 sats in 90's. Afebrile overnight. On antibiotics for\n possible pulmonary infection. Transfused 2 units of PRBC's and given\n fluids with improved blood pressure.\n Received Haldol for anxiety with some improvement.\n Creatinine improving.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:00 AM\n Levofloxacin - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.1\nC (97\n HR: 92 (87 - 101) bpm\n BP: 117/74(84) {91/33(45) - 181/164(168)} mmHg\n RR: 27 (21 - 36) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 3,000 mL\n 1,123 mL\n PO:\n 250 mL\n TF:\n IVF:\n 518 mL\n Blood products:\n 300 mL\n 355 mL\n Total out:\n 100 mL\n 1,600 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,900 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Moderate\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ,\n No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds: No(t) Clear\n : , Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished:\n , No(t) Absent : , No(t) Rhonchorous: ), Scattered rales anterior and\n posterior\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: 2+ edema, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 20 K/uL\n 122 mg/dL\n 3.1 mg/dL\n 17 mEq/L\n 4.7 mEq/L\n 93 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n 12:44 AM\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:464 mg/dL,\n Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:5.1 mg/dL\n Imaging: CXR: pleural mets. Increased interstitial markings at the\n bases.\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n HYPOXEMIA\n ANEMIA\n THROMBOCYTOPENIA\n Patient's dyspnea is likely multifactorial with anemia, hypoxemia,\n acidemia, restrictive lung disease from pleural mets and probably\n lymphangitic tumor. Renal function is improving - renal failure likely\n due to intravascular volume depletion. Treating possible pneumonia with\n antibiotics. Patient to have LENI's to assess for DVT - possible PE.\n Patient being transfused for his anemia (likely due to chemo; possible\n contribution from low level GI bleed). Will begin opiates for dyspnea\n with morphine; consider fentanyl patch.\n Platelet count down with chemo. No CNS bleed. Monitoring counts.\n LFT's elevated. Will assess with RUQ ultrasound. Hepatitis serology\n pending.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2196-01-13 00:00:00.000", "description": "ICU Event Note", "row_id": 429295, "text": "Clinician: Attending\n Patient remains tachypneic and dyspneic with O2 sat in mid-90's on 100%\n NRB mask. Patient has been transfused 2 units of PRBCs without change\n in hct. No blood per rectum and no melena.\n Long discussion with patient and his wife about his prognosis and his\n desires. Patient has indicated that he does not want to be intubated\n and does not want CPR. Team notified.\n He is also expressing that he does not want further chemo after he gets\n past the acute events of this hospitalization. Mrs. is having\n difficulty accepting his expressed wishes at this time. Staff offering\n support.\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429552, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\nd lasix\n 10mg IV x1 on previous shift and voided ~2L. Arousing to stimulation\n but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Family has been at pt\ns bedside t/o the night.\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429205, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429207, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429208, "text": "Hypotension (not Shock)\n Assessment:\n Sbp stable 96-130/\n Action:\n Transfused with total 2 units prbc\ns and hydrated with ns.\n Response:\n Stable. No decline in bp below 96/\n Plan:\n Monitor bp and vs . check hct post transfusion this am\n Anxiety\n Assessment:\n Anxious, expressing fear .no sleep\n Action:\n Haldol .5 mg iv times three with little effect. Pt requested wife to\n come back. Pt did call wife and she will be in early this am she is\n enroute\n Response:\n Hadol dose ineffective in redusing anxiety\n Plan:\n Discuss anxiety with doctors. Perhaps and increased dose or alternative\n medication for anxiety\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp rate 26-30\ns. Desats to 80\ns with any activity. It takes ~ 5 -10\n minutes for pt to recover from the drop in sats. HE needs a lot of\n encouragement to avoid panic.\n Action:\n NRB\n tried 100 % cool aerosol. Pt desaturated.to 88 %\n Response:\n Sats ~ 93 -95 % on NRB at rest\n Plan:\n Encourage pt to limit his activity.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinin3 4.3 in ed . improved to 3.1 k =4.7\n .\n Action:\n Check K with am hct and treat if elevated with kexelate 15 gm as\n ordered.\n Response:\n Plan:\n Check K.\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429460, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03.\n Pt DNR/DNI\n Events: CPAP trial. Sats 70\ns on 100%NRB & 6L NP. Unable to obtain IV\n access or bedside PICC.\n Family meeting with focus on getting pt home with hospice if possible\n and possibly 24 hr nursing.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 45 minutes first trail, 3.5 hrs second trial. Lasix 10\n mg IV x1\n Response:\n Sats up to mid 90\ns with second CPAP trail but now 70\ns on 100% NRB &\n 6L NP. >2L out with lasix but remains hypoxic\n Plan:\n Goals of care are to keep comfortable. CPAP for comfort\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapem\n Plan:\n * palliative care consult re: Transferring pt to home with palliative\n care consult & ? 24 hr nursing\n Cont fentanyl patch.. Assess resp status/distress. SL morphine sulfate\n as pt does not IV access.\n Support to family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Lasix 10 mg IV\n Response:\n >2L out but remains hypoxic\n Plan:\n Gaols of care comfort and gettinh\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429463, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03.\n Pt DNR/DNI\n Events: CPAP trial. Sats 70\ns on 100%NRB & 6L NP. Unable to obtain IV\n access or bedside PICC.\n Family meeting with focus on getting pt home with hospice if possible\n and possibly 24 hr nursing.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 45 minutes first trail, 3.5 hrs second trial. Lasix 10\n mg IV x1\n Response:\n Sats up to mid 90\ns with second CPAP trail but now 70\ns on 100% NRB &\n 6L NP. >2L out with lasix but remains hypoxic\n Plan:\n Goals of care are to keep comfortable. CPAP for comfort\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapam\n Plan:\n * palliative care consult re: Transferring pt to home with palliative\n care & ? 24 hr nursing\n Cont fentanyl patch. Assess resp status/distress. SL morphine sulfate\n as pt does not IV access.\n Support to family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Lasix 10 mg IV\n Response:\n >2L out but remains hypoxic\n Plan:\n Goals of care are comfort and getting pt home\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429356, "text": "DNR/DNI\n Pt intermittently very anxious but slept fot 1-2hr periods off and on\n after 2300.\n ST w/HR 102 to 110\ns t/o shift, blood pressures stable.\n Continues to void in urinal w/ >400cc per void\n Lost IV access in R hand, PIV in L a/c patent.\n AM labs pending, pt difficult to draw\nwas able to obtain labs from vein\n near L index finger\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt tachypneic in 30\ns, on 100% NRB, desats to 78-79% with turns/effort,\n anxious\n Action:\n Remains on NRB. Morphine 3mg IV x2, klonopin as ordered, encouraged\n slow, deep breathing\n Response:\n Good response to morphine/klonopin admin: Pt had some calm periods of\n rest/sleep as noted above with sats in low 90\ns however, desats to\n 82-85% when voiding. Also continues to experience periods of\n spontaneous tachypnea with desat to 88-89%.\n Plan:\n IV abx as ordered, morphine IV prn. Suggest foley placement if pt will\n allow. Pastoral and or SW consult appropriate\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429353, "text": "DNR/DNI\n Pt intermittently very anxious but slept fot 1-2hrs off and on after\n 2300.\n ST w/HR 102 to 110\ns t/o shift, blood pressures stable.\n Continues to void in urinal w/ >400cc per void\n Lost IV access in R hand, PIV in L a/c patent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt tachypneic in 30\ns, on 100% NRB, desats to 78-79% with turns/effort,\n anxious\n Action:\n Remains on NRB. Morphine 3mg IV x2, klonopin as ordered, encouraged\n slow, deep breathing\n Response:\n Good response to morphine/klonopin admin: Pt had some calm periods of\n rest/sleep as noted above with sats in low 90\ns however, desats to\n 82-85% when voiding. Also continues to experience periods of\n spontaneous tachypnea with desat to 88-89%.\n Plan:\n IV abx as ordered, morphine IV prn\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429289, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K 6.3, crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity and immediately when mask off.. Afeb. On\n vanco, levoflox, ceftriaxone.\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats.. F/U results of studies. Follow temp, WBC. Cont\n antibiotics. Contact precautions for HX MRSA. Ruling out flu\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphine 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water & C/L\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance. Adjust antibiotics to renal function.\n After discussion with pt Dr. , pt & pt\ns wife a decision\n was made to make pt DNR.\n Crit 22.7 after unit PRBC\ns (two total). Plts unchanged at 21K. No\n evidence of active bleeding. Crit from 1800 pnd.\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429178, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n Mr. is a 64 yo M with metastatic lung cancer who presents with\n acute worsening of his dyspnea over the last 2 days. They note that\n while in the last 7 days he has had persistent mental status changes\n thought secondary to an increase in oxycontin. As well over the last\n few days he has had poor PO intake and nausea. He has been more\n hypoxic and has had episodes of shortness of breath. And the home 02\n monitor showed 02 sats in the 70-80s despite being on his home 02 of\n liters.\n .\n In the ED, the patient was initially found to be hypotensive with\n Initial vitals were 82/46, HR 80 02 sat 95% NRB. He was given a total\n of 2L NS and 1 U PRBCs. Additionally, Zosyn and vancomycin were given\n and IV insulin, D 50 and calcium gluconate for a k of 6.1. He was\n guaiac positive.\n .\n Upon arrival to the floor, the patient was found to be tachypnec and\n anxious with periodic hypoxia but without significant pain. He denied\n any recent nausea, vomiting, fever, chills, chest pain (other than rib\n pain). He did have some episodes of dizziness when he had low oxygen\n saturations. He had no syncope or presyncope. A CT scan of the head\n was performed and negative. CTA was deferred given renal failure.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n orthopnea, PND, urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS per last note:\n AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg\n Tablet - 1 Tablet(s) by mouth daily\n CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 0.5 mg\n Tablet - 1 Tablet(s) by mouth twice a day\n DEXAMETHASONE - 4 mg Tablet - 2 tabs Tablet(s) by mouth \n beginning 24 hrs prior to chemo Take for 3 days//6 doses\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider)\n - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth\n once daily\n FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth Twice daily\n LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain\n METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1\n Tablet(s) by mouth twice a day\n OXYCODONE [OXYCONTIN] - 10 mg Tablet Sustained Release 12 hr - 1\n Tablet(s) by mouth twice a day\n OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - \n Tablet(s) by mouth q4-6h prn pain\n OXYCONTIN - - 20 mg po twice a day\n OXYGEN - - Concentrator and LOX portable for ambulation; 2-3L\n via nasal cannula; Dx: COPD; O2 sat 96% on 2L\n PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1\n Tablet(s) by mouth q8 h as needed for nausea Take on the night\n after chemo and then for 2-3 days as needed\n SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg\n Tablet - 1 Tablet(s) by mouth daily\n TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,\n w/Inhalation Device - One capsule inhaled daily Use with\n HandiHaler device\n Medications - OTC\n ASPIRIN [ECOTRIN] - (Prescribed by Other Provider) - 325 mg\n Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily\n DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain\n IBUPROFEN - (OTC) - 800 mg Tablet - 1 Tablet(s) by mouth three\n times a day\n MISC NATURAL PRODUCT NASAL [PONARIS] - (OTC) - Dosage uncertain\n SENNA - (OTC) - Dosage uncertain\n Past medical history:\n Family history:\n Social History:\n COPD\n Metastatic squamous lung cancer: initially dx as stage Ia, s/r RUL\n resection at in who had recurence in and was restaged to\n IIIb. He had wedge resection and is now undergoing chemotherapy with\n intially cisplatin/taxol starting in , now getting gemcytabine\n s/p last dose on \n CEA\n Nc\n Occupation: retired\n Drugs:\n Tobacco: 40 pack year hx\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, no melena\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 05:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 92 (87 - 101) bpm\n BP: 121/71(80) {108/33(45) - 139/74(86)} mmHg\n RR: 26 (21 - 36) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,600 mL\n -400 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 20 K/uL\n 7.9 g/dL\n 122 mg/dL\n 3.1 mg/dL\n 93 mg/dL\n 17 mEq/L\n 108 mEq/L\n 4.7 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n \n 2:33 A12/10/ 12:44 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, Fibrinogen:464 mg/dL, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:5.1 mg/dL\n Imaging: CT chest on : CONCLUSION:\n 1. No pulmonary embolism. Extensive coronary atherosclerosis is\n present.\n 2. Interval disease progression with increased mediastinal\n lymphadenopathy and pleural deposits with involvement of the left chest\n as well as the left fifth rib in the mid axillary line.\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The\n appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy\n reflective of\n patient's underlying metastatic disease.\n ECG: NSR at 81 with new TWI in III, V2. OTW no sig change.\n Assessment and Plan\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429183, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n Mr. is a 64 yo M with metastatic lung cancer who presents with\n acute worsening of his dyspnea over the last 2 days. They note that\n while in the last 7 days he has had persistent mental status changes\n thought secondary to an increase in oxycontin. As well over the last\n few days he has had poor PO intake and nausea. He has been more\n hypoxic and has had episodes of shortness of breath. And the home 02\n monitor showed 02 sats in the 70-80s despite being on his home 02 of\n liters.\n .\n In the ED, the patient was initially found to be hypotensive with\n Initial vitals were 82/46, HR 80 02 sat 95% NRB. He was given a total\n of 2L NS and 1 U PRBCs. Additionally, Zosyn and vancomycin were given\n and IV insulin, D 50 and calcium gluconate for a k of 6.1. He was\n guaiac positive.\n .\n Upon arrival to the floor, the patient was found to be tachypnec and\n anxious with periodic hypoxia but without significant pain. He denied\n any recent nausea, vomiting, fever, chills, chest pain (other than rib\n pain). He did have some episodes of dizziness when he had low oxygen\n saturations. He had no syncope or presyncope. A CT scan of the head\n was performed and negative. CTA was deferred given renal failure.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n orthopnea, PND, urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS per last note:\n AMLODIPINE 10 mg daily\n CLONAZEPAM [KLONOPIN] -0.5 mg twice a day\n ESOMEPRAZOLE MAGNESIUM\n - 20 mg Capsule, daily\n FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth Twice daily\n LISINOPRIL\n METOPROLOL SUCCINATE - 25 mg \n OXYCODONE [OXYCONTIN] -20 mg Tablet Sustained Release 12 hr - 1\n Tablet(s) by mouth twice a day\n Percocet prn\n PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet prn\n SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg\n Tablet - 1 Tablet(s) by mouth daily\n TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,\n w/Inhalation DeviceQD\n ASPIRIN 325 mg\n IBUPROFEN 800 mg TID\n SENNA\n Past medical history:\n Family history:\n Social History:\n COPD\n Metastatic squamous lung cancer: initially dx as stage Ia, s/r RUL\n resection at in who had recurence in and was restaged to\n IIIb. He had wedge resection and is now undergoing chemotherapy with\n intially cisplatin/taxol starting in , now getting gemcytabine\n s/p last dose on \n CEA\n Nc\n Occupation: retired\n Drugs:\n Tobacco: 40 pack year hx\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, no melena\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 05:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 92 (87 - 101) bpm\n BP: 121/71(80) {108/33(45) - 139/74(86)} mmHg\n RR: 26 (21 - 36) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Pulsus: 6-8 mmHg\n Total In:\n 2,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,600 mL\n -400 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 20 K/uL\n 7.9 g/dL\n 122 mg/dL\n 3.1 mg/dL\n 93 mg/dL\n 17 mEq/L\n 108 mEq/L\n 4.7 mEq/L\n 142 mEq/L\n 22.7 %\n 4.3 K/uL\n [image002.jpg]\n \n 2:33 A12/10/ 12:44 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.3\n Hct\n 22.7\n Plt\n 20\n Cr\n 3.1\n Glucose\n 122\n Other labs: Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %,\n Mono:3.0 %, Eos:0.1 %, Fibrinogen:464 mg/dL, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:5.1 mg/dL\n Imaging: CT chest on : CONCLUSION:\n 1. No pulmonary embolism. Extensive coronary atherosclerosis is\n present.\n 2. Interval disease progression with increased mediastinal\n lymphadenopathy and pleural deposits with involvement of the left chest\n as well as the left fifth rib in the mid axillary line.\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The\n appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy\n reflective of\n patient's underlying metastatic disease.\n ECG: NSR at 81 with new TWI in III, V2. OTW no sig change.\n Assessment and Plan\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:17 PM\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429277, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats. NPO except C/L given tenuous resp status. F/U results\n of studies\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphne 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance\n P\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429412, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Continues. Pt on face mask oxygen this AM and satting\n low 90\ns while sleeping. Increased work of breathing despite\n morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 2. Hypotension/Acute Renal failure: Both have resolved. Likely due\n to decreased Po intake and intravascular volume.\n - redose meds now that renal failure improved\n - continue to monitor BP\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving, but still elevated. Possibly due to\n hypotension on presentation. RUQ us unremarkable per prelim read\n making concern for malignancy less likely.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429278, "text": "HX NSCLA S/p resection, lobectomy, MRSA, P/W SOB, hypotension. Pt\n reports SOB 7-10 days PTA, worse 2days PTA. Had been taking motrin,\n percocett at home for L rib pain. In EW. K , crit 23. CXR LL\n opacity OB positive for rectal exam Afeb. Given 2L IVF, vanco, zosyn,\n insulin D50. Trans to ICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 100% NRB. RR 20\ns. BS clear, diminished at bases.\n Desaturates with activity\n Action:\n TTE, LENI\ns, abd U/S done\n Response:\n Very limited activity tolerance, reserve\n Plan:\n Follow RR, sats. NPO except C/L given tenuous resp status. F/U results\n of studies\n Anxiety\n Assessment:\n Awake, most of the shift. Per pt\ns family, pt has stated he is afraid\n to close his eyes because he is afraid he is going to die. Oriented, FC\n Action:\n Morphine sulfate 2mg IV x1\n Response:\n Family reports he slept for minute intervals a couple of X\n after receiving morphine sulfate\n Plan:\n Clonapin 0.5mg started. Will start fentanyl patch 25 mcg when\n available. Morphne 3mg now & 2-3mg PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Voided several X\ns. C/O thirst.\n Action:\n Drinking water\n Response:\n Repeat labs reflecting improved renal status\n Plan:\n Follow BUN, creat, Fld balance\n P\n" }, { "category": "Physician ", "chartdate": "2196-01-13 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 429161, "text": "TITLE: MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n admission note by Dr. , including the assessment and plan. I\n would emphasize and add the following points: 64M NSCLC\n (/) c/b metastasis and ? lymphangitic tumor\n treated with recent gemcytobine. Brought in with hypoxemia with altered\n mental status in the recent past and low-grade hemoptysis. Hypotensive\n in the ED, transfused, eventually had NRB placed to allow improved\n oxygenation.\n Exam notable for Tm 98.1 BP 118/74 HR 70 RR 16 with sat 95 on 2L. Labs\n notable for WBC 4K, HCT 23, K+ 6.1, Cr 4.3. CXR c BLL ASD (decreased\n since ) and apical bullae. CT c apical bulla on R, pleural mass on\n L, diffuse micronodual pattern with bronchovascular thickening.\n 64M NSCLC p/w respiratory distress. Agree with plan to treat possible\n pneumonia with vanco / levo / ctx; will check sputum, legionella Ag,\n and influenza swab. Will d/c levo if legionella negative. Will aslo\n check beta-glucan and galactomannan. Doubt PE but can't completely\n exclude this possibility. Will check LENIs in AM and hold on anticoag\n for now and check echo; no clear evidence of recent MI or tamponade.\n ARF is likely mediated by volume and poor forward flow. Will volume\n resuscitate, check lytes and sed, hold NSAIDs. Will give kayexalate as\n needed for hyperkalemia but hold off on renal consult for now. LFT\n abnormalities may also be mediated by flow, but are concerning for\n liver infiltration or viral infection. Will consider USG eval if this\n gets worse. In addition, the combination of ARF, thrombocytopenia,\n anemia, schistocytes and altered mental status makes TTP/HUS spectrum\n disorders possible, though precipitant unclear. check hemolysis\n labs, DIC panel, repeat CBC and smear and consider form evaluation by\n heme. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429397, "text": "Chief Complaint: Respiratory distress, hypoxemia, pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Echo showed increased LVEDP and moderately dilated RV. Patient's work\n of breathing has increased overnight. O2 sats are down from yesterday.\n LENI negative for DVT.\n RUQ ultrasound without significant pathology.\n Hct did increase with transfusion.\n Creat has normalized.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n , , simvastatin, protonix, Klonapin,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 105 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 26 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Moderate\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : Anterior and at bases, No(t)\n Bronchial: , Wheezes : Prolonged expiratory phase, No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: ), Using expiratory accessory\n muscles.\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 26 K/uL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ANEMIA\n ACIDOSIS\n Patient rating dyspnea as despite fentanyl patch. With\n transfusions, patient may have beome volume overloaded. Echo compatible\n with this. Would try diuresing today, now that renal function has\n normalized. Will also try CPAP for comfort and to reduce afterload.\n Continue antibiotics.\n Hct has responded to transfusion. Still unclear what was the source of\n the drop.\n Creat down to 1 with volume resuscitation.\n Blood pressure has normalized with volume resuscitation.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429398, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429409, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt sleeping\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec,\n HEENT: : Normocephalic, eyes closed\n Cardiovascular: mildly tachy, ns1/ Prominent p2,\n Respiratory / Chest: recruitment of extra-respiratory muscles,\n bibasilar rales,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis\n Neurologic: sleeping\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Continues. Pt on face mask oxygen this AM and satting\n low 90\ns while sleeping. Increased work of breathing despite\n morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 2. Hypotension/Acute Renal failure: Both have resolved. Likely due\n to decreased Po intake and intravascular volume.\n - redose meds now that renal failure improved\n - continue to monitor BP\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving Given hypotension, potentially ischemic\n secondary to poor perfusion. Will also send off hepatitis serologies\n as could have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429421, "text": "HX squamous cell lung ca S/p resection, lobectomy, MRSA, P/W SOB,\n hypotension, ARF.Pt reports SOB 7-10 days PTA, worse 2days PTA. Had\n been taking motrin, percocett at home for L rib pain. In EW. K 6.3,\n crit 23 SBP 82. CXR LL opacity, OB positive for rectal exam. Afeb.\n Given 2L IVF, vanco, zosyn, insulin D50. Trans to ICU for further\n management.\n Hx lung ca S/P RUL resection with recurrence 7 restaged to\n IIIb. Had wedge resection & now undergong chemotherapy (gemcytabine)\n s/p last dose 12/03\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt in resp distress this Am with sats low to mid 80\ns with periods to\n high 80\ns, RR 20\ns to low 30\n Action:\n CPAP for approx 35 minutes first trail.\n Response:\n Plan:\n Anxiety\n Assessment:\n Periods of feeling anxious. Sasts in the 80\n Action:\n Morphine sulfate 3mg X2 with additional 1mg IVP X1. Clonazapam 0.5mg\n increased to TID in addition to fentanyl patch when as initiated last\n eve at 1800.\n Response:\n Pt eventually able to better tolerate CPAP after morphine sulfate,\n clonazapem\n Plan:\n Cont fentanyl patch. Increased clonazapem. Morphine sulfate PRN. Assess\n resp status/distress. Hold clonazapam & morphine for increased\n somnolence, MS changes, R <10\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 1.1,\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429431, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient using NIV intermittently but continues to be SOB the whole\n shift first time spent 45 minutes on , second time 3.5 hours, still\n tachypneic and tachycardic on NRB + 6L nasal cannula, family members\n still at bedside, patient breathing at a frequency of 30 to 40, remains\n in distress, will continuous to be followed.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429507, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429509, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. At\n Action:\n 10mg SL morphine, repositioned\n Response:\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429511, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. At 21:20 pt desaturated\n to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Of note, pt has not voided this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation.\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429514, "text": "DNR/DNI\n Pt is a 64M w/ recurrence of NSCLC (/) who\n presented to ED with dyspnea increasing over 2d PTA. s/p RUL\n resection at in and subsequent MRSA infxn, wedge resection of\n LL in , had been undergoing chemotx, last rec\nd gemcytobine on\n .\n Pt had increased O2 requirements w/ occasional episodes of MS changes,\n low-grade hemoptysis and nausea for ~7 days prior. Hypotensive,\n hyperkalemic in the ED: transfused, given IV abx for possible\n infection, IV insulin, D50 and Ca gluconate. NRB placed to allow\n improved oxygenation and transferred to Fin MICU for further\n management.\n CXR shows marked increase in b/l opacities, ?infection vs\n lymphangitic tumor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\ns, BP\n WNL, sats 82-83%. Of note, pt has not voided this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Family has been at pt\ns bedside t/o the night.\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429371, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429383, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:00 AM\n - ENT deferred inpatient consult and recommended that patient follow-up\n as an oupatient for work-up of hoarseness, should be arranged when he\n is closer to discharge (clinic x27500)\n - Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred\n fentanyl patch until am\n - restarted klonipin\n - TTE -(LVEF>55%). Increased left ventricular filling pressure\n (PCWP>18mmHg). The right ventricular cavity is moderately dilated with\n moderate global free hypokinesis. There is abnormal septal\n motion/position consistent with right ventricular pressure/volume\n overload. Mild (1+) mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n - LEFT LENI - no dvt\n - RUQ u/s - PENDING\n - updated code status to DNR/DNI\n - Hct - 22.7 > 22.7 > 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 103 (90 - 113) bpm\n BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg\n RR: 29 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 1,228 mL\n 50 mL\n PO:\n 250 mL\n TF:\n IVF:\n 623 mL\n 50 mL\n Blood products:\n 355 mL\n Total out:\n 3,850 mL\n 1,050 mL\n Urine:\n 3,850 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,622 mL\n -1,000 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, tachypnec\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Prominent p2\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Occasionally\n confused, agitatied\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia: Known metastatic lung cancer, but presents with change in\n sputum with occasional hypoxia. Given CXR and recent chemo, infection\n likely. Thus have started on broad spectrum antibiotics and sputum\n cultures are sent. Other potential infections include fungal and\n viral. Non infectious etiologies include pulmonary embolism and\n progression of his cancer. Given acute renal failure and abnormal\n chest x-ray, both CTA and V/Q scan are suboptimal choices. Though\n getting a Q scan to assess solely perfusion could be considered.\n Having progression of his know metastatic disease especially in the\n form of lymphangitic spread could explain current hypoxia, though the\n progression may be somewhat acute.\n - Vanc, ceftriaxone, levofloxacin\n - Repeat CXR in AM\n - Consider non-contrast CT versus perfusion scan\n - follow up viral and sputum cultures\n - urine legionella antigen\n 2. Hypotension Acute Renal failure: Patient presents with acute renal\n failure in the setting of hypotension, NSAID use, and hypovolemia.\n Thus cause for renal failure is likely multifactorial. Will evaluate\n with u/a, urine culture, will need to evaluate urine sediment. As well\n will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT\n abnormalities, that patient could have tamponade. Pulsus 6 on initial\n eval but will recheck.\n - IVF\n - urine studies\n - renally dose meds\n 3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or\n consumption in the setting of occult bleeding. Will repeat diff in AM\n and hct. If persistent low plt with schistocytes and no signs of DIC\n will contact heme for phasmaphoresis.\n - Tx plt if <20\n - hct/plt\n - consider heme c/s if still low and concern for TTP\n 4. Acute hepatitis: Given hypotension, potentially ischemic secondary\n to poor perfusion. Will also send off hepatitis serologies as could\n have reactivation of Hep B in the setting of chemotherapy.\n Additionally could be infection or metatastases.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429480, "text": "DNR/DNI\n" }, { "category": "Nursing", "chartdate": "2196-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429492, "text": "DNR/DNI\n 64M NSCLC (/) c/b metastasis and ? lymphangitic\n tumor treated with recent gemcytobine. Brought in with hypoxemia with\n altered mental status in the recent past and low-grade hemoptysis.\n Hypotensive in the ED, transfused, eventually had NRB placed to allow\n improved oxygenation.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429589, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. CXR\n yesterday with significant interval changes concerning for acute\n infectious process. Pt now with Increased work of breathing and on SL\n morphine as pt has no IV access. Pt made CMO last night and plans in\n motion for d/c home with hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429590, "text": "Chief Complaint: Respiratory distress, lung ca, pneumonia, anemia,\n acute renal failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient kept comfortable overnight with opiates - sublinqual morphine.\n Oxygenation marginal with NRB mask plus O2 via nasal cannula. Patient\n diuresed with 3L negative fluid balance yesterday.\n Afebrile\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:38 AM\n NON-INVASIVE VENTILATION - START 09:45 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - STOP 10:30 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - START 12:43 PM\n NIV restarted again at 1243 PM PSV 8&8 80%\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - STOP 05:19 PM\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 79%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, Mild respiratory\n distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Extremities: Right: 1+ edema, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 26 K/uL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n RESPIRATORY DISTRESS\n ANEMIA\n PNEUMONIA\n Focus of care continues to be comfort for patient. No labs obtained.\n Morphine being administered.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments: Not applicable.\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :D/C Home\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429594, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Pt on face mask and nasal cannula this AM. CXR\n yesterday with significant interval changes concerning for acute\n infectious process. Pt now with Increased work of breathing and on SL\n morphine as pt has no IV access. Pt made CMO last night and plans in\n motion for d/c home with hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 09:54 ------\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429595, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 79%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n Labs / Radiology\n No labs or radiology studies today.\n Assessment and Plan\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429596, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittently\n required Non-invasive respiratory support. CXR with acute changes\n concerning for infection. No micro data to provide treatment\n guidance.\n Last evening, pt made CMO. Plans initiated for home hospice care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 116 (98 - 155) bpm\n BP: 126/76(88) {126/61(83) - 149/115(118)} mmHg\n RR: 38 (26 - 38) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, appears somnolent and minimally arousable, family at\n bedside.\n Labs / Radiology\n No labs or radiology studies today.\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 64 yo man with NSCLC admitted with hypotension, SOB; now ICU day 3. Pt\n on face mask and nasal cannula this AM. CXR yesterday with significant\n interval changes concerning for acute infectious process. Pt now with\n Increased work of breathing and on SL morphine as pt has no IV\n access. Pt made CMO last night and plans in motion for d/c home with\n hospice today.\n - d/c to home\n - continue SL morphine and supplemental for symptom relief\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines: No Access\n Prophylaxis:\n Communication:\n Code status: DNR / DNI ; CMO\n Disposition: home with hospice.\n" }, { "category": "Nutrition", "chartdate": "2196-01-15 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429598, "text": "Comments:\n Noted patient is CMO. Will sign off, please reconsult if plan of care\n changes.\n 10:33 AM\n" }, { "category": "General", "chartdate": "2196-01-14 00:00:00.000", "description": "ICU Event Note", "row_id": 429474, "text": "Clinician: Attending\n Patient diuresed today but oxygenation has worsened. Able to maintain\n O2 sat of 90% on Mask Ventilation, but sats drop to 70-85% on 100% NRB\n mask. He remains uncomfortable with dyspnea.\n Family meeting held with patient's wife and 2 daughters. Medical\n condition detailed along with poor prognosis. Decision made to make\n comfort measures the top priority and to attempt to make arrangements\n for home hospice for tomorrow.\n Total time spent: 60 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429582, "text": "Chief Complaint:\n 24 Hour Events:\n Increased shortness of breath over the morning . Intermittantly\n required Non-invasive respiratory support. CXR with\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal Canula/NRB\n RR (Spontaneous): 34\n FiO2: 6L NC and NRB @15L.\n SpO2: 85%\n Physical Examination\n GEN: Tachypnic, family at bedside, appears somnolent and minimally\n arousable.\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n 1. Hypoxia/Malignancy: Continues. Pt on face mask and nasal cannula\n this AM. CXR yesterday with acute interval changes concerning for\n infectious changes. Pt now Increased work of breathing and on SL m\n despite morphine. Currently on Vanc, ceftriaxone, levofloxacin.\n - continue abx\n - Repeat CXR this AM\n - follow up viral and sputum cultures\n 3. Thrombocytopenia: Has been stable. Suspect this is due to\n progression of malignancy.\n - Tx plt if <20\n 4. Acute hepatitis: Improving, but still elevated. Possibly due to\n hypotension on presentation. RUQ us unremarkable per prelim read\n making concern for malignancy less likely.\n - hepatitis serologies\n - repeat LFTs\n - Likely do CT torso\n - echo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429563, "text": "Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:38 AM\n NON-INVASIVE VENTILATION - START 09:45 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - STOP 10:30 AM\n Wife and nurse to stop NIV put patient back on NRB, NIV\n started at 0945 stopped at 1030, for a total of 45 mins.\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - START 12:43 PM\n NIV restarted again at 1243 PM PSV 8&8 80%\n NON-INVASIVE VENTILATION - START 12:43 PM\n NON-INVASIVE VENTILATION - STOP 05:19 PM\n Assessment:\n Assumed care of pt on 6L NC and NRB @15L. Sleeping but arousable.\n Tachypneic with RR in 30\ns, sats in low 80\ns. No IV access. At 21:20\n pt desaturated to 74-75% with a subsequent run of SVT to 160\n Action:\n 10mg SL morphine, repositioned. Addition 10mg SL morphine about an\n hour later for anxiety. Unable to sip water so PO admin of klonopin\n precluded.\n Response:\n SVT self-limiting. VSS then remained mostly stable with HR 110\n BP\ns WNL, sats 82-83%. Incontinent of urine x1 this shift; had rec\n lasix 10mg IV x1 on previous shift and voided ~2L. Arousing to\n stimulation but otherwise .\n Plan:\n Goal of care is to discharge pt to home with hospice today. \n , Palliative NP, was consulted over the phone at ~6pm last\n night and plans to be in this am around 8. Family states that they are\n not emotionally prepared to acquire hospice care on their own. This RN\n had initial contact with Hospice of who will accept pt; HSS\n needs to be phoned again at 8am (. MICU team to write Rx\n for SL morphine and ativan which family should have filled at Procare.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 04:00 AM\n Ceftriaxone - 05:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 111 (98 - 155) bpm\n BP: 126/76(88) {103/61(83) - 149/115(118)} mmHg\n RR: 28 (26 - 37) insp/min\n SpO2: 85%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 71 Inch\n Total In:\n 331 mL\n 1 mL\n PO:\n 80 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 3,790 mL\n 0 mL\n Urine:\n 3,790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,459 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 820 (777 - 820) mL\n PS : 8 cmH2O\n RR (Spontaneous): 34\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 20 cmH2O\n SpO2: 85%\n ABG: ////\n Ve: 23 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 26 K/uL\n 9.0 g/dL\n 157 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 46 mg/dL\n 108 mEq/L\n 142 mEq/L\n 26.3 %\n 7.4 K/uL\n [image002.jpg]\n 12:44 AM\n 11:36 AM\n 05:11 PM\n 04:45 AM\n WBC\n 4.3\n 4.1\n 5.0\n 7.4\n Hct\n 22.7\n 22.7\n 25.2\n 26.3\n Plt\n 20\n 21\n 25\n 26\n Cr\n 3.1\n 1.8\n 1.1\n Glucose\n 122\n 148\n 157\n Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,\n Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,\n Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Echo", "chartdate": "2196-01-13 00:00:00.000", "description": "Report", "row_id": 64797, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function. Hypoxia\nHeight: (in) 73\nWeight (lb): 260\nBSA (m2): 2.41 m2\nBP (mm Hg): 117/74\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV motion\nabnormality cannot be fully excluded. TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free \nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Due to suboptimal technical quality,\na focal motion abnormality cannot be fully excluded. Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nThe right ventricular cavity is moderately dilated with moderate global free\n hypokinesis. There is abnormal septal motion/position consistent with\nright ventricular pressure/volume overload. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is more dilated with more prominent free hypokinesis.\nThe estimated pulmonary artery systolic pressure is slightly higher.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050219, "text": " 6:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for obvious brain mass, ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with cancer, need for anticoagulation\n REASON FOR THIS EXAMINATION:\n eval for obvious brain mass, ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg TUE 8:16 PM\n no hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with cancer, needs anticoagulation. Evaluate\n for brain mass, intracerebral hemorrhage.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus, shift of\n normally midline structure, or evidence of major vascular territorial infarct.\n The -white matter differentiation is preserved. Hypodensities in the\n periventricular and subcortical white matter reflect chronic microvascular\n ischemic change, not significantly changed from . The visualized\n paranasal sinuses and mastoid air cells remain normally aerated. The\n surrounding soft tissues and osseous structures are normal.\n\n IMPRESSION: No acute intracranial abnormality. If there is concern regarding\n metastases, an MRI with gadolinium is more sensitive.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1050389, "text": " 3:26 PM\n UNILAT LOWER EXT VEINS Clip # \n Reason: EVALUATE FOR LEFT LOWER EXT DVT/LT LEG SWELLING\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with LLE edema\n REASON FOR THIS EXAMINATION:\n evaluate for Left Lower ext dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 6:59 PM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND\n\n HISTORY: 64-year-old man with left lower extremity edema. Evaluate for DVT.\n\n COMPARISON: Bilateral lower extremity venous ultrasound from .\n\n FINDINGS: On Doppler son of bilateral common femoral and left-sided\n superficial femoral, and popliteal veins were performed. All vessels\n demonstrated normal flow, augmentation, compressibility and waveforms. No\n intraluminal thrombus was identified.\n\n IMPRESSION: No evidence for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050512, "text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrates.\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hypoxia. Pt has had worse hypoxia overnight. Now in 80's,\n increased work of breathing.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening hypoxia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is a marked increase\n of the pre-existing bilateral reticular and reticulonodular opacities in both\n lungs. The increasing opacities obscure both heart borders and parts of the\n diaphragm. The pre-existing bilateral pleural thickening is unchanged. Also\n unchanged is the moderate mediastinal widening.\n\n The described changes could be caused by either infection or acute\n exacerbation of underlying fibrotic lung disease.\n\n Dr. , the referring physician, notified over telephone.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050197, "text": " 5:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with shortness of breath, hypoxia, hypotension\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, hypoxia, hypertension. History of lung cancer\n post-resection.\n\n COMPARISON: Chest CT , chest CTA .\n\n UPRIGHT AP VIEW OF THE CHEST: Patient is status post left upper lobe wedge\n resection. Left-sided pleural disease is again noted with a dominant area of\n pleural thickening in the left upper hemithorax relatively unchanged from the\n previous examinations. Clips are again demonstrated within the right superior\n mediastinum. Cardiac, mediastinal, and hilar contours are relatively\n unchanged with prominence of the hilar regions compatible with underlying\n pulmonary arterial hypertension. Additionally, widening of the mediastinum\n and fullness of the right paratracheal stripe reflects underlying mediastinal\n lymphadenopathy. There continues to be a patchy ill-defined opacity within the\n left lower lobe, which was seen on the prior study from ,\n which could represent developing infection, lymphatic spread of tumor, or\n atelectasis. Areas of fibrosis are again noted within the right lower lung\n laterally with unchanged area of pleural thickening in the right upper\n hemithorax. No pleural effusions or pneumothorax are identified. The\n patient's known lytic lesion within the left anterior fifth rib is not well\n visualized on the current examination.\n\n IMPRESSION:\n 1. Patchy opacity within the left lower lobe, which could represent\n pneumonia, lymphangitic spread of tumor, or atelectasis. The appearances are\n relatively unchanged from the CT from .\n 2. Left-sided pleural disease and mediastinal lymphadenopathy reflective of\n patient's underlying metastatic disease.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1050390, "text": ", M. MED 3:26 PM\n UNILAT LOWER EXT VEINS Clip # \n Reason: EVALUATE FOR LEFT LOWER EXT DVT/LT LEG SWELLING\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with LLE edema\n REASON FOR THIS EXAMINATION:\n evaluate for Left Lower ext dvt\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-13 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1050391, "text": " 3:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: LUNG CA, ELEVATED LFT, EVAL FOR CBD DILITATION AND GALLSTONES\n Admitting Diagnosis: DYSPNEA;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with Lung ca and lft elevations\n REASON FOR THIS EXAMINATION:\n evaluate for cbd dilitation and gallstones\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lung cancer and LFT elevations.\n\n COMPARISON: CT from and \n\n LIVER/GALLBLADDER ULTRASOUND: Grayscale and color Doppler son images\n were obtained and demonstrate the liver to be of normal contour but of\n increased echogenicity with a geographic area of hypodensity seen in the left\n lobe; this is avascular and does not displace vessels. Body habitus limits\n the study, but the gallbladder does not appear distended, and there is no\n apparent cholelithiasis, pericholecystic fluid, or gallbladder \n thickening. The common bile duct measures 7.1 mm, without evidence of\n obstruction. There is no ascites.\n\n IMPRESSION:\n 1. No evidence for gallbladder pathology.\n 2. Likely focal fatty sparing in the left lobe of the liver.\n 3. Diffuse fatty liver in the remaining portion; ultrasound cannot\n distinguish diffuse fatty infiltration from other forms of cirrhosis/fibrosis.\n\n\n\n" }, { "category": "ECG", "chartdate": "2196-01-12 00:00:00.000", "description": "Report", "row_id": 132829, "text": "Baseline artifact. Sinus rhythm. Borderline P-R interval prolongation.\nLow voltage throughout. ST-T wave abnormalities. Since the previous tracing\nof the rate has decreased. ST-T wave abnormalities are more marked.\nClinical correlation is suggested.\n\n" } ]

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49yo F with h/x of metastatic breast cancer to liver, lungs, brain who was admitted with confusion and altered mental status experienced at an outpatient scheduled CT scan. Currently on cycle #4 Doxil Day #30 and recieving whole brain treatment. First whole brain radiation was (5 treatments thus far, cycle is complete as of ). . # Altered Mental Status- most likely caused by the mutliple new brain massess from her breast cancer metastases. Patient has been very depressed with confusion at times.Head CT scan showed- 1. Innumerable hyperdense lesions distributed throughout the brain with mild mass effect and edema surrounding the largest lesion in the left thalamus. Started whole brain radiation in house, recieved 5 treatments the last being .Did not place patient on anti seizure medications because she had no history of seizures and there is no evidence in patients with brain mets prophylactic anti seizure meds are benficial.Continued Dexamethasone 4 mg Q6H IV to decrease intracranial pressure. Dexamethasone will be tapered per radiation oncology recommendations on discharge.Got Palliative Care consult- which followed the case, have decided to start home w/ nursing services and home resources. Husband was made the proxy via interpreter Dr. had seen the patient and recommended EEG which revealed no seizure activity(indicated moderate encephalopathy). We started Ritalin in attempt to raise her affect and activity level (which was started ). We got a head MRI to better stage her disease which showed :Innumerable enhancing lesions throughout the brain, as on the prior CT, with relatively little edema or mass effect. Largest lesion is a 2-cm left thalamic lesion with mild mass effect on the third ventricle. These are compatible with metastases, not appreciably changed from the head CT. . # Breast Cancer: metastatic, currently on Doxil Cycle # 4 Day # 30 with zometa. -Patient is BRCA1/2 negative. - f/u per primary oncologist Dr. . # Right arm and right leg weakness- most likely caused by her brain metastases, especially given large lesion in the left thalamus. . - the weakness is power in the right upper and lower extremities compared to the left which is power. Her right hand however is limp, unless she is told to move it and the grasp is much weaker than the left hand. These symptoms correlate with her lesion in her thalamus. . # FEN: regular diet # PPx: Pain controlled with morphine, DVT PPx with sc heparin

A large lesion in the left thalamus has surrounding edema and mild mass effect on the third ventricle without hydrocephalus. Findings are non-specific and tracing may be within normal limits.Since the previous tracing of sinus bradycardia is now present. Innumerable bilateral pulmonary nodules, which are also minimally larger in size, without evidence of new lesions. REASON FOR THIS EXAMINATION: Please comment on the location of lesions in the brain No contraindications for IV contrast PFI REPORT Large number of enhancing lesions throughout the brain as on the prior CT, with relatively little edema or mass effect. REASON FOR THIS EXAMINATION: Please comment on the location of lesions in the brain No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 3:46 PM Large number of enhancing lesions throughout the brain as on the prior CT, with relatively little edema or mass effect. Redemonstrated are innumerable bilateral pulmonary nodules, which are only minimally larger compared to prior study. IMPRESSIONS: Innumerable enhancing lesions throughout the brain, as on the (Over) 12:05 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please comment on the location of lesions in the brain Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: FINAL REPORT (Cont) prior CT, with relatively little edema or mass effect. The largest lesion is located in the left thalamus, measuring 1.8 x 2.1 cm, which exerts mild mass effect on the third ventricle. (Over) 2:00 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: restaging, please compare with prior scans from and Ap Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) OSSEOUS STRUCTURES: Redemonstrated are innumerable sclerotic metastatic lesions throughout the thoracolumbar spine, sternum, femurs, and pelvis, which are not significantly changed from prior study. Within the limitations of this study, no large extra-axial hematomas are detected. These are compatible with metastases, not appreciably changed from the head CT. Many of these lesions, however, demonstrate only minimal to no surrounding edema. Largest lesion is a 2-cm left thalamic lesion with mild mass effect on the third ventricle. The major intracranial vascular flow voids are unremarkable. Th largest is a 2 cm left thalamic lesion with mild mass effect on 3rd ventricle. Th largest is a 2 cm left thalamic lesion with mild mass effect on 3rd ventricle. A few scattered retroperitoneal lymph nodes are not enlarged by CT size criteria, with the aortocaval nodes measuring up to 5 mm in short axis. A few scattered lesions are noted in the mid brain. CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are without pericardial effusion. Innumerable hyperdense lesions distributed throughout the brain with mild mass effect and edema surrounding the largest lesion in the left thalamus. The ventricles and sulci are normal in caliber and configuration, except for mild compression of the third ventricle. A few scattered mediastinal lymph nodes are not significantly changed, and not enlarged by size criteria, measuring up to 6 mm in the paratracheal station. Many of the lesions demonstrate low attenuation, compatible with necrosis. For example, a lesion within the right lobe of the liver (2:51) measures 18-mm, previously measured approximately 10 mm. Stable diffuse osseous metastases. TECHNIQUE: Contiguous axial images were acquired through the head without intravenous contrast. Some vasogenic edema is seen surrounding this lesion. OSSEOUS STRUCTURES AND SOFT TISSUE: There is a lucent lesion in the left frontal vertex (2:25), which, given additinal findings is suspicious for metastatic disease. Innumerable hyperdense lesions are seen diffusely distributed throughout the cerebral hemispheres and the cerebellum. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are unremarkable. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the symphysis pubis with the administration of IV contrast only. Left frontal lucent lesion are concerning for metastatic disease. Some lesions are situated along the subependymal surface along the lateral ventricles. Abnormal signal within the left frontal calvarium indicates a site of bony metastasis, as indicated on the head CT. The stomach, small bowel, and large bowel are unremarkable. Sinus rhythm with borderline sinus bradycardia. Other lesions are found predominantly throughout the cerebral hemispheres at the -white junction, along the ventricles, in the cerebellum, and a few in the midbrain. Other lesions are found predominantly throughout the cerebral hemispheres at the -white junction, along the ventricles, in the cerebellum, and a few in the midbrain. A few smaller lesions are present within the subcortical white matter.

5

[ { "category": "Radiology", "chartdate": "2197-08-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1142246, "text": " 2:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: restaging, please compare with prior scans from and Ap\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with met breast cancer\n REASON FOR THIS EXAMINATION:\n restaging, please compare with prior scans from and \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer, restaging.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with the administration of IV contrast only. Coronal and\n sagittal reformations were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are without\n pericardial effusion. The great vessels are within normal limits. A few\n scattered mediastinal lymph nodes are not significantly changed, and not\n enlarged by size criteria, measuring up to 6 mm in the paratracheal station.\n\n Redemonstrated are innumerable bilateral pulmonary nodules, which are only\n minimally larger compared to prior study. For example, a nodule within the\n right upper lobe (2:14) measures 9 mm x 9 mm, previously measured 8 mm x 8 mm.\n A nodule within the left upper lobe measures 11 mm x 9 mm, previously measured\n 10 mm x 8 mm. A nodule within the left lower lobe (2:33) measures 16 mm x 14\n mm, previously measured 15 mm x 14 mm. No new lesion is identified. There is\n no pleural effusion.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver is infiltrated by numerous\n metastatic lesions. There is a different enhancement pattern of the lesions\n compared to prior study, making direct comparison difficult. Many of the\n lesions demonstrate low attenuation, compatible with necrosis. Though direct\n comparison is difficult, there is an increase in number of the lesions, as\n well as an increase in size of several of the lesions. For example, a lesion\n within the right lobe of the liver (2:51) measures 18-mm, previously measured\n approximately 10 mm. There is also increasing capsular retraction of the\n liver. The portal venous system is patent without evidence of thrombus. The\n gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable.\n\n The stomach, small bowel, and large bowel are unremarkable.\n\n There is no free air or free fluid. A few scattered retroperitoneal lymph\n nodes are not enlarged by CT size criteria, with the aortocaval nodes\n measuring up to 5 mm in short axis.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are\n unremarkable. There is no pelvic lymphadenopathy or free fluid.\n (Over)\n\n 2:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: restaging, please compare with prior scans from and Ap\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: Redemonstrated are innumerable sclerotic metastatic\n lesions throughout the thoracolumbar spine, sternum, femurs, and pelvis, which\n are not significantly changed from prior study. There is no evidence for\n pathologic fracture.\n\n IMPRESSION:\n 1. Innumerable hepatic metastases, which are increased in number and slightly\n increased in size compared to prior study.\n 2. Innumerable bilateral pulmonary nodules, which are also minimally larger\n in size, without evidence of new lesions.\n 3. Stable diffuse osseous metastases.\n\n" }, { "category": "Radiology", "chartdate": "2197-08-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1142276, "text": " 3:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with confusion/AMS, h/o breast CA\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 4:36 PM\n Multiple hyperdense lesions seen throughout the brain. A large lesion in the\n left thalamus has surrounding edema and mild mass effect on the third\n ventricle without hydrocephalus. Basal cisterns are patent, no evidence of\n herniation or midline shift. Left frontal lucent lesion are concerning for\n metastatic disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with confusion and altered mental status, has a\n history of metastatic breast cancer.\n\n COMPARISON: MRI of the brain and orbit .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast. However, the patient has had contrast enhanced CT of\n the torso an hour ago, limiting evaluation for subarachnoid bleed.\n\n Innumerable hyperdense lesions are seen diffusely distributed throughout the\n cerebral hemispheres and the cerebellum. The largest of these lesions is\n present within the left thalamus (2:15), measuring 2.3 x 1.8 cm, causing mass\n effect on the third ventricle. Some vasogenic edema is seen surrounding this\n lesion. No shift of midline structures or herniation is detected. Within the\n limitations of this study, no large extra-axial hematomas are detected. There\n is no hydrocephalus. The ventricles and sulci are normal in caliber and\n configuration, except for mild compression of the third ventricle.\n\n OSSEOUS STRUCTURES AND SOFT TISSUE: There is a lucent lesion in the left\n frontal vertex (2:25), which, given additinal findings is suspicious for\n metastatic disease. The visualized paranasal sinuses and mastoid air cells\n are clear.\n\n IMPRESSION:\n 1. Innumerable hyperdense lesions distributed throughout the brain with mild\n mass effect and edema surrounding the largest lesion in the left thalamus.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1143197, "text": " 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with metastatic breast cancer to liver, lungs, brain who was\n admitted with confusion and altered mental status experienced at an outpatient\n scheduled CT scan.\n REASON FOR THIS EXAMINATION:\n Please comment on the location of lesions in the brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 3:46 PM\n Large number of enhancing lesions throughout the brain as on the prior CT,\n with relatively little edema or mass effect. Th largest is a 2 cm left\n thalamic lesion with mild mass effect on 3rd ventricle. Other lesions are\n found predominantly throughout the cerebral hemispheres at the -white\n junction, along the ventricles, in the cerebellum, and a few in the midbrain.\n\n PFI VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with confusion and altered mental status,\n history of metastatic breast cancer.\n\n COMPARISON: Head CT . Brain MR, .\n\n TECHNIQUE: Pre- and post-contrast sequences were obtained through the brain.\n MP-RAGE sequences could not be obtained due to patient discomfort.\n Diffusion-weighted sequences were acquired.\n\n BRAIN MRI: Innumerable round, enhancing lesions are present throughout the\n brain. Many demonstrate increased signal on both T1- and T2-weighted\n sequences. Many of these lesions, however, demonstrate only minimal to no\n surrounding edema. The largest lesion is located in the left thalamus,\n measuring 1.8 x 2.1 cm, which exerts mild mass effect on the third ventricle.\n Most of the lesions are located in the bilateral cerebral hemispheres,\n predominantly at the -white matter junction. Some lesions are situated\n along the subependymal surface along the lateral ventricles. A few smaller\n lesions are present within the subcortical white matter. Innumerable\n additional lesions are present within the cerebellar hemispheres. A few\n scattered lesions are noted in the mid brain. Abnormal signal within the left\n frontal calvarium indicates a site of bony metastasis, as indicated on the\n head CT.\n\n There is no intracranial hemorrhage or large mass effect. There is no\n infarction. Ventricles and sulci are normal in size and configuration. The\n major intracranial vascular flow voids are unremarkable. The globes are\n intact, without abnormal enhancement.\n\n IMPRESSIONS: Innumerable enhancing lesions throughout the brain, as on the\n (Over)\n\n 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior CT, with relatively little edema or mass effect. Largest lesion is a\n 2-cm left thalamic lesion with mild mass effect on the third ventricle. These\n are compatible with metastases, not appreciably changed from the \n head CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1143198, "text": ", S. OMED 11R 12:05 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please comment on the location of lesions in the brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with metastatic breast cancer to liver, lungs, brain who was\n admitted with confusion and altered mental status experienced at an outpatient\n scheduled CT scan.\n REASON FOR THIS EXAMINATION:\n Please comment on the location of lesions in the brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large number of enhancing lesions throughout the brain as on the prior CT,\n with relatively little edema or mass effect. Th largest is a 2 cm left\n thalamic lesion with mild mass effect on 3rd ventricle. Other lesions are\n found predominantly throughout the cerebral hemispheres at the -white\n junction, along the ventricles, in the cerebellum, and a few in the midbrain.\n\n\n\n" }, { "category": "ECG", "chartdate": "2197-08-02 00:00:00.000", "description": "Report", "row_id": 223715, "text": "Sinus rhythm with borderline sinus bradycardia. Low precordial lead\nQRS voltage. Findings are non-specific and tracing may be within normal limits.\nSince the previous tracing of sinus bradycardia is now present.\n\n" } ]

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67year old male h/o HTN, bipolar off meds, tobacco abuse admitted with weeks/months of feeling "unhealthy", chronic NP, mild DOE, chronic LBP. Poor historian but stated he was just feeling bad for so long that decided to come in, though denied any acute changes in cough/dyspnea/fevers/chills. On arrival to ER, he was febrile (pt not aware) and hypoxic 88%RA, CXR with LLL PNA, got 3L IVFs, Levaquin, O2 and transfered to MICU overnight. Did well in ICU, thus transfered to floor . Since on Gen Med floor, continued to do better clinically, was afebrile and cough improved, however had persistant hypoxia, requiring 4L O2. Underwent CT chest which showed extensive linguilar/LLL opacities with b/l GGO. Given clinical improvement in terms of fever and white count down, decided to keep on levaquin X10days with follow up imaging for resolution. He is being discharged on oxygen 3L with rest, 4L with exertion with pulmonary follow up for further w/u (esp given b/l GGOs and months of "fatigue/malaise"). Of note, peviously 2-3PPD X30years (now 6cigs/day) which raises concern for COPD, but CT w/o empysematous changes and exam w/o prolonged expiration. nevertheless given tobacco history, was d/c'd on combivent. Other issues here, has a mid-lower back 5cm circular wound that wound care believes is likely thermal wound (uses heat packs), reccommend silvedine. SW saw pt while here given his unusual social situation. He will return to monastery on discharge. He has f/u arranaged with new PCP and pulm at (see below) . . See progress note below for details: . 67 year old male with h/o HTN, bipolar d/o, heavy tobacco abuse admitted with weeks of malaise, , ?dyspnea, with acute worsening, found to have PNA with hypoxia, sepsis (resolved), now doing much better except for persistant hypoxia . . Community Acquired PNA: admission c fevers, leukocytosis, tachycardia, and tachypnea-->sepsis resolved. NO sputum cx obtained but clinically improved on levaquin. Persistant hypoxia (4L) and CT with extensive LLL/linguilar consolidation and bilateral GGOs. -cont levaquin, day -chest CT as above, will need follow up CXR or CT to ensure resolution or needs further w/u -cont guaifenesin as expectorant -have set up for home O2, 3L at rest, 4L with exertion, hopefully can wean this overtime -continue combivent for possible COPD component, will clarify need base on spirometry after PNA resolved. -vaccines as outpt since ongoing PNA . . Hypoxia: LLL PNA extensive with bilateral GGO seen on CT. Clinically improved though persistant O2 requirement. ?underlying COPD given heavy tobacco history, though admission ABG w/o much hypercapnea and CT w/o emphysema. Not sure if has baseline hypoxia causing his chronic malaise history or whether all due to PNA -as above, set up with home O2 3L rest, 4L exertion -set up with pulm f/u for further w/u hypoxia (spirometry), also needs repeat imaging (f/u nodule and GGOs) . . Wound: mid back. doesnt look infected. pt not at risk for pressure ulcer. Per wound care nurse, more suggestive of thermal injury (pt uses heat packs for chronic LBP) -silvedine cream and dressing changes per wound care -low suspicion for malignancy, but would refer to derm if no improvement over next few weeks . . Social situation: conflicting stories but pt did confide to nurse that his house burned down and he is currenlty homeless living in monastery. This is confirmed and they are happy to pick up patient from hospital -SW/CM have confirmed that pt has insurance/resources to pay for meds/O2 (medicare) . . HTN: Echo with LVH. BNP low so no heart failure causing GGO/crackles/hypoxia. -baseline Echo today prior to d/c, f/u read as outpt . . Bipolar d/o: pleasant, compensated. Poor historian but that he is not used to be hospitalized and is guarded given his social situation -follow, SW c/s as above, no need for psych . . Tobacco abuse: offer nicotine patch while here. . . . Dispo/code: Full Code. Will d/c back to monastery today. has VNA set up, home O2 set up, PCP appt for with Dr. at 2:30pm and pulm appt for Wed with Dr. . Pt has to check in at 3:30pm for breathing test, and then will meet Dr. at 4pm.

Hypoxia.Height: (in) 69Weight (lb): 150BSA (m2): 1.83 m2BP (mm Hg): 103/87HR (bpm): 61Status: InpatientDate/Time: at 11:38Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. Pt transferred to ICU for further care secondary to occasional desatting to low 90s even with O2 4L. 24 Hour Events: Allergies: Lithium Unknown; Ibuprofen Unknown; Erythromycin Base Diarrhea; Last dose of Antibiotics: Levofloxacin - 09:28 AM Infusions: Other ICU medications: Furosemide (Lasix) - 12:20 AM Heparin Sodium (Prophylaxis) - 06:00 AM Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Respiratory: Cough Flowsheet Data as of 10:19 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38C (100.4 Tcurrent: 36.3C (97.4 HR: 67 (67 - 93) bpm BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg RR: 31 (14 - 43) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch Total In: 3,220 mL 522 mL PO: 420 mL TF: IVF: 20 mL 102 mL Blood products: Total out: 400 mL 1,650 mL Urine: 400 mL 1,650 mL NG: Stool: Drains: Balance: 2,820 mL -1,128 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 93% ABG: 7.40/39/63/26/0 Physical Examination General Appearance: No acute distress, Thin, disshelveled Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 12.6 g/dL 245 K/uL 100 mg/dL 0.9 mg/dL 26 mEq/L 4.5 mEq/L 14 mg/dL 104 mEq/L 141 mEq/L 37.6 % 11.0 K/uL BNP 158 10:24 PM 03:55 AM WBC 13 11.0 Hct 37.6 Plt 245 Cr 0.9 TCO2 25 Glucose 100 Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL Imaging: CXR- LLL infiltrate Microbiology: No new data.

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[ { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 442163, "text": "Chief Complaint: LBP, cough\n 24 Hour Events:\n Pt did well o/n on 5L NC sating low 90's and above\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states he feels the same as last night. Has same\n cough. No CP, SOB. Wants to eat breakfast\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 77 (75 - 93) bpm\n BP: 129/63(79) {114/57(70) - 156/75(94)} mmHg\n RR: 25 (14 - 43) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 264 mL\n PO:\n 180 mL\n TF:\n IVF:\n 20 mL\n 84 mL\n Blood products:\n Total out:\n 400 mL\n 1,450 mL\n Urine:\n 400 mL\n 1,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 245 K/uL\n 12.6 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442171, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442083, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 99.6, pt A/O x 3, tachypneic at times with RR between 24 and 32,\n LS with crackles in L side, rhonchi in R side, on O2 3.5 L NC.\n Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63. Sample for MRSA nares obtained.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442173, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic. Given symmetric crackles on exam, concern for volume\n overload.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - Check BNP/TTE\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442174, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n BNP 158\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - TTE ordered\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442081, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n" }, { "category": "Physician ", "chartdate": "2177-02-21 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 442077, "text": "TITLE:\n Chief Complaint: tachypnea, fevers\n HPI:\n This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n no home medications\n Past medical history:\n Family history:\n Social History:\n \"strained left ventricle\"\n Both parents with ETOH abuse. No DM or CAD.\n Occupation: retired construction worker\n Drugs: denies\n Tobacco: PPD x 50 yrs\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Mild\n Pain location: low back\n Flowsheet Data as of 11:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 81) bpm\n BP: 141/65(83) {141/65(83) - 141/65(83)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,208 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,058 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: 7.40/39/63//0\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar; L>R, Rhonchorous: sparse left rhonci)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: back: 2 cm round lesion, ? ulcer healed; minimally\n tender, no fluctuance\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/13/ 10:24 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 25\n Other labs: Lactic Acid:0.8 mmol/L\n Imaging: CXR: Lingular infiltrate, otherwise, no e/o volume overload or\n effusions.\n ECG: ECG: sinus tachycardia at 100. LVH with strain pattern.\n otherwise no significant ECG changes. Not markedly changed from\n previous ECG in .\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: NPO for now; likely can eat in AM\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending/Resident Admission Note - MICU", "row_id": 442079, "text": "TITLE:\n Chief Complaint: tachypnea, fevers\n HPI:\n This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia. He\n then improved to 93-94% on 4L. ECG without any ischemic changes. His\n vitals prior to transfer were 88, 110/50, RR 44 94% 4L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n no home medications\n Past medical history:\n Family history:\n Social History:\n \"strained left ventricle\"\n Both parents with ETOH abuse. No DM or CAD.\n Occupation: retired construction worker\n Drugs: denies\n Tobacco: PPD x 50 yrs\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Mild\n Pain location: low back\n Flowsheet Data as of 11:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 81) bpm\n BP: 141/65(83) {141/65(83) - 141/65(83)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,208 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,058 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: 7.40/39/63//0\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar; L>R, Rhonchorous: sparse left rhonci)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: back: 2 cm round lesion, ? ulcer healed; minimally\n tender, no fluctuance\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/13/ 10:24 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 25\n Other labs: Lactic Acid:0.8 mmol/L\n Imaging: CXR: Lingular infiltrate, otherwise, no e/o volume overload or\n effusions.\n ECG: ECG: sinus tachycardia at 100. LVH with strain pattern.\n otherwise no significant ECG changes. Not markedly changed from\n previous ECG in .\n Assessment and Plan\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands\n - check sputum culture\n - check urine legionella\n - f/u blood cx. UA without UTI\n - currently BP ok and tachycardia responded to IVF boluses\n - cont IVF boluses to maintain SBP>100\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n - hold off on CVL/A-line for now; get second PIV\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 3L NC. Likely this is due to LLL Pnemonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely.\n - check ABG\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n - check BNP\n # FEN: NPO for now; consider restarting regular diet in AM\n # Access: 18G PIV; will get second PIV. hold on CVL for now\n # PPx: hep sc\n # Code: FULL\n # Dispo: ICU for now\n # Comm: with patient\n ICU Care\n Nutrition: NPO for now; likely can eat in AM\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Attending Note: patient was seen and examined with Dr. . The\n above note reflects our discussion. I would add the following: Mr \n is a 67 yr old\n ppd smoker, with\nstrained left ventricle\n diagnosed\n many years ago, LVH on ECG, on no meds, who presented with dyspnea and\n productive cough x 1 week, question of vomiting, chills but no\n documented fever, back pain. In ED temp 101, HR 91, BP 161/67, RR 44,\n sat 88% on RA, 98% on NRB. Started on levoflox, given 3 L IVF. O2sat\n improved to 94% on 4L. No ischemic changes on EKG. Transferred to MICU\n because of hypoxemic respiratory failure.\n Currently desats to 91% on 4 L, appears unkempt, RRR, bilat crackles\n L>R, abdomen benign, no LE edema.\n Labs significant for WBC 13.1 with left shift, no bands, u/a neg, utox\n negative. ABG shows pO2 63. PA & lat CXR reviewed\n lingular\n infiltrate.\n Impression: hypoxemic respiratory failure due to lingular pneumonia\n with fever, tachypnea, hypoxemia, leukocytosis and lingular infiltrate.\n There may be superimposed CHF. Doubt PE. Given smoking history, should\n consider possibility of malignancy. Agree with levofloxacin. Would\n recommend gentle diuresis. Would get sputum culture if possible, check\n BNP and do TTE. He will need repeat CXR to document improvement,\n possible a chest CT.\n Patient is cooperative and although somewhat eccentric, is a reliable\n historian. Patient is critically ill. 35 minutes spent.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:18 ------\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442082, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442125, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pt is homeless for the past few months, has been living with friends.\n is a full code.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.6 this a.m . Pt A/O x 3, tachypneic at times with RR\n between 24 and 32, LS with crackles in L side, rhonchi in R side, on O2\n 3.5 L NC. Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV lasix\n overnight .Sample for MRSA nares obtained. Medicated with Tylenol 650\n mg po for elevated temp at 0615.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 442123, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 99.6, pt A/O x 3, tachypneic at times with RR between 24 and 32,\n LS with crackles in L side, rhonchi in R side, on O2 3.5 L NC.\n Frequent moist non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV\n lasix.Sample for MRSA nares obtained.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 442213, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 67 yr old smoker presented with fever, tachypnea, hypoxemia,\n leukocytosis and lingular infiltrate.\n 24 Hour Events:\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Levofloxacin - 09:28 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 10:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.3\nC (97.4\n HR: 67 (67 - 93) bpm\n BP: 104/56(67) {104/48(63) - 156/75(94)} mmHg\n RR: 31 (14 - 43) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 522 mL\n PO:\n 420 mL\n TF:\n IVF:\n 20 mL\n 102 mL\n Blood products:\n Total out:\n 400 mL\n 1,650 mL\n Urine:\n 400 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: No acute distress, Thin, disshelveled\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Crackles : Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.6 g/dL\n 245 K/uL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n BNP 158\n 10:24 PM\n 03:55 AM\n WBC\n 13\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR- LLL infiltrate\n Microbiology: No new data.\n Assessment and Plan\n This is a 67 year-old male with no significant PMH who presents with\n fevers, tachypnea, and LLL/lingular pneumoia\n Plan:\n # Respiratory distress/hypoxemia\n Oxygen weaned down to NC, but still\n tachypneic.\n - Check sputum culture\n - Check urine legionella\n - Continue levofloxacin\n - F/U cultures\n - TTE ordered\n # FEN: Advance diet\n Other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2177-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 442190, "text": "Chief Complaint: LBP, cough\n 24 Hour Events:\n Pt did well o/n on 5L NC sating low 90's and above\n Allergies:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:20 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states he feels the same as last night. Has same\n cough. No CP, SOB. Wants to eat breakfast\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 77 (75 - 93) bpm\n BP: 129/63(79) {114/57(70) - 156/75(94)} mmHg\n RR: 25 (14 - 43) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,220 mL\n 264 mL\n PO:\n 180 mL\n TF:\n IVF:\n 20 mL\n 84 mL\n Blood products:\n Total out:\n 400 mL\n 1,450 mL\n Urine:\n 400 mL\n 1,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,820 mL\n -1,186 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.40/39/63/26/0\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 245 K/uL\n 12.6 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 141 mEq/L\n 37.6 %\n 11.0 K/uL\n [image002.jpg]\n 10:24 PM\n 03:55 AM\n WBC\n 11.0\n Hct\n 37.6\n Plt\n 245\n Cr\n 0.9\n TCO2\n 25\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:488/3/, Lactic Acid:0.8 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assesment: This is a 67 year-old male with no significant PMH who\n presents with fevers, tachypnea, and tachycardia with ? LLL pneumoia\n Plan:\n # Sepsis - fevers, leukocytosis, tachycardia, and tachypnea. LLL\n infiltrate; UA negative. Blood cultures pending. lactate 1.1. No bands.\n Now WBC down to 11 from 13 on admission. Tachycardia resolved. Pt\n tachypnea intermittent now\n - check sputum culture\n - check urine legionella\n - f/u blood cx.\n - levofloxacin for LLL infiltrate; no recent hospitalization, no need\n for vanco/zosyn at that time; will broaden if decompensates\n # Hypoxia: tachypneic, leading to ICU admission. Currently satting\n well on 4L NC. Likely this is due to LLL Pneumonia. other causes\n include pulm edema though no h/o CHF and CXR without significant e/o\n volume overload. PE possible, though unlikely. BNP not elevated on\n admission\n - O2 as needed to maintain sat>92%\n - treat PNA as above\n -TTE ordered for Mon given LVH on EKG\n -Nebs ordered today PRN\n # FEN: Reg diet. Ordered Ca, Vit D, MVI\n # Access: PIVs\n # PPx: hep sc\n # Code: FULL\n # Comm: with patient\n consulting SW today for problems with\n homelessness and dog left in pt\ns car on admission. Pt refused to name\n next of or HCP. Staying at local monastery with whom he seems to be\n on good terms.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2177-02-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 442191, "text": "This is a 67 year-old male with no significant PMH who presents with\n dyspnea and cough x almost 1 week. He is not a very good historian,\n and he states his cough may have been present for weeks, though on\n further questioning, states its only x 1 week. It has been a\n productive cough, though he has been swallowing it. He also had some\n nausea, and vomiting the last few days, but states he closes his mouth\n and swallows it. He denies chest pains, abdominal pain, diarrhea. He\n reports chills, but hasn't checked his temp at home. He also has\n chronic low back pain.\n In the ED, initial vitals were T101, 91, 52, 161/77, 88% RA. He\n improved to 98% on NRB. He appeared ill, tachypneic, and tachycardic.\n He had bilateral crackles. CXR concerning for LLL PNA- he was given\n levofloxacin 750 mg x 1. He was also given 3L NS for tachycardia,\n started on O2 NC 4L.\n Pt transferred to ICU for further care secondary to occasional\n desatting to low 90\ns even with O2 4L.\n Pt is homeless for the past few months, has been living with friends.\n is a full code.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt A/O x 3, tachypneic at times with RR between 24 and 32, LS with\n crackles in L side, rhonchi in R side, on O2 4 L NC. Frequent moist\n non productive cough noted.\n Action:\n Blood gas obtained, PO2 63 7.40/39/0. diuresed with 20 mg IV lasix\n overnight .Sample for MRSA nares obtained. Medicated with Tylenol 650\n mg po for elevated temp at 0615. Nebs as ordered.\n Response:\n O2 increased to 5L NC based on Spo2, with good effect, Spo2 maintains\n above 95%. Good effect from diuresis, less crackles noted.\n Plan:\n Continued to monitor hemodynamic status, O2 as tolerated to maintain\n sats above 92%.\n Social work is consulted to help Pt. locate dog. Dog was removed from\n Pt.\ns truck by Animal control and is most likely in a shelter. Pt. has\n been staying in a local monastery after his home was burned down. Pt.\n originally from .\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 86.4 kg\n Daily weight:\n Allergies/Reactions:\n Lithium\n Unknown;\n Ibuprofen\n Unknown;\n Erythromycin Base\n Diarrhea;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: \" strained left ventricle\"\n Surgery / Procedure and date: /'. Open reduction and internal\n plate fixation of L zygoma fracture.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:52\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 24h total in:\n 490 mL\n 24h total out:\n 1,650 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:55 AM\n Potassium:\n 4.5 mEq/L\n 03:55 AM\n Chloride:\n 104 mEq/L\n 03:55 AM\n CO2:\n 26 mEq/L\n 03:55 AM\n BUN:\n 14 mg/dL\n 03:55 AM\n Creatinine:\n 0.9 mg/dL\n 03:55 AM\n Glucose:\n 100 mg/dL\n 03:55 AM\n Hematocrit:\n 37.6 %\n 03:55 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with Pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: wooden cross on clear (fishing line).\n Transferred from: ICU 410\n Transferred to: 1176\n Date & time of Transfer: 1145\n" }, { "category": "Echo", "chartdate": "2177-02-25 00:00:00.000", "description": "Report", "row_id": 103511, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypoxia.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 103/87\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 11:38\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w normal LV\ndiastolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild thickening of mitral\nvalve chordae. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS.\nPhysiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith normal LV diastolic function. Right ventricular chamber size and free\nwall motion are normal. The aortic root is mildly dilated at the sinus level.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. The pulmonic valve\nleaflets are thickened. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Normal diastolic function.\nDilated thoracic aorta. Trivial aortic regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2177-02-23 00:00:00.000", "description": "Report", "row_id": 311512, "text": "Sinus rhythm. Poor R wave progression. J point and ST segment elevation\nin leads V3-V6. Clinical correlation is suggested. Non-specific T wave\nchanges in leads III and aVF. Compared to the previous tracing of \nthe inferior T wave changes are new. The ST segment elevation is new and\nleads V2-V3 are now in the correct position.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-02-22 00:00:00.000", "description": "Report", "row_id": 311513, "text": "Sinus rhythm. Possible reversal of leads V2-V3. Prominent QRS voltage\nsuggests left ventricular hypertrophy. Compared to the previous tracing\nof leads V2-V3 are probably reversed and ventricular rate is slower.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-02-21 00:00:00.000", "description": "Report", "row_id": 311514, "text": "Sinus rhythm with borderline sinus tachycardia\nBorderline left axis deviation is nonspecific\nProminent QRS voltage suggests left ventricular hypertrophy\nSince previous tracing of , rate faster and axis appears more leftward\n\n" } ]

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1. Respiratory: The infant was intubated soon after admission due to increased work of breathing and her ventilator settings at the time of transfer were PIP of 16, a PEEP of 5 and a breath rate of 16 breaths per minute. The infant was in room air. He received one dose of surfactant. His blood gas drawn after that was a pH of 7.33, PCO2 of 42 and a PO2 of 35. His chest x-ray is consistent with mild respiratory distress syndrome. 2. Cardiovascular: The infant received two boluses of normal saline each of 10 cc per kg for mean blood pressures in the low 20s. His blood pressure after the second bolus was 45/30 with a mean of 35. No murmur has been heard. 3. Fluids, electrolytes and nutrition: The initial dextrose stick was 36. The infant required two boluses each of 3 cc per kg of 10% dextrose. His glucose prior to transfer was 78. At the time of transfer he has a double-lumen umbilical venous catheter in running with 10% dextrose at 100 cc per kg per day. 4. Gastrointestinal: There are no issues. 5. Infectious disease: The infant was started on ampicillin and gentamicin at the time of admission for sepsis risk factor. A blood culture was sent prior to administration of antibiotics and his complete blood count showed a white count of 11.1 with a differential of 45 polys and one band. His hematocrit was 42 and the platelet count was 297,000. 6. Hematology: The infant has had no blood product transfusions during the Neonatal Intensive Care Unit stay. 7. Sensory: Audiology screening was not performed but is recommended prior to discharge. 8. State screen was sent.

To begin Amp/ Gent as ordered.DEV: Initial temp - 96.9 rectally- warmed to 97.9 axillary. D10W bolus given and subsequent D/S 78. Baby to be to TCH due to B.I. Pregnancy noteable for bright spot on heart, decline amnio, 1 SAB and 1SVD in . Mother had progressive PTL, infant had decels. Initial BP 36/19(25). Gent and Ampi given. NPN -2100Xray done to confirm placement of lines. Received stim, BMV and bulb sxn'ing. To begin D10w w/ .5u heparin/cc at 80cc/kg/d once line placement is confirmed. tube secured with 3.0 at upper lip. Baby at 2115hrs. + intercostal/subcostal retractions.RR 60's. Neonatology NP Procedure NoteEndotracheal IntubationIndication: surfactant deficiency3.0 ETt placed orally through cords under direct laryngoscopy. DUVC placed. Infat briefly shown to parents and then transported to NICU.RESP: Infant was intubated w/ #3ETT- received first dose of Survanta at 1815. NICU NURSING ADMISSION NOTE Baby is 29wk infant born at . RESPIRATORY CARE NOTEBaby received intubated on vent settings 16/5 rate 20 FiO2 21%. CXR shows tip of tube ~ 2 cm above carina.Infant tolerated procedure well. D/S 48 at . D10W with hep infusing well via DLUVC. Smaller cuff placed on infant- 44/25(30). Neonatology NP Procedure NotePlacement of umbilical venous catheterIndication : need for longterm IV therapy.Umbilical area prepped and draped. double lumen UV line placed. Fetus with some decels today, BPP .Pedi--, ClinicInfant delivered today at 1729 by vaginal delivery following induction due to fetal decels. cxr shows tip of catheter in RA,, line pulled back 1.5 cm.Infant tolerated procedure well. FIO2 has weaned to 21%. tone aga.CXR/KUB: UV line high--pulled back, lung findings c/w RDS.Labs: CBC with WBC=11, 45 P 1 B, crit=42%, plt=297 blood culture sent first blood gas after intubation: 7.33/42/35Imp/Plan: 29 week AGA infant with HMD, hypotension, hypoglycemia, and possible sepsis.--transfer to 7N--wean vent as tolerated, further surfactant doses if infant with elevated MAP and/or high FiO2--NPO, continue IVF D10W at 80 cc/kg/d, monitor dstx closely--monitor BP closely, may require dopamine if hypotension persists.if hypotension persists will need arterial line.--start amp and gentamicin due to possible sepsis, particularly in setting of PTL, hypoglycemia and hypotension. PKU drawn.ID: SEPSIS: CBC w/ Diff + blood cx sent- results are pending. Skin is intact.Plan- for transfer to TCH via TCH transport team Pt ready for transfer. tube secured with 8at upper lip. 3.5 double lumen uvc inserted into umbilical vein and advanced to 9 cm. Map's again drifted to 25-28- re'd first NS bolus (12cc) at 1835 via UVC. Born quickly via NVD. Eyes are open- rec'd erythro ointment and Vit K injection as ordered. line draws back and flusbes easily. Hr 130-150's.F&N: BW-1.190gms. Neonatology at delivery--infant emerged active, cyanotic with increased respiratory distress requiring initial PPV and then CPAP. Attending MD called transport team from TCH and they are en route.VSS. Placed on SIMV- current support of 16/5 x 20. BP and D/S stable. Intial D/s- 36- rec'd D10W bolus at 1840. No complications.Umbilical arterial line attemped X 2 both lines false tracked. Voided since birth. Apgars 6,7. Parents in to visit and transfer consent obtained. Venous gas drawn PO2 35 CO2 42 PH 7.33 rate decreased to 16. Unsuccessful with UA line placement.Infant noted to be hypotensive requiring 2 normal saline boluses (first BP with mean of 25, repeat mean of 30);infant also received 2 glucose boluses for initial dstx of 36, repeat of 48. repeat after 2nd bolus pendingInfant started on IVF at 100cc/kg/dCurrent vent settings of 17/5 x 16 RA with oxygen sat=97%, s/p 1 dose of surfactantPE: wt=1190g (25-50%), L=41 cm (75%), HC=26.5 cm (25-50%) active, intubated infant, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mild ic/sc retx. + Pectis noted.CV: Poor perfusion. NNP aware. Parents given directions and phone number for 7N at TCH. MAp's unchanged- rec'd second bolus at 1850. breath sounds equal, abdomen soft, nontender, nondistended, ext warm, initially decreased perfusion, now improved. Brought to NICU for further care.Upon arrival, infant intubated due to increased work of breathing. GBS unknown, no maternal fever, ROM > 24 hours. length of treatment to be determined based on blood culture results and clinical course.--will need to recheck CXR to recheck UV line placement maternal antibiotics > 4 hours prior to delivery. Equal breath sounds and good chest wall movement present. PTL with PPROM on at 1:30 prompting betamethasone administration due to concern for delivery; infant given 2 doses (2nd dose 6/7 at 8 am), maternal amp and erythro due to PTL but no signs of chorio. Mother was transferred from today due to PROM. full. Infant emerged crying weakly. Infant is only slightly active. Breath sounds are coarse/ crackly. Neonatology Attending Admit and Transfer Note:29 week infant with respiratory distress admitted to NICU for evaluation/care and being transferred to NICU due to lack of beds at NICU.Infant born to a 39 year old G3P1 mother blood type A positive, antibody negative, HepBSAg negative, RPR NR and RI. Unable to place UAC. No meconium passed.

6

[ { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912316, "text": "NICU NURSING ADMISSION NOTE\n Baby is 29wk infant born at . Mother had progressive PTL, infant had decels. Born quickly via NVD. Infant emerged crying weakly. Received stim, BMV and bulb sxn'ing. Apgars 6,7. Infat briefly shown to parents and then transported to NICU.\n\nRESP: Infant was intubated w/ #3ETT- received first dose of Survanta at 1815. Placed on SIMV- current support of 16/5 x 20. FIO2 has weaned to 21%. Breath sounds are coarse/ crackly. + intercostal/subcostal retractions.RR 60's. + Pectis noted.\n\nCV: Poor perfusion. Initial BP 36/19(25). Smaller cuff placed on infant- 44/25(30). Map's again drifted to 25-28- re'd first NS bolus (12cc) at 1835 via UVC. MAp's unchanged- rec'd second bolus at 1850. Hr 130-150's.\n\nF&N: BW-1.190gms. Intial D/s- 36- rec'd D10W bolus at 1840. Voided since birth. No meconium passed. DUVC placed. To begin D10w w/ .5u heparin/cc at 80cc/kg/d once line placement is confirmed. Unable to place UAC. PKU drawn.\n\nID: SEPSIS: CBC w/ Diff + blood cx sent- results are pending. To begin Amp/ Gent as ordered.\n\nDEV: Initial temp - 96.9 rectally- warmed to 97.9 axillary. Infant is only slightly active. Eyes are open- rec'd erythro ointment and Vit K injection as ordered. Skin is intact.\n\nPlan- for transfer to TCH via TCH transport team\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912317, "text": "Neonatology NP Procedure Note\nEndotracheal Intubation\nIndication: surfactant deficiency\n3.0 ETt placed orally through cords under direct laryngoscopy. tube secured with 3.0 at upper lip. Equal breath sounds and good chest wall movement present. tube secured with 8at upper lip. CXR shows tip of tube ~ 2 cm above carina.\nInfant tolerated procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912318, "text": "Neonatology NP Procedure Note\nPlacement of umbilical venous catheter\nIndication : need for longterm IV therapy.\nUmbilical area prepped and draped. 3.5 double lumen uvc inserted into umbilical vein and advanced to 9 cm. line draws back and flusbes easily. cxr shows tip of catheter in RA,, line pulled back 1.5 cm.\nInfant tolerated procedure well. No complications.\n\nUmbilical arterial line attemped X 2 both lines false tracked.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912319, "text": "Neonatology Attending Admit and Transfer Note:\n\n29 week infant with respiratory distress admitted to NICU for evaluation/care and being transferred to NICU due to lack of beds at NICU.\n\nInfant born to a 39 year old G3P1 mother blood type A positive, antibody negative, HepBSAg negative, RPR NR and RI. Mother was transferred from today due to PROM. Pregnancy noteable for bright spot on heart, decline amnio, 1 SAB and 1SVD in . PTL with PPROM on at 1:30 prompting betamethasone administration due to concern for delivery; infant given 2 doses (2nd dose 6/7 at 8 am), maternal amp and erythro due to PTL but no signs of chorio. Fetus with some decels today, BPP .\n\nPedi--, Clinic\n\nInfant delivered today at 1729 by vaginal delivery following induction due to fetal decels. GBS unknown, no maternal fever, ROM > 24 hours. maternal antibiotics > 4 hours prior to delivery. Neonatology at delivery--infant emerged active, cyanotic with increased respiratory distress requiring initial PPV and then CPAP. Brought to NICU for further care.\nUpon arrival, infant intubated due to increased work of breathing. double lumen UV line placed. Unsuccessful with UA line placement.\nInfant noted to be hypotensive requiring 2 normal saline boluses (first BP with mean of 25, repeat mean of 30);\ninfant also received 2 glucose boluses for initial dstx of 36, repeat of 48. repeat after 2nd bolus pending\nInfant started on IVF at 100cc/kg/d\nCurrent vent settings of 17/5 x 16 RA with oxygen sat=97%, s/p 1 dose of surfactant\n\nPE: wt=1190g (25-50%), L=41 cm (75%), HC=26.5 cm (25-50%) active, intubated infant, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mild ic/sc retx. breath sounds equal, abdomen soft, nontender, nondistended, ext warm, initially decreased perfusion, now improved. tone aga.\n\nCXR/KUB: UV line high--pulled back, lung findings c/w RDS.\nLabs: CBC with WBC=11, 45 P 1 B, crit=42%, plt=297\n blood culture sent\n first blood gas after intubation: 7.33/42/35\n\nImp/Plan: 29 week AGA infant with HMD, hypotension, hypoglycemia, and possible sepsis.\n--transfer to 7N\n--wean vent as tolerated, further surfactant doses if infant with elevated MAP and/or high FiO2\n--NPO, continue IVF D10W at 80 cc/kg/d, monitor dstx closely\n--monitor BP closely, may require dopamine if hypotension persists.\nif hypotension persists will need arterial line.\n--start amp and gentamicin due to possible sepsis, particularly in setting of PTL, hypoglycemia and hypotension. length of treatment to be determined based on blood culture results and clinical course.\n\n\n--will need to recheck CXR to recheck UV line placement\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912320, "text": "NPN -2100\nXray done to confirm placement of lines. NNP aware. D/S 48 at . D10W bolus given and subsequent D/S 78. D10W with hep infusing well via DLUVC. Gent and Ampi given. Parents in to visit and transfer consent obtained. Parents given directions and phone number for 7N at TCH. Attending MD called transport team from TCH and they are en route.\nVSS. BP and D/S stable. Pt ready for transfer.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-18 00:00:00.000", "description": "Report", "row_id": 1912321, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 16/5 rate 20 FiO2 21%. Venous gas drawn PO2 35 CO2 42 PH 7.33 rate decreased to 16. Baby to be to TCH due to B.I. full. Baby at 2115hrs.\n" } ]

22,508

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The patient underwent PTC by interventional radiology. Please refer the procedure report on line in the medical records for further details. Post procedure, the patient was admitted to the medical service for further observation. The surgical team was consulted for possible surgical intervention. During his overnight stay for observation, the patient experienced hypertension, going from blood pressure of 100/72 post procedurally to pressure of 85 over palpable. Hematocrit drifted down preprocedurally from 43.7 to 26.7. The patient was complaining of right upper quadrant pain, weakness and nausea, which was confirmed on physical examination showing right upper quadrant tenderness to light palpation. The patient received Crystalloid resuscitation of two units of PRBC's and was transferred to the Intensive Care Unit for further management. A CAT scan study after the patient was stabilized showed a large, subhepatic hematoma, measuring three cms in thickness. Intrahepatic biliary ductal dilatation to the level of the common hepatic duct was also seen. During his resuscitation, the patient received a total of four units of PRBC's, three units of FFP and one unit of platelets. The patient remained normotensive with stable hematocrit and was transferred to the Intensive Care Unit on hospital day number eight. The patient was also receiving Levaquin p.o. prophylactically, status post manipulation of the biliary system. Once on the floor and stable, the patient received PTC of the left side to finish decompression of his biliary system, considering his elevation of the total bilirubin level. The patient underwent left sided PTC by interventional radiology without any complications. A repeat CAT scan of the abdomen revealed a stable, subcapsular, hepatic hematoma which had not changed in size. There was no evidence of active extravasation. Transthoracic echocardiogram noted a possible pericardial effusion and this was evaluated with CT of the chest which showed no pericardial effusion but worsening of the right pleural effusion which extends across the posterior mediastinum. There was also a small effusion on the left. The patient underwent a thoracentesis of the right chest, draining 1.5 liters of old clotted blood. The patient underwent the procedure without any complications. Considering his differential diagnosis of primary sclerosing cholangitis versus Klatskin tumor, the patient underwent ultrasound guided needle biopsy of the liver. The procedure was completed without any complications. The pathology and the cytology came back negative for malignant cells. The patient was discharged on hospital day number 13, stable, without any complaints.

SG catheter terminates in right ventricular outflow tract. A pulmonary artery catheter has been placed, and terminates in the region of the right ventricular outflow tract. 11:37 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY Reason: r/o internal bleed. IMPRESSION: (Over) 11:37 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY Reason: r/o internal bleed. He was noted on an MRCP to have a dilated left hepatic duct and multiple abnormal right hepatic ducts and the question of a mass in the common duct just below the bifurcation. 2) Persistant subcapsular hepatic hematoma. Intrahepatic biliary ductal dilatation to the level of the common hepatic duct. The right ducts are noted to have multisegmental disease throughout however a biliary drainage catheter has been placed from the right with inadequate drainage on the right lobe. A right internal jugular vascular catheter has been placed, terminating in the lower SVC near the junction of the right atrium. The injection of contrast material revealed a stricture of the common duct and a small collapsed common duct extending toward the ampulla. Liver hematoma post PTC now with new pulmonary and pericardial effusion. Injection of contrast material outlined multiple small abnormal ducts in the central area of the right lobe and on the lateral view this was seen to be anteriorly almost certainly representing the medial segment of the left lobe or the anterior segment of the RUL(segment 5). TECHNIQUE: Helically-acquired contiguous axial images of the abdomen and pelvis were obtained without and after intravenous administration of contrast. Discoid atelectasis left mid and lower lung zone. Injection of contrast material revealed filling of a single irregular duct going posteriorly in the liver. Within the upper abdomen, note is made of contrast within the gallbladder and a drainage catheter in the right upper quadrant. LEFT ductal system FINAL REPORT INDICATION: Status post hepatic subcapsular hematoma after PTC placement. The obstructing mass lesion of the common hepatic duct identified on MR is not as clearly seen on this exam. Mild (1+) mitral regurgitation is seen. Otherwise hemodynamics stable overnight.RESP: LSCTA. Mild (1+)mitral regurgitation is seen.TRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. Moderate [2+]tricuspid regurgitation is seen. tolerates lying flat wo co. cv=initially borderline hypotensive w maps <60, pads , w 9, cvp 5-6 & co/ci/svr 6.8/3.76/595-initially rxed w total 1l ns w sl improvement. CCU NPN: please see flowsheet for objective dataCardiac: hemodynamically stable no issuesResp: lungs clear,sats mid 90's RAGI: decreased drainage from biliary bag. IMPRESSION: 1) Stable appearance of subcapsular hepatic hematoma. The leftventricular cavity size is normal.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - akinetic; mid inferior - akinetic; septal apex -hypokinetic; inferior apex - akinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal. There is abnormal diastolic septal motion/position consistent withright ventricular volume overload.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild pulmonary artery systolichypertension. heme=hct stable-34.8. PAP's remain low.Resp: Lungs CTA. There is interval decrease in the amount of pneumobilia but persistent mild intrahepatic biliary dilatation. Inferior myocardial infarction of indeterminate age.Clinical correlation is suggested. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is a large pericardial effusion. There is abnormaldiastolic septal motion/position consistent with right ventricular volumeoverload. 4) Continued presence of biliary stents, pneumobilia, and mild intrahepatic biliary dilatation. Resting regional wall motionabnormalities include inferior akinesis with inferoseptal hypokinesis. If hemodynamically stable overnight swan will be dc'd in am. incisional pain unchanged . Left ventricular wall thicknesses arenormal. cultured-bl & urine (low svr).a:hypotensive w <hct-responded to rbc & calcium.p:follow lung assessment-watch for failure. pulm=breath sounds=clear. Abd softly distended with BS times four quadrants. r biliary drain intact-drained 105 dk bilious drainage. The left ventricular cavity size is normal. GI WISE POS BS ABD SOFT, R FLANK DSG DRY AND INTACT DRAIN PUT OUT 240CC BILE THIS SHIFT HO AWARE, PT STARTED ON PROTONIX SKIN INTACT BUT JAUNDICE PEDAL PULSES DIFF TO DOPPLER, NO ANASARCA NOTED. T-tube to gravity and draining bilious in moderate amounts.Tolerating POS well.ID: Afebrile. passing flatus-wo bm. inr > from 1.1 to 1.4-rxed w 1uffp & 5mg vit k--am labs donot reflect rx. The aortic valve leaflets (3) appear structurally normal with goodleaflet excursion and no aortic regurgitation. There is diverticulosis but no diverticulitis. The effusion appearsloculated. The effusion appearsloculated. RESP WISE PT'S LUNGS CLEAR ON LEFT DIMINISHED ON R WITH FEW CRACKLES INITIALLY PT ON ARRIVAL HAD EXP WHEEZES , PT CONT ON RA SAT'S 97%. contin to co sl abd discomfort-rlq. Inferior myocardial infarction - age undetermined.Lateral T wave changes offer additional evidence of ischemia. The mitral valve leaflets arestructurally normal. ?dc pa-line--chg to mlc. CT PELVIS AFTER IV CONTRAST: A small amount of high density free fluid is seen in the pelvis, decreased from the prior exam.

24

[ { "category": "Radiology", "chartdate": "2185-07-08 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 795990, "text": " 11:37 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY\n Reason: r/o internal bleed. please do both CT and CT angio\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p PCA and plasty of CBD stricture (likely cholangioca)\n REASON FOR THIS EXAMINATION:\n r/o internal bleed. please do both CT and CT angio\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post PCA and CBD plasty. Decreased hematocrit.\n\n TECHNIQUE: Helically-acquired contiguous axial images of the abdomen and\n pelvis were obtained without and after intravenous administration of contrast.\n\n CONTRAST: 70 cc Optiray.\n\n COMPARISON: MR .\n\n CT ABDOMEN W/O AND W/ CONTRAST: There is a large subcapsular hepatic hematoma\n measuring 3 cm in thickeness. The hematoma is high attenuation, reflecting\n the subacute stage. Dependent within the hematoma is a layer of high-density\n material, which may be either acute layering blood or contrast given during\n the recent procedure. There is no active extravasation of contrast\n material. The liver is displaced towards the midline by pressure effect. The\n liver enhances homogeneously.\n There is diffuse intrahepatic biliary ductal dilatation involving both lobes.\n The percutaneous biliary drainage catheter enters the right lobe of the liver\n travelling into the CBD, and terminates in the duodenum. Pneumobilia from\n recent intervention is seen in the left lobe of the liver. The obstructing\n mass lesion of the common hepatic duct identified on MR is not as clearly\n seen on this exam. There is mild thickening of the common hepatic duct wall.\n Vicarious excretion of contrast material is within the gallbladder. A focus\n of gas is seen within the gallbladder.\n\n The pancreas, spleen, adrenal glands and kidneys are unremarkable. Ascites is\n distributed around the spleen, abdomen and pelvis. Small and large bowel are\n normal in caliber without bowel wall thickening or dilatation.\n\n CT OF THE PELVIS: There is a balloon Foley catheter is within the bladder. A\n gas- fluid level is seen within the bladder. The prostate is enlarged at 4.7\n x 3.4 cm.\n\n There are small bilateral pleural effusions with adjacent atelectasis, right\n greater than left.\n\n BONE WINDOWS: No blastic or lytic lesions identified.\n\n IMPRESSION:\n (Over)\n\n 11:37 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CC NON IONIC CONTRAST SUPPLY\n Reason: r/o internal bleed. please do both CT and CT angio\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Large subacute subcapsular hepatic hematoma. No evidence for active\n bleed.\n\n 2. Intrahepatic biliary ductal dilatation to the level of the common hepatic\n duct. No extrahepatic biliary tree mass is identified.\n\n Findings discussed with the surgical team prior to dictation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-07 00:00:00.000", "description": "INTRO PERC TRNASHEPATIC STENT", "row_id": 795836, "text": " 7:43 AM\n PTBD Clip # \n Reason: CHOLANGIO CA\n Contrast: OPTIRAY Amt: 80CC\n ********************************* CPT Codes ********************************\n * INTRO PERC TRNASHEPATIC STENT BILIARY STRICTURE DILATION NO *\n * -51 MULTI-PROCEDURE SAME DAY PERC TRANSHEPATIC CHOLANGIOGRA *\n * -51 MULTI-PROCEDURE SAME DAY CATH/STENT FOR INT/EXT BILIARY *\n * BILIARY STRICTURE DILATION NO -59 DISTINCT PROCEDURAL SERVICE *\n * PERC TRANSHEPATIC CHOLANGIOGRA CATH, TRANSLUM ANGIO NONLASER *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n This is a 64 y/o man who presents with jaundice and a bilirubin of 12. He was\n noted on an MRCP to have a dilated left hepatic duct and multiple abnormal\n right hepatic ducts and the question of a mass in the common duct just below\n the bifurcation.\n\n Informed consent was obtained and the patient was prepped and draped. A\n puncture was then made into the right duct system and contrast material\n outlined a dilated duct near the hilum of the liver that could either\n represent the left or right duct. Injection of contrast material revealed\n filling of a single irregular duct going posteriorly in the liver. It was\n decided to enter this duct peripherally and after the duct was punctured far\n posteriorly a glide wire was passed through the dilated structure in the\n central region. The injection of contrast material revealed a stricture of\n the common duct and a small collapsed common duct extending toward the\n ampulla.\n\n Because this duct was not deemed adequate three other punctures were made; two\n very high in the right lobe without success although one duct was entered. It\n did not connect with the hilum because of obstruction peripheral to the hilum\n but central to the puncture. Injection of contrast material outlined multiple\n small abnormal ducts in the central area of the right lobe and on the lateral\n view this was seen to be anteriorly almost certainly representing the medial\n segment of the left lobe or the anterior segment of the RUL(segment 5). There\n was no filling of the dilated left hepatic duct and actually no contra\n st material in ducts in segments 6 or 7 and 8.\n\n It was then decided to use the only accessible duct and eventually the\n stricture centrally in what would appear to be the right duct system was\n entered and passed into the common duct. The stricture just below the\n bifurcation was dilated partially with an 8 mm balloon and an 8.5 biliary\n catheter was placed in satisfactory position for drainage. Over approximately\n 5 days the tube continues to drain and Mr. has been scheduled for a\n drainage of the left duct system and further evaluation of the right.\n\n Drainage of the Left duct system was accomplished on .\n\n\n\n (Over)\n\n 7:43 AM\n PTBD Clip # \n Reason: CHOLANGIO CA\n Contrast: OPTIRAY Amt: 80CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 1556687, "text": "\"IM COLD\"\nAT 10AM PT TRANSFERRED FROM CC7. PT HYPOTENSIVE, OVERNIGHT AND MORE SO THIS AM RECEIVED 1.5 LITERS OOVER NIGHT AND AN ADDITIONAL 500CC BOLUS PRIOR TO COMING TO CCU ONLY 175CC URINE OUT. PT C/O NAUSEA AND PAIN AT DRAIN SITE.\nWHEN PT ARRIVED TO CCU HE WAS JAUNDICE SCLERA INVOLVED ALSO, HAD 1ST UNIT OF BLOOD AND A LITER OF NS WIDE OPEN. 15 MINUTES LATER 2ND UNIT OF BLOOD UP WIDE OPEN. PT SHIVERING C/O HE WAS COLD TEMP 97.5 PO.\nSICU TEAM ACCOMPANIED PT ON ARRIVAL R RADIAL ALINE PLACED W/O DIFFICULTY AND THEN R IJ PLACED PA LINE FLOATED IN W/O DIFFICULTY PT TOLERATED WELL.\nPORT CXR DONE PA LINE ADVANCED D/T PLACEMENT SHOWN ON XRAY. PT TAKEN TO CT SCAN TO ASSESS PROBABLE SUBCAPSULAR LIVER HEMATOMA AFTER PTC PROCEDURE. LABS DRAWN AT 11AM STAT HCT WAS 34.3% PT 1 BAG OF PLATELETS PRE BAG PLTS 276 GIVEN BECAUSE PT WAS ON ASA AND PLAVIX. FSBS WAS 100 AT 1P AND THEN AT 430P WAS 96. LABS DRAWN AT 3P HO AWARE OF RESULTS HCT 30.2% PT, PTT, INR WNL AND PLTS 245. HO SAW PT AT 430P INCREASED HCT TO BE DRAWN Q4 VS Q6 STARTING AT 5P. HO ASKED ABOUT GIVING PAIN MED TO PT - NOT AT THIS TIME NOT WANT TO MASK ANYTHING. PT SLEPT MOST OF AFTERNOON. WIFE IN ROOM WITH PT MOST AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-10 00:00:00.000", "description": "Report", "row_id": 1556692, "text": "Nursing Progress Note\n\nCV: Tele sinus rhythm with occ PVC's. Swan dc'd changed to Triple lumen CXR shows good placement. Denies chest pain.\n\nResp: Lungs CTA. O2 sats 95-98% 2l.\n\nGU/GI: Diet advanced. Tolerating sm amts of clear liquids. Not much of an appetite. Abd is soft with bowel sounds. Passing flatus. Biliary drain to gravity. RLQ pain with palpation. OOB to chair tolerated well. Hct 34 for 24hrs.\n\nA&P: Hct remains stable. To remain in unit for observation overnight then transfer to floor in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-11 00:00:00.000", "description": "Report", "row_id": 1556693, "text": "ccu nsg progress note-nsicu border.\no:cv=hemody stable throughout night.\n gi=bm x1-semiformed guiac neg. prior to & after co increased abdominal discomfort (not simular to rlq discomfort) more located around umbilicus. nsicu resident notified. hct/plat stable 35.7/205. ast/alt/alk phos sl elevated.\n id=afebrile. wbc 7.3.\n labs=k 3.6. cal 8.1. phos 1.9.\n\na:new onset abd discomfort.\n\np:abd to be evaluated. am labs need to be addressed. contin present management.\n" }, { "category": "Radiology", "chartdate": "2185-07-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796904, "text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check for pneumo, size of the effusion\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with bile obstruction, s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n please check for pneumo, size of the effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis.\n\n CHEST, AP PORTABLE: There is interval withdrawal of right IJ central line.\n There is a slight reduction of the left pleural effusion. There is no\n evidence of pneumothorax. There is a small right pleural effusion. The left\n hemidiaphragm is not well-visualized, consistent with a left lower lobe\n collapse/consolidation.\n\n IMPRESSION: There is slight reduction in the size of the left pleural\n effusion, without evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 796809, "text": " 8:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate pericardial effusion\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with liver bleed post PTC, now w/ new pulm and pericardial\n effusions\n REASON FOR THIS EXAMINATION:\n evaluate pericardial effusion\n CONTRAINDICATIONS for IV CONTRAST:\n renal function\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pericardial effusion with loculation seen on cardiac echo today.\n Please evaluate further. Liver hematoma post PTC now with new pulmonary and\n pericardial effusion. Please evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast CT of the chest.\n\n FINDINGS: There is minimal thickening of the pericardium anteriorly, however,\n there is no pericardial effusion. The pleural space on the right, which is\n filled with intermediate density fluid, extends across the posterior\n mediastium and perhaps explains in part the finding on echocardiography. There\n is also some loculated fluid extending along the medial border of the pleural\n space on the right. There are portions of this large effusion which do appear\n loculated. There a smaller effusion on the left. There is adjacent compressive\n atelectasis but no true consolidative change seen within the lungs. There may\n be a left sided Bochdalek hernia containing fat. The airways are patent\n centrally. There is no mediastinal adenopathy and the heart is not enlarged.\n The bones reveal minor degenerative changes in the spine.\n\n The imaged organs of the upper abdomen are described in detail on the CT of\n the abdomen performed earlier today.\n\n IMPRESSION: No CT evidence for pericardial effusion. Finding on\n echocardiogram may be explained by extension of the right pleural space across\n the spine in the posterior mediastinum containing loculated fluid.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-15 00:00:00.000", "description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER", "row_id": 796686, "text": " 9:24 AM\n CATH CHEK/REMV Clip # \n Reason: R tube not flashing, please evaluate\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: CONRAY Amt: 30\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C -76 BY SAME PHYSICIAN *\n * TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ? klatzkin tumor\n REASON FOR THIS EXAMINATION:\n R tube not flashing, please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n This is a 63 year old man with a Klatzkin tumor who required a biliary\n catheter check because the tube did not appear to be flushing adequately.\n Patient was brought to the interventional suite and prepped and draped.\n Contrast material was injected into the biliary tree that showed good position\n and complete drainage of the biliary system.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796179, "text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check new line position\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with PA line changed over wire to cvl\n REASON FOR THIS EXAMINATION:\n Check new line position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INDICATION: Line placement.\n\n Comparison is made to previous radiograph of 2 days earlier.\n\n A right internal jugular vascular catheter has been placed, terminating in the\n lower SVC near the junction of the right atrium. No pneumothorax is\n identified. Cardiac and mediastinal contours are stable. There are bilateral\n small pleural effusions, increased on the left and new on the right. There are\n also increasing opacities in the retrocardiac region bilaterally.\n\n IMPRESSION:\n 1) Vascular catheter in satisfactory position, with no pneumothorax.\n 2) Bilateral pleural effusions, increased on the left and new on the right.\n Adjacent basilar lung opacities likely reflect atelectasis, but other process\n such as an infection cannot be excluded in the appropriate setting.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-14 00:00:00.000", "description": "INTRO PERC TRNASHEPATIC STENT", "row_id": 796567, "text": " 8:14 AM\n PTC Clip # \n Reason: LEFT BILIARY DRAINAGE\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * INTRO PERC TRNASHEPATIC STENT -58 SERVIC BY SAME MD DURING POST OP *\n * BILIARY BIOSPY VIA T-TUBE 78 RELATED PROCEDURE DURING POSTOPER *\n * -51 MULTI-PROCEDURE SAME DAY BILIARY STRICTURE DILATION NO *\n * 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY *\n * CHALNAGIOGRAPHY VIA EXISTING C -76 BY SAME PHYSICIAN *\n * -51 MULTI-PROCEDURE SAME DAY CATH/STENT FOR INT/EXT BILIARY *\n * BILIARY STRICTURE DILATION NO -59 DISTINCT PROCEDURAL SERVICE *\n * TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n 63 year old male who enters with an ERCP and MRCP.\n\n A tube cholangiogram was performed via the indwelling right biliary drainage\n catheter. The right ducts are noted to have multisegmental disease\n throughout however a biliary drainage catheter has been placed from the right\n with inadequate drainage on the right lobe. The left biliary tree was noted\n to continue to be markedly dilated and under ultrasound guidance a needle was\n passed into the left biliary tree. After the ducts were filled a second\n puncture was made more peripherally into the left ducts outlining marked\n dilatation and obstruction of the ducts at the bifurcation of the superior and\n inferior segments of the lateral segment of the left lobe. The small\n guidewire was then passed into the left biliary tree to the obstruction into\n the common bile duct after which the small sheath was exchanged for a 7 French\n bright-tipped sheath and the obstruction dilated with an 8 mm balloon. The\n balloon was removed as well as the sheath and an 8 French biliary drain was\n placed with the pigtail coiled in the duodenum. The sideports of the biliary\n drainage catheter were left in satisfactory position to drain internally the\n left duct system.\n\n CONCLUSION: S/P balloon dilatation of a stricture which appears malignant.\n Biopsies were also taken prior to biliary tube placement. The material sent\n to the Pathology lab for histology. The appearance on the biliary tree is\n that of sclerosing cholangitis and primary carcinoma of the bile ducts in the\n position that would be called a Klatzkin tumor.\n\n\n\n\n\n\n\n\n (Over)\n\n 8:14 AM\n PTC Clip # \n Reason: LEFT BILIARY DRAINAGE\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2185-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 795985, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, check PA placement\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new RIJ PA line\n REASON FOR THIS EXAMINATION:\n r/o PTX, check PA placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Pulmonary artery catheter placement.\n\n A pulmonary artery catheter has been placed, and terminates in the region of\n the right ventricular outflow tract. No pneumothorax is evident. The heart\n size and mediastinal contours are within normal limits for technique. Linear\n opacities are seen in the left mid and lower lung zones. There is also slight\n blunting of the left costophrenic sulcus. Biapical thickening is noted and\n may relate to apical pleural thickening or fluid tracking to the apices on\n this supine projection.\n\n Within the upper abdomen, note is made of contrast within the gallbladder and\n a drainage catheter in the right upper quadrant.\n\n IMPRESSION:\n\n 1. SG catheter terminates in right ventricular outflow tract.\n 2. Discoid atelectasis left mid and lower lung zone.\n 3. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-12 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 796353, "text": " 10:11 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: evaluate liver and biliary system, esp. LEFT ductal system\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p hepatic subcapsular hematoma after PTC placement\n REASON FOR THIS EXAMINATION:\n evaluate liver and biliary system, esp. LEFT ductal system\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hepatic subcapsular hematoma after PTC placement.\n Evaluate biliary ductal system.\n\n COMPARISON: There are no prior examinations for comparison.\n\n FINDINGS: The liver is grossly normal in echogenicity. There is a large\n subcapsular hematoma measuring 2.3 cm in thickness. There is no intrahepatic\n or extrahepatic biliary ductal dilatation. The common bile duct is normal at\n 3 mm. The gallbladder wall is thickened, however the gallbladder is\n contracted. No gallstones are identified. A drainage catheter is seen\n traversing through the right lobe of the liver. No focal hepatic lesions\n identified.\n\n IMPRESSION:\n 1) No evidence for biliary ductal dilatation.\n 2) Persistant subcapsular hepatic hematoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-07-16 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 796796, "text": " 12:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Evaluate for effusions/pericardial effusion. Evaluate liver\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Klatskin tumor, s/p liver bleed post PTC\n REASON FOR THIS EXAMINATION:\n Evaluate for effusions/pericardial effusion. Evaluate liver hematoma. (C+)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH IV CONTRAST\n\n CLINICAL INDICATION: Klatskin tumor, post PTC.\n\n TECHNIQUE: Helically aquired images are obtained through the abdomen and\n pelvis after 150 cc Optiray.\n\n CONTRAST: Nonionic contrat was chosen because of the patient's generalized\n debility.\n\n Comparison is made to study of .\n\n CT ABDOMEN AFTER IV CONTRAST: There is a moderate/large sized right pleural\n effusion and a small left effusion, both larger since the prior exam. There\n is associated bibasilar atelectasis. The superior aspect of the pericardium\n is not imaged but there is no visualized pericardial effusion. The patient\n has left and right sided internal/external biliary drains which terminate in\n the duodenum. There is interval decrease in the amount of pneumobilia but\n persistent mild intrahepatic biliary dilatation. A subcapsular hepatic\n hematoma is not changed in size. There is no evidence of active extravasttion\n (would be indicated by extravasation of contrast). There is some residual high\n density material within the gallbladder and a small amount of air is also seen\n within the gallbladder. The spleen, adrenal glands, and kidneys appear\n normal. There is a parapelvic cyst in the left kidney. The pancreas enhances\n homogeneously. There is no interval pancreatic duct dilatation. The portal\n vein, splenic vein, SMV, and SMA are patent. There is no adenopathy within the\n abdomen.\n\n CT PELVIS AFTER IV CONTRAST: A small amount of high density free fluid is\n seen in the pelvis, decreased from the prior exam. The ureters are\n nondilated. The bladder is not thickened. There is diverticulosis but no\n diverticulitis. There are no pelvic masses or enlarged inguinal lymph nodes.\n There are no suspicious lytic or blastic osseous lesions.\n\n IMPRESSION:\n 1) Stable appearance of subcapsular hepatic hematoma.\n\n 2) Interval worsening of bilateral pleural effusions and associated\n atelectasis.\n (Over)\n\n 12:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Evaluate for effusions/pericardial effusion. Evaluate liver\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3) Decreae in amount of high density (likely bloody) ascites.\n\n 4) Continued presence of biliary stents, pneumobilia, and mild intrahepatic\n biliary dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2185-07-18 00:00:00.000", "description": "BX-NEEDLE LIVER BY RADIOLOGIST", "row_id": 796925, "text": " 1:20 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)\n Reason: US GUIDED BX OF L HEPATIC LOBE. PT WITH CIRRHOSIS AND KLATSKIN TUMOR\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\ PTC/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Klatskins tumor, ? PSC.\n REASON FOR THIS EXAMINATION:\n (US-guided biopsy of L hepatic lobe) cirrhosis, tumor.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND GUIDED LIVER BIOPSY :\n\n HISTORY: Abnormal LFTs.\n\n TECHNIQUE & FINDINGS: Alternatives, benefits and risks, including infection\n and bleeding, were explained to the patient. Informed consent was obtained.\n Skin was prepped and draped in the usual sterile manner. Local anesthesia was\n infiltrated. Left lobe of the liver was localized using ultrasound guidance,\n an 16 gauge core biopsy of the liver was performed. Patient tolerated the\n procedure well without immediate complications.\n\n IMPRESSION: Successful ultrasound guided biopsy of the left lobe of the liver.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 1556688, "text": "PT A/O, CARDIAC WISE SR OCC PVCS 60-70, ALINE PRESSURES 80-100'S SYS\nDIPS WHEN HE IS SLEEPING HO AWARE. PA PRESSURES 20'S/TEENS PWCP 14 CVP 4. RESP WISE PT'S LUNGS CLEAR ON LEFT DIMINISHED ON R WITH FEW CRACKLES INITIALLY PT ON ARRIVAL HAD EXP WHEEZES , PT CONT ON RA SAT'S 97%. GI WISE POS BS ABD SOFT, R FLANK DSG DRY AND INTACT DRAIN PUT OUT 240CC BILE THIS SHIFT HO AWARE, PT STARTED ON PROTONIX SKIN INTACT BUT JAUNDICE PEDAL PULSES DIFF TO DOPPLER, NO ANASARCA NOTED. URINE IN FOLEY DK YELLOW 70-100/HR AVERAGE.\nPLAN CONTINUE TO MONITOR HCT, RESP STATUS (HURTS TO TAKE DEEP BREATH)\nLEVEL OF PAIN, NEED FOR MAINTENCE MEDS (THYROID MED?)\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-09 00:00:00.000", "description": "Report", "row_id": 1556689, "text": "ccu nsg progress note-nsicu border.\no:neuro=alert/awake oriented. cooperative. very pleasant.\n pulm=initially on ra w sats low 90's-abg @ 2300 7.39/38/86/24/-1 w sat 95-nc added @ 2l--abg @ 0500 7.39/38/69/24/-1 w sat 95-nc increased to 4l. breath sounds=clear. wo co sob/dyspnea. tolerates lying flat wo co.\n cv=initially borderline hypotensive w maps <60, pads , w 9, cvp 5-6 & co/ci/svr 6.8/3.76/595-initially rxed w total 1l ns w sl improvement. hct found to be 27.5/26.5 down from 30.8-tx w total 2 u rbc & calcium/mg/k replaced w improvemnt in #'s-maps >60-70, pad 12-16, w 10, cvp 8 & co/ci/svr 7.3/4.03/723. rhythm sr w short pr occas/freq pvc's-episodes of sb w rate to mid 50's. synthroid restarted-tsh sent.\n gi=npo. r biliary drain intact-drained 105 dk bilious drainage.\n heme=hct <to 26.5-tx w 2urbc-reck pending. inr > from 1.1 to 1.4-rxed w 1uffp & 5mg vit k--am labs donot reflect rx.\n gu=foley. adeq uo. approx 4.8l positive overall.\n id=afebrile. cultured-bl & urine (low svr).\n\na:hypotensive w <hct-responded to rbc & calcium.\n\np:follow lung assessment-watch for failure. maint maps >60. #'s. maint hct >30 & follow inr. ck am labs-rx as indicated. contin present management. support as indicated.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-11 00:00:00.000", "description": "Report", "row_id": 1556694, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: hemodynamically stable HR 56-82 SB-SR,BP 126-146/61/88\n\nResp: lungs clear,sats on RA 92-94. pt experiencing pain with deep breaths\n\nGU: UO 35-90/hr biliary drain put out 500cc this shift\n\nComfort: having abd pain felt a little better after breakfast,team is aware. also having incisional pain,no pain meds ordered.\n\nA/P: called out,no beds\n pt may need pain meds as deep breathing is diff .\n" }, { "category": "Nursing/other", "chartdate": "2185-07-12 00:00:00.000", "description": "Report", "row_id": 1556695, "text": "CCU Nursing Progress Note: 1900-0700\nS-\"I just feel lousey.\"\n\nSEE CAREVUE FOR ALL VS AND OBJECTIVE DATA\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:A/O/X/3. Very pleasant and cooperative. C/o pain at inscion site and surgical team still denying pt of pain medication. Given Bendadryl to help sleep and sleeping comfortably overnight with tolerable pain.\nCV-HR 60s to 80s. NSR with very few PVCs. SBPs 100s to 130s. Otherwise hemodynamics stable overnight.\nRESP: LSCTA. Placed on 2L for RA Sat of 92-93%. Currently sating > 95%. Denies SOB but has inscional pain on deep inspiration.\nGU/GI: Foley DC'd and since has voided 300cc in urinal. Urine brown and clear in appearance. Abd softly distended with BS times four quadrants. T-tube to gravity and draining bilious in moderate amounts.\nTolerating POS well.\nID: Afebrile. No issues. Continues Abx empirically.\nACC: Aline and TLL dc'd and left with 2PIVs\nA/P: Transfer to floor when bed available.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-07-12 00:00:00.000", "description": "Report", "row_id": 1556696, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: hemodynamically stable no issues\n\nResp: lungs clear,sats mid 90's RA\n\nGI: decreased drainage from biliary bag. fair to poor appetite. incisional pain unchanged . c/o nausea this afternoon and received 2mg zofran.\n\nGU: voiding using urinal\n\nActivity: OOB x2 to chair. this am sat up in chair for 2hrs this am,less time at lunch\n\nID: afebrile\n\nA/P: stable awaiting floor bed\n" }, { "category": "Nursing/other", "chartdate": "2185-07-09 00:00:00.000", "description": "Report", "row_id": 1556690, "text": "Nursing Progress Note\n\n\nO: CV: Tele sinus to sinus brady with occ PVC's. See flow sheet for vital signs. PAP's remain low.\n\nResp: Lungs CTA. O2 sat 96-98% on 4l NP.\n\nGU/GI: Pt remains NPO. Abd is soft with bowel sounds present. C/o R LQ pain intermittently. G tube to gravity drained 400cc of bile. Denies nausea or vomiting. HCt 34/35. LFT's declining. TB 8.6. IV fluid decreased to 20/hr. Urine output > 80/hr.\n\nNeuro: Alert and oriented. MAE.\n\nA&P: Hct stable after 2 UPRBC's. Continue to monitor HCT Q4 overnight. If hemodynamically stable overnight swan will be dc'd in am.\n" }, { "category": "Nursing/other", "chartdate": "2185-07-10 00:00:00.000", "description": "Report", "row_id": 1556691, "text": "ccu nsg progress note-nsicu border.\no:neuro=slept. responsive/appropriate.\n pulm=breath sounds=clear.\n cv=hemody stable throughout night. see care view for #'s.\n gi=remains npo. contin to co sl abd discomfort-rlq. passing flatus-wo bm.\n gu-adeq uo.\n id=afebrile.\n heme=hct stable-34.8.\n labs=am sent. k 3.7 & phos 2.1.\n\na:stable throughout night.\n\np:contin present management. ?dc pa-line--chg to mlc. ?dc a-line. support as indicated.\n" }, { "category": "Echo", "chartdate": "2185-07-15 00:00:00.000", "description": "Report", "row_id": 72346, "text": "PATIENT/TEST INFORMATION:\nIndication: evaluate LV and PASP prior to possible liver transplant.\nHeight: (in) 68\nWeight (lb): 142\nBSA (m2): 1.77 m2\nStatus: Inpatient\nDate/Time: at 15:12\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - akinetic; mid inferior - akinetic; septal apex -\nhypokinetic; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal. There is abnormal diastolic septal motion/position consistent with\nright ventricular volume overload.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a large pericardial effusion. The effusion appears\nloculated. There are no echocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly decreased (LVEF 40%). Resting regional wall motion\nabnormalities include inferior akinesis with inferoseptal hypokinesis. Right\nventricular chamber size and free wall motion are normal. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+]\ntricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is a large pericardial effusion. The effusion appears\nloculated. There are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2185-07-08 00:00:00.000", "description": "Report", "row_id": 178299, "text": "Sinus bradycardia. Inferior myocardial infarction - age undetermined.\nLateral T wave changes offer additional evidence of ischemia. Since the\nprevious tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2185-07-07 00:00:00.000", "description": "Report", "row_id": 178300, "text": "Sinus bradycardia. Inferior myocardial infarction of indeterminate age.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n" } ]

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65yo F w/ widely metastatic breast cancer, on dexamethasone taper for brain metastases, and w/ bilat nephrostomy p/w SOB and fever w/ likely PNA +/- UTI. Given symptoms of fever, nonproductive cough, hypoxia, and CTA findings of new nodular and linear ground glass opacities, initially treated for pneumonia. Given her recent history of long hospitalizations and recent NH stay, will treat for health-care acquired pneumonia with cefepime, levaquin, and vancomycin. She was also presumably started on IV bactrim in the ER for ? of PCP (given that she was on dexamethasone) and new ground-glass opacities on CT, LDH elevated from baseline. Upon transfer to the ICU, the patient refused positive pressure ventilation, stating that she just wanted to be comfortable. After discussing the matter with her and the health care team, the patient was made comfort measures only. Antibiotics were discontinued and she was put on a morphine gtt to treat her sense of dyspnea. She expired at 4:50am on with her family at the bedside.

Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Infusions: Other ICU medications: heparin sc. URINE CULTURE (Pending): from L and R nephrosotomies Urine legionella PND BCx PND Assessment and Plan Hypoxia/respiratory distress with desats to mid 80s on NRB this AM. Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Meropenem, cipro, bactrim, vanco, prednisone. Chief Complaint: Hypoxia, hypotension HPI: For full details, please see admission H&P. Left mastectomy and multiple chemo regimens, including adria and cytoxan. Left mastectomy and multiple chemo regimens, including adria and cytoxan. Comfort care (CMO, Comfort Measures) Assessment: Action: Response: Plan: Pt was comfortable on morphine gtt .pt expired @ 0445 am . Upon arrival to ICU, pt was placed on droplet precautions. Upon arrival to ICU, pt was placed on droplet precautions. Will change ciprofloxacin to levofloxacin for atypical coverage. URINE CULTURE (Pending): from L and R nephrosotomies Urine legionella PND BCx PND Assessment and Plan Hypoxia/respiratory distress - presented with hypoxia most likely to infectious source. - will change ciprofloxacin to levofloxacin for atypical coverage. CXR was initially read as pneumonia of the RML and she was given cefepime 2gm IV x1 and levofloxacin 750mg IV x1. Patient admitted from: History obtained from Medical records Allergies: Codeine Unknown; Niacin Flushing; Flonase (Nasal) (Fluticasone Propionate) Headache; Last dose of Antibiotics: Bactrim (SMX/TMP) - 09:30 PM Ciprofloxacin - 10:17 PM Vancomycin - 11:17 PM Meropenem - 12:00 AM Infusions: Other ICU medications: Other medications: Medications on transfer: Zonisamide 100 mg PO BID Keppra 750 mg PO TID SQHeparin Protonix 40 mg PO Q12H Celexa 10 mg PO daily Nystatin Oral Suspension MVI Compazine PRN Vancomycin 1000 mg IV Q12H ISS Morphine IR 7.5 mg PO Q6H PRN Tylenol PRN Prednisone 40 mg PO BID Meropenem 500 mg IV Q6H Ciprofloxacin 400 mg IV Q12H Bactrim 400 mg IV Q12H Past medical history: Family history: Social History: 1. Assessment and Plan RESPIRATORY DISTRESS HYPOXEMIA HYPOTENSION PNEUMONIA METASTATIC BREAST CA ANEMIA THROMBOCYTOPENIA URINARY INFECTION CXR picture with diffuse, primarily upper zone infiltrates most suggestive of atypical pneumonia. ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 10:17 PM Indwelling Port (PortaCath) - 10:19 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Comfort measures only Disposition :ICU Total time spent: Patient is critically ill Anemia Chronic, will monitor. Anemia Chronic, will monitor. She was transferred to the for possible non-invasive ventilation (BiPAP) and closer hemodynamic monitoring. She was transferred to the for possible non-invasive ventilation (BiPAP) and closer hemodynamic monitoring. - f/u induced sputum to r/o PCP. Plan to d/c antibiotics, steroids, and add morphine prn dyspnea/pain. Plan to d/c antibiotics, steroids, and add morphine prn dyspnea/pain. - pt requesting to be comfortable andpass in peace, will change to CMO - will d/c all antibiotics and steroids for HCAP and PCP coverage Continue droplet precautions until influenza is ruled out - Continue oxygen support with NC and face mask, consider mask ventilation if tolerated. Metastatic Breast CA s/p several therapies Further management per primary oncologist. Metastatic Breast CA s/p several therapies Further management per primary oncologist. Since the previous tracingof sinus tachycardia is now present. Given recent hospitalizations, will cover broadly for HAP. - prn morphine Pneumonia As above Hypotension Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will send nasopharyngeal aspirate to r/o influenza. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. She was given cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Also given XRT to pelvic mets which led to hydronephrosis and bilateral neprhostomy tubes. Also given XRT to pelvic mets which led to hydronephrosis and bilateral neprhostomy tubes. Assessment and Plan RESPIRATORY DISTRESS HYPOXEMIA PNEUMONIA METASTATIC BREAST CA ANEMIA ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines / Intubation: 22 Gauge - 10:17 PM Indwelling Port (PortaCath) - 10:19 PM Comments: Prophylaxis: DVT: SQ UF Heparin Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: ICU Total time spent: 60 minutes Patient is critically ill

14

[ { "category": "ECG", "chartdate": "2121-01-04 00:00:00.000", "description": "Report", "row_id": 274006, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Since the previous tracing\nof sinus tachycardia is now present.\n\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317025, "text": "This is a 65 y/o female with metastatic breast cancer who lives in the\n NH where she was found to be hypoxic to 80% on RA, associated with\n nonproductive cough, SOB, nausea, abdominal pain and weakness. In the\n ED, Temp was 102.2, BP 142/86, HR 113, and sats 80% on RA, improving to\n 95% on 5LNC. CXR revealed ? pneumonia of the RML and she was given IV\n antibiotics vs PCP. was admitted on to the floor under\n oncology service with cough, SOB, and hypoxia.\n On the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. On the floor, in the PM , the patient triggered\n for hypoxia with an oxygen saturation of 90% on a NRB. She was also\n SOB. She is currently being treated for pneumonia, possible PCP\n pneumonia vs. HAP. She is on broad-spectrum ABx including Bactrim +\n steroids for PCP. was also found to be hypotensive earlier in the\n evening with SBPs in the 80s which also resulted in a trigger. She was\n given a 500 mL IVF bolus and her SBP improved to the 100s. Her code\n status was confirmed with the patient and her family, DNR/DNI. She was\n transferred to the for possible non-invasive ventilation (BiPAP)\n and closer hemodynamic monitoring. Upon arrival to ICU, pt was placed\n on droplet precautions. Oxygen administered via NRB 100% as well as NC\n 5 LPM which has maintained the sat above 90%, hence, the BiPAP has\n never been needed.\n Dyspnea (Shortness of breath)\n Assessment:\n Dyspneac, non-productive cough, sat 89-98%, afebrile, LS crackles\n throughout, anxious, and restless, c/o headache, BP dropped to low 80s.\n Action:\n Oxygen administered via NRB 100% and NC 5 LPM, respiratory status\n monitored very closely as pt pulls out the oxygen occasionally which\n results in desaturation to low 80s, given Tylenol for headache and\n Morphine Po as ordered PRN for restlessnesswith moderate effect, given\n a bolus of 250 cc NS, multiple antibiotics (Vancomycin, Bactrim,\n Ciprofloxacin, Levofloxacin, and Meropenam IV) administered.\n Response:\n Continues to be very restless, saturation maintained above 90% with O2\n on, tolerated fluids well, headache relieved, BP improved to systolic\n above 90.\n Plan:\n Monitor respiratory status very closely, wean Oxygen as tolerated to\n maintain sat above 90%, monitor BP and bolus as needed to maintain SBP\n above 82 as per HO, continue antibiotics, keep pt on droplet\n precautions to R/O the flue, may need deep tracheal suctioning to\n induce sputum to be sent for cx., consider administering anti-anxiety\n meds, reassure pt and keep her and family updated on her condition and\n POC. Pt is /DNR, no pressors as confirmed by pt, she also doesn\n like BiPAP as she reported but might consider, but definitely no\n intubation.\n" }, { "category": "Physician ", "chartdate": "2121-01-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 317017, "text": "Chief Complaint: 65 year old woman with metastatic breast ca,\n transferred to MICU with respiratory distress and hypoxemia, and\n hypotension.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Admitted yesterday with cough and shortness of breath to OMED\n yesterday. Tonight developed worsening hypoxemia and hypotension.\n Patient had several weeks of weakness at her nursing home. No hx of\n orthopnea or PND\n Initially came to ED with O2 sats in the 80's. Sent for CTA, which\n showed evidence of possible atypical pneumonia. Given Bactrim for\n possible PCP, with Cefipime, vanco, cipro, and steroids.\n Tonight O2 sats dropped. Placed on 100% NRB. Code status changed to\n DNR/DNI tonight. Transferred to MICU for possible non-invasive\n ventilation. Had BP in the 80's; responded to fluid resuscitation.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meropenem, cipro, bactrim, vanco, prednisone.\n Past medical history:\n Family history:\n Social History:\n Metastatic breast ca - dx . Left mastectomy and multiple chemo\n regimens, including adria and cytoxan. Developed bone mets in .\n Brain mets in --given whole brain radiation. Also given XRT to\n pelvic mets which led to hydronephrosis and bilateral neprhostomy\n tubes. Brain mets recurred in treated with cyberknife. On seizure\n prophylaxis.\n Nephrostomy tube for hydronephrosis\n Hypertension\n Cataracts\n L-hip replacement\n s/p carpal tunnel release.\n Occupation:\n Drugs:\n Tobacco: Former smoker\n Alcohol: Occasional\n Other: Divorced\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Signs or concerns for abuse : No\n Pain location: Hip\n Flowsheet Data as of 11:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 80 () bpm\n BP: 103/57\n RR: 22 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 60 mL\n PO:\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -290 mL\n Respiratory\n O2 Delivery Device: High flow nasal cannula, High flow neb\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90\n 28.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:// INR 1, Differential-Neuts:69, Band:20,\n Lactic Acid:1.9, LDH:795, Ca++:8, Mg++:1.7, PO4:3.0\n Fluid analysis / Other labs: UA - moderate bacteria, WBC's, leukocyte\n esterase from nephrostomy tube\n Imaging: CXR - interstitial to alveolar infiltrates bilaterally.\n CT - bilateral, primarily in upper zone- ground glass opacities. Region\n of atelectasis right mid zone. Probable new liver met.\n Assessment and Plan\n RESPIRATORY DISTRESS\n HYPOXEMIA\n PNEUMONIA\n METASTATIC BREAST CA\n ANEMIA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 317018, "text": "Chief Complaint: 65 year old woman with metastatic breast ca,\n transferred to MICU with respiratory distress and hypoxemia, and\n hypotension.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Admitted yesterday with cough and shortness of breath to OMED\n yesterday. Tonight developed worsening hypoxemia and hypotension.\n Patient had several weeks of weakness at her nursing home. No hx of\n orthopnea or PND\n Initially came to ED with O2 sats in the 80's. Sent for CTA, which\n showed evidence of possible atypical pneumonia. Given Bactrim for\n possible PCP, with Cefipime, vanco, cipro, and steroids.\n Tonight O2 sats dropped. Placed on 100% NRB. Code status changed to\n DNR/DNI tonight. Transferred to MICU for possible non-invasive\n ventilation. Had BP in the 80's; responded to fluid resuscitation.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications: heparin sc.\n Other medications:\n Meropenem, cipro, bactrim, vanco, prednisone.\n Past medical history:\n Family history:\n Social History:\n Metastatic breast ca - dx . Left mastectomy and multiple chemo\n regimens, including adria and cytoxan. Developed bone mets in .\n Brain mets in --given whole brain radiation. Also given XRT to\n pelvic mets which led to hydronephrosis and bilateral neprhostomy\n tubes. Brain mets recurred in treated with cyberknife. On seizure\n prophylaxis.\n Nephrostomy tube for hydronephrosis\n Hypertension\n Cataracts\n L-hip replacement\n s/p carpal tunnel release.\n Occupation:\n Drugs:\n Tobacco: Former smoker\n Alcohol: Occasional\n Other: Divorced\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Dyspnea, Tachypnea\n Signs or concerns for abuse : No\n Pain location: Hip\n Flowsheet Data as of 11:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 80 () bpm\n BP: 103/57\n RR: 22 ()\n SpO2: 98\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 60 mL\n PO:\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -290 mL\n Respiratory\n O2 Delivery Device: High flow nasal cannula, High flow neb\n SpO2: 98%\n ABG: ////\n Physical Examination\n Patient comfortable lying at 30 degrees with NRB mask and nasal prongs.\n . Chest with rales anteriorally bilaterally. No wheeze. PMI\n diffuse. No gallop or murmur. S1 and S2 normal. Active bowel sounds.\n Abdomen soft and non-tender. Extremities warm and well perfused, no\n edema. Patient alert and oriented.\n Labs / Radiology\n 90\n 28.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:// INR 1, Differential-Neuts:69, Band:20,\n Lactic Acid:1.9, LDH:795, Ca++:8, Mg++:1.7, PO4:3.0\n Fluid analysis / Other labs: UA - moderate bacteria, WBC's, leukocyte\n esterase from nephrostomy tube\n Imaging: CXR - interstitial to alveolar infiltrates bilaterally.\n CT - bilateral, primarily in upper zone- ground glass opacities. Region\n of atelectasis right mid zone. Probable new liver met.\n Assessment and Plan\n RESPIRATORY DISTRESS\n HYPOXEMIA\n HYPOTENSION\n PNEUMONIA\n METASTATIC BREAST CA\n ANEMIA\n THROMBOCYTOPENIA\n URINARY INFECTION\n CXR picture with diffuse, primarily upper zone infiltrates most\n suggestive of atypical pneumonia. The 20% bands on WBC differential,\n however, is more suggestive of bacterial infection. This bandemia may\n relate to the probable urine infection rather than the pulmonary\n infection. I concur with the presumptive treatment for PCP given her hx\n and the elevated LDH on her blood studies. Bronchoscopy now could not\n be accomplished without intubating the patient and she does not want to\n go that route. Will switch cipro to levofloxacin to get better\n coverage of atypical organisms. Legionella antigen pending. Will send\n DFA for influenza. At this point ,O2 sats are acceptable on NRB mask.\n Will hold on mask ventilation for now.\n Patient with widely metastatic breast ca\n new liver met noted on CT\n scan. Patient is DNR/DNI.\n Anemia is chronic and likely related to chemo and tumor. No evidence\n of bleeding now. No need for transfusion now. Platelet count dropping;\n concern about marrow involvement with tumor. Will check for HIT.\n Patient with hypotension on OMED unit. Is responding to fluids.\n Probable drop in SVR in association with infection. Getting stress dose\n steroids as part of treatment for PCP. BP drops further, will need\n to address possible vasopressors. Team will address with patient now.\n ICU Care\n Nutrition: oral diet\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments: Family notified.\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 317022, "text": "Chief Complaint: Hypoxia, hypotension\n HPI:\n For full details, please see admission H&P. In brief, this is a 65 y/o\n female with metastatic breast cancer who was admitted yesterday to the\n oncology service with cough, SOB, and hypoxia. Hypoxic to 80% on RA at\n NH -> in ambulance improved to 100% on NRB. She had been c/o weakness\n for the past several weeks along with worsening back pain. She has had\n a nonproductive cough 3 days PTA. She has had intermittent nausea and\n some abdominal pain, but no vomiting. She denies any burning when she\n urinates but does note that her R nephrostomy tube has been painful and\n the urine in it has been bloodier. She denies any swelling in her legs,\n PND, or orthopnea. She denies any recent bruising, bleeding, or skin\n changes.\n In the ED, VS on arrival were T 102.2, BP 142/86, HR 113, and sats were\n 80% on RA, improving to 95% on 5LNC. CXR was initially read as\n pneumonia of the RML and she was given cefepime 2gm IV x1 and\n levofloxacin 750mg IV x1. However, radiology said her CXR did not show\n evidence of pneumonia so she was sent for CTA which was concerning for\n atypical pneumonia. Given her ongoing dexamethasone taper, she was\n given bactrim 350 mg IV x 1 for PCP.\n the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. ID was consulted and agreed with the above management.\n On the floor, in the PM , the patient triggered for hypoxia with\n an oxygen saturation of 90% on a NRB. She was also SOB. She is\n currently being treated for pneumonia, possible PCP pneumonia vs. HAP.\n She is on broad-spectrum ABx including Bactrim + steroids for PCP. \n was also found to be hypotensive earlier in the evening with SBPs in\n the 80s which also resulted in a trigger. She was given a 500 mL IVF\n bolus and her SBP improved to the 100s. Her code status was confirmed\n with the patient and her family, DNR/DNI. She was transferred to the\n for possible non-invasive ventilation and closer hemodynamic\n monitoring.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:30 PM\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Medications on transfer:\n Zonisamide 100 mg PO BID\n Keppra 750 mg PO TID\n SQHeparin\n Protonix 40 mg PO Q12H\n Celexa 10 mg PO daily\n Nystatin Oral Suspension\n MVI\n Compazine PRN\n Vancomycin 1000 mg IV Q12H\n ISS\n Morphine IR 7.5 mg PO Q6H PRN\n Tylenol PRN\n Prednisone 40 mg PO BID\n Meropenem 500 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Bactrim 400 mg IV Q12H\n Past medical history:\n Family history:\n Social History:\n 1. Breast cancer - dx by chest MRI, s/p left mastectomy - ER+,\n her2/neu +, LN +, treated initially w/ adriamycin, cytoxan,\n developed bone mets in , treated w/ xeloda, then herceptin +\n gemcitabine, then herceptin + paclitaxel, brain mets dx -> s/p\n WBXRT, 2000cGy, completed in , also underwent XRT to thoracic and\n lumbar mets, XRT to pelvic mets in , pelvic involvement ->\n hydronehprosis -> bilateral nephrostomy tubes, had also been receiving\n herceptin, vinblastine, and , mets recurred in -> s/p\n 5 treatments w/ Cyberknife in for recurrence; also on seizure\n medication currently, chemotherapy changed to Tykerb and Xeloda \n 2. HTN\n 3. GERD\n 4. Cataracts s/p surgery\n 5. Breast reduction surgery \n 6. Left hip replacement \n 7. Tendon releases and carpal tunnel release\n N/C.\n Occupation: Retired\n Drugs: None\n Tobacco: Quit several years ago\n Alcohol: Occasional\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Pain: Mild\n Pain location: Lower back\n Flowsheet Data as of 12:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 84 (80 - 84) bpm\n BP: 110/62(74){76/50(57) - 110/62(74)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Total In:\n 1,072 mL\n 233 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 133 mL\n Blood products:\n Total out:\n 350 mL\n 260 mL\n Urine:\n 350 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n -27 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n Physical Examination\n General Appearance: Thin, Mild respiratory distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Anteriorly B/L., No(t) Wheezes : , Diminished: Bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 90\n 9.4\n 127\n 0.6\n 19\n 24\n 103\n 3.9\n 139\n 28.4\n 4.9\n [image002.jpg]\n Other labs: PT / PTT / INR:12.1/28.0/1.0, Differential-Neuts:69,\n Band:20, Lymph:3, Mono:2, Eos:0, Ca++:8, Mg++:1.7, PO4:3.0\n Imaging: CXR - Interstitial and alveolar infiltrates B/L.\n CTA - B/L upper zone ground glass opacities, right mid zone\n atelectasis. Probably new liver met.\n Microbiology: U/A grossly positive\n UCx pending\n BCx pending\n Urine Legionella pending\n Urine histoplasma pending\n Assessment and Plan\n Hypoxia/respiratory distress\n Pt presented with hypoxia most likely to infectious source. CTA\n negative for PE. CXR with diffuse, primarily upper zone infiltrates c/w\n atypical PNA. She does have significiant bandemia on her CBC which\n would indicate a bacterial etiology. Bandemia may also be to UTI.\n Given recent hospitalizations, will cover broadly for HAP. Will\n continue meropenem and vancomycin. Will change ciprofloxacin to\n levofloxacin for atypical coverage. ID also following, appreciate recs.\n F/u cultures and various studies. Will send nasopharyngeal aspirate to\n r/o influenza. Continue droplet precautions. Given her recent high dose\n steroids will continue empiric treatment for PCP with Bactrim and\n steroids. Obtain induced sputum to r/o PCP. bronch given necessity\n for intubation which pt clearly does not want. Continue oxygen support\n with NC and face mask. Consider mask ventilation if needed.\n Pneumonia\n As above\n Hypotension\n Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will\n support with PRN IVF bolus. Pt clearly does not want pressors or\n central line placement if that was required to support her blood\n pressure. Will monitor.\n UTI\n U/A grossly positive from both right and left nephrostomy tubes. UCx\n pending. Continue levofloxacin and meropenem.\n Anemia\n Chronic, will monitor. No evidence of bleeding.\n Thrombocytopenia\n Concern for marrow involvement of tumor vs. HIT. Will send HIT\n antibody.\n Metastatic Breast CA s/p several therapies\n Further management per primary oncologist. Likely new liver met on CT.\n Continue antiseizure meds for brain mets.\n ICU Care\n Nutrition: Regular diet.\n Glycemic Control: ISS while on steroids.\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 317073, "text": "Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL \n Transferred to last night for hypoxemia and potential initiation\n of NIPPV\n Borderline hypotensive in the 80s upon arrival, given gentle IVF\n Remained on NRB overnight\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone 20 mg x5 days, insulin sliding scale, mvt, celexa,\n protonix, heparin, keppra\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Genitourinary: hematuria/pain from nephrostomy tubes\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 89 (80 - 90) bpm\n BP: 98/60(69){76/46(57) - 110/63(74)} mmHg\n RR: 19 (18 - 26) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,853 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,753 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 88%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, Anxious, appears uncomfortable\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, also anteriorly)\n Abdominal: Soft, Non-tender, bilateral nephrostomy tubes\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 90 K/uL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: CXR today: worsened bilateral alveolar opacities, especially\n in the upper lobes\n Microbiology: Cx from bilateral nephrostomy tubes growing GNR\n DFA for influenza pending\n Cryptococcal Ag pending\n Assessment and Plan\n 65 y/o F with metastatic breast Ca who presents with hypoxemic\n respiratory failure of unclear etiology. Differential includes\n bacterial infection, viral infection, hypersensitivity pneumonitis,\n COP, versus lymphangitic spread of her malignancy. Patient currently\n is 93% on NRB plus nasal cannula, and expressed to us that she does not\n wish to be aggressively treated any longer. She does not want to try\n NIPPV and only wants to be made comfortable. Plan to d/c antibiotics,\n steroids, and add morphine prn dyspnea/pain. Family and Oncology are\n aware.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Comfort measures only\n Disposition :ICU\n Total time spent: 25\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317079, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n This am patient expresses her wishes to the team to pass away\n comfortably, refused supplemental O2, pressors or any lines that may\n need to be placed to support vitals. Patient is DNR/DNI. Patient status\n discussed w/family yesterday.\n Action:\n CMO, IVF/IV ABX D/C, morphine drip started ASDIR and titrated to\n accommodate patient comfort level , palliative care nurse consulted to\n help the patient and family to cope w/patient\ns decision and status,\n priest called per family request\n Response:\n Patient appears to be comfortable, family at bedside\n Plan:\n Continue w/morphine drip, titrate as needed, provide support to family\n for end of life care\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317047, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n Hypoxia/respiratory distress - presented with hypoxia most likely \n to infectious source.\n -CTA negative for PE.\n - CXR with diffuse, primarily upper zone infiltrates c/w atypical PNA.\n with significiant bandemia on her CBC. However. bandemia may also be\n to UTI.\n - continue broad HAP coverage with meropenem and vancomycin.\n - will change ciprofloxacin to levofloxacin for atypical coverage.\n - f/u ID recs.\n - continue empiric treatment for PCP with Bactrim and steroids.\n - F/u nasopharyngeal aspirate to r/o influenza. Continue droplet\n precautions.\n - f/u induced sputum to r/o PCP.\n /u fungal studies (bd glucan, galactomannan)\n - not a bronch candidate\n - Continue oxygen support with NC and face mask. Consider mask\n ventilation as needed.\n - prn morphine\n Pneumonia\n As above\n Hypotension\n Concern for sepsis given hypotension, fever, pneumonia, and UTI. Will\n support with PRN IVF bolus. Pt clearly does not want pressors or\n central line placement if that was required to support her blood\n pressure. Will monitor.\n UTI\n U/A grossly positive from both right and left nephrostomy tubes. UCx\n pending. Continue levofloxacin and meropenem.\n Anemia\n Chronic, will monitor. No evidence of bleeding.\n Thrombocytopenia\n Concern for marrow involvement of tumor vs. HIT. Will send HIT\n antibody.\n Metastatic Breast CA s/p several therapies\n Further management per primary oncologist. Likely new liver met on CT.\n Continue antiseizure meds for brain mets.\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI, consider CMO\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 317050, "text": "Chief Complaint: hypoxemic respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL \n Transferred to last night for hypoxemia and potential initiation\n of NIPPV\n Borderline hypotensive in the 80s upon arrival, given gentle IVF\n Remained on NRB overnight\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone 20 mg x5 days, insulin sliding scale, mvt, celexa,\n protonix, heparin, keppra\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Genitourinary: hematuria/pain from nephrostomy tubes\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 89 (80 - 90) bpm\n BP: 98/60(69){76/46(57) - 110/63(74)} mmHg\n RR: 19 (18 - 26) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,853 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,753 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 88%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, Anxious, appears uncomfortable\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, also anteriorly)\n Abdominal: Soft, Non-tender, bilateral nephrostomy tubes\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 90 K/uL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: CXR today: worsened bilateral alveolar opacities, especially\n in the upper lobes\n Microbiology: Cx from bilateral nephrostomy tubes growing GNR\n DFA for influenza pending\n Cryptococcal Ag pending\n Assessment and Plan\n 65 y/o F with metastatic breast Ca who presents with hypoxemic\n respiratory failure of unclear etiology. Differential includes\n bacterial infection, viral infection, hypersensitivity pneumonitis,\n COP, versus lymphangitic spread of her malignancy. Patient currently\n is 93% on NRB plus nasal cannula, and expressed to us that she does not\n wish to be aggressively treated any longer. She does not want to try\n NIPPV and only wants to be made comfortable. Plan to d/c antibiotics,\n steroids, and add morphine prn dyspnea/pain. Family and Oncology are\n aware.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Comfort measures only\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317059, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n Hypoxia/respiratory distress\n with desats to mid 80\ns on NRB this AM.\n - pt requesting to be comfortable and\npass in peace\n, will change to\n CMO\n - will d/c all antibiotics and steroids for HCAP and PCP coverage\n Continue droplet precautions until influenza is ruled out\n - Continue oxygen support with NC and face mask, consider mask\n ventilation if tolerated.\n - IV morphine gtt titrated to comfort\n - Pt clearly does not want pressors or central line placement\n - no further labs draws\n Metastatic Breast CA s/p several therapies\n - will contact oncologist re: change in level of care\n - Continue antiseizure meds\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: d/c regular insulin sliding scale, d/c FSG checks\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: d/c SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI changing to CMO today\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317070, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n This am patient expresses her wishes to the team to pass away\n comfortably, refused supplemental O2, pressors or any lines that may\n need to be placed to support vitals. Patient is DNR/DNI. Patient status\n discussed w/family yesterday.\n Action:\n CMO, IVF/IV ABX D/C morphine drip started ASDIR and titrated to\n accommodate patient comfort level , palliative care nurse consulted to\n help the patient and family to cope w/patient decision and status,\n priest called per family request\n Response:\n Patient appears to be comfortable, family at bedside\n Plan:\n Continue w/morphine drip, titrate as needed, provide support to family\n for end of life care\n" }, { "category": "Physician ", "chartdate": "2121-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 317044, "text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 10:19 PM\n came from 11 with portocath line\n NASAL SWAB - At 06:05 AM\n AND NASAL ASPIRATE COLLECTED FOR INFLUENZE/VIRAL CULTURES\n Allergies:\n Codeine\n Unknown;\n Niacin\n Flushing;\n Flonase (Nasal) (Fluticasone Propionate)\n Headache;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:17 PM\n Vancomycin - 11:17 PM\n Levofloxacin - 01:17 AM\n Bactrim (SMX/TMP) - 04:00 AM\n Meropenem - 06:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (80 - 90) bpm\n BP: 91/53(62){76/46(57) - 110/63(74)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 66.4 kg\n Height: 63 Inch\n Total In:\n 1,072 mL\n 1,812 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,072 mL\n 1,712 mL\n Blood products:\n Total out:\n 350 mL\n 1,725 mL\n Urine:\n 350 mL\n 1,725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Non-rebreather\n SpO2: 89%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 7.9 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 24.1 %\n 5.0 K/uL\n [image002.jpg]\n 05:26 AM\n WBC\n 5.0\n Hct\n 24.1\n Plt\n 90\n Cr\n 0.4\n Glucose\n 85\n Other labs: PT / PTT / INR:12.0/26.9/1.0, Ca++:7.2 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Imaging: and CXRs reads PND\n Microbiology: CRYPTOCOCCAL ANTIGEN (Pending)\n 7:00 pm URINE CATHETER, RIGHT NEPHROSTOMY.\n URINE CULTURE (Pending):\n from L and R nephrosotomies\n Urine legionella PND\n BCx PND\n Assessment and Plan\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 10:17 PM\n Indwelling Port (PortaCath) - 10:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2121-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317118, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n Pt was comfortable on morphine gtt .pt expired @ 0445 am . Both sons\n were at the bedside at time of death\n" }, { "category": "Nursing", "chartdate": "2121-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 317034, "text": "This is a 65 y/o female with metastatic breast cancer who lives in the\n NH where she was found to be hypoxic to 80% on RA, associated with\n nonproductive cough, SOB, nausea, abdominal pain and weakness. In the\n ED, Temp was 102.2, BP 142/86, HR 113, and sats 80% on RA, improving to\n 95% on 5LNC. CXR revealed ? pneumonia of the RML and she was given IV\n antibiotics vs PCP. was admitted on to the floor under\n oncology service with cough, SOB, and hypoxia.\n On the floor, she was treated for PCP pneumonia vs. HAP. She was given\n cefepime, ciprofloxacin, vancomycin, and bactrim + steroids. Influenza\n was never sent. On the floor, in the PM , the patient triggered\n for hypoxia with an oxygen saturation of 90% on a NRB. She was also\n SOB. She is currently being treated for pneumonia, possible PCP\n pneumonia vs. HAP. She is on broad-spectrum ABx including Bactrim +\n steroids for PCP. was also found to be hypotensive earlier in the\n evening with SBPs in the 80s which also resulted in a trigger. She was\n given a 500 mL IVF bolus and her SBP improved to the 100s. Her code\n status was confirmed with the patient and her family, DNR/DNI. She was\n transferred to the for possible non-invasive ventilation (BiPAP)\n and closer hemodynamic monitoring. Upon arrival to ICU, pt was placed\n on droplet precautions. Oxygen administered via NRB 100% as well as NC\n 5 LPM which has maintained the sat above 90%, hence, the BiPAP has\n never been needed.\n Dyspnea (Shortness of breath)\n Assessment:\n Dyspneac, non-productive cough, sat 89-98%, afebrile, LS crackles\n throughout, anxious, and restless, c/o headache, BP dropped to low 80s.\n Action:\n Oxygen administered via NRB 100% and NC 5 LPM, respiratory status\n monitored very closely as pt pulls out the oxygen occasionally which\n results in desaturation to low 80s, given Tylenol for headache and\n Morphine Po as ordered PRN for restlessnesswith moderate effect, given\n a bolus of 250 cc NS, multiple antibiotics (Vancomycin, Bactrim,\n Ciprofloxacin, Levofloxacin, and Meropenam IV) administered.\n Response:\n Continues to be very restless, saturation maintained above 90% with O2\n on, tolerated fluids well, headache relieved, BP improved to systolic\n above 90.\n Plan:\n Monitor respiratory status very closely, wean Oxygen as tolerated to\n maintain sat above 90%, monitor BP and bolus as needed to maintain SBP\n above 82 as per HO, continue antibiotics, keep pt on droplet\n precautions to R/O the flue, may need deep tracheal suctioning to\n induce sputum to be sent for cx., consider administering anti-anxiety\n meds, reassure pt and keep her and family updated on her condition and\n POC. Pt is /DNR, no pressors as confirmed by pt, she also doesn\n like BiPAP as she reported but might consider, but definitely no\n intubation.\n" } ]

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A/P: 24M w/ T1DM, admitted to OSH w/ acute n/v following binge drinking episode, noted to have pneumomediastinum on CT chest, transferred for further management. . 1. DKA: He was admitted with a metabolic acidosis with anion gap of 17 and glucose in the 300s. He was taken into the MICU, where an insulin drip was D5 1/2NS was started with potassium repletion. His gap normalized and his sugars quickly became controlled. There were no clear infection though low grade temperature and initial wbc count on admission to osh. He was pan cultured here with no indications of infection by microbiology or chest xray. After stabilization and discontinuation of the insulin drip, he was started on 38U of glargine with good control of his sugars. His morning sugars were 85 and 57 and his glargine was decreased to 35U prior to discharge with close follow up at . His prandial sugars were controlled on a carbohydrate counting regiment. 2. Pneumomediastinum: He experienced severed nausea and vomitting secondary to alcohol abuse prior to admission. On chest xray he was noted to have a possible pneumomediastinum. Thoracic surgery was called, and on follow up CT showed pneumomediastinum with no clear esophageal perforation, this was consistent with the negative barium swallow conducted at the outside hospital, no antibiotics were started. His throat pain improved and his diet was advanced. He tolerated POs without difficulty. Thoracics was consulted prior to discharge and did not have recommendations for further outpatient studies to evaluate the pneumomediastinum but rather just follow clinically. He was advised to terminate his alcohol consumption as this was clearly associated with his pneumomediastinum. He was clearly instructed that continued alcohol use could result in esophageal rupture, recurrent DKA, and or death. He acknowledged his understanding of this information and agreed to stop drinking alcohol. 3. Etoh/Smoking: He agreed that he would stop smoking and drinking, he was prescribed zyban and a nicotine patch to assist in his positive goal 4. Lung Nodule: Small <5mm lung non calcified lung nodules were noted on his chest CT, he was advised to follow up with his PCP and reevaluate these lesions after one year. 5. ARF: His elevated creatinine resolved with hydration. . 6. FEN: diet.NPO, IVF + Kcl for repletion. lytes, diabetic diet . 7. PPX: SQ heparin, PPI IV . 8. Full Code, presumed . 9. Dispo: Follow up with his Diabetes Physician, PCP

NO INTERVENTION NECESSARY R/T PNEUMOMEDIASTINUM AT THIS TIME. The mediastinal and hilar contours are normal. LS= CLEAR/DIM. BBS= ESSENTIALLY CLEAR. NSR @ 71-92, NO ECTOPY NOTED. Heart, great vessels, and pericardium are normal. ABD SOFT, PRESENT BS. DENIES ANY CHEST PAIN. DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS.GI: ABLE TO TOLERATE PO'S WELL. INDICATION: Pneumomediastinum. The esophagus appears normal without a disproportionate volume of mediastinal air. SBP OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPTOENSIVE CRISIS NOTED. IMPRESSION: Pneumomediastinum. FINDINGS: The heart size is normal. IV ZOSYN D/C'D AND PO CIPRO Q12HRS AND PO FLAGYL TID ORDERED FOR PROPHYLAXIS. MAE X 4 WITHOUT DIFFICULTY. TX TO FOR FURTHER MANAGEMENT OF DKA AND PNEUMOMEDIASTINUM.NEURO: VERY PLEASANT, ALERT AND ORIENTED X 3. B ilateral, layering pleural effusions are tiny. SOME THROAT PAIN- NO C/O N,V,D. NO C/O SOB OR DIFFICULTY BREATHING. NO C/O SOB OR DIFFICULTY BREATHING. ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. REPEAT CHEST CT DONE THIS AM TO EVAL PNEUOMEDIASTINUM. SPEECH CLEAR. CONTINUE ICU SUPPORTIVE CARE. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. TECHNIQUE: Multidetector noncontrast images of the chest were performed. AFEBRILE.RR: BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. UA SENT AS ORDERED. PM LYTES K=3.4, NA=141, GLU=139. BARIUM SWALLOW NEGATIVE FOR EXTRAVASATION- CHEST CT SHOWED AGAIN PNEUMOMEDIASTINUM WITHOUT CLEAR ESOPHAGEAL RUPTURE. ALERT AND ORIENTED X 3- ABLE TO PERFORM ADL'S WITHOUT DIFFICULTY AND ASSIST WITH CARE. Bones and imaged upper abdomen are normal. DENIES PAIN. FOLLOWS COMMANDS, SPEECH CLEAR. DENIES SOB OR DIFFICULTY BREATHING. IMPRESSION: 1. NBP= 119-150/61-90. PASSING FLATUS, NO BM THIS SHIFT.GU: ABLE TO VOID IN URINAL WITHOUT DIFFICULTY, CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.SKIN: GROSSLY INTACT.ENDO: GAP IS CLOSING. Few air locules are noted in the superior pneumomediastinum and a thin sliver of air is seen tracking along the descending aorta. SP02 > OR = TO 95.CV: S1 AND S2 AS PER AUSCULTATION. FOLLOW UP W/ THORACIC FOR ANY INTERVENTION OR TREATMENT. The tracheobronchial tree is intact. BS X 4 QUADRANTS. BS X 4 QUADRANTS. PIV X3, LEFT ANTECUB #18G X2 AND RIGHT HAND #20G X1. CHEST X-RAY, AP PORTABLE VIEW. TOLERATES.SOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.PLAN: REPEAT CT CHEST TO R/O RUPTURED ESOPHAGEOUS. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.INTEG: GROSSLY INTACT.ENDO: AS PT 20UNITS OF LANTUS. THORACIC TEAM CONSULTED FOR RECOMM OF TREATMENT. There are no pleural effusions. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. BILATERAL CHEST EXPANSION NOTED. BILATERAL CHEST EXPANSION NOTED. NO ISSUES.PLAN: CONTINUE ATTEMPTS AT CONVERTION TO LONG LASTING INSULIN COVERAGE. MAE X 4. CT OF THE CHEST WITHOUT CONTRAST: A small volume of pneumomediastinum tracks into the soft tissues of the lower neck. AFEBRILE. AFEBRILE. PT ALERT AND ORIENTED X3. No pneumothorax. THANK YOU! THANK YOU! PLEASANT, COOPERATIVE W/ CARE. Two, tiny noncalcified lung nodules are identified, one in the left upper lobe (3 mm, 3:12) and another in the left lower lobe (4 mm, 3:36). PT ARRIVED VIA EMS IN NO ACUTE DISTRESS- TX TO MICU 777 WITH NO UNTOWARD INCIDENT.THIS IS A 24 Y/O M PT WITH PMH SIGNIFICANT ONLY FOR DM- FOLLOWED AT THE CLINIC. 02 SAT 96-100% ON RA. PERRLA, 3/BRISK. AM WBC= 10.2. Two noncalcified, less than 5-mm nodules. PT HAS SOME TENDERNESS TO RT SIDE OF NECK- VERY SMALL AMOUNT OF CREPITUS NOTED BUT VERY MINIMAL. WEAN OFF OF INSULIN GTT. No lymphadenopathy. PERRLA, 3/. FULL CODE. PER THORACIC VIA VERBAL REPORT FROM DR. / MICU PT ALLOWED TO EAT. PASSING FLATUS.GU: ABLE TO VOID IN URINAL. PT H20 AND CRACKERS W/O DIFFICULTY, REPORTED NO BURNING EFFECT AFTER SWALLOWING. CURRENTLY ON INSULIN GTT- TITRATING AS PROTOCOL. SP02 > OR = TO 95%.CV: S1 AND S2 AS PER AUSCULTATION. NO SEIZURE ACTIVITY NOTED. BEDREST MAINTAINED. The lung fields are clear. No mediastinal fluid or inflammatory stranding is seen. There is no pneumothorax. PT'S ENVIRONMENT SECURED FOR SAFETY.NEURO: VERY PLEASANT. SYMPTOM REPORTED TO DR. / MICU TEAM. DENIES CP. No CT evidence to suspect airway or esophageal tear. WILL CONTINUE TO MONITOR. D51/2 NS W/ 40MEQ KCL INFUSING AT 150CC/HR AS ORDERED. RECEIVED TOTAL OF 2 GMS MAG, CURRENTLY RECEIVING MAINTANENCE FLUID WITH POTASSIUM.GI: NPO AT THIS TIME. WILL ATTEMPT TO WEAN OFF AS PT. THIS AM- BS ARE IN THE 300'S- CAUTIOUS COVERAGE WITH REGULAR INSULIN AS TO NOT BOTTOM OUT BLOOD GLUCOSE WITH LONG ACTING INSULIN. 2. NO BM, NO N/V. NO STOOL THIS SHIFT. SEE PROGRESS NOTES. One-year followup CT chest is recommended. PT HAS 18G PIV TO LT AC AND 20G PIV TO RT HAND. PERLA- 3MM/, . COMPARISON: None. 1900-0700 NPN:PLEASE SEE CAREVUE FLOWHSEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. ROOM AIR. STRONG PEDAL PULSES. BLD CX X2 AND URINE CX SENT FOR R/O INFECTION ATTRIBUTING TO DKA. RR 15-20. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. 9:07 AM CT CHEST W/O CONTRAST Clip # Reason: for evaluation of pneumomediatstinum Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM MEDICAL CONDITION: 24 year old man with dka, n/v, pneumomediastinum reported at osh REASON FOR THIS EXAMINATION: for evaluation of pneumomediatstinum No contraindications for IV contrast FINAL REPORT PROCEDURE: CT chest without contrast.

5

[ { "category": "Nursing/other", "chartdate": "2166-08-30 00:00:00.000", "description": "Report", "row_id": 1578297, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: VERY PLEASANT. ALERT AND ORIENTED X 3- ABLE TO PERFORM ADL'S WITHOUT DIFFICULTY AND ASSIST WITH CARE. PERRLA, 3/. SPEECH CLEAR. MAE X 4. AFEBRILE.\n\nRR: BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. ROOM AIR. BILATERAL CHEST EXPANSION NOTED. RR 15-20. NO C/O SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. DENIES ANY CHEST PAIN. SBP OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS.\n\nGI: ABLE TO TOLERATE PO'S WELL. DID NOT EAT TOO MUCH FOR DINNER- HOPEFULLY- WILL BE ABLE TO CONSUME MORE THIS MORNING. SOME THROAT PAIN- NO C/O N,V,D. BS X 4 QUADRANTS. NO STOOL THIS SHIFT. PASSING FLATUS.\n\nGU: ABLE TO VOID IN URINAL. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: GROSSLY INTACT.\n\nENDO: AS PT 20UNITS OF LANTUS. WE ARE BASING NPH COVERAGE BASED ON PT'S RECOMMENDATION AS HE CALCULATES THIS BASED ON WHAT HE HAS CONSUMED. INSULIN GTT HAS BEEN OFF SINCE 9PM. THIS AM- BS ARE IN THE 300'S- CAUTIOUS COVERAGE WITH REGULAR INSULIN AS TO NOT BOTTOM OUT BLOOD GLUCOSE WITH LONG ACTING INSULIN. PT TO RECEIVE ANOTHER DOSE OF NPH AFTER BREAKFAST THIS MORNING- AWAITING ORDER FROM MD.\n\nSOCIAL: MOM IN TO VISIT. NO ISSUES.\n\nPLAN: CONTINUE ATTEMPTS AT CONVERTION TO LONG LASTING INSULIN COVERAGE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2166-08-29 00:00:00.000", "description": "Report", "row_id": 1578295, "text": "NURSING ADMISSION AND PROGRESS NOTE 2200-0700\nREPORT RECEIVED FROM HOSPITAL. PT ARRIVED VIA EMS IN NO ACUTE DISTRESS- TX TO MICU 777 WITH NO UNTOWARD INCIDENT.\n\nTHIS IS A 24 Y/O M PT WITH PMH SIGNIFICANT ONLY FOR DM- FOLLOWED AT THE CLINIC. PT WAS IN USUAL STATE OF HEALTH UNTIL THIS PAST PT ADMITS TO HAVING DRANK CAPTAIN RUM HEAVILY THIS WEEKEND AND ON MONDAY STARTED TO HAVE SEVERE NAUSEA AND VOMITING- UNABLE TO KEEP ANYTHING DOWN FOR SEVERAL DAYS. FINGERSTICKS INCREASED TO > 600- ON , PT PRESENTED HOSPITAL ER WITH HE WAS NOTED TO BE IN DKA WITH BS > 300 AND CXR SIGNIFICANT FOR PNEUMOMEDIASTINUM (D/T WRETCHING AND VIOLENT VOMITING). BARIUM SWALLOW NEGATIVE FOR EXTRAVASATION- CHEST CT SHOWED AGAIN PNEUMOMEDIASTINUM WITHOUT CLEAR ESOPHAGEAL RUPTURE. TX TO FOR FURTHER MANAGEMENT OF DKA AND PNEUMOMEDIASTINUM.\n\nNEURO: VERY PLEASANT, ALERT AND ORIENTED X 3. FOLLOWS COMMANDS, SPEECH CLEAR. MAE X 4 WITHOUT DIFFICULTY. PERRLA, 3/BRISK. AFEBRILE. NO SEIZURE ACTIVITY NOTED. PT RECEIVED ONE TIME DOSE OF 15MG TORADOL FOR BACK PT FEELS THIS IS DUE TO BED- \"I'M NOT USED TO SLEEPING ON HOSPITAL BEDS- THEY'RE STIFF\".\n\nRR: RA. NO C/O SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED. PT HAS SOME TENDERNESS TO RT SIDE OF NECK- VERY SMALL AMOUNT OF CREPITUS NOTED BUT VERY MINIMAL. SP02 > OR = TO 95.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-80'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPTOENSIVE CRISIS NOTED. DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAS 18G PIV TO LT AC AND 20G PIV TO RT HAND. RECEIVED TOTAL OF 2 GMS MAG, CURRENTLY RECEIVING MAINTANENCE FLUID WITH POTASSIUM.\n\nGI: NPO AT THIS TIME. ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. PASSING FLATUS, NO BM THIS SHIFT.\n\nGU: ABLE TO VOID IN URINAL WITHOUT DIFFICULTY, CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: GROSSLY INTACT.\n\nENDO: GAP IS CLOSING. CURRENTLY ON INSULIN GTT- TITRATING AS PROTOCOL. WILL ATTEMPT TO WEAN OFF AS PT. TOLERATES.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nPLAN: REPEAT CT CHEST TO R/O RUPTURED ESOPHAGEOUS. WEAN OFF OF INSULIN GTT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n" }, { "category": "Nursing/other", "chartdate": "2166-08-29 00:00:00.000", "description": "Report", "row_id": 1578296, "text": "1900-0700 NPN:\n\nPLEASE SEE CAREVUE FLOWHSEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT, COOPERATIVE W/ CARE. PERLA- 3MM/, . DENIES PAIN. LS= CLEAR/DIM. 02 SAT 96-100% ON RA. DENIES SOB OR DIFFICULTY BREATHING. REPEAT CHEST CT DONE THIS AM TO EVAL PNEUOMEDIASTINUM. THORACIC TEAM CONSULTED FOR RECOMM OF TREATMENT. SEE PROGRESS NOTES. NSR @ 71-92, NO ECTOPY NOTED. NBP= 119-150/61-90. DENIES CP. STRONG PEDAL PULSES. AFEBRILE. PIV X3, LEFT ANTECUB #18G X2 AND RIGHT HAND #20G X1. INSULIN GTT INFUSING AT 2U/HR FOR MOST OF SHIFT W/ FS= 110-138, GTT INCREASED TO 3U/HR AT 1800 FOR FS= 150. SEEN BY CLINIC MD- RECOMM LANTUS INSULIN IF PT EATING W/ HUMALOG S/S COVERAGE PER CARBOHYDRATE RATIO. PER THORACIC VIA VERBAL REPORT FROM DR. / MICU PT ALLOWED TO EAT. NO INTERVENTION NECESSARY R/T PNEUMOMEDIASTINUM AT THIS TIME. WILL CONTINUE TO MONITOR. DIABETIC 2200CAL DIET ORDERED- AWAIT DINNER TRAY. PT C/O BURNING SENSATION FROM RIGHT SIDE OF THROAT DOWN TO RIGHT ARMPIT AREA W/ SIP OG GINGERALE. SYMPTOM REPORTED TO DR. / MICU TEAM. PT H20 AND CRACKERS W/O DIFFICULTY, REPORTED NO BURNING EFFECT AFTER SWALLOWING. IV ZOSYN D/C'D AND PO CIPRO Q12HRS AND PO FLAGYL TID ORDERED FOR PROPHYLAXIS. AM WBC= 10.2. BLD CX X2 AND URINE CX SENT FOR R/O INFECTION ATTRIBUTING TO DKA. D51/2 NS W/ 40MEQ KCL INFUSING AT 150CC/HR AS ORDERED. PM LYTES K=3.4, NA=141, GLU=139. ABD SOFT, PRESENT BS. NO BM, NO N/V. PT VOIDING ADEQUATE TO LARGE AMTS OF CLEAR YELLOW URINE IN URINAL AT BEDSIDE. UA SENT AS ORDERED. BEDREST MAINTAINED. FULL CODE. PT'S PARENTS AT BEDSIDE VISITING FOR MOST OF SHIFT- UPDATED ON POC.\nPLAN- TITRATE INSULIN GTT PER KOSLIN PROTOCOL. ADMIN LANTUS AND HUMALOG AS ORDERED R/T % AND CARBS AT DINNER. TEAM REQUEST INSULIN BE GIVEN AFTER DINNER INCASE N/V RESUMES. FOLLOW UP W/ THORACIC FOR ANY INTERVENTION OR TREATMENT. CONTINUE ICU SUPPORTIVE CARE.\n" }, { "category": "Radiology", "chartdate": "2166-08-29 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 882426, "text": " 9:07 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: for evaluation of pneumomediatstinum\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with dka, n/v, pneumomediastinum reported at osh\n\n REASON FOR THIS EXAMINATION:\n for evaluation of pneumomediatstinum\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n INDICATION: Pneumomediastinum. DKA with nausea and vomiting.\n\n TECHNIQUE: Multidetector noncontrast images of the chest were performed.\n\n CT OF THE CHEST WITHOUT CONTRAST: A small volume of pneumomediastinum tracks\n into the soft tissues of the lower neck. The tracheobronchial tree is intact.\n The esophagus appears normal without a disproportionate volume of\n mediastinal air. No mediastinal fluid or inflammatory stranding is seen. B\n ilateral, layering pleural effusions are tiny. Two, tiny noncalcified lung\n nodules are identified, one in the left upper lobe (3 mm, 3:12) and another in\n the left lower lobe (4 mm, 3:36).\n\n Heart, great vessels, and pericardium are normal. No lymphadenopathy. Bones\n and imaged upper abdomen are normal.\n\n IMPRESSION:\n 1. Small amount of pneumomediastinum and lower neck soft tissue emphysema,\n likely a result of wretching against a closed glottis in a patient with this\n history. No CT evidence to suspect airway or esophageal tear.\n 2. Two noncalcified, less than 5-mm nodules. One-year followup CT chest is\n recommended.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882382, "text": " 11:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: for pneumomediastinum\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PNEUMOMEDIASTINUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with ?pneumomediastinum\n REASON FOR THIS EXAMINATION:\n for pneumomediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old man with pneumomediastinum.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: None.\n\n FINDINGS: The heart size is normal. The mediastinal and hilar contours are\n normal. Few air locules are noted in the superior pneumomediastinum and a\n thin sliver of air is seen tracking along the descending aorta.\n\n The lung fields are clear. There are no pleural effusions. There is no\n pneumothorax.\n\n IMPRESSION: Pneumomediastinum. No pneumothorax.\n\n\n" } ]

29,008

145,153

In summary, Mr. is a 22 year old male admitted following motor vehicle accident for multiple fractures and diaphragmatic rupture. Hospital course was complicated by delerium, peristent tachycardia, and transaminitis. . S/p MVA. Patient was admitted to the Trauma Service and taken directly to the operating room for exploratory lap and repair of his diaphragmatic injury. Orthopedics was consulted given his multiple bone fractures; he was taken to the operating room for washout and debridement of left open tibia fracture to bone; closed reduction left supracondylar femur fracture with manipulation; closed reduction left proximal tibia fracture with manipulation; application multiplanar external fixator; IM nail left femur and closed reduction right wrist fracture with manipulation. There were no intraoperative complications. . Pain. Patient had difficulty with pain control initially. PCA Dilaudid was initiated and the dose was quickly increased to 0.37 mg. Dilaudid 1-2 mg IV prn for rescue pain was also added and he did seem to benefit from this. It was discussed with patient and his mother that at some point long acting narcotics would likely be initiated for long term pain control. He was placed on an aggressive bowel regimen. However, patient developed delerium in setting of opioid use, so opioids were discontinued and patient was started on ultram. Tylenol is being avoided due to elevated LFTs. NSAIDs are being avoided due to impaired bone healing. Opioids are being avoided due to recent delerium. Pain was adequately controlled at time of discharge on standing ultram. . Delerium. Patient developed delerium during hospitalization. It was felt to be due to opioid pain medications which were stopped. Patient was evaluated by neurology and psychiatry. Vit B12, folate, TSH, RPR within normal limits. LP performed showed no evidence of infection. EEG and Brain MRI were normal. He was placed on standing seroquel at night. Opioids were avoided. Delerium resolved and patient was alert and oriented on day of discharged. . Elevated transaminases. Likely multifactorial etiology, including systemic inflammatory response, medications including Zosyn. LFTs continue to trend down. ALT peaked at 385 on , AST peaked at 220 on , LDH peaked at 457 on . Alk Phos continued to trend up on discharge, likely secondary to active bone remodeling. Acetaminophen was discontinued on . Please check LFTs weekly until fully resolved. . Thrombocytosis. Patient had elevated platelet count to 1.5 million, likely reactive thrombocytosis due to systemic inflammatory state due to trauma and multiple operations. Platelets were trending down and were 1 million at time of discharge. . Tachycardia. Patient had sinus tachycardia post-operatively to the 150s, that was thought to be pain and stress related. A PE CT was done and was negative for PE. Metoprolol was started to prevent tachycardia-induced cardiomyopathy. An echo was done and was normal. Metoprolol is being titrated down beginning on . Goal is to stop metoprolol as HR improves. Overall tachycardia is improving. . Insomnia. Patient reported difficulty sleeping due to discomfort, multiple braces/casts in place, etc. He was getting standing seroquel at night with minimal improvement. Benzodiazepines and ambien were avoided due to delerium. He was given prn benadryl and standing seroquel. Seroquel should ultimately be stopped but patient is currently using it for insomina. . Prophylaxis. Patient was maintained on Lovenox daily. S/p prophylactic IVC filter placement. . Communication. Patient and mother .

Incompletely evaluated displaced femoral diaphysis fracture. Possible nondisplaced fracture of the navicular. There is a small area of ill-defined lucency at the lateral aspect of the navicular suspicious for nondisplaced fracture. Intra-articular distal tibial fracture. AP PELVIS: There is incompletely evaluated fracture of the femoral diaphysis with significant displacement and overriding fracture fragments. IMPRESSION: Biliary sludge; otherwise unremarkable abdominal ultrasound. Very small left apical pneumothorax is, in retrospect, unchanged compared to the recent chest radiograph, with visceral apical line just below the left second posterior rib level. Along with this, the left hemidiaphragm is largely absent, retracted medially to its spinal attachment. TECHNIQUE: Non-contrast CT of right ankle was performed. Small amount of intraperitoneal air, an unusual finding in a setting of blunt trauma, and free fluid, likely related to chest tube placement, traversing the peritoneal space. IMPRESSION: Extensively comminuted, intra-articular left olecranon fracture. FINDINGS: There is an undisplaced fracture through the distal tibia involving the articular surface of the tibial plafond and extending into the medial malleolus. CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is small amount of intraperitoneal air and small amount of free fluid adjacent to the anterior abdominal wall. Findings concerning for significant left diaphragmatic injury. INDICATION: Pneumothorax. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, prostate, and the seminal vesicles are unremarkable. FINAL REPORT CT RIGHT ANKLE INDICATION: MVC. Equivocal tiny pneumothorax at right lung apex is also noted, not clearly seen on the prior studies. Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR FINAL REPORT INDICATION: IVC filter placement. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT Reason: EX FIX LEFT TIBIA AND FEMURAL NAILING Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR FINAL REPORT HISTORY: Multiple fractures assed in o.r. They demonstrate open reduction internal fixation of comminuted ulnar fracture and comminuted radial fracture. PE No contraindications for IV contrast FINAL REPORT STUDY: CTA chest with and without contrast and reconstructions. There is a fibular neck fracture and proximal fibular shaft fractures. There is a comminuted fracture of the lateral process of the talus. RIGHT WRIST - Overlying material obscures fine detail status post ORIF of distal radial comminuted fracture, with no obvious hardware-related complications. IMPRESSION: Enlarging, still small left basilar effusion. There is a fracture line involving the anterior aspect of the talus involving the articular surface of the talar head. There is a comminuted nondisplaced fracture of the proximal fibular shaft. There is a small radiolucent line on the medial aspect of the left lower hemithorax. Nondisplaced fractures through the medial malleolous extending the mortise. Sinus tachycardiaOtherwise normal ECGNo previous tracing available for comparison IMPRESSION: Thin radiolucency along the medial aspect of the left lower hemithorax may represent a small pneumothorax. Minimal blunting of the left medial pleural sulcus probably due to residual effusion. CT OF THE CHEST WITHOUT IV CONTRAST: There is a small-to-moderate left pleural effusion with associated compressive atelectasis of the dependent left lower lobe. FINDINGS: The left-sided chest tube has been removed with a small residual pneumothorax. IMPRESSION: Normal unenhanced head CT. There is a non-displaced fracture at the lateral aspect of the patella. spiral comminuted tibial metediaphyseal fx with mild posterior displacement of distal frag. mildly displaced oblique fibular head and mid shaft fx. SUPINE ABDOMINAL RADIOGRAPH: There is a nonobstructive bowel gas pattern. The estimated pulmonary artery systolic pressure isnormal. Sinus tachycardiaBorderline short P-R interval - is nonspecific and probably normal variantSince previous tracing of , probably no significant change Left pleural effusion is again noted. Small-to-moderate left pleural effusion and associated compressive (Over) 10:23 AM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT CHEST W/O CONTRAST Reason: with p.o. Normal biventricular cavity sizes with preservedglobal and regional biventricular systolic function. There is nomitral valve prolapse. Small left pleural effusion. marked lipohemarthrosis and soft tissue edema. small lateral patellar avulsion type fx. The P-R interval is shortwithout evidence of pre-excitation. The medial femoral condyle appears preserved. Right ventricular function.Height: (in) 71Weight (lb): 165BSA (m2): 1.95 m2BP (mm Hg): 120/60HR (bpm): 117Status: InpatientDate/Time: at 12:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The right PICC line tip terminates in superior SVC. Right PICC line terminates within the mid superior vena cava. CT OF THE PELVIS WITHOUT IV CONTRAST: The patient is status post interval ORIF of proximal left femoral fracture. Normal PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Interval diaphragmatic repair with spleen and stomach and other abdominal organs now below the diaphragm without evidence of herniation. Left pleural effusion and adjacent basilar atelectasis is unchanged. COMPARISON: Radiographs, left knee, . The stomach and spleen are now below the diaphragm without evidence of herniation.

40

[ { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991009, "text": " 3:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o evolution of PTX\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with chest tube to w/s s/p mvc with multiple fractures and\n placement of chest tube\n REASON FOR THIS EXAMINATION:\n r/o evolution of PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Pneumothorax.\n\n Very small left apical pneumothorax is, in retrospect, unchanged compared to\n the recent chest radiograph, with visceral apical line just below the left\n second posterior rib level. Equivocal tiny pneumothorax at right lung apex is\n also noted, not clearly seen on the prior studies. Left hemidiaphragm appears\n less distinct compared to the previous study, likely due to a small amount of\n pleural fluid. Examination is otherwise unchanged with left-sided chest tube\n remaining in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "R CT LOW EXT W/O C RIGHT", "row_id": 991021, "text": " 5:01 PM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: evaluate R ankle fractures -- DO CT with 3D recons of Right\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mvc with multiple lower extremity fractures -- DO CT of\n Rigth ankle with 3D recons\n REASON FOR THIS EXAMINATION:\n evaluate R ankle fractures -- DO CT with 3D recons of Right ankle\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb FRI 7:10 PM\n Complex comminuted talar fracture extending from the lateral to medial side\n with fracture lines extending to the talar dome. Please see series 401b\n images 52 -55 for minimal (1mm) vertical offset of the talar dome. Mildly to\n non-displaced comminuted fractures of the medial and lateral malleoli also\n also present, with medial nondisplaced fractures extending to the mortise.\n ______________________________________________________________________________\n FINAL REPORT\n CT RIGHT ANKLE\n\n INDICATION: MVC. Evaluate for fracture.\n\n COMPARISON:\n\n Radiograph right ankle, .\n\n TECHNIQUE:\n\n Non-contrast CT of right ankle was performed. Axial, coronal, and sagittal\n reconstructions were reviewed.\n\n FINDINGS:\n\n There is an undisplaced fracture through the distal tibia involving the\n articular surface of the tibial plafond and extending into the medial\n malleolus. There is a fracture involving the tip of the lateral malleolus\n with some adjacent soft tissue swelling. The peroneal tendons abut this\n fracture line but are not entrapped.\n\n There is an intra-articular fracture through the talar dome. There is a\n fracture line extending from the anterior aspect of the talar dome\n anteroinferiorly to the talar neck. There is a fracture line involving the\n anterior aspect of the talus involving the articular surface of the talar\n head. There is a comminuted fracture of the lateral process of the talus. The\n talus fracture involves the posterior subtalar joint. There is minimal (less\n than 1 mm) impaction of the talar dome fracture.\n\n There is a small area of ill-defined lucency at the lateral aspect of the\n navicular suspicious for nondisplaced fracture.\n\n The calcaneus is not completely included on the scan range but the visualized\n (Over)\n\n 5:01 PM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: evaluate R ankle fractures -- DO CT with 3D recons of Right\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n calcaneus is normal. The cuboid and cuneiforms are normal. The metatarsal\n bases are normal.\n\n There is no evidence of a significant soft tissue injury. The ATFL and PTFL\n are intact.\n\n IMPRESSION:\n 1. Intra-articular distal tibial fracture.\n 2. Talar fracture involving the articular surface of the talar dome, talar\n head, and posterior subtalar joint with comminuted fracture of lateral process\n of the talus.\n 3. Possible nondisplaced fracture of the navicular.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "LO WRIST(3 + VIEWS) LEFT IN O.R.", "row_id": 990682, "text": " 11:30 AM\n WRIST(3 + VIEWS) LEFT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n -76 BY SAME PHYSICIAN\n : FX SET IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n LEFT WRIST THREE VIEWS.\n\n HISTORY: Patient with distal radius fracture.\n\n FINDINGS: Three fluoroscopic images from the operating room demonstrates\n fracture involving the right distal radius with intra-articular extension.\n There is ulnar positive variance, likely due to the impaction. There is\n slight dorsal tilt of the radial articular surface. Please refer to the\n operative note for additional details.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L ELBOW, AP & LAT VIEWS LEFT", "row_id": 990601, "text": " 5:27 AM\n ELBOW, AP & LAT VIEWS LEFT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n THREE VIEWS OF THE LEFT ELBOW\n\n INDICATION: 23-year-old man status post MVC. Evaluate for fracture.\n\n COMPARISON: Not available.\n\n FINDINGS: There is an extensively comminuted fracture of the left olecranon,\n extending to the articular surface with significant destruction of fracture\n fragments. Intra-articular small bony fragments are present.\n\n IMPRESSION: Extensively comminuted, intra-articular left olecranon fracture.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 992707, "text": " 9:58 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please evaluate for DVT\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fever of unknown etiology\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with fever of unknown etiology. Please evaluate\n for DVT.\n\n COMPARISON: None available.\n\n LOWER EXTREMITY BILATERAL VENOUS ULTRASOUND: Ultrasound evaluation of the left\n and right lower extremity deep venous system using -scale, color, and\n pulse wave Doppler demonstrates the common femoral vein, superficial femoral\n vein, popliteal vein, and posterior tibial veins to be fully compressible and\n demonstrate normal phasic respiratory variation of flow.\n\n IMPRESSION: No ultrasonographic evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 992176, "text": " 6:02 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: 22 yo with persistent tachycardia, febrile after polytrauma?\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with persistent tachycardia, febrile after polytrauma--? PE\n REASON FOR THIS EXAMINATION:\n 22 yo with persistent tachycardia, febrile after polytrauma? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA chest with and without contrast and reconstructions.\n\n INDICATION: 22-year-old male with persistent tachycardia and febrile after\n polytrauma.\n\n TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet\n to the upper abdomen with IV contrast administration. Multiplanar reformatted\n images were obtained.\n\n COMPARISON: CT chest without contrast from the same date.\n\n CTA CHEST: No dissection flap is identified in the thoracic aorta to suggest\n dissection. No filling defects are identified within the central pulmonary\n arteries and proximal segmental branches to suggest pulmonary embolism. The\n bolus was not optimized to detect subsegment filling defects within the\n pulmonary arteries. There is no pericardial effusion. The heart and great\n vessels appear unremarkable. There is unchanged appearance to a small-to-\n moderate left pleural effusion with associated relaxation atelectasis. There\n is no right pleural effusion. The major airways are patent down to the\n subsegmental level. No pulmonary parenchymal abnormalities are identified.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. No evidence of aortic dissection or central/segmental pulmonary artery\n emboli.\n\n 2. Mild-to-moderate left pleural effusion and associated relaxation\n atelectasis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-21 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 991087, "text": " 8:52 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o evo of ptx\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with chest tubes\n REASON FOR THIS EXAMINATION:\n r/o evo of ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-VIEW CHEST ON .\n\n Comparison made to prior study of . Again seen is a left-sided chest\n tube, with tip directed towards the apex. No discrete pneumothorax is seen.\n There is a slight increase in the amount of left pleural fluid. Otherwise\n lungs are clear. Heart and mediastinal contours unchanged.\n\n IMPRESSION: Enlarging, still small left basilar effusion. No discrete\n pneumothorax seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-25 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 991655, "text": " 11:37 AM\n WRIST(3 + VIEWS) RIGHT; ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: assess alignment s/p ORIF\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n assess alignment s/p ORIF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ORIF.\n\n Three views of the right wrist and two views of left elbow are compared to\n and .\n\n RIGHT WRIST - Overlying material obscures fine detail status post ORIF of\n distal radial comminuted fracture, with no obvious hardware-related\n complications. The cross-table lateral projection is not optimal. The\n triquetral-pisiform interval appears mildly increased, however it might be a\n projectional.\n\n LEFT ELBOW - Overlying material obscures fine details. Two K pins and wire\n fixation of olecranon fracture in near autonomic alignment and no obvious\n hardware-related complications. No new fractures or dislocations. Surgical\n clips are present.\n\n IMPRESSION: ORIF right wrist and left elbow with no obvious hardware-related\n complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-26 00:00:00.000", "description": "OL TIB/FIB (AP & LAT) IN O.R. LEFT", "row_id": 991818, "text": " 10:58 AM\n TIB/FIB (AP & LAT) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. IN O.R. LEFTClip # \n Reason: ORIF LEFT TIBIA IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Left tibia/fibula two views of the .\n\n HISTORY: ORIF left tibia and fibula in the OR\n\n FINDINGS: Thirteen fluoroscopic images from the operating room demonstrates\n interval placement of a large fracture plate along the medial proximal tibia\n fixating a complex comminuted fracture of the tibial plateau. There are also\n interfragmentary screws seen within the tibial plateau. There are fracture\n plates seen within the distal femur fixating a distal metaphyseal fracture.\n Portion of an intramedullary rod within the distal femur is also seen.\n Interfragmentary screw through the lateral femoral condyle is also visualized.\n There is a fracture involving the proximal shaft of the fibula. Please refer\n to the operative note for additional details.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 990598, "text": " 4:55 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for diaphragm rupture\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for diaphragm rupture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH INTRAVENOUS CONTRAST\n\n INDICATION: 22-year-old man status post MVC. Evaluate for diaphragm rupture.\n\n COMPARISON: Not available.\n\n TECHNIQUE: MDCT axial images of chest, abdomen, and pelvis were obtained\n following administration of 110 cc of Optiray intravenously. Coronal and\n sagittal reformatted images were obtained.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The stomach and spleen are located within\n the thoracic cavity, immediately overlying the posterior ribs (\"dependent\n viscera\" sign). Along with this, the left hemidiaphragm is largely\n absent, retracted medially to its spinal attachment. There are small air\n locules posterior to the stomach, which may represent small residual\n pneumothorax. Patchy opacities, predominantly at the right base likely\n represent contusion, aspiration is another consideration. Central airways are\n patent to the segmental levels, bilaterally. The patient is intubated, with\n endotracheal tube terminating at the level of the clavicular heads. The aorta\n and great vessels are unremarkable. There is no pericardial or pleural\n effusion.\n\n Left-sided chest tube enters at the thoracoabdominal junction and traverses\n peritoneal space adjacent to the spleen and a stomach, reaching apical pleural\n space.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is small amount of\n intraperitoneal air and small amount of free fluid adjacent to the anterior\n abdominal wall. Abdominal loops of large and small bowel are unremarkable\n given lack of oral contrast. The liver, spleen, adrenal glands, pancreas,\n gallbladder are unremarkable. Kidneys enhance equally and excrete contrast\n normally. There are no pathologically enlarged mesenteric or retroperitoneal\n lymph nodes.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, prostate, and\n the seminal vesicles are unremarkable. There is a Foley catheter within the\n urinary bladder.\n\n BONE WINDOWS: Demonstrate no evidence of fracture.\n\n (Over)\n\n 4:55 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for diaphragm rupture\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Stomach and spleen located within the thoracic cavity, very concerning for\n extensive left diaphragmatic rupture, with retraction.\n\n 2. Left lower lobe collapse/consolidation.\n\n 3. Patchy opacities predominantly at the right lung base, in the setting of\n trauma likely represent parenchymal contusions; aspiration is another\n diagnostic consideration.\n\n 3. Small amount of intraperitoneal air, an unusual finding in a setting of\n blunt trauma, and free fluid, likely related to chest tube placement,\n traversing the peritoneal space. While no bowel injury is seen, this cannot be\n completely excluded. Comparison with any CT done prior to the chest tube\n placement would be most helpful if available.\n\n Findings were discussed with Dr. (Trauma Surgery) upon completion\n of the study.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 990599, "text": " 5:03 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with mvc, intubated\n REASON FOR THIS EXAMINATION:\n fx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN WED 5:59 AM\n normal cervical spine ct , md\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE WITHOUT CONTRAST\n\n INDICATION: 22-year-old man status post MVC, intubated. Question fracture.\n\n COMPARISON: Not available.\n\n TECHNIQUE: CT of the cervical spine without intravenous contrast.\n\n FINDINGS: There is no acute fracture or abnormal alignment. The odontoid\n process is midline. Atlanto-axial and atlanto-occipital relationships are\n maintained. There is no prevertebral soft tissue swelling.\n\n Patient is intubated, ET tube terminating at the level of clavicular heads.\n\n Imaged lung apices are clear.\n\n IMPRESSION: No acute fracture or abnormal alignment in the cervical spine.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L FEMUR (AP & LAT) LEFT", "row_id": 990600, "text": " 5:27 AM\n FEMUR (AP & LAT) LEFT; KNEE (2 VIEWS) LEFT Clip # \n TIB/FIB (AP & LAT) LEFT\n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR AND LEFT TIBIA AND FIBULA, FIVE IMAGES.\n\n LEFT FEMUR: There is a proximal segmental oblique spiral fracture of the femur\n with marked displacement and overriding of the fragments, at least 6.5 cm.\n\n There is an extensively comminuted intra-articular distal femoral fracture,\n centered at diametaphysis with multiple fracture lines reaching articular\n surface, particularly laterally, with multiple intra-articular bony fragments.\n There is dorsal angulation of distal fracture fragments.\n\n LEFT TIBIA/FIBULA: There is extensively comminuted intra-articular tibial\n fracture, specifically lateral components, with multiple displaced intra-\n articular fragments. There is extensive comminution of the spiral component at\n proximal tibial metadiaphysis and 2.8 cm overriding, and dorsal and fibular\n angulation of the distal fracture fragments.\n\n There is a fibular neck fracture and proximal fibular shaft fractures.\n\n Single view of ankle is intact.\n\n IMPRESSION: Extensively comminuted fractures of the distal femur and proximal\n tibia, with displaced and angulated fractures of the proximal femur and\n fibula.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990696, "text": " 1:20 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval ct placement/diaphram\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man sp L diaphragmatic hernia repair/chest tube\n REASON FOR THIS EXAMINATION:\n eval ct placement/diaphram\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left diaphragmatic hernia repair with chest tube.\n\n FINDINGS: No previous images, except for the CT scan showing diaphragmatic\n traumatic hernia.\n\n The heart and lungs are essentially within normal limits at this time. The\n left chest tube is in place and there is no pneumothorax. Endotracheal tube\n tip lies about 4 cm above the carina and nasogastric tube extends well into\n the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 990596, "text": " 4:49 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST AND AP PELVIS:\n\n INDICATION: Trauma.\n\n FRONTAL CHEST, ONE VIEW: The study is read in conjunction with subsequently\n obtained CT torso. Cardiomediastinal silhouette is normal. Stomach,\n containing the NG tube, lies within the left hemithorax, with left lower lobe\n collapse, findings concerning for diaphragmatic injury. The left chest tube\n enters at the left thoracoabdominal junction, traverses adjacent to the\n stomach and terminates within the stomach, projecting over the left\n hemithorax.\n\n AP PELVIS: There is incompletely evaluated fracture of the femoral diaphysis\n with significant displacement and overriding fracture fragments.\n\n IMPRESSION:\n 1. Findings concerning for significant left diaphragmatic injury.\n 2. Incompletely evaluated displaced femoral diaphysis fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 990597, "text": " 4:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC vs tree\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST\n\n INDICATION: 22-year-old man status post high speed MVC. Evaluate for\n hemorrhage.\n\n COMPARISON: Not available.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, shift of normally\n midline structures or hydrocephalus. The density values of brain parenchyma\n are within normal limits. The -white matter differentiation is preserved.\n Surrounding soft tissues and osseous structures are unremarkable. Imaged\n paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION: No acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "OL FEMUR (AP & LAT) IN O.R. LEFT", "row_id": 990635, "text": " 8:49 AM\n FEMUR (AP & LAT) IN O.R. LEFT; -77 BY DIFFERENT PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: FEMUR FX IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Femoral fracture.\n\n Two lateral radiographs of the left femur obtained in O.R. show a transverse\n fracture of the mid shaft of the femur with 100% posterior displacement of the\n distal fragment relative to the proximal fragment and some overlap with loss\n of length. Bone detail is not optimally assessed.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "L LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT", "row_id": 990679, "text": " 11:26 AM\n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n TIB/FIB (AP & LAT) IN O.R. LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: EX FIX LEFT TIBIA AND FEMURAL NAILING\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple fractures assed in o.r.\n\n These three exams consist of twelve radiographs of the left hip, left femur,\n and left knee obtained in O.R. There is a comminuted transverse fracture of\n the midshaft of the femur fixated by a long intramedullary rod introduced\n proximally with single interlocking trochanteric proximal nail. Below the tip\n of this rod external traction screws have been placed in the distal femoral\n shaft. There is a markedly comminuted fracture of the distal femur as well as\n proximal portions of the left fibula and tibia. Marked widening of the lateral\n knee compartment. No radiographs obtained of the presumed traction screws in\n the distal tibia. Bone detail suboptimally assessed in these intraoperative\n radiographs.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-26 00:00:00.000", "description": "O ABD (SINGLE VIEW ONLY) IN O.R.", "row_id": 991836, "text": " 12:42 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: IVC FILTER IN O.R.\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: IVC filter placement.\n\n 1 fluoroscopic image submitted after IVC filter placement. A radiologist was\n not present in the OR. An IVC filter is seen with the tip overlying the\n L1 vertebra.\n\n Impression: IVC filter in appropriate position\n\n" }, { "category": "Radiology", "chartdate": "2115-12-24 00:00:00.000", "description": "LOP ELBOW, AP & LAT VIEWS LEFT IN O.R. PORT", "row_id": 991565, "text": " 9:20 PM\n ELBOW, AP & LAT VIEWS LEFT IN O.R. PORT; WRIST(3 + VIEWS) RIGHT IN O.R. PORTClip # \n Reason: ORIF L ELBOW & R WRIST IN OR\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL INFORMATION: ORIF left elbow and right wrist in the operating room.\n\n FINDINGS:\n\n Two views of the left elbow and eight views of the right wrist are submitted.\n These are intraoperative fluoroscopic spot views. They demonstrate open\n reduction internal fixation of comminuted ulnar fracture and comminuted radial\n fracture. Both fractures are intra-articular. Please refer to operative note\n for full detail. These images are not of diagnostic quality.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 992381, "text": " 2:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval hepatobiliary anatomy, please perform RUQ U/S\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC, diaphragmatic hernia repair, multiple orthopaedic\n procedures now with elevated LFTs\n REASON FOR THIS EXAMINATION:\n please eval hepatobiliary anatomy, please perform RUQ U/S\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with motor vehicle collision, diaphragmatic hernia\n repair. Now with elevated LFTs.\n\n COMPARISON: CT abdomen and pelvis, and .\n\n ABDOMINAL ULTRASOUND: The liver is homogeneous in echotexture, with no focal\n liver lesions identified. The hepatic parenchymal echogenicity is normal. The\n gallbladder demonstrates a moderate amount of sludge. There is no evidence of\n gallstones. There is no intrahepatic biliary ductal dilatation, and the\n common bile duct measures 2 mm. The pancreas is not well visualized secondary\n to bowel gas.\n\n The aorta is unremarkable. No ascites is identified.\n\n IMPRESSION: Biliary sludge; otherwise unremarkable abdominal ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 992131, "text": " 10:23 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT CHEST W/O CONTRAST\n Reason: with p.o. and IV contrast please, please eval for diaphragma\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Field of view: 43\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p diaphragmatic rupture now w/abdominal pain\n REASON FOR THIS EXAMINATION:\n with p.o. and IV contrast please, please eval for diaphragmatic/intraabdominal\n injury, if unable to inject full load of IV contrast through PICC please\n perform with decreased amount of IV contrast or with p.o. contrast only\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male after motor vehicle accident with traumatic\n diaphragmatic rupture, status post laparotomy and repair, now with abdominal\n pain.\n\n COMPARISON: CT torso , abdominal radiograph .\n\n TECHNIQUE: MDCT axial images of the full torso after oral contrast, but no IV\n contrast due to lack of peripheral IV access. The patient has a PICC\n catheter, but this is not suitable for CT power injection.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: There is a small-to-moderate left\n pleural effusion with associated compressive atelectasis of the dependent left\n lower lobe. Small subcentimeter foci of density along the pleural surface of\n the right middle lobe are probably the sequela of resolving contusion.\n Otherwise, the lungs are clear. The unopacified view of the heart and great\n vessels is unremarkable.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The patient is status post laparotomy\n and diaphragmatic repair. The stomach and spleen are now below the diaphragm\n without evidence of herniation. The non-contrast view of the liver, spleen,\n gallbladder, adrenal glands, pancreas, kidneys, and bowel are unremarkable.\n Oral contrast passes freely through to the descending colon and stool mixed\n with gas extends to the rectum. No free gas within the peritoneum is\n identified. An IVC filter is in standard configuration.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The patient is status post interval\n ORIF of proximal left femoral fracture. There is a small amount of low-\n density fluid in the deep pelvis. Foley catheter is within the decompressed\n bladder. The pelvic loops of bowel are unremarkable.\n\n BONE WINDOWS: The patient is status post ORIF of left proximal femur\n fracture.\n\n IMPRESSION:\n 1. Interval diaphragmatic repair with spleen and stomach and other abdominal\n organs now below the diaphragm without evidence of herniation.\n 2. Small-to-moderate left pleural effusion and associated compressive\n (Over)\n\n 10:23 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT CHEST W/O CONTRAST\n Reason: with p.o. and IV contrast please, please eval for diaphragma\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Field of view: 43\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n atelectasis of the dependent left lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 992702, "text": " 9:33 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for structural abnormalities\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with multiple fractures, diaphragm rupture, now with\n delirium\n REASON FOR THIS EXAMINATION:\n Please evaluate for structural abnormalities\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 22-year-old man status post MVA with multiple fractures\n and delirium.\n\n TECHNIQUE: Sagittal short TR, short TE spin echo images were obtained through\n the brain. Axial imaging was performed with long TR, long TE, fast spin echo,\n FLAIR, gradient echo and diffusion technique. Axial, coronal, short TR, short\n TE spin echo imaging was repeated after intravenous gadolinium contrast.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n There is no abnormal enhancement.\n\n IMPRESSION: Normal study.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-19 00:00:00.000", "description": "RP TIB/FIB (AP & LAT) RIGHT PORT", "row_id": 990901, "text": " 11:22 PM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: please obtain tibia and fibula in addition to ankle, please\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with right ankle tenderness and ecchymosis\n REASON FOR THIS EXAMINATION:\n please obtain tibia and fibula in addition to ankle, please eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right ankle tenderness and ecchymosis status post MVC.\n\n Two views of the right tibia were obtained portably. No dedicated views of\n the right ankle were obtained. There is some overlying material.\n\n There are several fractures about the ankle -- a subtle fracture rising from\n the lateral aspect of the distal fibula, with some overlying soft tissue\n swelling; a probable small fracture fragment along the lateral calcaneus; and\n a nondisplaced fracture of the medial malleolus. Irregularity along the medial\n talar dome is noted - ? OCD or more likely overlap from the medial malleolus.\n\n At the periphery of these films, an unusual lucent cleft is seen in the\n posterior knee joint and there is a small knee joint effusion.\n\n No fracture is detected involving the diaphysis of the tibia or fibula.\n\n IMPRESSION - RIGHT LOWER LEG:\n\n 1. Suspect multiple fractures about the right ankle for which dedicated ankle\n views would be recommended.\n\n 2. Right tibial plateau fracture cannot be excluded and should be correlated\n clinically.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990936, "text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p chest tube to water seal\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with diaphragmatic rupture s/p repair POD 2 now s/p\n chest tube to water seal.\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p chest tube to water seal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male status post MVC with diaphragmatic rupture status\n post repair, now status post chest tube to waterseal. Evaluate for\n pneumothorax.\n\n COMPARISON: .\n\n SEMI-UPRIGHT PORTABLE CHEST, ONE VIEW: Left chest tube unchanged in position.\n There is a small radiolucent line on the medial aspect of the left lower\n hemithorax. This may represent a very small pneumothorax, however right\n lateral decubitus films are recommended for better evaluation. There is no\n apical or lateral pneumothorax. Lungs are otherwise grossly clear. Pleural\n surfaces are normal. Cardiomediastinal silhouette is stable.\n\n IMPRESSION: Thin radiolucency along the medial aspect of the left lower\n hemithorax may represent a small pneumothorax. Right lateral decubitus is\n recommended for better evaluation.\n\n Findings were communicated to by telephone at the time of\n interpretation.\n\n jr\n\n" }, { "category": "Radiology", "chartdate": "2115-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991381, "text": " 8:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with traumatic diaphragmatic rupture s/p repair, now with chest\n pain, tachycardia.\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:51 P.M. ON \n\n HISTORY: Diaphragmatic rupture and repair.\n\n IMPRESSION: AP chest compared to through 15:\n\n Lungs clear. Heart size normal. Minimal blunting of the left medial pleural\n sulcus probably due to residual effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991967, "text": " 9:47 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 38cm DL PICC inserted to R cepjalic. Pls determine tip place\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with mult inj related to MVA\n REASON FOR THIS EXAMINATION:\n 38cm DL PICC inserted to R cepjalic. Pls determine tip placement. Pg #.\n Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10 A.M.\n\n COMPARISON: at 1:30 a.m.\n\n INDICATION: PICC line placement.\n\n Right PICC line terminates within the mid superior vena cava. There is\n otherwise no substantial change from a recent study performed several hours\n earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992312, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess picc line\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with right PICC who attempted to pull it out\n REASON FOR THIS EXAMINATION:\n assess picc line\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line position.\n\n Portable AP chest radiograph compared to .\n\n The right PICC line tip terminates in superior SVC. The heart size is normal.\n Mediastinal contours are unremarkable. Lungs are clear. Left pleural\n effusion is again noted.\n\n IMPRESSION: Appropriate position of the right PICC line.\n\n Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 992159, "text": " 1:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA w/ changing mental status\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 22-year-old male status post motor vehicle accident with change\n in mental status. Evaluate for acute intracranial hemorrhage.\n\n COMPARISON: .\n\n FINDINGS: No acute intracranial hemorrhage, mass lesion, shift of normally\n midline structures or hydrocephalus is identified. The -white matter\n differentiation is normal. The surrounding soft tissues and osseous\n structures are unremarkable. The paranasal sinuses and mastoid air cells are\n clear.\n\n IMPRESSION: No acute intracranial abnormality detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992117, "text": " 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for cardiopulm process\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mult orthopaedic operations, now w/temperature\n REASON FOR THIS EXAMINATION:\n please eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Right PICC line continues to terminate in the superior vena cava but appears\n to have increased redundancy in the region of the right axilla compared to\n previous exam. Left pleural effusion and adjacent basilar atelectasis is\n unchanged. No new areas of consolidation are identified to suggest acute\n infectious pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991917, "text": " 1:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p mult c fevers 102 s/p prev diaphragm repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fevers.\n\n Layering left pleural effusion appears larger compared to the previous\n examination. New poorly defined left perihilar and retrocardiac opacity may\n potentially represent an area of aspiration or developing infection and\n attention to these areas on followup radiographs is suggested.\n Mild-to-moderate gastric distention is present in the upper abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 993589, "text": " 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate resolution of pulmonary contusion\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with pulmonary contusion and diaphragmatic rupture.\n REASON FOR THIS EXAMINATION:\n evaluate resolution of pulmonary contusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP VIEW\n\n Compared to a chest radiograph.\n\n REASON FOR EXAM: Evaluate resolution of pulmonary contusions. This is a 22-\n year-old man, status post MVA with pulmonary contusion and diaphragmatic\n rupture.\n\n FINDINGS:\n\n There is no airspace disease or interstitial disease in either lung. No\n pulmonary contusions. There is no pneumothorax or pleural effusion. Again\n noted is a right PICC line catheter with distal tip projecting over the\n brachiocephalic/atrial junction. Cardiomediastinal structures are\n unremarkable. No osseous fractures are seen.\n\n IMPRESSION:\n 1. No evidence of pulmonary contusion.\n 2. No pneumothorax or pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 992562, "text": " 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for structural abnormality\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with delirium\n REASON FOR THIS EXAMINATION:\n Please evaluate for structural abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 22-year-old man with delirium. Assess for structural abnormality.\n\n TECHNIQUE: Contiguous 5 mm axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: Comparison is made to and .\n\n There are no intracranial hemorrhages or masses. The /white matter\n differentiation is maintained. The ventricles and extra-axial CSF spaces are\n normal.\n\n The visualized orbits are normal. The visualized paranasal sinuses, mastoid\n air cells, and middle ear cavities are clear. No suspicious bony\n abnormalities are seen.\n\n IMPRESSION: Normal unenhanced head CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-19 00:00:00.000", "description": "L CT LOW EXT W/O C LEFT", "row_id": 990879, "text": " 4:51 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: CT of LEFT KNEE - evaluate left tibial plateau fracturePLEAS\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVA with left tibial plateau fracture, has ex-fix\n REASON FOR THIS EXAMINATION:\n CT of LEFT KNEE - evaluate left tibial plateau fracturePLEASE DO REFORMATS\n CONTRAINDICATIONS for IV CONTRAST:\n NO IV CONTRAST NECESSARY\n ______________________________________________________________________________\n WET READ: 5:59 PM\n comminuted distal femoral fx with impaction , intrarticular extension, and\n marked dorsal angulation of distal frag. The medial femoral condyle appears\n preserved. spiral comminuted tibial metediaphyseal fx with mild posterior\n displacement of distal frag. Comminuted tibial plateua fx with intraarticular\n extension and 1.5 cm lateral deviation of the lateral tibil plateau with\n widening of the lateral compartment suggestive of ligamentous injury.\n numerous large intra-articular bony fragments. mildly displaced oblique\n fibular head and mid shaft fx. small lateral patellar avulsion type fx.\n marked lipohemarthrosis and soft tissue edema.\n ______________________________________________________________________________\n FINAL REPORT\n CT LEFT KNEE\n\n INDICATION: Evaluate for tibial plateau fracture.\n\n TECHNIQUE: Non-contrast CT was performed through the left knee.\n\n COMPARISON: Radiographs, left knee, .\n\n FINDINGS:\n\n There are comminuted fractures of the distal femur, proximal tibia and fibula\n and of the patella.\n\n There is an intramedullary rod in the left femoral shaft. The distal end of\n the rod is visualized in the current CT scan field of view. There is a\n markedly comminuted fracture of the distal femur transversely across the\n supracondylar portion of the femur and extending down to the intercondylar\n notch at the articular surface. The component of the fracture line extends to\n the articular surface of the lateral femoral condyle. There is at least 2 cm\n of impaction and shortening of the femur fracture. There is a prominent\n displaced angulated fragment arising from the distal lateral diametaphyseal\n cortex angulated 90 degrees, laterally, projecting into the overlying soft\n tissues. There is anterior angulation of the distal component of the femoral\n fracture.\n\n There is a comminuted fracture of the proximal tibia extending from the\n intercondylar eminence through to the proximal tibial shaft. The fracture\n involves the articular surfaces of the medial and lateral tibial plateaus\n adjacent to the intercondylar eminence. There is between 4 and 6 mm inferior\n (Over)\n\n 4:51 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: CT of LEFT KNEE - evaluate left tibial plateau fracturePLEAS\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n displacement of the lateral tibial plateau with respect to the medial tibial\n plateau (6 mm posteriorly 4 mm anteriorly). As a result of the comminuted\n fracture, the medial and lateral tibial plateaus both from separate bony\n fragments from each other and from the remainder of the tibial shaft. There\n is approximately 8 mm of lateral displacement of the distal tibial component\n suspect to the medial tibial shaft.\n\n There is a fracture through the proximal fibula involving the head and neck of\n the fibula. There is probable avulsion or tear of the conjoined tendon. There\n is a comminuted nondisplaced fracture of the proximal fibular shaft.\n\n There is wide diastasis of the lateral compartment of the knee joint,\n measuring approximately 2 cm.\n\n There is a non-displaced fracture at the lateral aspect of the patella.\n\n There is an external fixator in situ, fixated at the distal femoral shaft and\n proximal-to-mid tibial shafts.\n\n There are multiple intra-articular fragments.\n\n IMPRESSION:\n 1. Comminuted intra-articular fractures of the distal femur and proximal\n tibia.\n 2. Fractures of the lateral aspect of the patella and fibula.\n 3. Probable injury to the conjoined tendon insertion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-20 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 990944, "text": " 9:27 AM\n ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: Need dedicated ankle films - AP, Lateral and MORTISE views (\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p polytrauma, right ankle injury\n REASON FOR THIS EXAMINATION:\n Need dedicated ankle films - AP, Lateral and MORTISE views (previous imaging\n did not include mortise)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post polytrauma with right ankle injury.\n\n FINDINGS: Five radiographs of the right ankle are reviewed without\n comparison. This is a comminuted fracture through the distal lateral\n malleolous as well as a mildly displaced fracture of the lateral talus. There\n are also nondisplaced fracture lines extending through the medial malleolous,\n some of which extend to the ankle mortise. Mortise alignment is intact. There\n is a subtle lucency through the medial talus that may also represent a\n nondisplaced fracture. There is marked soft tissue swelling.\n\n IMPRESSION:\n 1. Distal lateral malleolous and lateral talar avulsion fractures.\n 2. Nondisplaced fractures through the medial malleolous extending the mortise.\n\n Given multiplicity of fractures, a CT scan is recommended for further\n evaluation. Findings discussed with Dr. today on the phone.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-18 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 990627, "text": " 8:33 AM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: ABDOMIN TRAMA\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 22-year-old with abdominal trauma.\n\n COMPARISON: None.\n\n SUPINE ABDOMINAL RADIOGRAPH: There is a nonobstructive bowel gas pattern. Tip\n of NG tube is seen within the stomach. Left sided chest tubd is incompletely\n imaged. Streaky linear lucencies are identified in the left lateral abdomen,\n which likely represents post-operative intrabdominal air. Staples overlie the\n midline abdomen and right pelvis/flank. No radiopaque foreign body is\n otherwise detected.\n\n IMPRESSION: No evidence of obstruction or retained foreign body.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-21 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 991116, "text": " 1:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o ptx s/p left chest tube pull\n Admitting Diagnosis: RUPTURED DIAPHRAM;FRACTURED FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p MVC with diaphragmatic rupture, L comminuted femur fx, now\n s/p chest tube pull on left.\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p left chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: Diaphragmatic rupture status post chest tube pull.\n\n FINDINGS: The left-sided chest tube has been removed with a small residual\n pneumothorax. There is a small pleural effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 85592, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Tachycardia s/p trauma. ?pericardial effusion. Right ventricular function.\nHeight: (in) 71\nWeight (lb): 165\nBSA (m2): 1.95 m2\nBP (mm Hg): 120/60\nHR (bpm): 117\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RAP (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%) Transmitral and tissue Doppler\nimaging suggests normal diastolic function, and a normal left ventricular\nfilling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\nIMPRESSION: Normal study. Normal biventricular cavity sizes with preserved\nglobal and regional biventricular systolic function. No pericardial effusion.\nResting tachycardia.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 218340, "text": "Artifact is present. Sinus tachycardia. The P-R interval is short\nwithout evidence of pre-excitation. Compared to the prior tracing\nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2115-12-23 00:00:00.000", "description": "Report", "row_id": 218341, "text": "Sinus tachycardia\nBorderline short P-R interval - is nonspecific and probably normal variant\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2115-12-18 00:00:00.000", "description": "Report", "row_id": 218342, "text": "Sinus tachycardia\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" } ]

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1. Cardiac: 3rd degree heart block s/p pacemaker placement; HTN Patient initially very bradycardic with mild HTN upon admission. Her EKG showed a RBBB with a ventricular rate of 36. Her atenolol was decreased from 75 mg to 25 mg qd. Her cardiac enzymes were negative. The patient was placed on telemetry and transferred to the floor. Shortly after transfer, it was noted on telemetry that the patient had progressed into 3rd degree heart block. She was mentating normally and was hemodynamically stable, but her heart rate continued in the 30s. Cardiology was consulted and it was decided at this time that the patient should be transferred from the medicine service to the CCU. In the CCU, the patient had a temporary pacer initially placed. Then on a pacemaker was placed. Patient did experience a lead misplacement complication and a mild pericardial effusion. She did recover from this and was completely asymptomatic at the time of discharge to the rehab facility. An echo was repeated on which showed that the overall left ventrical systolic function was preserved, right ventrical size and motion was normal, small pericardial effusion which was slightly larger than the prior study, no tamponade. Her EF was 45-50% c mild aortic and moderate mitral regurgitation. A chest x-ray following her pacer placement showed that her cardiac leads were in the correct position and there was no active lung disease. The patient also became hypotensive following pacer placement and therefore all hypertensive medications were held. Her blood pressure then increased to 148/73 and atenolol 25 mg qd was re-started with good control. The patient became mildly hypertensive and therefore her out-patient regimen was restarted except that Norvasc 5 mg qd was held. Therefore the patient was d/c'ed c atenolol 50' qd, Zestril 40' qd and ASA 325' qd. The patient will follow-up with her PCP for further evaluation and monitoring in one week and will follow-up with the device clinic on c Dr. . 2. Hematology The patient's hematocrit was noted to have decreased following her pacer placement from the high 30s to the low 30s. She was asymptomatic, no BRBPR, guiac negative, no hematuria. A CT of the abdomen showed that there was no retroperitoneal hemorrhage. She was closely monitored and her hematocrit stabilized and she remained asymptomatic. It was felt that this likely had been due to her procedure and the pericardial effusion. Her rehab facility will re-check her hematocrit in days to ensure stabilization. The patient was also started on Vitamin B12, Folate 1' qd and Iron 325' qd. 3. GERD/Esophageal stricture s/p EGD The patient remained asymptomatic throughout her hospital stay and was maintained on her out-patient protonix 40 mg qd. She will follow-up with PCP for further care. 4. Hypothyroidism The patient remained stable and her outpatient Levoxyl was continued as previously prescribed. 5. r/o DVT The patient experienced new onset left foot swelling following her pacer placement. Patient had also been taking estrogen upon admission. There were no palpable cords, no calf tenderness, no SOB/CP. No tenderness in foot or lower extremity. An US of the extremity was performed to verify there were no DVTs. She had pneumoboots for the majority of her hospital stay as well.

Pt denies pain.VAnco IV s/p pacemaker.PULM: RRR, on RA. Distal pulses palpable.Resp: LS CTA. EKG confirmed CHB. Cont to wean Dopamine as tolerated. CXR this AM reveal wire had migrated approx 2 cm back, EP aware and in to advance wire, settings unchanged. Following Ativan doses pt speech slowed. Pt remains off of Dopamine gtt. Pt slept w/ minimal interruption remainder of noc.CV: Hemodynamically improving. CHEST, AP: There is stable cardiomegaly. DP/ PT pulses +2/+1MS:MS: AAOx3. Call out to floor if VS/effusion remain stable. The hilar and mediastinal contours are within normal limits. Pt denies SOB/ difficulty breathing. NBP 85-107/36-49. Pt denied any pain overnoc. Pt remained asymptomatic and NBP stable. Became hypotensive after removal of temporary pacemaker. DDD pacemaker placed . Pt remains off of antihypertensives. Interval removal of pacer wire and placement of permanent pacer with right atrial and ventricular leads appropriately positioned. Effusion stable. DDD permanent pacemaker placed. Remains +200cc LOSID: Pt afebrile. NIBP 98-112/42-49. CT PELVIS W/O IV CONTRAST: The rectum, sigmoid colon, distal ureters are all within normal limits. Pt cont to be covered empirically w/ Vancomycin following permanent pacemaker placement. Cont to ambulate as tolerated. There has been interval removal of temporary pacer wire. Remains on Dopamine gtt peripherally for BP support. AM Hct 36.2. Distal pulses palpable w/ ease. Pt tolerating po liquids w/o difficulty. vagal episode per report. Permanent pacemaker placed w/o difficulty but pt vagaled following removal of temp wire via RIJ. Speech slowed following Ativan doses. Pt ambulated to commode w/ the assist of two w/o incidence. Permanent pacemaker placed. Pt denies any pain. RR 14-20.GI/GU: Abd soft. Pt remained vpaced remainder of shift w/o incidence. Initial BP obtained 86/39. Pt exhibited good response to bolus w/ BP in 100's/50's-Dopa slowly weaned to off at 1400-remains off w/ range high 80's-90's w/ MAP's in 60's. +BS. + BS. CHEST AP: There is stable LV enlargement. Right femoral venous sheath site stable. Otherwise unchanged radiographic appearance of the chest compared to previous study. CHEST AP: Permanent pacemaker leads remain in appropriate positioning. CCU Nursing Progress Note 7p-7aS: "That number is pretty low for me (in reference to BP)O: Please see careview for complete VS/ additional objective dataMS: AAOx3. Pt remained hypotensive requiring fluid boluses and Dopamine for support. No vomitus but + dry heaves. IVF WO. Pulses Paroduxes negative. Echo this am for further evaluation of hypotension following permanent pacemaker placement. HCT cont to trend down. w/ SPC-supervision onlyResp-Lungs CTA bilat, SpO2 on RA 95-98%, 0 SOB noted Pt HR stable Vpaced-AV paced at times 70's 0 ectopy noted. Nausea x2 tx w/ 2 mg Zofran.ID: Afebrile overnoc.Skin: IntactAccess: 2 PIVA/P: CHB. 3) Small pericardial effusion Nursing Shift NoteS:"I don't feel my heart beating anymore"O: Pt A+Ox3, pleasant and cooperative w/ care, ambulatory w/ P.T. Administered 2mg Zofran w/ gd effect. Venous sheath site stable. HO aware of marginal BP and no additional pressor support or fluids ordered. There are noechocardiographic signs of tamponade.Conclusions:Overall left ventricular systolic function is grossly preserved. Overall leftventricular systolic function is mildly depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Mild to moderate (+) mitral regurgitation isseen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. Mild (1+) aorticregurgitation is seen.3. Atrial sensed ventricular paced rhythmSince previous tracing of , no significant change Regular ventricular pacingPacemaker rhythm - no further analysisSince previous tracing, ventricular paced rhythm noted The left ventricular cavity size is normal. Shortness of breath.Height: (in) 64Weight (lb): 147BSA (m2): 1.72 m2BP (mm Hg): 115/57HR (bpm): 64Status: InpatientDate/Time: at 11:07Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. Mild to moderate (+)mitral regurgitation is seen. There are no echocardiographic signs of tamponade.Compared with the findings of the prior study (tape reviewed) of , thepreviously trivial pericardial effusion is now larger. 2) No other significant cardiopulmonary abnormality. Mild (1+) aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. FINDINGS: The heart is normal in size. The right IJ temporary pacing electrode tip is at the apex of the right ventricle, in good position on the single view provided. Since the previous tracingof no significant change. Rightventricular chamber size and free wall motion are normal. There is mildmitral annular calcification. IMPRESSION: No active lung disease. Allowing for technical differences the position is not significantly changed since the earlier study of the same day. FINDINGS: A single AP supine image. R/o pericardial effusion.Height: (in) 64Weight (lb): 146BSA (m2): 1.71 m2BP (mm Hg): 103/42HR (bpm): 84Status: InpatientDate/Time: at 08:24Test: Portable TTE (Complete)Doppler: Limited doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.PERICARDIUM: There is a small pericardial effusion. Left ventricular function. There is a smallpericardial effusion. Overall left ventricularsystolic function is difficult to assess but is probably mildly depressed.Septal hypokinesis is present.2. The cardiac leads are in position. A-V dissociationConduction defect of RBBB typePossible old inferior myocardial infarctionSince previous tracing, A-V dissociation noted IMPRESSION: 1) Satisfactory placement of temporary pacing wire. Sinus bradycardia - consider sinus rhythm with 2:1 S-A block.Conduction defect of RBBB typeInferior infarct - age undeterminedNo previous tracing for comparison There is no evidence of cardiac failure. Regular ventricular pacingPacemaker rhythm - no further analysisSince previous tracing, faster heart rate PATIENT/TEST INFORMATION:Indication: Hypotension. ischemiaOld inferior myocardial infarctSince previous tracing, ST segment depression noted TECHNIQUE: PA and lateral chest radiograph. The lungs are clear. There is no apparent abnormalities in bony structures. The aortic valve leaflets are mildly thickened. There is no pneumothorax.

25

[ { "category": "Nursing/other", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 1553954, "text": "CCU Nursing Progress Note 7p-7a\nS: \" I didn't think that this would be such a long ordeal. I figured I would be home by now\".\n\nO: Please see careview for complete VS/ additional objective data.\n\nIn brief pt found to be in CHB while on F2. Transferred to CCU overnoc for temporary pacing wire placement. Permanent pacemaker placed yesterday evening w/o incidence. Upon removal of RIJ cordis/ temp wire while still in EP lab ? vagal episode per report. Pt became hypotensive w/ SBP to the 50s. Pt received 1 mg Atropine and started on Dopamine gtt. IVF WO. Dopamine gtt titrated to 5 mcg/kg/min. Per report pt nauseated while in lab ? r/t hypotension or effects of Fentanyl/ Versed received in lab.\nCV: Pt transferred to CCU and arrived on 2.5 mcg of Dopamine. Initial BP obtained 86/39. Dopamine gtt titrated up to 10 mcg/kg/min but decreased to 7.5 mcg for most of shift. Pt received 500cc NS IVFB x2. DDD permanent pacemaker placed. A sensed, V paced. Settings 60-120. HR 74-120. No ectopy. NBP 85-107/36-49. Goal to maintain MAPs>60. HO aware of marginal BP and no additional pressor support or fluids ordered. Venous sheath site stable. Sm hematoma noted per EP nurse. noted. PM HCT stable at 40. AM Hct 36.2. DP/ PT pulses +2/+1MS:\n\nMS: AAOx3. Pleasant and cooperative. Pt denies any pain or discomfort. Upon return from EP lab pt nauseated. No vomitus but + dry heaves. Administered 2mg Zofran w/ gd effect. No other issue until 0630 when dry heaves reappeared but resolved w/ additional 2 mg. No other change in VS noted. Echo obtained while in EP lab. if there is an effusion it is very sm in size. EF noted to be 45-50%.\n\nResp: LS cta. Pt on 2L NC. No ^ need for O2 requirements. No SOB or difficulty breathing. Pt tolerating lying flat. O2 sats 96-99%.\n\nGI/GU: +BS. Abd soft. Nausea x2 tx w/ 2 mg Zofran.\n\nID: Afebrile overnoc.\n\nSkin: Intact\n\nAccess: 2 PIV\n\nA/P: CHB. Permanent pacemaker placed. Remains on Dopamine gtt peripherally for BP support. Central access. Cont to wean Dopamine as tolerated. Echo this am for further evaluation of hypotension following permanent pacemaker placement. Cont teaching. Cont to support pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 1553955, "text": "Nursing Shift Note\nS:\"I don't feel my heart beating anymore\"\n\nO: Pt A+Ox3, pleasant and cooperative w/ care, ambulatory w/ P.T. w/ SPC-supervision only\n\nResp-Lungs CTA bilat, SpO2 on RA 95-98%, 0 SOB noted\n\n Pt HR stable Vpaced-AV paced at times 70's 0 ectopy noted. This AM BP 90's/50's, MAP's 60's, team order 500cc NS over 60 minutes w/ intention to wean off Dopamine. Pt exhibited good response to bolus w/ BP in 100's/50's-Dopa slowly weaned to off at 1400-remains off w/ range high 80's-90's w/ MAP's in 60's. Pacer interrogated successfully this AM and CXR confirm lead placement, pacer site CDI -hem/ooze w/ positive distal pulses, repeat Echo this AM reveal 0 change in effusion from previous study- repeat Hct 34 from 36 this AM.\n\nGI- BS+x4, Abd soft, NT, ND-good appetite and able to take PO's easily\n\nGU-I+O's approx 2L negative since admit however, >30cc/hr UOP-foley D/C at 1500 today-DTV by 2100-2300\n\nSkin-WDI, R groin CDI -hem/ooze, R IJ temp wire site CDI, raised however, 0 evidence of hematoma\n\nMusk-OOB today, ambulate w/ P.T.-superviion w/cane. Pt requesting rehab stay however, await rec's for D/C\n\nID-3rd dose Vanco today empirically s/p pacer placement, WBC elevated to 14(7), pt remains afebrile w/ 0 other s/s infection. UA sent and negative for leukocytes, Blood cultures x 2 sent and pending\n\nA/P: Pt is an 87 y/o female s/p DDD pacer placement complicated by vagal post temp wire removal requiring Dopa-now remains slightly hypotensive but hemodynamically stable and tolerating new pace rhythm good. Plan to continue close monitoring of BP-team made aware of any changes below baseline, follow cultures and fever curve, DTV as above, D/C planning\n" }, { "category": "Nursing/other", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 1553952, "text": "CCU Nursing Progress Note 7p-7a\nS: \" How long will this be in my neck\"\n\nO: Please see careview for complete VS/ additional objective data.\n\nMS: Upon arrival pt 3. Pleasant and cooperative w/ care. Pt anxious upon arrival requiring reassurance at times. Pt received 0.5mg IV Ativan x2 doses for ^ anxiety during temp wire placement. Pt yelling out stating she wanted the drape off her face. Following Ativan doses pt speech slowed. Pt was able to respond accordingly as to where she was, and the date but stated that the year was and she was unclear as to whom the president was.\n\nCV: CHB. HR 32-37( rate occasionally noted to be ^ 50s yet upon further review abherrant P waves were noted as being conducted.) Pt remained asymptomatic and NBP stable. Pt denied any pain overnoc. After attempting Atropine .6 and 1 mg doses and Albuterol neb w/o improvement team elected to place temp wire. Temporary pacemaker in place at 0430 after lengthy attempt at introducer placement. Wire placement confirmed by CXR. Pt vpaced at 60 bpm. Threshold 0.60 and sensitivity 0.060. Pacing wires attached to pacing box and wires also secured to pt. Site CDI. Pt remained vpaced remainder of shift w/o incidence. H/H and electrolytes stable. Norvasc dose dc'd and Atenolol dose decreased from 75mg- 25mg. Atenolol had been ^d to 75mg (50mg) in the past week. Distal pulses palpable.\n\nResp: LS CTA. No SOB/ difficulty breathing. Pt tolerated lying flat during procedure. RR 10-19. O2 sats 94-97% on RA. During temp pacemaker placement while draped pt sats decreased to 94%. Placed on 2L NC w/ improved sats to 98-100%.\n\nGI/GU: Abd soft. + BS. Gd appetite per report. No BM. No f/c per request of pt. Pt voiding sm amts of urine 25-100cc/hr. BUN/CR 14/0.9.\n\nID: Afebrile. No abx. WBC 7.1.\n\nSkin: Intact.\n\nAccess: 2 PIVs, Transvenous introducer via RIJ.\n\nSocial: Daughter in law called for update this am. Will be into visit after rounds around 11 am\n\nA/P: 87 yo female presented to EW w/ abd/ epigastric pain . While on F2 HR 37 bpm. EKG confirmed CHB. Pt transferred to CCU for temp transvenous pacing wire. Pt arrived to CCU w/ HR in 30s but otherwise VSS. Attempted to ^ HR w/ Atropine and Albuterol doses w/o effect. Although VSS, transvenous pacing wire placed at 0430 this am. Speech slowed following Ativan doses. No other issues overnoc.\n? F/C placemnt if pt cont to void sm amts of urine.\nPermanent pacemaker placement scheduled for this afternoon. Cont to support pt and family as indicated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 1553953, "text": "Nursing Note\nS:\"Have I gone for the pacemaker yet\"\n\nO: Neuro-A+Ox3, however, requires occasional reminders for day of week\n\nResp-Lungs CTA bilat, 0 SOB noted, SpO2 on 2LNC 98%\n\nCar-Pt currently 100% Vpaced-pacer set to VVI, rate of 66, 8 mA w/ threshold 0.6 sec. BP stable 100's-120's/60's, does report feelings of \"heart beating\" from temporary wire. CXR this AM reveal wire had migrated approx 2 cm back, EP aware and in to advance wire, settings unchanged. Pt exhibited episode x 1 this AM of pacer noncapture, voltage increased from 5 to 8 mA w/ relief of symptoms. Awaiting pacer placement this afternoon\n\nGI-NPO since AM, BS+ x 4, Abdomen soft nontender. Pt has h/o esophageal strictures\n\nGU- foley patent and draining CYU, >35 cc/hr UOP, o burning or pain w/ urination\n\nSkin- WDI, 0 open lesions\n\nMusk-gait not assessed, moves all extremities, previously functioned I'ly in senior housing\n\nSocial- Lives alone has adult son who quadriplegic, daughter-in-law has been appointed contact person however, is resistant to signing HCP, has daughter who lives in VA, no contact yet. Sister-in-law phone # in chart.\n\nIV-PIV x 2, #20's both patent and flush easily.\n\nA/ Pt is an 87 y.o. female who presents to F2 with CHB, pain in chest and recent c/o dizziness and GI upset, transfer to CCU for temporary wire placement in anticipation of permanent pacer placement today.\n\n\nSkin- WDI,\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 1553956, "text": "CCU Nursing Progress Note 7p-7a\nS: \"That number is pretty low for me (in reference to BP)\n\nO: Please see careview for complete VS/ additional objective data\n\nMS: AAOx3. Extremely pleasant and cooperative. Pt MAE. Follows commands w/o difficulty. Pt denies any pain. Pt ambulated to commode w/ the assist of two w/o incidence. Pt requested to walk but around the same time BP remained lower. Pt declined use of sleep aid. Pt slept w/ minimal interruption remainder of noc.\n\nCV: Hemodynamically improving. AV/ V paced. DDD pacemaker placed . A sensing/ Vpaced. HI/Lo settings 80-120. Pacemaker appropriately sensing/capturing. LIJ pacemaker dsg site CDI. RIJ site stable. No hematoma/ ooze yet slightly reddened. Right femoral venous sheath site stable. HR 74-83. No ectopy noted. NIBP 98-112/42-49. MAPs improving and remained consistently > 60. Pt remains off of Dopamine gtt. No IVFB given. HCT at 2100 30.9(34.1 prior draw and 10 pt drop in past 24hrs). HO notified and pt was ordered for Abd CT to r/o peritoneal bld. Scan results negative. Distal pulses palpable w/ ease. Pulses Paroduxes negative. AM labs still pending. Per Echo EF 50% and sm anterior effusion unchanged.\n\nResp: LS cta. Faint bibasilar crackles upon auscultation. Pt was off all supplemental O2 but NC 2L reapplied overnoc to improve sats from 93% to 99%. Pt denies SOB/ difficulty breathing. RR 14-20.\n\nGI/GU: Abd soft. +BS. No stool since admission. Improved appetite per report. Pt tolerating po liquids w/o difficulty. F/c dc'd on prior shift. Pt dtv but ambulated to commode and able to urinate. Pt voiding 200cc cyu q 2hrs. Remains +200cc LOS\n\nID: Pt afebrile. Tmax 98.3 po. Pt cont to be covered empirically w/ Vancomycin following permanent pacemaker placement. WBC improved 9.6(14).\n\nSkin: Intact. No breakdown noted. Sm amt of peripheral edema noted.\n\nAccess: 1 PIV\n\nSocial: Daughter called and spoke w/ pt.\n\nA/P: Pleasant 87 yo female found to be in CHB on floor. Pt sent to CCU for temp pacing wire. Permanent pacemaker placed w/o difficulty but pt vagaled following removal of temp wire via RIJ. Pt remained hypotensive requiring fluid boluses and Dopamine for support. BP steadily showing improvement and remains stable off of Dopamine gtt overnoc. Effusion stable. HCT cont to trend down. No active S/S of bld. Sent for Abd ct which was negative for retroperitoneal bld. Pt remains off of antihypertensives. ? need for swan to evaluate fluid status. Cont to ambulate as tolerated. ? Call out to floor if VS/effusion remain stable.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 1553957, "text": "NPN 8a-330pm:\n\nNeuro/ID: A&Ox3, pleasant, cooperative. AFebrile. Pt denies pain.\nVAnco IV s/p pacemaker.\n\nPULM: RRR, on RA. O2 sats>94%\n\nCV: 100% Vpaced rate 70-80. SBP >110. off dopamine. HCT 32.1 up from 29 yesterday. ASA given MD recommendation.\n\nGi/GU: Good appetite, bS present. NO BM. MOM and given.\n\nSocial: Daughter inlaw called for update, talked to pt on phone.\n\nPLAn: Transfer to floor when bed available, transfer note complete\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834029, "text": " 8:32 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o PTX , assess leads\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placementdual chamber\n REASON FOR THIS EXAMINATION:\n r/o PTX , assess leads\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status post pacemaker placement. Evaluate for\n pneumothorax and assess leads.\n\n CHEST AP: Permanent pacemaker leads remain in appropriate positioning. The\n lungs are clear without evidence of pneumothorax. Otherwise unchanged\n radiographic appearance of the chest when compared to previous study dated\n at 12:09AM.\n\n IMPRESSION: No pneumothorax. Appropriately positioned pacemaker leads.\n Otherwise unchanged radiographic appearance of the chest compared to previous\n study.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-03 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 834288, "text": " 2:43 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LT LEG SWELLING\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placement c new onset left foot swelling, no\n pain or other associated symptoms\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 87-year-old woman with new onset left foot swelling. Please\n evaluate for deep vein thrombosis.\n\n COMPARISON: None.\n\n -scale and Doppler son of the left common femoral, superficial\n femoral and popliteal veins were performed. Normal flow, augmentation and\n compressibility and wave forms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833999, "text": " 11:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o mediastinal bleed\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacemaker placement- pt became hyptonesive after temp\n pacemaker removed\n REASON FOR THIS EXAMINATION:\n r/o mediastinal bleed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status post pacemaker placement. Became\n hypotensive after removal of temporary pacemaker. Evaluate for mediastinal\n bleed.\n\n COMPARISON: .\n\n CHEST AP: There is stable LV enlargement. The aorta is tortuous. The hilar\n and mediastinal contours are within normal limits. The lungs are clear.\n Pulmonary vasculature is normal. There are no pleural effusions. There has\n been interval removal of temporary pacer wire. There is a new dual-lead\n permanent pacer with leads appropriately positioned. Osseous and soft-tissue\n structures are unremarkable.\n\n IMPRESSION: No evidence of mediastinal hematoma. Interval removal of pacer\n wire and placement of permanent pacer with right atrial and ventricular leads\n appropriately positioned.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "P CHEST FLUORO WITHOUT RADIOLOGIST PORT", "row_id": 833889, "text": " 4:05 AM\n CHEST FLUORO WITHOUT RADIOLOGIST PORT Clip # \n Reason: please help is assessment of temporary pacer wire placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with complete heart block\n REASON FOR THIS EXAMINATION:\n please help is assessment of temporary pacer wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST FLUORO:\n\n A chest fluoro was performed without a radiologist present. 25 seconds of\n fluoro time was used. No films submitted.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833890, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PACERWIRE PLACEMENT\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87 year old woman status-post pacer wire placement.\n\n COMPARISON .\n\n CHEST, AP: There is stable cardiomegaly. The aorta is unfolded and tortuous.\n Hilar and mediastinal contours are otherwise unremarkable. The pulmonary\n vasculature is normal. The lungs are clear. There are no pleural effusions.\n Pacer wire tip is in the right ventricle. Osseous and soft tissue structures\n are unremarkable.\n\n IMPRESSION: Pacer wire tip in right ventricle. No other acute\n cardiopulmonary process observed on chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2195-06-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 833872, "text": " 5:20 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman c h/o angina presents with epigastric and chest pain x \n days.\n REASON FOR THIS EXAMINATION:\n R/O MI\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n INDICATION: Chest pain.\n\n The heart is upper limits of normal in size and demonstrates left ventricular\n configuration. The aorta is tortuous and the pulmonary vascularity is normal.\n The lungs appear clear, and there are no pleural effusions. Degenerative\n changes are seen in the spine.\n\n IMPRESSION: Left ventricular configuration of the heart and tortuous thoracic\n aorta. Is there a history of systemic hypertension?\n\n No evidence of acute pulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 834109, "text": " 11:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for retroperitoneal bleed\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with s/p R heart cath yesterday, now w/ 10 pt hct drop and\n hypotension.\n REASON FOR THIS EXAMINATION:\n please evaluate for retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right heart catheterization with ten point hematocrit\n drop and hypotension. Evaluate for retroperitoneal bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Helically aquired contiguous axial images were obtained from the\n lung bases to pubic symphysis without IV contrast.\n\n CT ABDOMEN W/O IV CONTRAST: Tiny pleural effusions are present bilaterally.\n There is mild dependent atelectasis as well. Cardiac pacemaker wires are also\n identified. A small pericardial effusion is seen. The noncontrast enhanced\n liver, pancreas, spleen, adrenal glands, kidneys, ureters, stomach, and loops\n of large and small bowel are all within normal limits. There is no free air\n or free fluid. There is no mesenteric or retroperitoneal lymphadenopathy. The\n gallbladder is not well visualized. There is no evidence of retroperitoneal\n hemorrhage.\n\n CT PELVIS W/O IV CONTRAST: The rectum, sigmoid colon, distal ureters are all\n within normal limits. There is no free fluid in the pelvis. There is air\n seen within the bladder without bladder wall thickening. These findings may\n be related to recent instrumentation. No significant pelvic or inguinal\n lymphadenopathy is identified. No pelvic hematoma is seen.\n\n BONE WINDOWS: Degenerative changes are noted within the lower lumbosacral\n spine. No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1) No evidence of retroperitoneal hemorrhage.\n\n 2) Tiny bilateral pleural effusions with mild atelectatic changes at the lung\n bases.\n\n 3) Small pericardial effusion\n\n" }, { "category": "Radiology", "chartdate": "2195-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833910, "text": " 9:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval temp pacemaker wire placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with temp pacemaker wire- please eval placement\n REASON FOR THIS EXAMINATION:\n please eval temp pacemaker wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Evaluate placement of temporary pacemaker electrode.\n\n FINDINGS: A single AP supine image. Comparison study taken five hours\n earlier.\n\n The right IJ temporary pacing electrode tip is at the apex of the right\n ventricle, in good position on the single view provided. Allowing for\n technical differences the position is not significantly changed since the\n earlier study of the same day. The heart and pulmonary vessels are\n unremarkable. There is no evidence of cardiac failure. No pulmonary\n infiltrates or pleural effusions can be identified.\n\n IMPRESSION:\n 1) Satisfactory placement of temporary pacing wire.\n\n 2) No other significant cardiopulmonary abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 834074, "text": " 2:55 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for lead placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman c h/o angina presents with epigastric and chest pain x \n days.\n REASON FOR THIS EXAMINATION:\n please assess for lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 year old woman with angina.\n\n TECHNIQUE: PA and lateral chest radiograph. The comparison is made with the\n previous chest radiograph dated and 4th.\n\n FINDINGS: The heart is normal in size. The cardiac leads are in position.\n The lungs are clear. There is no pneumothorax. There is no apparent\n abnormalities in bony structures.\n\n IMPRESSION: No active lung disease.\n\n" }, { "category": "Echo", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 103171, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial/ventricular ectopy. Left ventricular function. Shortness of breath.\nHeight: (in) 64\nWeight (lb): 147\nBSA (m2): 1.72 m2\nBP (mm Hg): 115/57\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:07\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild to moderate (+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is difficult to assess but is probably mildly depressed.\nSeptal hypokinesis is present.\n2. The aortic valve leaflets are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen.\n\n\n" }, { "category": "Echo", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 103146, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. S/P pacemaker placement. R/o pericardial effusion.\nHeight: (in) 64\nWeight (lb): 146\nBSA (m2): 1.71 m2\nBP (mm Hg): 103/42\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 08:24\nTest: Portable TTE (Complete)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is grossly preserved. Right\nventricular chamber size and free wall motion are normal. There is a small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (tape reviewed) of , the\npreviously trivial pericardial effusion is now larger.\n\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312969, "text": "A-V dissociation\nConduction defect of RBBB type\nPossible old inferior myocardial infarction\nSince previous tracing, A-V dissociation noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312970, "text": "Sinus bradycardia - consider sinus rhythm with 2:1 S-A block.\nConduction defect of RBBB type\nInferior infarct - age undetermined\nNo previous tracing for comparison\n\n" }, { "category": "ECG", "chartdate": "2195-07-03 00:00:00.000", "description": "Report", "row_id": 312963, "text": "Atrial sensed and demand ventricular pacing. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2195-07-02 00:00:00.000", "description": "Report", "row_id": 312964, "text": "Atrial sensed ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2195-07-01 00:00:00.000", "description": "Report", "row_id": 312965, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, faster heart rate\n\n" }, { "category": "ECG", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 312966, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, ventricular paced rhythm noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-30 00:00:00.000", "description": "Report", "row_id": 312967, "text": "A-V paced rhythm\nSince previous tracing, paced rhythm noted\n\n" }, { "category": "ECG", "chartdate": "2195-06-29 00:00:00.000", "description": "Report", "row_id": 312968, "text": "A-V dissociation\nRight bundle branch block\nLateral ST depression - ? ischemia\nOld inferior myocardial infarct\nSince previous tracing, ST segment depression noted\n\n\n" } ]

20,965

133,030

1. GASTROINTESTINAL: The patient with presumed cholangiocarcinoma and history of cholangitis being treated with antibiotics for coagulase-negative Staphylococcus and in her bile. The patient reports no fevers since discharge. The patient had followed up with Hematology/Oncology and per the discussion of Hematology/Oncology and the family there was a decision made to not prefer any surgical options. The patient had represented for elective internalization of the percutaneous drains. The patient had finished a full course of the fluconazole, Flagyl, vancomycin; however, Levofloxacin had been extended for an additional week. The patient underwent successful internalization of her drains; however, the percutaneous drains were left in place to ensure no further issues. The plan was to have the drains removed at a later time. It was clear that these stents were fully functional. 2. RESPIRATORY: The patient had reported no respiratory distress on admission; however, on the day of intended discharge on , the patient developed sudden onset of acute shortness of breath while showering prior to discharge. The patient's oxygen saturations dropped and the patient was diagnosed with a massive pulmonary embolus. The patient was transferred to the Cardiac Catheterization Laboratory for thrombectomy and required intubation for severe respiratory distress. At that time, it was found that the right pulmonary artery was occluded in the superior portion as well as the inferior portion. The inferior portion was successfully Angiojetted with local lytics to restore flow to that area. Also, at that time, an IVC filter was placed. 3. CARDIAC: On the morning of , the patient had a massive pulmonary embolus with resulting cardiogenic shock. The patient was intubated and placed on pressors subsequently. The patient was maintained on Levophed and Vasopressin throughout the night. However, on the morning of , it became evident that the patient not only had shock liver but acute renal failure in the setting of decreased blood pressures on the prior day. The patient had also been given Amiodarone for rapid atrial fibrillation post procedure and had tolerated this well. The patient's family including her three daughters were aware of the situation and the significant decline in the patient's health. They were aware of the heart failure and subsequent shock liver and acute renal failure. Given the fact that the patient had expressed prior wishes to be DNR/DNI and it was only reversed in the setting of the acute event, the continued care of the patient was discussed with her three daughters. It was decided on the morning of to withdrawal pressor support. After withdrawal of pressor support, the patient's blood pressure rapidly declined and she was pronounced at 12:21 p.m. on . The patient's family was present and declined postmortem examination. The approximate cause of death was cardiac arrest due to pulmonary embolism in the setting of cholangiocarcinoma. , M.D. Dictated By: MEDQUIST36 D: 02:12 T: 14:21 JOB#:

There issevere global right ventricular free wall hypokinesis.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Unstable SVT episodes resolved with AMio drip. There is apical sparing of the right ventricular dysfunctionwhich is consistent with (but not diagnostic for pulmonary embolus).The aorticvalve leaflets are mildly thickened. CCU Nursing Progress noteS: Orally IntubatedO: ID - hypothermic, with WBC 27.1. Requiring intubation and max Levophed support. Lactic Acid 17.7A: Cholangiocarcinoma; admitted for IR procedure. ABG acidotic requirirng bicarb resuscitation. Pulses dopplerable, extremities cool and mottled.RESP: Intubated. BP is maintained on pressors Levo 04-0.6mcgs and Vasopressin 0.5u. Cont on triple Abx, Flagyl, Vanco and Levofloxacin.CV - HR SR/ST with frequent APC's, and rare PVC's. 7:37 AM BILIARY STENT Clip # Reason: STENT Admitting Diagnosis: CHOLANGIOCARCINOMA\BILIARY DRAIN Contrast: OPTIRAY Amt: 10 ********************************* CPT Codes ******************************** * BILIARY STRICTURE DILATION WIT 78 RELATED PROCEDURE DURING POSTOPER * * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER * * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER * * -59 DISTINCT PROCEDURAL SERVICE CHALNAGIOGRAPHY VIA EXISTING C * * 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY * * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER * * -59 DISTINCT PROCEDURAL SERVICE BILIARY STRICTURE DILATION NO * * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON * * -59 DISTINCT PROCEDURAL SERVICE TUBE CHOLANGIOGRAM * * TUBE CHOLANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** FINAL REPORT INDICATIONS: 83 y/o woman with biliary obstruction who had bilateral biliary drains placed previously. PATIENT/TEST INFORMATION:Indication: Tamponade.Status: InpatientDate/Time: at 11:10Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: The left ventricular cavity is unusually small. There is severe global right ventricular free wallhypokinesis. Last ABG (1700) 7.12/28/268/10; 2 amps of bicarb given.GI: Hypoactive BS. Trivial mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Vasopressin started 0.05u/hr. Venous sheath in right groin; venous and arterial sheath in left groin.S/O: Intubated. ICa 0.89, 2g IV Ca Gluc infusing. Heparin dc'd x2hrs per house staff, then resumed @300u/hr.Resp - Orally intubated with coarse BS. The right ventricularcavity is markedly dilated. ANESTHESIA: MAC and local 1% lidocaine. IMPRESSION: Bilateral tube cholangiograms confirming previously observed high common bile duct stricture extending into right and left hepatic ducts. DSG on upper abd and r flank for clamped bile duct drains. (Over) 7:37 AM BILIARY STENT Clip # Reason: STENT Admitting Diagnosis: CHOLANGIOCARCINOMA\BILIARY DRAIN Contrast: OPTIRAY Amt: 10 FINAL REPORT (Cont) Post stenting cholangiogram demonstrating brisk flow through the stents into the common bile duct and duodenum. Repeat labs after repletion. Clamped drains on abdomen.GU: Dark colored urine via foley catheter.NEURO: On arrival, MAE, following commands. Cont with drips. The tricuspid valve leaflets are mildly thickened.Moderate to severe [3+] tricuspid regurgitation is seen. Sx for minimal bloody secretsions. The right catheter was cut and wire was advanced into the duodenum. Now returns for stenting of the obstructed area. Restart Heparin per scale. Respiratory Care:Ptrecieved from the cath lab holding area on a vent. Final abdominal image demonstrated appropriate positioning of the bilateral biliary drains. with ABG 268-22-7.0. With the sheath tips positioned at the respective right and left hepatic ducts, cholangiograms were performed which confirmed the previously high common duct stricture extending into both the right and left hepatic ducts. CCU NPN: Admit Note82y.o. Intubated. Multiple episodes of SVT with no BP, tx by sinus massage. s/p PE today with RPA pulmonary angiography and thrombectomy. Arrived to CCU on Heparin at 800u/hr, Levophed at 0.4mcg/kg/min, and vented. 1% lidocaine was infused at both of the catheter exit sites. They were simultaneously deployed with their distal tips just distal to the area of obstruction and the proximal ends within the respective right and left hepatic ducts. Hemodynamics obtained. Labs- Alt, 1257, Ast 3353, Amylase 1017, T. bili 5.9, LDH 3616.GU - Foley draining scant amts brown urine. There is nopericardial effusion. Left ventricular systolic function is hyperdynamic (EF>75%).RIGHT VENTRICLE: The right ventricular cavity is markedly dilated. BUN 23/Creat 1.8Neuro/ Sedation - Fentanyl 50mgcs and Versed 1mg IVP given for comfort q2-3hrs. On pressors, Antiarryhtmics.P: DNR. Rx with 3 amps NaHCo3 with subsequent ph 7.21. Levophed at max of 0.8mcg/kg/min. Emergently brought to cath lab for pulmonary angiography with thrombectomy; clot found in RPA.

8

[ { "category": "Nursing/other", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 1537278, "text": "Respiratory Care:\nPtrecieved from the cath lab holding area on a vent. She had an\nangio-jet for removal of a clot from her PA. w/greatly improved blood\nflow post procedure. Vent. settings as per CareVue. She has been very Acidotic w/hyperventilation from Met. Acidosis\n" }, { "category": "Nursing/other", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 1537279, "text": "CCU NPN: Admit Note\n82y.o. female admitted this hospitalization for internalization of Percutaneous Transhepatic drains by IR as palliative care for cholangiocarcinoma. Procedure successfully done . This am walking to BR became SOB, with low SBP, found to be in SVT/A-fib. Emergently brought to cath lab for pulmonary angiography with thrombectomy; clot found in RPA. IVC also placed during procedure. Hemodynamics obtained. VS very tenuous during procedure. Requiring intubation and max Levophed support. ABG acidotic requirirng bicarb resuscitation. To CCU for monitoring. Pt DNR/DNI prior to event this AM, but made a full-code for emergent procedure. Arrived to CCU on Heparin at 800u/hr, Levophed at 0.4mcg/kg/min, and vented. Venous sheath in right groin; venous and arterial sheath in left groin.\n\nS/O: Intubated. PLease see FHP for more details.\n\nCV: HR 85-220 ?NSR/ST/ A-fib. Multiple episodes of SVT with no BP, tx by sinus massage. BP 59-107/40's. Levophed at max of 0.8mcg/kg/min. AMio drip bolus given and drip started at 1mg/min. Vasopressin started 0.05u/hr. Heparin drip at 800u/hr, PTT 150 drip held per protocol. Other coags severely elevated. Unstable SVT episodes resolved with AMio drip. ICa 0.89, 2g IV Ca Gluc infusing. Pulses dopplerable, extremities cool and mottled.\n\nRESP: Intubated. O2 sats difficult to obtain. Vent A/C 650 26 60% 5. LS coarse throughout. Last ABG (1700) 7.12/28/268/10; 2 amps of bicarb given.\n\nGI: Hypoactive BS. Clamped drains on abdomen.\n\nGU: Dark colored urine via foley catheter.\n\nNEURO: On arrival, MAE, following commands. Fentanyl and Ativan IVP given for comfort sedation.\n\nSOC: 3 daughters involved in decision making. Family meeting with MDs resulted in DNR code status, support with meds at current time. Family in to see pt.\n\nID: On antbx previously. WBC 21.9. Lactic Acid 17.7\n\nA: Cholangiocarcinoma; admitted for IR procedure. s/p PE today with RPA pulmonary angiography and thrombectomy. Intubated. Acidotic. On pressors, Antiarryhtmics.\n\nP: DNR. Cont with drips. Wean pressors as tolerated. Repeat labs after repletion. Follow ABGs. Restart Heparin per scale.\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537280, "text": "CCU Nursing Progress note\nS: Orally Intubated\n\nO: ID - hypothermic, with WBC 27.1. Cont on triple Abx, Flagyl, Vanco and Levofloxacin.\n\nCV - HR SR/ST with frequent APC's, and rare PVC's. Amio load 6hr @1mg/min completed then decreased to 0.5mg/min. BP is maintained on pressors Levo 04-0.6mcgs and Vasopressin 0.5u. Pt is flat and up to 15' for bilateral sheaths. Venous in r is oozing bloody drainage and pressure dsg applied. L groin venous and art sheaths have minimal bloody drainage and have transparent dsg intact. Pulses +3/D bilaterally. Extremitities are cool and dusky. Soft limb restraints both legs, d/t pt bending at knee. Heparin restarted 8pm at 550u/hr with subsequent PTT >150/PT 42.8 and INR 12.1. Heparin dc'd x2hrs per house staff, then resumed @300u/hr.\n\nResp - Orally intubated with coarse BS. Sx for minimal bloody secretsions. Vent settings 60%/650/26br. with ABG 268-22-7.0. Rx with 3 amps NaHCo3 with subsequent ph 7.21. Able to decrease FI02 to 40%. Finger sats not registering on monitor.\n\nGI - Abd is soft with hypoactive BS and +flatus. Pt is oozing foul smelling mucoid bloody, yellow stool. DSG on upper abd and r flank for clamped bile duct drains. Labs- Alt, 1257, Ast 3353, Amylase 1017, T. bili 5.9, LDH 3616.\n\nGU - Foley draining scant amts brown urine. BUN 23/Creat 1.8\n\nNeuro/ Sedation - Fentanyl 50mgcs and Versed 1mg IVP given for comfort q2-3hrs. Pt seemingly able to sleep for periods of time. Intermittently nods head to simple questions (pt primary language Portugese) posed by daughters. 3 daughters taking turns at bedside throughout night.\n\nA: Cont to require 2 pressors and antiarrhythmics, Acidotic\n\nP: Cont monitor labs closely, Bicarb as ordered, titrate Heparin per PTT, Turn and position for comfort with Fentanyl and Versed prn, cont help support family through hospitalization.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537281, "text": "pt.remains on ac ventilation, abg acidotic, bs appear claer bilat., will remain a is for today\n" }, { "category": "Nursing/other", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 1537282, "text": "AFTER DISCUSSION C FAMILY PT MADE COMFORT MEASURES ONLY . PT MED C MSO4,WAS UNRESPONSIVE .PRESSERS DC,PT EXTUBATED AND PT DIED SOON AFTER .\n" }, { "category": "Radiology", "chartdate": "2134-03-30 00:00:00.000", "description": "CHANGE PERC BILIARY DRAINAGE CATHETER", "row_id": 821966, "text": " 7:37 AM\n BILIARY STENT Clip # \n Reason: STENT\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\BILIARY DRAIN\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * BILIARY STRICTURE DILATION WIT 78 RELATED PROCEDURE DURING POSTOPER *\n * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER *\n * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER *\n * -59 DISTINCT PROCEDURAL SERVICE CHALNAGIOGRAPHY VIA EXISTING C *\n * 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY *\n * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER *\n * -59 DISTINCT PROCEDURAL SERVICE BILIARY STRICTURE DILATION NO *\n * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON *\n * -59 DISTINCT PROCEDURAL SERVICE TUBE CHOLANGIOGRAM *\n * TUBE CHOLANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 83 y/o woman with biliary obstruction who had bilateral biliary\n drains placed previously. Now returns for stenting of the obstructed area.\n\n ANESTHESIA: MAC and local 1% lidocaine.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and who was\n present and supervising throughout. The patient's abdomen was prepped and\n draped in standard sterile fashion. 1% lidocaine was infused at both of the\n catheter exit sites. The right catheter was cut and wire was advanced\n into the duodenum. The catheter was subsequently exchanged for a 7 French\n bright tipped sheath. The left catheter was then cut and exchanged over a\n wire for a 6 French bright tipped sheath. With the sheath tips positioned at\n the respective right and left hepatic ducts, cholangiograms were performed\n which confirmed the previously high common duct stricture extending into both\n the right and left hepatic ducts. The area of obstruction was measured and it\n was determined that bilateral 4 cm stents would be appropriate. After\n exchanging both wires for exchanged length wires, two 8 mm x 4 cm smart\n stents were advanced. They were simultaneously deployed with their distal\n tips just distal to the area of obstruction and the proximal ends within the\n respective right and left hepatic ducts. The stents were then dilated with 6\n mm x 4 cm balloons. Post stenting cholangiogram was performed through each\n sheath demonstrating appropriate positioning of the stents with good flow into\n the common bile duct and into the duodenum. The right and left sheaths were\n then exchanged for new 8 French biliary drains. The pigtails were locked and\n the catheters were secured with 0 silk sutures. Final abdominal image\n demonstrated appropriate positioning of the bilateral biliary drains. The\n drains were capped to internal drainage. The patient tolerated the procedure\n well and there were no immediate post procedure complications.\n\n IMPRESSION: Bilateral tube cholangiograms confirming previously observed high\n common bile duct stricture extending into right and left hepatic ducts.\n\n Successful deployment of Kissing 8 mm x 4 cm smart stents across biliary\n obstruction. The stents were balloon dilated with a 6 mm x 4 cm balloon.\n (Over)\n\n 7:37 AM\n BILIARY STENT Clip # \n Reason: STENT\n Admitting Diagnosis: CHOLANGIOCARCINOMA\\BILIARY DRAIN\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Post stenting cholangiogram demonstrating brisk flow through the stents into\n the common bile duct and duodenum.\n\n Placement of bilateral 8 French internal external biliary drains which are\n capped to internal drainage. The patient is to return in one week for tube\n cholangiogram and biliary drain removal.\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 76110, "text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nStatus: Inpatient\nDate/Time: at 11:10\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity is unusually small. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Left ventricular systolic function is hyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: The right ventricular cavity is markedly dilated. There is\nsevere global right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\nto severe [3+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nechocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Left\nventricular systolic function is hyperdynamic (EF>75%). The right ventricular\ncavity is markedly dilated. There is severe global right ventricular free wall\nhypokinesis. There is apical sparing of the right ventricular dysfunction\nwhich is consistent with (but not diagnostic for pulmonary embolus).The aortic\nvalve leaflets are mildly thickened. No aortic regurgitation is seen (limited\nviews). The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate to severe [3+] tricuspid regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2134-03-31 00:00:00.000", "description": "Report", "row_id": 186315, "text": "Atrial fibrillation with rapid ventricular response\nInferior ST-T changes are nonspecific\nRepolarization changes may be partly due to rate/rhythm\nLow QRS voltages in precordial leads\nSince previous tracing of , rate increased and atrial fibrillation is new\n\n" } ]

2,733

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1. CAD/Ischemia-NSTEMI (subendocardial, inferior distribution). Cardiac catheterization showed 100% occlusion of distal RCA which could not be stented (could not be crossed by wire). Post procedure TTE showed that her RV was had good systolic motion. She was continued on ASA, statin BB, ACEI, and she will return as an outpatient for replacement of her Aortic valve; at this time, decision will be made whether graft to RCA would be beneficial. She had no further chest pain while in-house. 2. Pump: TTE post-procedure showed EF=55% with no significant wall motion abnormalities. She was kept euvolemic with respect to I/O's while in-house. 3. Severe AS: As per catheterization, AV area was 0.7 cm2. Peak gradient by TTE was 84 mm HG. CT surgery was consulted, and the decision was made for AV replacement as an outpatient, and she will return for this procedure. 4. Rhythmn: NSR on telemetry while in-house. 5. Back Pain-percocet PRN, morphine PRN were used while in-house. 6. Disposition: She was discharged in good condition, to return in weeks for surgery for AV replacement.

Transferred for cath which revealed critical AS (gradient 0.70 cm2). Absence of septal Q waves in leads I and aVL. Distal pulses palpable bilaterally.Resp: LS cta. Clinical correlation isrequired. +BS. CO/CI 6.5/3.02. Low amplitudeT waves in lead II. NIBP 84-112/50s. Pt denies SOB.GI/GU: Abd soft. Normal regional LV systolic function. S/p STEMI. NoAR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal ECG. Normal ECG. Cont on ASA, BB. Tmax 98.4 po. The ICA to CCA ratio is 1.2. Popssible inferior pathology. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.Conclusions:1. The ascending aorta is mildly dilated.3. Sinus rhythmConsider possible inferior infarct - age undeterminedNo change from previous BUN/Cr 15/0.6.ID: Afebrile. Small Q wavesin leads II, III and aVF. DC swan in am. Pt is currently receiving 1st liter. Repleted w/ 40 meq IV KCL. Sinus rhythm. K+ 3.4. Will return this am. Echo in am. Started on Colace. T wave inversions in leads III and aVF. The cardiac, mediastinal, and hilar contours are unremarkable. HR 54-62. Sinus bradycardia. Sinus bradycardia. Received Percocet x1 w/o further complaint.CV: VSS. Cont IVF/ avoid diuresis for presumed RV involvment and preload dependece. Repeat 3.9. Minimal plaque was identified. Name of meds unclear. Pt remains on 2L supplemental O2. Pt c/o back pain d/t limited movement. Compared to the previous tracing of nodiagnostic interim change.TRACING #2 Hold Plavix until decision is made re AVR. No abx. PEARL. HCT stable at 31.8. Tolerating po meds. REASON: Aortic stenosis. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 65Weight (lb): 209BSA (m2): 2.02 m2BP (mm Hg): 109/63HR (bpm): 66Status: InpatientDate/Time: at 10:12Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Right femoral arterial line dc'd at 2300. Unsuccessful PCI of RCA. There is mild impaction of the right third wisdom. IMPRESSION: Roots appear normal. Ordered for a total of 2.5L. Will reattempt PTCA of lesion during this admission. Mildly dilated ascending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. On the left, peak systolic velocities are 86, 54, 80. Compared to the previous tracing of no significant change. Nomid-cavitary gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. MAE. No further c/o chest pain. No BM. Cont supportive care. Regional left ventricular wall motion is normal.2. Severe AS. There is severeaortic valve stenosis.4. Cont mgmt of pain. REASON FOR THIS EXAMINATION: stenosis/occlusion FINAL REPORT STUDY: Carotid series complete. Faint bibasilar crackles. PAP 30s/15-20. In the left front incisor and the adjacent incisor, a defect is present suggesting carries. Mixed venous 70%. No ectopy noted. This is consistent with no stenosis. This is consistent with no stenosis. IMPRESSION: No acute cardiopulmonary process identified. Pt is currently -2L since admission. Advance activity as tolerated. No resting LVOT gradient. COMPARISON: None. Received mylanta x1 for indigestion.Received 230cc of contrast during intervention post cath IVF of 1/2NS cont at 75cc/hr. UO via f/c 330-400cc q 1-2hrs. FINDINGS: Duplex evaluation was performed of both carotid arteries. MAPs>65. Cks this am 574(peaked 602). No previous tracing available for comparison.TRACING #1 Non VIP swan. Soft tissues and surrounding osseous structures are unremarkable. On the right, peak systolic velocities are 76, 66, 90 in the ICA, CCA, and ECA respectively. The mitral valve leaflets are mildly thickened. Cont to follow. Dentition in reasonable condition. There is antegrade flow in both vertebral arteries. Spoke to pt and spouse regarding HCP. RR 9-16. Pt tolerating lying flat without difficulty. CCU Nursing Progress Note 1900-0700S: "That was worst than the procedure (re art sheath pull)O: Please see careview for complete VS/additional objective data.MS: AAOx3. The aortic valve leaflets are severely thickened/deformed. Hemostasis achieved after 25 minutes. Pt received IV Fentanyl 25 mcg upon arrival. After initial dose of 12.5 mg po Metoprolol SBP transiently noted to be 84. IMPRESSION: No evidence of stenosis in either carotid artery. No PCWP attempted. The lungs are clear. O2 sats 96-100%. Left ventricular wall thickness, cavity size, and systolic function arenormal (LVEF>55%). Cath also revealed occluded distal RCA lesion as well as ^RV/PCWP consitent w RV involvement. PANOREX VIEW: Multiple fillings are present but no lucencies or abnormalities in the region of any of the roots seen. When he returns today he and pt will complete. At 0400 pt requesting additional pain med. given to husband. Awaiting consult from surgery for AVR. Husband will bring in today. Pleasant and cooperative. No additional calls or visitors .A/P: 57 yo female w/ no significant hx. Pt was extremely uncomfortable while pressure was held at sight. SINGLE AP PORTABLE UPRIGHT VIEW CHEST: A left sided Swan-Ganz catheter is seen with its tip in the pulmonary artery trunk. Pt was also asleep at that time. REASON FOR THIS EXAMINATION: evaluate dentition, assess risk given plan for AV replacement FINAL REPORT CLINICAL HISTORY: Evaluate dentition prior to aortic valve replacement. No additional diuresis since mg administered in cath lab. WBC 8.8.Skin: Intact.Social: Husband very supportive. During arterial sheath pull pt received additional 50 mcg IV Fentanyl as well as Percocet x2 with resolution of pain. 7:14 AM CHEST (PORTABLE AP) Clip # Reason: pulmonary edema, infiltrate Admitting Diagnosis: CHEST PAIN\CATH MEDICAL CONDITION: 57 year old woman with NSTEMI and dyspnea on exertion.

9

[ { "category": "Echo", "chartdate": "2144-03-20 00:00:00.000", "description": "Report", "row_id": 78964, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 209\nBSA (m2): 2.02 m2\nBP (mm Hg): 109/63\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:12\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. No\nmid-cavitary gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS. No\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The ascending aorta is mildly dilated.\n3. The aortic valve leaflets are severely thickened/deformed. There is severe\naortic valve stenosis.\n4. The mitral valve leaflets are mildly thickened.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862000, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema, infiltrate\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with NSTEMI and dyspnea on exertion.\n REASON FOR THIS EXAMINATION:\n pulmonary edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman with chest pain and dyspnea on exertion.\n\n COMPARISON: None.\n\n SINGLE AP PORTABLE UPRIGHT VIEW CHEST: A left sided Swan-Ganz catheter is\n seen with its tip in the pulmonary artery trunk. The lungs are clear. The\n cardiac, mediastinal, and hilar contours are unremarkable. Soft tissues and\n surrounding osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-20 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 862083, "text": " 2:10 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: stenosis/occlusion\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with aortic stenosis to undergo aortic valve replacement.\n REASON FOR THIS EXAMINATION:\n stenosis/occlusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Aortic stenosis.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque was identified.\n\n On the right, peak systolic velocities are 76, 66, 90 in the ICA, CCA, and ECA\n respectively. The ICA to CCA ratio is 1.2. This is consistent with no\n stenosis.\n\n On the left, peak systolic velocities are 86, 54, 80. This is consistent with\n no stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: No evidence of stenosis in either carotid artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-21 00:00:00.000", "description": "TEETH (PANOREX FOR DENTAL)", "row_id": 862167, "text": " 4:05 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: evaluate dentition, assess risk given plan for AV replacemen\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with aortic stenosis to undergo aortic valve replacement.\n\n REASON FOR THIS EXAMINATION:\n evaluate dentition, assess risk given plan for AV replacement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Evaluate dentition prior to aortic valve replacement.\n\n PANOREX VIEW: Multiple fillings are present but no lucencies or abnormalities\n in the region of any of the roots seen. There is mild impaction of the right\n third wisdom. In the left front incisor and the adjacent incisor, a defect is\n present suggesting carries.\n\n IMPRESSION: Roots appear normal. Dentition in reasonable condition.\n\n\n" }, { "category": "ECG", "chartdate": "2144-03-21 00:00:00.000", "description": "Report", "row_id": 191404, "text": "Sinus rhythm\nConsider possible inferior infarct - age undetermined\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 191405, "text": "Sinus bradycardia. Normal ECG. Compared to the previous tracing of no\ndiagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 191406, "text": "Sinus bradycardia. Normal ECG. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-03-23 00:00:00.000", "description": "Report", "row_id": 191403, "text": "Sinus rhythm. Absence of septal Q waves in leads I and aVL. Small Q waves\nin leads II, III and aVF. T wave inversions in leads III and aVF. Low amplitude\nT waves in lead II. Popssible inferior pathology. Clinical correlation is\nrequired. Compared to the previous tracing of no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2144-03-20 00:00:00.000", "description": "Report", "row_id": 1297719, "text": "CCU Nursing Progress Note 1900-0700\nS: \"That was worst than the procedure (re art sheath pull)\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. Pt c/o back pain d/t limited movement. Pt has underlying back pain that is managed w/ pain meds/ relaxants at home. Name of meds unclear. Husband will bring in today. Pt received IV Fentanyl 25 mcg upon arrival. During arterial sheath pull pt received additional 50 mcg IV Fentanyl as well as Percocet x2 with resolution of pain. At 0400 pt requesting additional pain med. Received Percocet x1 w/o further complaint.\n\nCV: VSS. HR 54-62. No ectopy noted. K+ 3.4. Repleted w/ 40 meq IV KCL. Repeat 3.9. Cont to follow. NIBP 84-112/50s. MAPs>65. PAP 30s/15-20. Non VIP swan. No PCWP attempted. After initial dose of 12.5 mg po Metoprolol SBP transiently noted to be 84. Pt was also asleep at that time. Right femoral arterial line dc'd at 2300. Hemostasis achieved after 25 minutes. Pt was extremely uncomfortable while pressure was held at sight. No further c/o chest pain. Cont on ASA, BB. CO/CI 6.5/3.02. Mixed venous 70%. HCT stable at 31.8. Cks this am 574(peaked 602). Distal pulses palpable bilaterally.\n\nResp: LS cta. Faint bibasilar crackles. RR 9-16. O2 sats 96-100%. Pt tolerating lying flat without difficulty. Pt remains on 2L supplemental O2. Pt denies SOB.\n\nGI/GU: Abd soft. +BS. Started on Colace. No BM. Tolerating po meds. Received mylanta x1 for indigestion.\nReceived 230cc of contrast during intervention post cath IVF of 1/2NS cont at 75cc/hr. Pt is currently receiving 1st liter. Ordered for a total of 2.5L. No additional diuresis since mg administered in cath lab. UO via f/c 330-400cc q 1-2hrs. Pt is currently -2L since admission. BUN/Cr 15/0.6.\n\nID: Afebrile. Tmax 98.4 po. No abx. WBC 8.8.\n\nSkin: Intact.\n\nSocial: Husband very supportive. Will return this am. Spoke to pt and spouse regarding HCP. given to husband. When he returns today he and pt will complete. No additional calls or visitors .\n\nA/P: 57 yo female w/ no significant hx. S/p STEMI. Transferred for cath which revealed critical AS (gradient 0.70 cm2). Cath also revealed occluded distal RCA lesion as well as ^RV/PCWP consitent w RV involvement. Unsuccessful PCI of RCA. Will reattempt PTCA of lesion during this admission. Awaiting consult from surgery for AVR. Hold Plavix until decision is made re AVR. Cont IVF/ avoid diuresis for presumed RV involvment and preload dependece. Echo in am. DC swan in am. Advance activity as tolerated. Cont mgmt of pain. Cont supportive care.\n\n\n\n" } ]

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Resp failure most likely secondary to sepsis in setting of PNA on CXR- unlikely to be related to fluids since patient is presenting with picture of sepsis. He was hypotensive, low UOP, elevated WBC, febrile in the ED and found to have a RLL PNA on CXR. Also has underlying COPD. extubated , doing well. Note that the patient started at a baseline of multiple comorbidities so it is possible that only a small insult was necessary to exacerbate his FTT. SV02 was 78 - sputum culture grew: pseudomonas( to ceftaz) and strep pneum( to pcn) - legionella negative - on levaquin 750 po q daily (started ) requiring 14 day course ending on (switched to q 48 hours for CrCl of 34) - pt was OOB to chair with chest PT doing well - blood culture negative - U/A negative, urine culture negative . Cardiac: -Hypertension: -- metoprolol 25 -CAD: No evidence active ischemia on EKG. -- troponin 0.46, 0.38, 0.27, 0.26 -- on ASA and atorvastatin . Eye surgery: opthomalogy consulted and evaluated patient and recommended erythromycin ointment to eye - spoke with optho on phone, stitch stays in place for > 6 weeks - continue to monitor for signs of infection . COPD- continue nebs/ inhalers on vent. steroids stopped . DM- Tight control while in ICU. on ISS. would continue this in rehab. . Renal failure: creatinine had gone up in setting of lasix and diuresis. (1.6 appears to be baseline.) - discharge home with 40 po lasix q daily . FEN- on TF. able to tolerate thick nectar, soft po intake for meds with assistance. NGT left in place. . Psych meds: - continued on celexa as well as home dose ritalin and zyprexa for agitation and anxiety . Prophylaxis: PPI, pneumoboots, heparin SQ . Code- DNR/DNI

Suctioned via ETT scant whitish secretion noted.Late in the afternon put back to PS 15/+5/40%, tolerated ,ABG done 7.33/34/121, cont PS.CV- HR 65-80 NSR with occasional PVC's,BP 123/66-165/86. K = 3.7; will discuss repletion w/ MD.GI/GU: Abd obese, nontender, + bs. L SC TLC is patent and slightly ecchymotic at site.Resp: Pt. Pt tolerating TF at goal of 65cc/hr with minimal residuals. Minimnal edema noted to upper ext. General anasarca, peripheral pulses weak but palpable.Resp: Pt continues to be supported by vent. PT WITH LOW GRADE TEMP TO 100.4. No goal mentioned.Endo: Sliding scale and fixed doses in place.Skin: Pt. Respiratory Care Pt continues on CPAP/PSV in NARD. ABG this am on 60% HFN: 7.41/52/99/34.CV: HR 60's-80's, SR w/ rare-freq PACs/PVCs. Pt tolerating TFs via NGT @ goal of 65 cc/hr w/ free H2O boluses q 6 hr. TFs running @ goal of 65 cc/hr; pt tolerating well. Weak periph pulses, feet cool bilat, ?edema. Minimal movement of lower ext noted.RESP- Vent settings rec on A/C 650x18/40%/+5, sat 98-100,LS clear, diminished at the bases. MICU Nursing Progress Note 0700-1900Code: FullAllergies: NKDAUneventful shift, pt started on started on Lasix drip, vent weaned, pt tolerating well.Neuro: Pt remains lightly sedated on Fentanyl 75mcg/hr and Versed 2mg/hr. Calcium repleted.GI- Abd soft, BS+, TF 40ml/hr via OGT, then stopped TF for possible extubation.No BM this shift. Pt has generalized weeping of upper extrem.Lines: Left Subclavian TLC; WNL.ID: Afebrile o/n. When lightened up, pt nods approp to questions and MAEx4 on command.CV: HR=50-60s, SB to NSR w/ occ PVCs. Urine for Legionella sent.ENDO- Insulin gtt @ 8.5u/hr, blood sugar q 1hr.ID- Temp 96.8-97ax, cont on Abt Vancomycin, Ceftriaxone and Azithromycin.Awaiting culture.Skin- Intact, edema both arms noted.PLAN- To wean off vent, monitor resp status, neuro status, maintain on minimal sedation. FULL CODE Universal Precautions NKDANeuro: Sedated on fent at 25mcg/kg/min, versed at 3mg/hr w/ good effect. Repeat cardiac are tending down. BS=bilat, diminihsed aeration. PT NORMOTHERMIC, TMAX 98.6. PT SELF D/C;D. NOTED AT TIME OF RESP DISTRESS EPISODE THIS AM, ? NT suctionned by Resp tx X 1.CV: HR 70-105SR with freq PAC's/PVC's. R/T SEDATION, PROPAFOL D/C'D, PLEASE SEE BELOW. Peripheral pulses weakly palpable.ID: Afebrile. RIGHT EYE REMAINS COVERED WITH SOFT DSD, RECIEVING OINTMENT QID.GI--REPLETE WITH FIBER TF INFUSING AT GOAL RATE 65CC/HR WITH MIN RESIDUALS. AM lytes still pending.GI/GU: Abd soft/distended, + bs. Pt given Albuterol/Atrovent nebs x 2. LS coarse.CV: HR 70's-90's, SR w/ rare-freq PVCs. SUMP REPLACED, AND PLACEMENT CONFIRMED BY CXR. (2) Left Subclavian TLC; WNL.ID: Afebrile o/n. Lung sounds remain clear in apices and diminished in bases.Cardiac: Remains dependent on levophed gtt at 0.02mcg/kg/min to maintain b/p. Intubated w/ a #7.5 ETT 21 @lip. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Replete with fiber infusing at 30ml/hr and tolerating well with scant residuals.GU: Oliguric with u/o 15cc/hr. SR with occasional ectopy on monitor.GI: Abd soft/nontender. BS clear after suctioning. Hypothermic with temp 95.3 at start of shift. ABG this am: 7.49/39/71/31.CV: HR 70's-80's, SR w/ rare-freq PVCs. RIGHT RAD ALINE DAMPENED. admin mdi's q4h. Edema to upper ext and scrotum noted. Phos 2.2->pt rec'd neutraphos.GI: TF of replete with fiber @ goal 65ml/hr until 0600 when Dobhoff noted to be out of position. Placed back on A/C and again later placed on PSV w/CPAP. Requires freq K repletion. Cont to monitor lytes, with K+ to remain ~ 4.0. Mildly thickened aortic and mitralvalves. Temp currently 98.7 hugger off. Given 2L ns which led to resp compromise leading to intubation/pre-cept tlc placement. Left ventricular function.Height: (in) 69Weight (lb): 220BSA (m2): 2.15 m2BP (mm Hg): 134/65HR (bpm): 86Status: InpatientDate/Time: at 17:06Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.LEFT VENTRICLE: Normal LV cavity size. Respiratory Care NotePt received on HiFlo aerosol as noted. Bilateral LS clear and diminished at the base, thick yellow secreation on suction.O2 sats 99-100.Cv:NSR with occassional pvc's, SBP 120-190, monitored via rt radial a line. Pt's continues to be tachycardic even though sedation is at original (pre-wean) doses. Pt has gen anasarca +2 pitting to ext's with good pulses to palp. Wean sedation as tol by pt. SBP 90-130's monitoring via rt radial a line.GU/GI; continued on TF replete with fiber/65ml/hr as goal and with minimal residuaal. Am labs Na 138/K4.2 and HCT 40.4.GU/GI: NPO for possible extubation, abd soft distended, BS present. PT HYPOTHERMIC WITH TMIN 95 THIS AM, TEMP CURRENTLY 97'S WITH BAIR HUGGER OFF. STEROIDS D/C'D.CV--PT REMAINS IN SR/ST 58-100'S. Resp Care Note, Pt weaned off sedation to get RSBI done on 0 peep/5 ips 39 with increased WOB. Continued on ssame vent setting with A/C mode , 650/14/5 and 50% O2.Bilateral LS diminished on rt side and clear on lt side. LS this am clear with cx's to LLL (dependent).GI) Abd sl dist and soft to palp with + BS. Pt remains on insulin gtt as noted with FSBS checks q 1hr.GU) Pt has had low U/O via foley throughout this shift. Lasix today IF creatine improved this am. RIGHT EYE WITH LOOSE DSD APPLIED.GI--TF REPLETE WITH FIBER AT GOAL RATE 65CC/HR STARTED. resp careremains intubated/vented, reducing sedation and converted to spontaneous mode. Bilateral lung sounds clear to course and diminished at the base. Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details.Suctioned for sml amts thick yellow. Intubated w/a #7.5 ETT 21 @ lip. Suctioned for moderate amounts of thk tan secretions. When awake hypertensive and good response to few bolous of sedation.CVP 11-16 and SVo2 76-80. Pt is +1.5L since MN and +10L for LOS.Endo: Attempted to switch pt to sliding scale coverage with poor effect. Tolerating TF 65ml/hr with minimal residuals. Abd soft distended and BS present and no BM this shift. O2 sats 96-99%.Cv: NSR with occassional to frequent pvc"S and runs of v tac, self resolving and asymptomatic.

44

[ { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364310, "text": "Respiratory Care Note:\n Patient admitted to MICU with sepsis, intubated, sedated and on full vent support. BS=bilat, slightly diminished t/o. 7.5 ET tube is secure at 21cm by lip. Started on bronchodilators and plan is to attempt to compensate for met., deficit with increased ventilation. See Carevue flowsheet for settings and abgs.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364311, "text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: Sedated on fent at 25mcg/kg/min, versed at 3mg/hr w/ good effect. When lightened up, pt nods approp to questions and MAEx4 on command.\n\nCV: HR=50-60s, SB to NSR w/ occ PVCs. On levophed for BP - when no IV boluses are infusing, BP maintained at 100/50s w/ .02mcg/kg/min of Levo. Levo can generally be turned off when IV bolus is infusing. Weak periph pulses, feet cool bilat, ?edema. Repeat cardiac are tending down. CVP=, up to 13-14 when bolusing w/ fluids.\n\nResp: 40% 650x18, P=5 - ABG ok - no vent changes made. Lungs clear un upper fields, diminished in bases. This am, was coarse in R base. Sx for minimal bloody/brown secretions - spec sent. Maintaining RR 18. SV02=75-76% since the machine was recalibrated this am.\n\nGI/GU: abd large, round, +BS, passing flatus, but no BM. OGT clamped at this time - nutrition consult in, but will start some TF today and then nutrition can see him tomorrow. Foley cath w/ clear yellow urine, marginal u/o at 15-30cc hour. IVB don't increase u/o much.\n\nSkin: Bruise/hematoma w/ old bleeding on L wrist. Otherwise, intact. Heels/coccyx intact. E-mycin to R eye - taped closed per optho. Eye is not infected per optho.\n\nPain: Fent and versed gtts - pt comfortable, nods head \"no\" when asked about pain when light; when sedated, VSS indicating no discomfort.\n\nID: afebrile. On vanco, ceftriaxone, azithromycin. Sputum spec sent.\n\nLabs: Lytes repleted this am - repeat labs to be drawn this afternoon. FS 395 - insulin gtt started and following protocol.\n\nAccess: RIJ presept cath, R-rad aline, PIVx2.\n\nSocial: several family members at bedside today. Updated by team.\n\nPlan: Repeat labs - replete prn. Titrate insulin gtt protocol. Antibx as ordered. Monitor u/o and fluid status. Maintain fent and versed gtts for comfort. Tx R eye as ordered. Monitor cardiac/neuro/resp status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1364312, "text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364334, "text": "NPN 1900-0700 written at 0445 est\nreview care vue for all objective data\n\nCode: Full\nUnevent ful night.\n\nNeuro: lightly sedated with versed 2mg/hr and fentanyl 75mcg/hr gtt, Patient opening eyes, and MAE but not following commands. Bilateral wrist restraints are in place for safety.\n\nResp: sedated as above mentioned, no vent changes over night, continued on PSV 10 and peep 5 with fio2 50%. Bilateral lung sounds clear to coarse and diminished at the base. Thick whitish to yellow secreation with suction. RR 14-20 and O2 sats 95-100%. RSBI this am was 46 and will do SBT later.\n\nCv:NSR with occassional pvc's,lytes within normal limits, SBP 120-150.\n\nGI/GU: Tolerating TF replete w/fiber 65 ml/hr, abd soft distended, BS present but no bowel movements ?since admission no effect with reg colace and prn senna. Started on lasix iv gtt and titerated goal is to keep even while maintaing cvp >5.\n\nEndo: Insulin gtt as per ss and lantus 60u given as HS, aiming to switch ss and fixed dose.\n\nSkin :intact, except edema and redness on scortum.\nSocial: No calls\n\nPlan: SBT and blood gas later and wean sedation and vent as tolerated.\n Closely monitor blood sugar and d/c insulin drip\n Titarate lasix gtt aim even to neg balance.\n ? enema for bowel movements.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364335, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV in NARD. Pt passed SBT but was not extubated due to level of concinesus. B/S sl coarse sx'ing scant. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1364336, "text": "MICU NSG 7A-7P\nRESP--PT RECEIVED ON PS 10 PEEP 5 50%. PS DECREASED TO 5, AND THEN PT PLACED ON SBT PS 5 PEEP 0 50%. ABG WITHOUT CHANGE. PLANS TO EXTUB THIS EVENING. PT WEANED OFF SEDATION AND REMAINS HEAVILY SEDATED, WILL POSTPONE EXTUBATION TILL MORE AWAKE.\n\nNEURO--FENTANYL AND VERSED GTT WEANED TO OFF. PT OBTUNDED THIS AFTERNOON. PT RECEIVED THIS AM ( HOME DOSE) AND WAS LESS RESPONSIVE AFTER RECEIVING. TEAM AWARE AND ARE FOLLOWING.\n\nCV--TLCL RESITED, NOW IF LEFT SC. RIGHT IJ SITE REMOVED AND TIP SENT FOR CX. PT WITH LOW GRADE TEMP TO 100.4. PT CONTS WITH ANASARKA, ARMS/SCROTUM WEEPING. LASIX GTT REMAINS AT 2MG/HR AND PT DIURESING WELL, GOAL CVP IS >5.\n\nGI--TF ON HOLD AT 1300 FOR POSSIBLE EXTUBATION. NO BM THIS SHIFT, RECEIVED SENNA, LACTULOSE THIS AM. PASSING FLATUS. PT WEANED OFF INSULIN GTT AFTER TF SHUT OFF. FS 1700 68 AND PT 1 AMP D50.\n\nGU--U/O 100-200CC/HR VIA FOLEY.\n\nSOCIAL--FAMILY IN VISITING MOST OF DAY. UPDATED ON PT'S CONDITION AND PLAN OF CARE.\n\nPLAN--EXTUB WHEN MORE AWAKE.\n--LASIX GTT FOR DIURESES.\n--\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364332, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV as documented in NARD. B/S dim t/o sx'd for sm thick yellow. MDI's as documented. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364333, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nUneventful shift, pt started on started on Lasix drip, vent weaned, pt tolerating well.\n\nNeuro: Pt remains lightly sedated on Fentanyl 75mcg/hr and Versed 2mg/hr. Pt arousable to voice, able to MAE, but does not follow commands. Appears comfortable. Remains in bilateral wrist restraints for safety.\n\nCV: HR NSR 69-80 with occasional to frequent PVCs, ABP 118-132/57-68, CVP 6-11 with goal being 5. BP noted to increase to 160's during turns. Short 5 beat run of VT x 1, self-resolving and asymptomatic. General anasarca, peripheral pulses weak but palpable.\n\nResp: Pt continues to be supported by vent. Current settings CPAP+PS 50%/+ with ABG 7.34/43/146. RR 9-15, sats >97%, STV ~500, MV .\nLung sounds variable. Suctioned x 3 for small amounts of thick, yellow secretions.\n\nGI: BS x 4, no stool this shift, given PRN senna this AM with no effect. Pt tolerating TF at goal of 65cc/hr with minimal residuals. NGT patent, placement checked.\n\nGU: Foley patent and draining clear, yellow urine. UO 30-240. Started on Lasix drip, currently infusing at 3mg/hr. Fluid goal is to keep pt even while maintaining CVP ~ 5. Pt is +1L since MN, +12L for LOS. Being repleted with 40mEq K (AM K 4.1). Labs due to be drawn at 8pm.\n\nID: Tmax 98.9 PO, receiving ABX therapy of Ceftazidime, Levofloxacin and one time dose of Vancomycin for pseudomonas/streptococcus pneumonia.\n\nEndo: Remains on insulin drip. BS 129-161, drip being titrated according to protocol. Glargine dose increased, see for details.\n\nSkin: Intact, mild swelling to scrotum.\n\nSocial: Family at bedside most of day, updated on pt's condition and plan of care.\n\nPlan:\ncontinue to wean vent support\nsedation as needed for comfort\ntitrate lasix drip to CVP of 5 or even fluid balance\nmore aggressive stool regimen?\ncontinue to monitor BS\nroutine ICU care and monitoring\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 1364348, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Pt continues to have periods of ^ anxiety/aggitation, yelling/moaning out @ times, c/o of pain @ times, responds well w/ Morphine. 40 mg Lasix given x 1; pt diuresed ~ 800 cc after Lasix.\n\nROS:\n\nNeuro: Pt slept on and off throughout the night; anxiety/aggitation much improved when compared to previous nights (pt was started back on his Ritalin, Zyprexa yesterday). Oriented to person only, continues to yell out for help @ times (though much less than last night), also calls out for his wife frequently (this is his baseline per family). Follows simple commands, though somewhat inconsistently, MAE. Morphine prn for pain.\n\nResp: LS coarse, diminished @ bases. NTS x 1 for thick, tan secretions. Pt has a congested, somewhat weak cough and is not able to bring up secretions very effectively. Requires much encouragement to cough/deep breathe. RR 20's-30's, he was maintaining his sats >95% on 60% FiO2 via face tent until he fell asleep. Sats briefly dropped to 89%. FiO2 ^ to 80% @ that time. Sats have been 94-100% since.\n\nCV: HR 60's-80's, SR w/ rare-freq PVCs/PACs. NIBP 100's-120's / 50's-70's. CVP 6-8. HCT stable. + anasarca.\n\nGI/GU: Abd obese, nontender, + bs, no bm overnight. Pt tolerating TFs via NGT @ goal of 65 cc/hr w/ free H2O boluses q 6 hr. Foley intact, draining ~ 60-370 cc/hr of yellow urine w/ sediment. Lasix (40 mg) given x 1 tonight; pt diuresed ~ 800 cc after Lasix. He is negative ~ 600cc since midnight.\n\nSkin: Pt w/ large, red, raised, ring-shaped area on buttocks tonight. Barrier cream applied. Site is tender to touch, surrounding skin WNL. Pt has generalized weeping of upper extrem.\n\nLines: Left Subclavian TLC; WNL.\n\nID: Afebrile o/n. WBC slightly up this am (15 from 14.2). Continues on Levaquin for sputum growth.\n\nSocial: RN spoke w/ pt's wife and son o/n; both updated on pt's condition. Pt is a DNR/I.\n\nPlan: Continue to monitor resp status, pulm toilet prn; ? get oob to chair today; ? swallow study when ms/gag improves; frequent reorientation to environment; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 1364349, "text": "Nursing Progress Note:\n\nNeuro: Pt. has been alert at times, intermittently sleeping answers questions with yes/no or simple phrases such as \"you go right ahead\", singing along to . He makes eye contact, and is very pleasant but is confused. He moves upper ext. purposefully and lower ext. move on bed. Pt. OOB to chair for 2 hours and tolerated it well.\n\nCV: HR 60s-70s NSR with occasional PACs, NBP 100s-120s/30s-60s. Minimnal edema noted to upper ext. L SC TLC is patent and slightly ecchymotic at site.\n\nResp: Pt. remains on 80% face tent with RR in 20s and 02 sats >96%. he does desat into low 90s if Fi02 is lowered and sats go into 80s if face tent is removed. Pt. encouraged to deep breathe and cough, chest PT done with turns. Pt. now has productive cough and is able to bring secretions into back of throat and mouth.\n\nGI: Tube feeds at goal of 65cc/hour with minimal residuals, 250cc free H20 boluses being given q 4 hours. BSX4, no BM on shift. Pt. had speech/swallow and was approved for nectar thick liquids/soft solids.\n\nGU: UO brisk. 40mg Lasix given X1. Pt's fluid balance is currently even. No goal mentioned.\n\nEndo: Sliding scale and fixed doses in place.\n\nSkin: Pt. has a reddened, circular, slightly raised area to buttocks which has improved during the day.\n\nPlan: Dispo to rehab tomorrow. Pt. is already screened.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-10 00:00:00.000", "description": "Report", "row_id": 1364350, "text": "NSG 7AM-7PM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\nPT ALERT, , ORIENTED TO SELF ONLY/ CRIED OUT AT TIME: \"HELP ME\". NO APPARENT DISTRESS. MAE/ PEERLA. RESTING IN LONG NAPS. RESTLESS AT TIME/ MORPHINE 4MG X2 GIVEN WITH POS EFFECT.\n\nHEART RYTHM WITH RARE PVCS/ HR 60S-70S/ REMAINS ON METOPROL/ BP 110S-120S/MAP 60S-70S/ HEMODYNAMICALLY STABLE./ 5 RUNS OF VTACH ALARMED/ RESOLVED WITH NO INTERVENTION/K 40MEQ GIVEN TO KEEP K LEVEL:4.4. K LEVEL THIS AM:3.7/ WILL REPLETE PER TEAM DISCRETION.\n\nAFEBRILE/ TMAX:97.7 AXILLARY.\n\nRECEIVED LASIX 40MG/TO MAINTAIN FLUID GOAL NEG 500CC/ FLUID STATUS AT THIS HR NEG 400/ POSITIVE AT MN.\n\nRESP EFFORT UNLABORED AND EVEN/ RR:20S/ LUNG SOUNDS DIMINISHED/ MAITAINS SATO2 90S-100% ON 50% FACE TENT/ NO ATTEMPT TO WEAN. CONGESTED COUGH/ NASAL TRACH SUCTION ATTEMPTED/ SUCTIONED SMALL AMOUNT OF TENACIOUS TAN SPUTUM. STRONG COUGHS AT TIMES/ UNABLE TO EXPECTORATE.\n\nABD LARGE, OBESE/FIRM, POS BS. NO BM. NGT IN PLACE/ CONFIRMED WITH AIR BOLUS. REPLETE WITH FIBER AT GOAL 65CC/HR/ NO RESIDUAL.\n\nFOLEY PATENT DRAINING CLEAR YELLOW URINE.\n\nSKIN W/D/ STAGE II TO BIL GLUTEAL/ REPOS AND BARRIER CREAM APPLIED.\n\nWIFE CALLED THIS AM/ UPDATE GIVEN/ PT REMAINS \n\nCONT CURRENT POC\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 1364346, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Morphine (2 mg) given x 1 for ^ tachypnea/anxiety w/ good effect.\n\nROS:\n\nNeuro: Pt awake most of night, calling out for wife and frequently yelling for \"help\"; when asked what he needs he says, \"I don't know\". Per pt's wife, he calls for \"help\" @ baseline. Pt is oriented to person only, does follow simple commands, MAE.\n\nResp: Pt maintaining O2 sats b/w 95-100% on 60% HFN via face mask. RR 20's-30's. LS coarse throughout. + productive cough; however, he needs to be orally sxn to remove secretions and needs freq encouragement to cough/deep breathe. Chest PT done. ABG this am on 60% HFN: 7.41/52/99/34.\n\nCV: HR 60's-80's, SR w/ rare-freq PACs/PVCs. ABP 130's-140's / 60's-70's. CVP 2-6. + anasarca w/ generalized weeping. HCT stable this am. K = 3.7; will discuss repletion w/ MD.\n\nGI/GU: Abd obese, nontender, + bs. TFs running @ goal of 65 cc/hr; pt tolerating well. Foley draining ~ 30-100 cc/hr of yellow urine w/ sediment. Receiving doses of Lasix prn (none given o/n).\n\nLines: (1) Right Radial A-line; site red. (2) Left Subclavian TLC; WNL. All dressings changed.\n\nID: Afebrile o/n. WBC = 14.2 today (up from 11.9). Continues on Levaquin for sputum growth.\n\nSocial: RN spoke w/ wife and son o/n; both update on pt's condition. Pt is DNR/I---no plans for mask ventilation.\n\nPlan: Continue pulm toilet; get oob to chair today; morphine prn; Frequent reorientation to environment; support/info to pt/family; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364343, "text": "Respiratory Therapy\nPt presents on .8 hi flow via FT. Sats in hight 90's. BS slightly coarse bilat. 0630 Pt desatting to high 80's. BS coarse rhonchi rt W diminished base, on lt greatly diminished W coarse exp wheezes fine insp wheezes. NTS for moderate amount thick light tan secretions. Followed by alb/atrovent neb via FM tolerated well. Increased aeration bilaterally. Remains on .95% High flow via closed FM. Plan: continue to monitor and support.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 1364347, "text": "See and carevue for detailed documentation\n\nPatient agitated in early am, calling out, c/o pain in LE, c/o need to use bed pan. Patient with frequent PVC, tachycardia to 106, with BP 160/80's. Rec'd morphine with slight improvement. NP suctioned for moderate amounts thick creamy secretions. Neb given without change. Patient remained anxious, agitated. Rec'd 5mg IV lopressor with decreased HR, BP. Settled well. Patient again with c/o LE pain, anxious. Rec'd morphine with good result. Patient now restarted on olanzapine, methylphenidate. Plan to use morphine for c/o pain, restart baseline meds to control anxiety.\n\nNeuro: Patient oriented x1, occassionally interacting appropriately. Often calling out \"help\", wife's name-> baseline as per family. Reassured, comforted by visitors. Reoriented shift without result. OOB deferred as per family request for patient comfort.\n\nResp: Patient tachypneic with congested, non-productive cough. NP suctioned x2 for moderate amounts creamy secretions. Oral suction without result. Strong cough, poor gag. Nebs given shift without change. BS coarse out, diminished in bases.\n\nCV: In NSR HR now 70-80. Frequent PVCs. BP stable 120-130/50's. Afebrile. Aline removed as per team. L subclavian intact. CVP 10-12.\nContinues on levoquin,\n\nGU: Foley to gravity with good urine output. + ~800ml for shift. Lasix givne x1.\n\nGI: Tolerating tube feeds well with residual of 30-50ml. Small BM x2.\n\nSocail: Family at bedside shift. Anxious particularly with patient c/o pain. Sypportive of patient, stressing patient comfort priority. Discussed paln of care with attending this evening. Now hopeful for patient to transfer to rehab, although aware patient fragile and in need of ICU care at present.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364315, "text": "Nursing progress notes 0700-1900\nPt is 83y/o with PMH of IDDM, CHF, COPD TIA, s/p recent eye surgery presented to ED for lethargic/weak. In ED Temp 102.3, low B/P 80's,unable to walk. Given NS bolus 2l, intubated for resp compromise.Started to MICU for further treatment.Started on Levophed, sedated on fentanyl/Versed, Insulin gtt initiated for blood sugar over 200,cultures sent, Abt started.\nNeuro- Received sedated on Fentanyl 25mcg/hr, Versed 3mg/hr, stopped for 30 min for neurochecks, Pt became more awake, responding to verbal stimuli, opens eyes to verbal commands.Pupils reactive.Able to hold the hand. Minimal movement of lower ext noted.\n\nRESP- Vent settings rec on A/C 650x18/40%/+5, sat 98-100,LS clear, diminished at the bases. At 1100hr.Fentanyl decreased to 20 mcg/hr,Versed decreased to 2mg/hr. MV/RR reduced.At 1200 vent settings changed to PS 15/+5, pt did not tolerate well, BP high in 170's. back to A/C 650x14/40%/+5.Propofol started 10 mcg/hr. Fentanyl and Versed weaned off,sat maintains 99%. Suctioned via ETT scant whitish secretion noted.Late in the afternon put back to PS 15/+5/40%, tolerated ,ABG done 7.33/34/121, cont PS.\n\nCV- HR 65-80 NSR with occasional PVC's,BP 123/66-165/86. Levophed off since 0500hrs today. For high BP hydralazine 10 mg IVP given. Calcium repleted.\n\nGI- Abd soft, BS+, TF 40ml/hr via OGT, then stopped TF for possible extubation.No BM this shift. NGT inserted(Dobhoff), chest x ray done for the placement.\n\nGU- Foley patent, urine 25-40ml/hr. Urine for Legionella sent.\n\nENDO- Insulin gtt @ 8.5u/hr, blood sugar q 1hr.\n\nID- Temp 96.8-97ax, cont on Abt Vancomycin, Ceftriaxone and Azithromycin.Awaiting culture.\n\nSkin- Intact, edema both arms noted.\n\nPLAN- To wean off vent, monitor resp status, neuro status, maintain on minimal sedation. Antihypertensives as needed.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364316, "text": "Respiratory Care\nPt remains intubated and on vent support. Intubated w/ a #7.5 ETT 21 @lip. Vent changes were from A/C to PSV w/CPAP. While on PSV pt had a period that required sedation (^BP, ^RR). Placed back on A/C and again later placed on PSV w/CPAP. Pt remains on PSV. Lung sounds were clear and diminished in the bases (more in RLL). Pt continues to have a prolonged exp phase. Received MDI's with good effect. Suctioned for scant thick white. Last ABG showed metabolic acidosis. Care plan is to continue to wean PS and obtain a RSBI and SBT in AM ? of extubation tomorrow. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364317, "text": "Resp Care Note, Pt weaned down to 5/5.VT'S in the 300's. Sedated with propofol. Biting on the ETT @ times.RSBI done on 0 peep/5 ips 80. Suctioned for scant amts thick white secretions. MDI'S given. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364344, "text": "MICU NSG 7A-7PM\nRESP--PT WITH EPISODE OF RESP DISTRESS THIS AM. NTSX'D X2 FOR MOD TO COPIOUS AMOUNTS THICK YELLOW TO TAN SECRETIONS. PT WITH RR 40'S AND 02 SAT DROPPING TO 85%. PLACED ON 95% HIGH FLOW NEB WITH FACE MASK, HAD BEEN ON FACE TENT PREVIOUSLY. RECEIVED ALB/ATRO NEB AS WELL AS LASIX, AND LOPRESSOR. PT SLOWLY IMPROVED. PT WITH POOR COUGH, RECEIVING PULMON TOILET (CPT, COUGHING, DEEP BREATHING) WITH MIN MOVEMENT OF SECRETIONS. PT WITH POOR ACTIVITY TOLERANCE, BECOMES SOB WITH MIN ACTIVITY. ABG SENT, WITH MIN CHANGE FROM PREVIOUS ABG.\n\nNEURO--PT LETHARGIC AT TIMES, APPEARS FATIGUED,OTHERS YELLING OUT FOR \"HELP\". KNOWS NAME, BUT OTHERWISE DISORIENTED. FAMILY IN AT BEDSIDE, PROVIDING SUPPORT. PT ABLE TO MAE ON BED, BUT WEAK. SWALLOW EVAL ON HOLD DUE TO FATIGUE, AND POOR GAG/COUGH.\n\nCV--REMAINS IN SR WITH FREQ PAC'S, OCCAS PVC'S. RIGHT RAD ALINE DAMPENED. PT WITH , ARMS, SCROTUM WEEPING. AFEBRILE THIS SHIFT.\n\nGI--NGT FOUND OUT, ? PT SELF D/C;D. NOTED AT TIME OF RESP DISTRESS EPISODE THIS AM, ? PT . SUMP REPLACED, AND PLACEMENT CONFIRMED BY CXR. TF REPLETE WITH FIBER RESTARTED, CURRENTLY INFUSING AT 30CC/HR GOAL 65CC/HR. SM BM X3.\n\nRENAL--LASIX 20MG IV THIS AM WITH GOOD RESPONSE. U/O 30-200CC/HR.\n\nSOCIAL--FAMILY IN AT BEDSIDE, UPDATED ON PT'S CONDITION.\n\nPLAN--PULMON TOILET\n--PT DNR/DNI--NO PLANS FOR MASK VENTILATION\n--MORPHINE PRN FOR AIR HUNGER IF NO RELIEF FROM OTHER COMFORT ATTEMPTS\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364345, "text": "MICU NSG 7A-7PM\naddendum--pt med with morphine 1mg iv for anxiety, air hunger, dyspnea. pt currently resting comfortably.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364339, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: Pt doing well on 60% face tent; mental status seems to be improving. Sliding Scale added to fixed dose of insulin tonight, as blood sugars are now increasing w/ TFs. No significant events to report.\n\nROS:\n\nNeuro: Pt opening eyes spontaneously, follows simple commands @ times, MAE on bed. Making incomprehensbile sounds tonight, began calling out for help (per pt's wife, he often calls out for help @ baseline). No sedatives given o/n.\n\nResp: Pt s/p extubation yesterday afternoon; doing well on 60% face tent. RR 20's-30's, sats 98-100%. LS coarse, pt able to cough up secretions into the back of his throat (requires assist w/ yankeur sxn). LS coarse. ABG this am: 7.49/39/71/31.\n\nCV: HR 70's-80's, SR w/ rare-freq PVCs. ABP 130's-160's / 60's-70's. Requires freq K repletion. K this am = 3.6 (will discuss repletion w/ MD). + anasarca (w/ generalized weeping).\n\nGI/GU: Abd soft, distended, + BS, no stool o/n. TFs currently running @ 50 cc/hr (goal is 65). Tolerating well. Foley draining ~ 40-100 cc/hr of clear/yellow urine. Pt is negative ~ 200cc since midnight.\n\nLines: (1) Right Radial A-Line; WNL. (2) Left Subclavian TLC; WNL.\n\nID: Afebrile o/n. WBC trending down. Continues on ABX for PNA.\n\nSocial: Pt is DNR/DNI. Family in to visit late last night, also multiple phone calls o/n; all updated on poc, pt's condition.\n\nPlan: Monitor resp status and wean O2 as tolerated; replete lytes prn; support/info to pt/family; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364340, "text": "NURSING NOTE 0700HRS - 1600HRS\n\n\n\nEVENTS...MENTAL STATUS CONTINUES TO SLOWLY IMPROVE, OF ALL SEDATION..REQUIRES CHEST PT AND ENCOURAGEMENT WITH CLEARING OF SECRETIONS AND NEB TREATMENTS..? FOR LASIX THIS EVE..FOR SWALLOW EVAL TOMORROW..BBLOCKER FOR RATE/B/P CONTROL..SLIDING SCALE TIGHTENED\n\n\n\n\nNEURO..SLOWLY IMPROVING MENTAL STATUS LETHARGIC BUT ORIENATATED X1/2 OPENS EYES SPONTANEOUSLY, INCONSISTENTLY FOLLOWS COMMANDS ATTEMPTS MOVE LIMBS BUT IS SLOW TO DO SO... RECOGNISES FAMILY MEMBERS..DENIES PAIN..OF ALL SEDATION MEDS AT PRESENT, TO FOLLOW NEURO STATUS , IF PATIENT BECOMES AGITATED TO RE-REVIEW MEDS...\nOPTHOMOLGY FOLLOWING RERT EYE AND EYE DROPS CONTINUE TO BE APPLIED\n\n\n\nCVS...B/P STABLE @ 120-150 SYSTOLIC AND HR 75-85BPM WITH FREQUENT PCV'S/PAC'S [ TEAM AWARE] K @ 4.0 THIS PM AND IS PRESENTLY RECEIVING 20MCQ IV , TO TRY MAINTAIN K CLOSER TO 4.5...BBLOCKER COMMENCED FOR RATE CONTROL AND IS TOLLERTATING\nAFEBRILE, AB'S CONTINUE FOR LEFT LL PNEUMONIA...\nON LONG ACTING INSULIN @ 2000HRS THEN COVERED WITH S/S WHICH WAS TIGHTENED TODAY...\nPATIENT IS DNR AS PER FAMILY MEETING WITH DR YESTERDAY\n\n\nRESP..LUNGS SOUND COURSE UPPER DIMINSHED LOWER, BUT WITH CHEST PT HAS MANAGED TO COUGH SECRETIONS TO BACK OF THROAT THE YANKER USED TO EXTRACT..RECEIVING NEBS PRN..ABG STABLE THEREFORE O2 REDUCED TO 60% HIGH FLOW..NEEDS ENCOURAGEMENT TO COUGH/DEEP BREATH..RR AT 25-35 SATS MAINTAINED > 95%..PATIENT IS DNI ASOF FAMILY MEETING YESTERDAY\n\n\nGI...TOLLERATING FEED AT GOAL VIA PEDI-TUBE, LARGE BOWEL MOTION TODAY..SEEN BY SWALLOW BUT READY FOR EVAL TODAY AND WILL RE-REVIEW TOMORROW...PATIENT COUHGHED ON ICE CHIPS TODAY..\n\n\nGU..BORDERLINE U/O TODAY [ TEAM AWARE] TO HAVE DOSE OF LASIX THIS EVE..CREAT AT BASELINE @ 1.6\n\n\nSKIN..RE-POSTIONED INTACT\n\n\nLINES..ART /CENTRAL LINE PATENT..\n\n\nSOCIAL..MANY FAMILY MEMBERS TODAY...UPDATED BY TEAM TODAY\n\n\n\nPLAN.. CHEST PT/WEAN O2 AS TOLLERTED..FOLLOW NEURO STATUS ? TO RE-COMMENCE HOME PSYCH MEDS...LASIX THIS EVE FOR NEG BALANCE..MAINTAIN K > 4.0..SWALLOW EVAL TOMORROW..DNR/DNI STATUS\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1364341, "text": "Respiratory Care Note\nPt received on HiFlo aerosol as noted. Pt given Albuterol/Atrovent nebs x 2. BS coarse throughout - decreased on R side with 12N neb - with improved aeration after rx x 2. Attempted NT suction at 5pm - unalbe to pass catheter through either nare. Pt has a congested cough with a small amt thick, yellow secretions. BS clear after suctioning.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1364342, "text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt remains lethargic, generally follows commands. Unable to cough well on demand. Verbally denies pain, cont to frequently stat \"Help me\" as family reports he did PTA. Moving all extremeties on bed.\n\nResp: Pt has remained on high flow FT @ 80%FiO2, with O2 sat 91-99%. RR 24-34 and regular. Lung snds coarse throughout. Intermit strong, productive cough but pt swallows sputum. NT suctionned by Resp tx X 1.\n\nCV: HR 70-105SR with freq PAC's/PVC's. BP 126/92-150/65. CVP 5-8. K+ 3.5 repleted, and is 4.6 this am. Phos 2.2->pt rec'd neutraphos.\n\nGI: TF of replete with fiber @ goal 65ml/hr until 0600 when Dobhoff noted to be out of position. AM FSG 144, Humalog 4units (per sliding scale) held. Abd soft/obese with + bowel snds. Pt incont of soft, brown stool X 2.\n\nGU: Urine yellow/clear. Pt rec'd Lasix 20mg X 1 with good results. Fluid balance MN->0600 -640ml, but +6.5liters LOS.\n\nSkin: Multiple skin tears on arms, leg. Scrotum with skin tear.\n\nID: Temp 98.8ax.\n\nSocial: Son, wife called for status overnight.\n\nPlan: Cont to freq encourage C&DB. Chest PT. Cont to monitor lytes, with K+ to remain ~ 4.0. Support family. Pt presently DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364313, "text": "Pt is 83y/o male with PMH of IDDM, CHF, COPD, TIA, s/p recent eye surgery who presented to ED for feeling weak/lethargic. In ED Temp 102.3, b/p 80's, unable to walk. Given 2L ns which led to resp compromise leading to intubation/pre-cept tlc placement. Tx to MICU for further treatment. Started on Levophed when dropped sbp to 60's and additional 2L NS ineffective to maintain b/p. Sedated on Fent/Versed, insulin gtt initiated for blood sugars over 200. Bld, urine, sputum cultures sent.\n\nNeuro: Remains sedated on 25mcg/hr fentanyl and 3mg/hr versed. Able to nod head to yes/no questions and follow commands when sedation has been off for approx 45min. denies pain. Pupils reactive. Minimal movement of lower ext noted.\n\nResp: Vent setting unchanged this shift. A/C 650x18/40%/5 with Am abg showing adequate oxygenation and compensated metabolic acidosis. Lung sounds remain clear in apices and diminished in bases.\n\nCardiac: Remains dependent on levophed gtt at 0.02mcg/kg/min to maintain b/p. Current b/p 120's/60's. However systolic b/p dropps to 80's with gtt off. Can briefly turn gtt off if recently bolused with NS however. SR with occasional ectopy on monitor.\n\nGI: Abd soft/nontender. Positive bowel sounds. No BM this shift however. Replete with fiber infusing at 30ml/hr and tolerating well with scant residuals.\n\nGU: Oliguric with u/o 15cc/hr. AM BUN 36 Cr 1.4\n\nDerm: Grossly intact. Edema to upper ext and scrotum noted. Aline and TLC sites benign withpaten lumens. PIV x2 patent. Peripheral pulses weakly palpable.\n\nID: Afebrile. Hypothermic with temp 95.3 at start of shift. Bear hUgger initiated. Temp currently 98.7 hugger off. Continues on Vancomycin, ceftriaxone, and azrithromycin. Awaiting culture data.\n\nSocial: Family in to visit last noc. Updated by RN\n\nPlan: Wean off levophed as tolerated, frequent blood sugar checks, IV abx, follow culture data, neuro checks with sedation off. Full Code.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1364314, "text": "Respiratory Care Note:\n Patient remains intubated and sedated. No vent changes made overnight. ABGs with compensated metabolic acidosis. BS=bilat, diminihsed aeration. RSBI attempted, too sedate, tidal volumes only 200cc. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1364337, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Pt was not extubated overnight, as he remains unresponsive off of all sedatives.\n\nROS:\n\nNeuro: Pt unresponsive; he does w/d to pain @ times. Not opening eyes/not following commands. No sedation given o/n.\n\nResp: Remains intubated on PSV: 5/5/50%. RSBI this am = 88. ABG on above settings = 7.37/50/173/30. Will recheck another gas on SBT. RR mid-high 20's, sats 98-100%. LS coarse.\n\nCV: HR 70's-90's, SR w/ rare-freq PVCs. ABP 120's-150's / 60's-70's. HCT stable. CVP 6-8. + anasarca (w/ generalized weeping). AM lytes still pending.\n\nGI/GU: Abd soft/distended, + bs. TFs on hold for pending extubation. No bm o/n. Foley draining ~ 70-280 cc/hr of clear/yellow urine (on 2 mg/hr of Lasix). Pt is negative ~ 900cc since midnight.\n\nLines: (1) Right Radial A-Line; WNL. (2) Left Subclavian TLC; bleeding, but otherwise wnl.\n\nID: Low grade temps o/n. WBC stable. Continues on Abx for PNA.\n\nSocial: RN spoke w/ pt's son and wife o/n; both updated on poc, pt's condition. Pt is a full code.\n\nPlan: ? extubate this am (or head CT if ms does not improve); continue to diurese; replete lytes prn; continue abx and f/u on all cx data (reculture if pt spikes > 101); routine ICU care and monitoring.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1364338, "text": "NURSING NOTE 0700HRS - 1600HRS\n\nEVENTS..EXTUBATED AT 11.30HRS, FAMILY MEETING, PATIENT NOW DNR/DNI..\n\n\n\nNEURO...PATIENT CONTINUES NON ROUSBALE,VERY OCCASSIONALLY FOLLOWS COMMAND TO SQUEEZE HAND AND WRIGGLE TOES COUGHING AND BITING ONSUCTION CATHTER ..MOVEMENT NOTED ON RT ARM/LEG..LEFT PUPIL 3/REACTIVE RY EYE CLOSED POPST SURGERY AND EYE DROPS/EYE CARE CONTINUE..ALL SEDATION D/C AT THIS TIME , TO CONTINUE TO ENCOURAGE MOVEMENT FOLLOW NEURO STATUS CLOSELY...\n\n\n\nRESP...EXTUBATED AT 11.30HRS WITH SATISFCTORY POST ABG..CONTINUES WITH SATS > 95% RR 25-35 FAIRLY STRONG COUGH BUT REQUIRES SUCTIONING FROM BACK OF THROAT FOR THICK YELLOW SECRETIONS..LUNGS SOUND COURSE, CHEST PT CONTINUES..NOT FOR RE-INTBATION AFTER DISCUSSION WITH FAMILY...APPERAS COMFORTABLE AT THIS TIME...\n\n\nCVS...B/P 130-150 SYSTOLIC ..HR 70-80 WITH FREQUENT PAC'S /PVC,S K/MG STABLE FOR RE- DNR AS PER FAMILY\nAFEBRILE , AB'S CONTINUE..\nB/S STABLE SO FAR , NOW ON LONG ACTING INSULIN @ BEDTIME...\n\n\nGI...ORAL G TUBE REMOVED DURING EXTUBATION AND PEDI-TUBE PLACED XR CONFIRMING PLACEMENT..FEED RE-COMMENCED PM AT LOWER DOSE TO TITRATE UP TO GOAL..NO BOWEL MOTION AND B/ SPRESENT..\n\n\nGU..LAIX DRIP STOPPED THIS AM, AIM IS FOR EVEN BALANCE TODAY, PRESENTLY NEG, CONTINUE TO OBSERVE..\n\n\nSKIN..INTACT AND RE-POSTIONED..\n\n\nLINES..ART LINE SATISFACTORY , CENTRAL LINE RE-DRESSED..\n\n\nSOCIAL..MANY FAMILY VISITED TODAY, FAMILY MEETING DECISION AS ABOVE FRO DNR/DNI...\n\n\n\nPLAN..FOLLOW RESP/NEURO STATUS..MONITOR K/MG..SUPPORT FOR FAMILY\n\n\n" }, { "category": "Echo", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 99280, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function.\nHeight: (in) 69\nWeight (lb): 220\nBSA (m2): 2.15 m2\nBP (mm Hg): 134/65\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 17:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nLEFT VENTRICLE: Normal LV cavity size. Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal. LV\nsystolic function appears depressed with basal lateral hypokinesis. Estimated\nejection fraction (?45%). Right ventricular chamber size is normal. Right\nventricular systolic function is normal. Mildly thickened aortic and mitral\nvalves. There is no significant mitral regurgitation detected in suboptimal\nviews. There is no aortic valve stenosis. There is a trivial/physiologic\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the basal\nlateral wall motion abnormality was probably present previously although was\nnot reported.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364323, "text": "MICU NSG 7A-7PM\nRESP--PT REMAINS ORALLY INTUB VENT SETTINGS AC 14 650 PEEP 5 50%. BREATHING OVER VENT. SX'D FOR THICK YELLOW SECRETIONS VIA ETT. PLEASE SEE CAREVIEW FOR ABG'S. PSEUDOMONAS AND STREPTOCOCCUS CX'D FROM SPUTUM, AND ABX SWITHCED TO CEFTAZIDIME 2GM IV Q12, AZITHRO AND CEFTRIAXONE D/C'D.\n\nCV--RIGHT RAD ALINE DAMPENED AND POSITIONAL, BUT HAS GOOD BLOOD RETURN. BP TRENDING DOWN THIS AM, ? R/T SEDATION, PROPAFOL D/C'D, PLEASE SEE BELOW. PT WITH (+) EDEMA, WITH WEEPING FROM LEFT ARM PIV SITE. IV D/C'D. BLISTER NOTED ON SCRTOUM. PT NORMOTHERMIC, TMAX 98.6. PICC LINE ORDERED, IR PLANS TO PLACE IN AM. SVO2 70-80. RIGHT EYE REMAINS COVERED WITH SOFT DSD, RECIEVING OINTMENT QID.\n\nGI--REPLETE WITH FIBER TF INFUSING AT GOAL RATE 65CC/HR WITH MIN RESIDUALS. SM BROWN OB NEG BM THIS AM. INSULIN GTT CONTS, PLEASE SEE CAREVIEW FOR GTT TITRATION AND FS.\n\nNEURO--PROPAFOL GTT D/ AND PT TRANSITIONED TO FENT GTT CURRENTLY INFUSING AT 75MC/HR AND VERSED GTT CURRENTLY INFUSING AT 2MG/HR. PT TO VOICE, BUT NOT FOLLOWING COMMANDS. WHEN AWAKE, PT BECOMES RESTLESS AND THRASHES.\n\nRENAL--CREAT INC TO 1.7 THIS AM, LASIX ON HOLD FOR TODAY. PT U/O 12-100CC/HR.\n\nSOCIAL--FAMILY IN AT BEDSIDE, UPDATED ON PT'S CONDITION.\n\nPLAN--PICC TO BE PLACED BY IR IN AM\n--PT TO REST ON AC\n--NEW ABX\n--LASIX ON HOLD AT PRESENT DUE TO INC IN CREAT\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364324, "text": "resp care\nremaisn intubated/vented in ac mode. settings unchanged today. abg with metabolic acidosis. suctioning thick yellow. admin mdi's q4h. no weaning today per rounds, reassess daily.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364325, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick pl yellow secretions. MDI'S given. Sedated with fentanyl and midazolam. No spont resp @ this time will attempt an RSBI @ a later time.Cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364326, "text": "Resp Care Note, Pt weaned off sedation to get RSBI done on 0 peep/5 ips 39 with increased WOB. Placed back on A/C.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364320, "text": "Respiratory Care\nPt remains intubated and on vent support. Intubated w/a #7.5 ETT 21 @ lip. Vent changes were PSV w/CPAP to A/C due to ABG trending. pH 7.18 and PaCo2 trending up. Lung sounds were course to clear t/o and diminished in the bases. Suctioned for moderate amounts of thk tan secretions. Pt received MDI's with good effect. Pt continues to have a prolonged exp phase. Last ABG showed a metabolic acidosis that has improved, with good oxygenation. Care plan is to remain on A/C noc and obtain a RBSI in AM with a NIF. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364321, "text": "NPN 1900-0700, written at 0445 est\nReview care vue for all objective data\n\nNeuro: sedated, trying to open his eyes when awake, continue sedation when he is on ventilator to keep him comfortable.\n\nResp: sedated with propofol 25mic/kg/min and tried to titerate to 22when his SBP was around 90's and back to 25mic/kg/min when wake. Continued on ssame vent setting with A/C mode , 650/14/5 and 50% O2.\nBilateral LS diminished on rt side and clear on lt side. Moderate thick yellow secreation on suction.RSBI this am 85 and planing to do bloodgas and NIF later. O2 sats 96-99%.\n\nCv: NSR with occassional to frequent pvc\"S and runs of v tac, self resolving and asymptomatic. pottassium 40 meq repleted and am labs pending. SBP 90-130's monitoring via rt radial a line.\n\nGU/GI; continued on TF replete with fiber/65ml/hr as goal and with minimal residuaal. Abd soft distended and BS present and no BM this shift. Urine out 60-300ml/hr and no lasix given this shift.\n\nEndo: insulin gtt titarated as per blood glucose.\nSkin intact\nID: temp 98.2 and continued on antibiotics.\nSocial: wife telephoned last night.\n\nPLan: to wean sedation and vent as tolerated by patient/blood gas\n continue all other supportive tretment\n F/U echo result for cardiac function\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1364322, "text": "Resp Care Note, Pt remains on current vent settings.See vent flow sheet for details.Suctioned for sml amts thick yellow. MDI'S given. Sedated with propofol. Getting insulin. HR-PVC'S. RSBI 85. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364327, "text": "9pm to 7am:\n\nNeuro) Pt remains intubated (oETT) with fentanyl and versed gtt for sedation with good effect. Sedation off this am for about 15 min, and pt started to move all ext's with no purpose. Pt also started to become very restless and SBP increased to 170-190's. While sedated pt will occ open eyes to verbal stimuli. but does not follow any commands. Bil wrist restraints on for safty.\n\nCV) Pt remians in NSR with occ PVC's and rare short runs of VT (100-110). Afibrile with stable VS. MAP > 70 and CVP 6->10 this am. Pt has gen anasarca +2 pitting to ext's with good pulses to palp. A-line very positional with sharp to dampened wave form. Good blood return to A-line. Am labs pending.\n\nResp) No changes made to vent settings. Currently at 50%/650X14/5. Will repeat am ABG2/2 it was done while RSBI done by RT. Pt has been deep sx'd for sml amounts og thick yellow-> white secetions. Minimal oral secretions. No plans to extubate today MD. LS this am clear with cx's to LLL (dependent).\n\nGI) Abd sl dist and soft to palp with + BS. TF at goal at 65 cc/hr with no residuals. No BM at this shift. Pt remains on insulin gtt as noted with FSBS checks q 1hr.\n\nGU) Pt has had low U/O via foley throughout this shift. Pt given total of 500 cc in IV boluses with some effect on U/O.\n\nSkin) see care vue.\n\nPLAN: IR for PICC placement today.\n Wean sedation as tol by pt.\n ? Lasix today IF creatine improved this am.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364328, "text": "resp care\nremains intubated/vented, reducing sedation and converted to spontaneous mode. tolerating but more tachycardic and tachypnea due to lightening of sedation. small amts yellowish sputum. mdi's given q4h. c/w daily weaning assessment, due to cardiovascular status proceeding with slow weaning.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1364329, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nEvents: Attempted to transition to bolus sedation with poor effect, pt tolerating CPAP+PS, attempted to transition pt to sliding scale with poor effect, restarted on continuous IV sedation and insulin drip.\n\nNeuro: Pt sedated on Fentanyl 75mcg and Versed 3mg, unsuccessful attempt to transition pt to bolus sedation. Pt able to MAE, does not follow commands, arousable to voice. Pt appears more comfortable and less restless with increased sedation. Bilateral wrist restraints remain on for pt safety.\n\nCV: HR SR/ST 66-108 with occasional PVC, ABP 113-158/58-83, CVP 10-14, SVO2 77-89. Pt's HR and BP noted to increase with turns and mouth care. Attempted to wean sedation however pts HR increased to 110's with SBP to 170's. Pt's continues to be tachycardic even though sedation is at original (pre-wean) doses. Rare short run of VT, self resolving, asymptomatic. Anasacra noted, peripheral pulses difficult to palpate.\n\nResp: Pt currently on CPAP+PS, tolerating well, current vent settings 50%/+ with ABG of 7.30/45/134. Lung sounds clear to coarse in apices, diminished in bases. Suctioned x 3 for scant amounts of thick, white secretions. RR 12-22 with sats >94%, STV ~700, MV .\n\nGI/GU: BS x 4, no stool this shift. Given PRN senna with no effect. Tolerating TF at 65cc/hr with minimal residuals. Foley patent and draining clear, yellow urine. UO 25-75cc/hr. Pt is +1.5L since MN and +10L for LOS.\n\nEndo: Attempted to switch pt to sliding scale coverage with poor effect. Pt's BS to 200s, drip restarted and currently at 6 units/hour.\n\nID: Tmax 98.6, continues on ABX therapy (Ceftazidime) for streptococcus/psuedomonas pneumonia. No new culture data.\n\nSocial: Family at bedside most of the day, updated by MD on pt's condition and plan of care.\n\nPlan:\nsedate as needed for comfort\ncontinue to wean vent support\nmonitor BS and adjust drip according to protocol\nconsider diuresis once stable\nroutine ICU care and monitoring\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364330, "text": "NPN 1900-0700, written at EST\nreview carevue for all objective data\n\nFull code\nuneventful night\n\nNeuro: sedation titerated to keep him comforable over the vent and now versed 2mg/hr gtt and fentanyl 75mic/hr gtt.Eyes opens to pain. IN the begining of shift patient was agitated and improved with increasing sedation. Bilateral wrist restrints are in place to secure the lines and tubes.\n\nCV: NSR with occassional to frequent pvc's, stated the shift with tachycardia and nsr after increasing the fentanyl.sbp 110-140's monitoring via rt radial a-line.\n\nResp: sedated, no vent changes over night. RSBI this am was 43 and ontinued on SBT. AM blood gas 7.33/43/114 and may repeat blood gas later. Bilateral lung sounds clear to course and diminished at the base. Thick yellow secreation with suction.\n\nGU/GI:urine out put 30-40 ml/hr via foleys catheter. Tolerating TF 65ml/hr with minimal residuals. Abd soft distended, hypo active BS and no BM this shift, po senna given.\n\nEndo: Insulin on ss,titerated according to blood sugar.\nSKIN: intact except redness on his scortum, +2 edema present.\nSocial: wife telephoned\n\nPLan: Continue wean sedation/vent as tolerated\n close monitoring blood sugar and ? start ss and fixed dose\n No BM for many days\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1364331, "text": "Resp Care\nPt remains on vent. Intubated with 7.5 ett @ 21, patent and secure. Suctioned for mod amt of thick yellow secretions. Mdis given. Rsbi 43. Currently on sbt, awaiting abg. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364318, "text": "NPN 1900-0700, written at 0440 est\nreview carevue for all objective data\n\nFull code\n\nNeuro: Remains lightly sedated with propofol and when awake trying to open eyes to painful stimuli. Lower extrimities minimal movements and edematous. Wrist restaints are in place for safety.\n\nResp: Sedated with propofol 20mic/kg/min gtt and needs few bolous as when patient awake and biting tube and hypertensive. Vent weaned down to 5/5 and 40% and tidal volume 300's. RSBI done on peep 0/5, ips 80.Blood gas prior to RSBI 7.34/34/141 and will repeat on psv 5/5. Bilateral LS clear and diminished at the base, thick yellow secreation on suction.O2 sats 99-100.\n\nCv:NSR with occassional pvc's, SBP 120-190, monitored via rt radial a line. When awake hypertensive and good response to few bolous of sedation.CVP 11-16 and SVo2 76-80. Am labs Na 138/K4.2 and HCT 40.4.\n\nGU/GI: NPO for possible extubation, abd soft distended, BS present. No BM this shft. Urine out put 40-80ml/hr.\n\nEndo: Insulin gtt titerated as per blood glucose.\nSkin: intact, edema noted on extrimities.\nID: afebrile, 95.8 later in the shift, extra warming blanket given, continued on antibiotics.\n\nSocial: Telephoned by wife last night and updated his condition by RN\n\nPLAN: wean sedation and possible extubation if tolerated,\n monitor temp and bear hugger if still hypothermic\n frequent blood sugar checks/insulin gtt\n ?antihypertensive if hypertensive with weaning sedation.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1364319, "text": "MICU 6 NSG 7A-7PM\nRESP--PT RECEIVED ON PS 5 PEEP 5 40%. RR SLOWLY INC FROM 20-30 OVER COURSE OF AM, WITHSLOW DECREASE IN O2 SAT. ABG SENT 7.18/49/92. PT PLACED ON AC 14 650 PEEP 5 50%, BREATHING OVER VENT. PLEASE SEE CAREVIEW FOR REPEAT ABG'S. PT WITH THICK TAN PURULENT LOOKING SECRETIONS SX'D FROM ETT. STEROIDS D/C'D.\n\nCV--PT REMAINS IN SR/ST 58-100'S. WITH OCCAS PAC'S. BP LABILE 90-200/. RECEIVED HYDRALIZINE 25MG PO THIS AM FOR HTN WITH GOOD EFFECT. PLAN HAS BEEN TO DIURESE PT, WITH DECREASE IN CVP AND BP. BEDSIDE ECHO DONE WITH RESULTS PENDING. PT WITH (+)2 EDEMA IN EXTREMITIES. PT HYPOTHERMIC WITH TMIN 95 THIS AM, TEMP CURRENTLY 97'S WITH BAIR HUGGER OFF. RIGHT IJ TLCL SUTURE BROKEN AND REPLACED BY TEAM. WHITE PORT TPA'D WITH SUCCESS.\n\nNEURO--PT CONTS ON PROPAFOL GTT AT 20-30MC/KG/MIN. WHEN SEDATION OFF PT BECOMES RESTLESS, AND HYPERTENSIVE, FOLLOWS COMMANDS. RIGHT EYE WITH LOOSE DSD APPLIED.\n\nGI--TF REPLETE WITH FIBER AT GOAL RATE 65CC/HR STARTED. PEDI NGT COILED IN ESOPHAGUS AND REMOVED. NO BM THIS SHIFT. CONTS ON INSULIN GTT, PLEASE SEE CAREVIEW FOR GTT RATES AND FS.\n\nGU--CREAT 1.3 THIS AM. U/O POOR THIS AM 15-30CC/HR. WITH FAIR RESPONSE TO 12PM LASIX DOSE. WILL RECEIVE ANOTHER THIS PM.\n\nSOCIAL--WIFE, CHILDREN AND GRANDCHILDREN IN TO VISIT. UPDATED ON PT'S CONDITION.\n\nPLAN--DIURESE AS TOL\n--REPEAT LYTES THIS EVENING\n--ALLOW PT TO REST ON AC OVERNIGHT THEN CHECK RSBI AND NIF IN AM\n--INSULIN GTT PER SS\n" }, { "category": "ECG", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 288901, "text": "Sinus rhythm\nVentricular premature complexes\nAtrial premature complex\nRight bundle branch block\nQ-Tc interval appears prolonged but is difficult to measure - clinical\ncorrelation is suggested\nSince previous tracing of the same date, ventricular ectopy present\n\n" }, { "category": "ECG", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 285290, "text": "Sinus rhythm with atrial premature beats. Right bundle-branch block.\nNon-specific ST-T wave changes. Compared to the previous tracing of the\naxis is less leftward.\n\n" } ]

7,371

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1. Aortic dissection - The patient was admitted to the CCU for continuous monitoring and blood pressure control. The patient was started on Nipride and Labetalol drip with a goal systolic blood pressure of 100 to 120s. The patient did fairly well with the Nipride drips, Carvedilol drips. Amlodipine, Metoprolol and Captopril were titrated up and Labetalol and Nipride drips were weaned off. Vascular Surgery was consulted in the Emergency Department and they followed the patient throughout the hospital stay. Their recommendation was that he did not need any surgical intervention at this time as the patient did not show any evidence of myasthenia and repeat transthoracic echocardiogram and magnetic resonance imaging scans of the area of dissection were stable with only interval increased hematoma. Vascular Surgery signed off prior to discharge. Dr. and Batime recommended that we consult Cardiothoracic Surgery. CCU Team in conjunction with Cardiothoracic Surgery ordered further tests because of the computerized tomography scan and magnetic resonance imaging scan to further characterize the dissection regarding points of origin and extension and anatomy of the actual aorta. The patient was to follow up with Dr. and Dr. as an outpatient for possible future intervention such as graft placement. Serial vascular examinations were stable. Pulse was stable throughout entire stay. The patient's blood pressure was tightly controlled on oral medications and he was subsequently discharged on Amlodipine 5, two tablets p.o. q. day, Atenolol 100 mg tablets one tablet p.o. q.d. and Lisinopril 20 mg tablet, one tablet p.o. q. day with adequate systolic blood pressure control to less than 120. 2. Hypertension - Aggressive blood pressure control was done initially with Nipride and Labetalol drips. The patient was subsequently transferred over to an outpatient medication regimen with adequate control of blood pressure with systolics less than 120. He was discharged with Amlodipine, Metoprolol and Lisinopril. 3. Hypercholesterolemia - The patient was continued on his outpatient dose of Lipitor. 4. Urinary tract infection - The patient had some complaints of mild abdominal pain throughout the entire stay with subsequent suprapubic tenderness. No costovertebral angle tenderness on examination. Urinalysis was sent off and resulted in positive study for urinary tract infection. Urine culture was also sent off and subsequently grew out as an Escherichia coli. The patient was placed on Levaquin for a total of ten day treatment. 5. Derm - The patient on second day of admission developed a maculopapular rash on the back and abdomen as well as left deltoid. Etiology of the rash was likely due to one of the drugs that was administered, however, it was unclear as to which might have caused it. The rash was self-resolving and prior to discharge was completely gone. No evidence of eosinophilia on differential. 6. Gastrointestinal - The patient complained of intermittent epigastric pain. Abdominal examination was initially unremarkable and then had some mild suprapubic tenderness. Urinalysis was sent off and resulted in Escherichia coli growth in his urine. He was started on Levaquin for a ten day treatment. Despite that the patient still had some minor epigastric tenderness. Computerized tomography scan and magnetic resonance imaging scan were done which showed interval increase in his hematoma, unclear as to what his epigastric pain might have been coming from. I started him on an empiric trial of proton pump inhibitor, Pantoprazole and sent off his Helicobacter pylori serologies to be followed up as an outpatient. Etiology of the patient's intermittent mild epigastric pain was likely either gastritis or gastric component of reflux. The patient did much better on the proton pump inhibitor trial with resolution of his epigastric pain. 7. Fluids, electrolytes and nutrition - His electrolytes were checked q. day and repleted as needed. The patient was placed on a cardiac diet. 8. Prophylaxis - The patient was placed on a proton pump inhibitor and advised to ambulate on the unit. The patient was also placed on a diet.

CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is calcification surrounding the abdominal aorta. The intramural hematoma extends to the level of the diaphragmatic hiatus. Eccentric left lateral outpouching of lumen of the thoracic aorta at T7, T8 level, which may represent entrance site. CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There has been interval expansion of the intramural hematoma. Distally, the intramural hematoma extends to just above the celiac axis. IMPRESSION: Stable intramural hematoma of aorta, extending from the takeoff of the left subclavian artery to just above the celiac axis. The hematoma spans the thoracic aorta including the possible origin of the artery of Adamckewicz, which is not visualized. Initially on labetolol @ 0.5 and nipride @ 1mcg, both weaned off and restarted on PO meds. At the descending thoracic aorta, there is an eccentric area of outpouching at the left lateral aspect of the aorta at T7-T8 level. Evaluation of abdominal aorta again demonstrates intramural hematoma extending superiorly to the level above the celiac axis. DENIES C/O BACK/CHEST PAIN.RESP: ON ROOM AIR. DENIES C/O CHEST/BACK PAIN. (Over) 5:34 AM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: assess for change in dissection Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT *ABNORMAL! KEYWORD: AORTA DENIES C/O ITCH. A mild focal bulging of the aorta is noted 4 cm above the iliac bifurcation. There is a crescentic signal hyperintensity at the left lateral aspect of the descending thoracic aorta on the dark blood HASTE sequence, compatible with intramural hematoma (greater than 10 days age). The hematoma is best seen at the mid and lower thorax, and extends superiorly just to the origin of the left subclavian artery, which was confirmed on the coronal reconstructed contrast enhanced images. REASON FOR THIS EXAMINATION: assess for change in dissection No contraindications for IV contrast WET READ: PSLa FRI 5:56 AM enlarging intramural hematoma compared with , celiac SMA patent FINAL REPORT *ABNORMAL! DENIES C/O SOB.GI: ABD SOFT, + BOWEL SOUNDS, NO BM OVERNIGHT. Cont on captopril 75mg, norvasc 10mg, lopressor 100mg. MOVING ALL EXTREMITIES WELL, TO BEDSIDE COMMODE. DENIES ITCHINESS.ID: TEMP MAX 100.4 GIVEN TYLENOL 650 MG POSTABLE NOC. FINDINGS: Comparison is made to CT chest on . There is atheromatous plaque within the abdominal aorta. BP 100s-120s, well controlled on PO meds. MOVING ALL EXTREMITIES, TO VOID AT BEDSIDE. CT showed type B dissection from subclavian to celiac artery (no change in length) w/ expansion in width of hematoma. CCU NPN 7A-7PNeuro: A&Ox3, MAE. Sinus rhythm. LOPRESSOR AND CAPTOPRIL WELL. GAIT STEADY.CV: HR 58-64 SB-SR. NO VEA. (Cont) There is a tiny pulmonary nodule within the left lower lobe. There is a sub cm cyst seen in the upper pole of the left kidney, and a 1 cm cyst in the lateral interpolar region of the right kidney. At the arch, the aorta measures 2.7cm. CONTRAST: 150 cc of Optiray was administered. TECHNIQUE: Contiguous axial images were obtained from the lung apices to the aortic bifurcation before and after the administration of intravenous contrast. Foley d/c, voiding cl yellow urine. The SMA and celiac axis are patent. Sats 98% on RA.GI/GU: +BS, abd soft, non-tender. BP STABLE 88-101/45. CONGESTED, NONPRODUCTIVE COUGH NOTED. Otherwise, the remainder of the abdominal aorta demonstrates no evidence of dissection. 1:00 PM MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA Admitting Diagnosis: TYPE B DISSECTION Contrast: MAGNEVIST Amt: 40CC FINAL ADDENDUM ADDENDUM TO MRA OF CHEST AND ABDOMEN DATED : There is some atherosclerotic plaque in the infrarenal abdominal aorta. Started on PO protonix. IMPRESSION: There has been interval expansion of the intramural hematoma extending from immediately distal to the takeoff of the left subclavian artery to the level of the diaphragmatic hiatus. BP STABLE 92-104/54. The renal arteries are patent and there is normal perfusion of the kidneys bilaterally. DR. Voiding adequate amt CYU via urinal.Skin: Red raised rash on trunk and extremeties, denies itching. The aortic lumen which contains contrast is decreased in caliber. GIVEN AMBIEN FOR SLEEP WITH GOOD EFFECT.CV: HR 56-60 SB-SR, NO VEA NOTED. MRA on hold until Monday when radiologist is able to be here.Pulm: LS CTA, sats 97% on RA.GI/GU: +BS, abd soft, non-tender. -Abd bruit. Reports , need ativan. Nonetheless, this area could represent an entrance site of intramural hematoma due to ulcer. 1:00 PM MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA Admitting Diagnosis: TYPE B DISSECTION Contrast: MAGNEVIST Amt: 40CC FINAL REPORT INDICATION: Evaluate chest for aortic dissection versus hematoma. "O: PT. The heart and pericardium are unremarkable. REMAINS OFF NIPRIDE, LABETOLOL. Both renal arteries are patent.

7

[ { "category": "Radiology", "chartdate": "2168-01-15 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 809417, "text": " 5:34 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: assess for change in dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with type B aortic dissection now with worsening abdominal\n pain.\n REASON FOR THIS EXAMINATION:\n assess for change in dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa FRI 5:56 AM\n enlarging intramural hematoma compared with , celiac SMA patent\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Type B aortic dissection with worsening abdominal pain.\n\n COMPARISON: and .\n\n TECHNIQUE: Contiguous axial images were obtained from the lung apices to the\n aortic bifurcation before and after the administration of intravenous\n contrast.\n\n CONTRAST: 150 cc of Optiray was administered.\n\n CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There has been interval\n expansion of the intramural hematoma. The hematoma begins just distal to the\n left subclavian artery. The aortic lumen which contains contrast is decreased\n in caliber. The intramural hematoma extends to the level of the diaphragmatic\n hiatus. No intimal flap is identified. There is no evidence of aneurysmal\n dilatation of the aorta. The heart and pericardium are unremarkable. There\n is a subcentimeter nodule within the left lower lobe. The lungs are otherwise\n clear. There are no pleural effusions.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is\n calcification surrounding the abdominal aorta. There is atheromatous plaque\n within the abdominal aorta. The celiac axis and SMA are widely patent. Both\n renal arteries are patent. The liver, gallbladder, spleen, pancreas, adrenal\n glands and intra-abdominal bowel loops are unremarkable. The kidneys enhance\n symmetrically.\n\n There is no free fluid or free air within the abdomen.\n\n The osseous structures are unremarkable.\n\n IMPRESSION: There has been interval expansion of the intramural hematoma\n extending from immediately distal to the takeoff of the left subclavian artery\n to the level of the diaphragmatic hiatus. The SMA and celiac axis are patent.\n The renal arteries are patent and there is normal perfusion of the kidneys\n bilaterally.\n\n (Over)\n\n 5:34 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: assess for change in dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n There is a tiny pulmonary nodule within the left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2168-01-18 00:00:00.000", "description": "MR CHEST/MEDIASTINUM W&W/O CONTRAST", "row_id": 809697, "text": " 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM TO MRA OF CHEST AND ABDOMEN DATED :\n\n There is some atherosclerotic plaque in the infrarenal abdominal aorta. A\n mild focal bulging of the aorta is noted 4 cm above the iliac bifurcation. At\n this area, the aorta measures 2.5 cm, with the aorta diameter above and below\n measuring 1.8 cm.\n\n\n 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate chest for aortic dissection versus hematoma.\n\n TECHNIQUE: MRI examination of the abdomen was performed utilizing T1 weighted,\n T2 weighted, 3D gradient echo, true FISP and cine sequences before and after\n intravenous gadolinium injection. Abdominal aorta was also evaluated.\n\n Multiplanar reformatted images were generated on a 3D workstation, which was\n essential for delineation of anatomy.\n\n FINDINGS: Comparison is made to CT chest on .\n\n There is a crescentic signal hyperintensity at the left lateral aspect of the\n descending thoracic aorta on the dark blood HASTE sequence, compatible with\n intramural hematoma (greater than 10 days age). The hematoma is best seen at\n the mid and lower thorax, and extends superiorly just to the origin of the\n left subclavian artery, which was confirmed on the coronal reconstructed\n contrast enhanced images. Distally, the intramural hematoma extends to just\n above the celiac axis. No intimal flap is seen. At the descending thoracic\n aorta, there is an eccentric area of outpouching at the left lateral aspect of\n the aorta at T7-T8 level. This area measures 23-24 mm in length, and 32 mm in\n diameter, without significant change vs. most recent CT. This appearance of\n out- pouching is commonly seen in penetrating ulcer, however we do not see any\n atherosclerotic disease in elswhere in the thoracic aorta. Nonetheless, this\n area could represent an entrance site of intramural hematoma due to ulcer. The\n hematoma spans the thoracic aorta including the possible origin of the artery\n of Adamckewicz, which is not visualized. If relevant, a dedicated thin section\n spinal MRI can be performed to attempt to localize that vessel.\n\n The root of ascending aorta measures 3.0 cm in diameter. At the level of main\n pulmonary artery, the ascending aorta measures 3.2 cm, and the descending\n aorta measures 3.2 cm. The main pulmonary artery measures 2.4 cm. At the arch,\n the aorta measures 2.7cm. All measurement were done on axial plane.\n\n Evaluation of abdominal aorta again demonstrates intramural hematoma extending\n superiorly to the level above the celiac axis. Otherwise, the remainder of the\n abdominal aorta demonstrates no evidence of dissection. The liver, adrenal\n glands, the pancreas and the spleen are unremarkable. There is a sub cm cyst\n seen in the upper pole of the left kidney, and a 1 cm cyst in the lateral\n interpolar region of the right kidney.\n\n IMPRESSION: Stable intramural hematoma of aorta, extending from the takeoff of\n the left subclavian artery to just above the celiac axis. No intimal flap is\n seen. Eccentric left lateral outpouching of lumen of the thoracic aorta at T7,\n T8 level, which may represent entrance site. This area is also without\n significant change.\n\n (Over)\n\n 1:00 PM\n MR CHEST/MEDIASTINUM W&W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: PLEASE EVALUATE CHEST FOR DISSECTION/VS HEMATOMA\n Admitting Diagnosis: TYPE B DISSECTION\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n If clinically relevant, a dedicated thin section spinal MRI can be performed\n to evaluate artery of Adamkewicz, which is beyond the current study's\n resolution.\n\n Findings were discussed with (MD) upon finishing the study.\n\n KEYWORD: AORTA\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-01-17 00:00:00.000", "description": "Report", "row_id": 1360952, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"THIS RASH DOESN'T REALLY ITCH\"\n\nO: PT. A&O X3. MOVING ALL EXTREMITIES WELL, TO BEDSIDE COMMODE. GAIT STEADY.\n\nCV: HR 58-64 SB-SR. NO VEA. BP STABLE 88-101/45. TOL. LOPRESSOR AND CAPTOPRIL WELL. DENIES C/O BACK/CHEST PAIN.\n\nRESP: ON ROOM AIR. O2 SATS 95%. LUNGS CLEAR. CONGESTED, NONPRODUCTIVE COUGH NOTED. OFFERED COUGH SYRUP, REFUSED AT THIS TIME. DENIES C/O SOB.\n\nGU: VOIDING WELL, URINE CLEAR YELLOW.\n\nGI: APPETITE FAIR, NO BM YET AFTER RECEIVING COLACE AND SENNA. PASSING GAS. ABD SOFT.\n\nSKIN: STILL HAS RED, RASH OVER UPPER BODY AND LOWER EXTREMITIES. DENIES ITCHINESS.\n\nID: TEMP MAX 100.4 GIVEN TYLENOL 650 MG PO\n\nSTABLE NOC. SLEPT IN LONG NAPS AFTER RECEIVING AMBIEN.\n\nP: WAITING FOR MRA MON/TUES.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-15 00:00:00.000", "description": "Report", "row_id": 1360949, "text": "CCU Nsg admit\nCV: Tele SB-SR 50s-70s. Initially on labetolol @ 0.5 and nipride @ 1mcg, both weaned off and restarted on PO meds. Captopril 50mg, lopressor 100mg, norvasc 10mg. CT showed type B dissection from subclavian to celiac artery (no change in length) w/ expansion in width of hematoma. To go to MRA tonight/tomorrow to evaluate further for possible stenting on Monday.\n\nNeuro: A&O x 3, MAE.\n\nPulm: LS CTA. Sats 98% on RA.\n\nGI/GU: +BS, abd soft, non-tender. -Abd bruit. Taking POs w/o difficulty. Foley d/c, voiding cl yellow urine. BUN/Creat 23/0.8.\n\nSocial: Pt lives w/ his wife who is a nurse 2. Reports that he has stopped smoking since last admit and is using the patch. Also reports decrease in drinking-1-2 drinks/day x 3-4 days a week.\n\nA/P: Titrate BP meds as tol for goal SBP<120. MRA to evaluate further, possible aortic stenting on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-16 00:00:00.000", "description": "Report", "row_id": 1360950, "text": "nursing progress note 7p-7a\nS: \"WHAT COULD HAPPEN WITH THIS RASH?\"\n\nO: PT. A&O X3. ASKING APPROPRIATE QUESTIONS REGARDING HOSPITALIZATION AND MEDICATIONS. MOVING ALL EXTREMITIES, TO VOID AT BEDSIDE. GIVEN AMBIEN FOR SLEEP WITH GOOD EFFECT.\n\nCV: HR 56-60 SB-SR, NO VEA NOTED. TOL. INCREASED DOSE OF CAPTOPRIL. BP STABLE 92-104/54. DENIES C/O CHEST/BACK PAIN. REMAINS OFF NIPRIDE, LABETOLOL. AWAITS MRA ? TODAY.\n\nRESP: LUNGS CLEAR, O2 SATS 95% ON ROOM AIR. DENIES C/O SOB.\n\nGI: ABD SOFT, + BOWEL SOUNDS, NO BM OVERNIGHT. TAKING SIPS OF GINGER-ALE.\n\nGU: VOIDING USING URINAL IN GOOD AMTS.\n\nSKIN: RED, RAISED RASH NOTED ON TRUNK, ARMS, BACK, FACE (RIGHT SIDE), LEGS. DENIES C/O ITCH. DR. NOTIFIED AND IN TO SEE PT. WILL FOLLOW FOR NOW.\n\nACCESS: #20 G PIV RIGHT WRIST, FLUSHES EASILY, NO REDNESS NOTED.\n" }, { "category": "Nursing/other", "chartdate": "2168-01-16 00:00:00.000", "description": "Report", "row_id": 1360951, "text": "CCU NPN 7A-7P\nNeuro: A&Ox3, MAE. independently, amb in room.\n\nCV: Tele SR 60s-70s, no ectopy. BP 100s-120s, well controlled on PO meds. Cont on captopril 75mg, norvasc 10mg, lopressor 100mg. MRA on hold until Monday when radiologist is able to be here.\n\nPulm: LS CTA, sats 97% on RA.\n\nGI/GU: +BS, abd soft, non-tender. C/O epigastric pain this morning, reports having it a few times at home during the past week. Concerned about being able to distinguish this pain from dissection pain. Started on PO protonix. Voiding adequate amt CYU via urinal.\n\nSkin: Red raised rash on trunk and extremeties, denies itching. Cont to monitor.\n\nSocial: wife in to visit, updated by RN and HO.\n\nA/P: C/O to floor. MRA on hold until Monday, checklist done. Reports , need ativan. Emotional support for pt and family.\n" }, { "category": "ECG", "chartdate": "2168-01-15 00:00:00.000", "description": "Report", "row_id": 195112, "text": "Sinus rhythm. Compared to the previous tracing of no diagnostic\nchanges.\n\n" } ]

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A/P: 40M with HIV/AIDS (CD4 17) with chronic diarrhea cryptosporidium, c. diff, and CMV colitis, pancytopenia, electrolyte abnormalities, transfer from floor for hypotension, hypothermia, and new O2 requirement. . #) Septic shock: Likely due to Pseudomonas in blood +/- ? left lower lobe infiltrate He was started on Broad spectrum abx cefepime/levo to double cover for Pseudomonas. He was started on Levophed and dopamine was weaned off on to maintain MAPs>60. He completed a 7 day course of stress dose steroids. Intravenous fluids and antibiotics were continued until when patient was made comfort measures. . #) Pancytopenia : Multifactorial: Likely HIV + medication . a. Thrombocytopenia - ITP vs. medication (bactrim/ganciclovir/flagyl) vs. myelosuppression from HIV/AIDs. Also possible include infection with PCP, . s/p BMBx by heme on . . b. Anemia - Hct on admission 22.7. Likely from GIB and HIV. Peripheral smear did not show evidence of hemolysis and iron studies in consistent with anemia of chronic disease. Pt also has been having guaiac positive stools. On he was transfused 1U PRBCs and 2U PRBCs on . c. Neutropenia and lymphopenia - marrow suppression likely HIV, infection. GCSF was continued until blood counts increased and no longer neutropenic. . #) GIB/Coagulopathy: Likely from INR of 2.0 as well as low platelets. Patient has been putting out bloody watery BMs from mushroom cath. He was transfused with plts, PRBCs, received 10Sc of Vit K on and FFP. GI was consulted regarding GI Bleed - no intervention because of low platelet count. . #) Access: Patient had double lumen PICC placed. . #) Diarrhea - Etiology multifactorial including crytosporidia and C.Difficile, but completed a 14 day course of flagyl treatment. He was started on opium tincture and loperamide. Patient had over 4L stool production. He had frequent labs checked to replete electrolytes and aggressive fluid resuscitation. This was stopped when he was made comfort measures only. . #) AIDS - CD4 of 17 in . He was restarted on HAART medications but these were stopped when made comfort measures. . #) AIDS cholangiopathy - seen on RUQ u/s and pt with elevated AP. It is a biliary obstruction from infection associated strictures of biliary tract, most common being cryptosporidiumm as well as CMV, microsporidia, cyclospora. Followed LFTs. . #) Norwegian scabies-received ivermectin PO x 1 on and permethrin cream. He remained on contact precautions. . #) Esophageal candidiasis-originally dxd by EGD in and he is s/p 14 day trt with fluconazole. Pt again dxd with thrush at . Was on fluconazole IV (started ) but switched to Voriconazole until antibiotics were stopped. . #) Code Status - Patient was a DNR/DNI but initially was willing to have pressors. As treatments did not seem to be effective, GI losses remained great, and patient remained with low CD4 count despite HAART therapy a family meeting was held on with patient's infectious disease doctor, Dr. and the ICU team. The patient expressed his wishes to be comfort measures only. On all iv fluids and antibiotics were stopped. He was transitioned to a morphine drip and passed away peacefully with his family at his bedside on at 7:25p.m.

w/ Permetherine @ 00:00 and has patches of severe dry skin, tx w/ Eucerin @ .Endo: FSBS 130-150, follow SSSocial: Dr. met w/ pt. Gtt.C/V: pt on Dopa and Levo Gtts, able to wean and d/c Dopa, but Levo continues @ 0.232 mcq/min/kq down from .280mcq. Able to wean of Dopa Gtt but continues on Levo. PATIENT/TEST INFORMATION:Indication: Tachycardia; Evaluate for endocarditisHeight: (in) 68Weight (lb): 78BSA (m2): 1.37 m2BP (mm Hg): 100/50HR (bpm): 100Status: InpatientDate/Time: at 16:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. recieved of Norepinephrine 0.235 mcg/kg/hr weaned to 0.093 mcg/kg/hr.Tolerated well. PM lytes to be checked @ MN.RESP: LS coarse upper, diminished @ bases. appears to be less lethargic since RBC/PLt/FFP transfusion.Resp: Pt. candidiasis, C. diff colits. BP-86-96/60's, HR has come down from 140's ST to 98-105's with Dopa being off. Ivermectin due .Permethrin due . Potassium 2.7.Neuro:A&Ox3, articulates well, follows commands, PERRL, labored MAE, cachectic, weak cough.Resp: LS cta dim @ bases,SpO2:97-100%,RR 30's,weak, nonproductive cough, Sputum sent for 3rd TB.CV:Pt. is on 2L NC, O2 sats 98-100%, LS clear in upper lobes and diminished in lower lobes, occasional dry cough, CXR shows right mid-lobe PNA, ENT consult : multiple samples sent, no nodules visualized indicating doubtful of TB, although pt. has received 1 L D5W w/ 60mEq K+Cl for K+=2.6 and an additional 1 L D5W w/ 60mEq K+Cl is currently infusing. received on Dopamine @ 20mcg/kg/min and Levophed @ 0.15mcg/kg/min w/ sbp=88-94, Map=58-70 and HR 110-140s. 4gm Ca+Glu repleted today for ICa+=0.9. 4:38 PM CHEST (PA & LAT) Clip # Reason: R/o infectious or infiltrative processPt needs mask. Levofloxacin D/C'd. Pt refusing PO meds.CV: NSR 60s-90s. CMV colitis, Cryptosporidium, esoph. CMV colitis, Cryptosporidium, esoph. repleted 60mEq K+Cl for K+=3.5 and 15mmol Phosp repleted for Phos=1.7, and 500cc FB for sbp 90 and HR 120-140s, HR decreased to 9\85-93 w/ FB.Neuro: Pt. micu west 1900-0700 npn****Code Status: DNR/DNI***Allergy: Iodine*Precuations: Droplet for question TB and Contact for scabiesSignificant Events: Pt. is currently receiving Levophed 0.235 mc/kg/hr, sbp 90-115, MAP>60, HR 90-140 NS/ST no ectopy, HR decreasing from 140 to 100 since IVF and blood products infusing, suggesting need for hydration/volume, Dopamine OFF now for 24 hrs. agreed to D'C anti-retroviral mediction as effectiveness and absorption is in question. Access has not been obtained as of now due to decreased PLT.Id: Temp 95.7-99.5 for shift, Bair Hugger adjusted accordingly, Vanco Dc'd, ABX: Cefepime/Flagyl/Levofloxacon/VeroconizoleEndo: FSBS covered per SSSkin: Applied Eucerin on dry areas/neck, coccyx abrasion/breakdown protected w/ duoderm, Scabies present on skin.Social: Friends visited today/Health Care Proxy came and will visit tomorrow morning, Dr. met w/ pt. Repeat Lytes sent are PND.HEME: HCT-stable @ 30.4, PLT-29, PT/PTT 14/30.0 INR- 1.2. Monitor I&O's, as replete fluids as needed. PICC port was clotted off, 1 cc of TPA was given with good effect. Was ordered for U/S but has not been done as yet.RESPIR: Remains on RA with O2 sats 98-100%, RR 24-28, L/S clear.GU: U/O 60-80cc/hr, BUN/CRE 37/0.8. need to replete remaining PO KCL via IV.Resp: Patient continues to maintian >95% O2 sats on RA. HAD BEEN ALERT AND ORIENTED X 3- LUCID AND NEUROLOGICALLY INTACT ENOUGH TO TAKE CARE OF LAST WILL AND TESTAMENT WHICH WAS WITNESSED AND NOTARIZED AT THE BEDSIDE. CLEAR BIL BREATHSOUNDS NOTED ON AUSCULTATION. PT PASSES AWAY AT ON , DR PRONOUCED. skin appears to be improving, rec'ing creme's as ordered. Respiratory Precautions D/C'd. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES. MIcu Nursing note Neuro pt is awake and alert following commands, this morning pt sent for head ct which was neg for a bleed, they felt his mental staus was slighly off, pt knows place sometimes is unable to state month.Cv pt hemeodymanically stable, pulses weak but palp, bilaterally, pthad 2 episodes where hr down in the 40's when asleep, bp stable at that time. PT WOULD LIKE TO KEEP BAG ON.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. MONITOR FOR HYPOTENSION AND FLUID BOLUS IF NECESSARY. Nsg Progress Note 0700-1900CV - Pt hemodynamically stable. CO2-14CV:HR:89-111 ST/NSR, SBP:100-111,Mean:73-95,Fluid goal 1 to 1 1/2 L positive, pedal pulses positive.Calcium Gluconate repletion. AM K+-3.3, rec'd 60mEq IV, Ca 7.5, MagS+ 1.7, was repleted. LYTES RESULTS PENDING POST REPLETION.RESPI. Continue IV antibx's. SOCIAL SERVICES IS ACTIVELY ATTEMPTING TO ARRANGE PLCMT INTO HOSPICE NH.PT HAS BEEN COMFORTABLE FOR MOST OF SHIFT. POSITIVE SKIN BREAKDOWN IN COCCYX.ID. Nursing Note:0700-1900Code Status:DNR/DNIPrecautions:Contact and Allergies:IodineNeuro:Calm, Cooperative Male,A&Ox3,PERRL,Pt OOB to Chair with2 assists; tolerated well. Micu Nursing note Neuro to very lathargic this am when bp 80/50 pt fluid boluses with 1l n/s and 1 liter Bp improved over an hr pt became more responsive when sbp > 100/. Pt has padding and diaper on; chg'd q1hr. Pt receiveing MSO4 as requested to keep him comfortable. REMAINS LUCID- ORIENTED X 3- LETHARGIC AT TIMES. START CALORIE COUNT. PT CONTINUES TO BE ON RETROVIALS AND ANTIBIOTICS.PLAN. OCCASSIONAL COUGHING NOTED, ENCOURAGED PATIENT TO TURN MORE OFTEN, AMENABLE.GI/GU. 60mEq PO of KCL, and 40mEq IV of KCL were ordered for correction of a Potassium level of 2.9. MAE's, but stregnth is weak.CV: HR has been ST with no ectopy this shift. Did not want to get out of bed today.C/V: BP stable to 98-110/60, HR 70's-80's SR with no ectopy noted. Rec'ing IVF- NS 125cc/hr, Na+-141, T CO2-19.ID: Temp 96-95.6, WBC-11.3. Dr discussed issues with the family.A/P: Continue to replete Lytes as needed, and continue IVF's as ordered. micu Nursing note Neuro pt awake and alert this am, at 1400 woke pt to turn was confused didn;t understand why i was turning him even after explaining it to pt took 10 min to reorient pt to what we were doing, pt follows commands but seem to have periods on confusion.Cv pt through most of the day hr 70-90 sr at 1400 pt turned hr ^ 130 st called resident Bp stable at the time pt boluses with 500 cc n/s , hr dropped back to the 80's while getting bolus then after bolus finished hr back up into 120's Ivf changed to 1/2 ns at 150 hr, labs sent at that time ( and pending ) nowGi abd soft nontender, pt still has flexflow rectal tube system passing green lig stool 800 cc this shift pt continues on octotide and opium for loose stool, pt taking poor intake incouraged to eat and drink but still has poor po intake, pt passing clear yellow urine via foley 100-200 cc hr.Id pt hypothermic again was in bear hugger x5 hr pt remain on iv antibiotics and antivirals hct 27, wbc 14 plt 38 this amSkin pt still picking at skin pulling off scabs on neck and head told that he must stop because skin below and is bleeding , scalp washed andcream applied to head and body, scale covered with cap in order to remind pt not to pick at skin, pt remains on multi skin creams for dry skin and scabes,Social spoke with family today about pt and that he does have periods of confusion they would like to speak with hiv specialist tomorrow to have a time line about therapy of new drug, also we need social service andcase worked to see pt about what type of care will be needed and if pt should be dischaged back to a long term care facility or a medical floor, at present pt talking a large amount of nursing time for care and would be to much care for nursing on floor, with need for lyte replacement and nutrition support and dirrehea control along with the fact pt will need a privite room, Right now is the time we need to balance the needs of the psycosocial along with medical, have the most amount of freedom and least restrictive enviornment, with the need for medical care will address this again with house staff tomorrow and also need to speak with id about long term needs, for isolation,A/p follow up with social services, care worked, Hiv and id, follow up with labs tonight may need replacement lytes and now looks to need more iv fluids, follow mental status and would talk with hiv speicalist about mental status and what meds may be part of making pt more confused

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[ { "category": "Echo", "chartdate": "2150-07-31 00:00:00.000", "description": "Report", "row_id": 80574, "text": "PATIENT/TEST INFORMATION:\nIndication: Tachycardia; Evaluate for endocarditis\nHeight: (in) 68\nWeight (lb): 78\nBSA (m2): 1.37 m2\nBP (mm Hg): 100/50\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 16:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , there is no\ndefinite change.\n\n\n" }, { "category": "ECG", "chartdate": "2150-08-01 00:00:00.000", "description": "Report", "row_id": 204011, "text": "Baseline artifact\nSinus tachycardia\nDiffuse nonspecific ST-T wave changes\nSince previous tracing of , further T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2150-07-29 00:00:00.000", "description": "Report", "row_id": 204012, "text": "Technically difficult study\nSinus tachycardia\nST-T wave abnormalities\nSince previous tracing, precordial QRS voltages less\n\n" }, { "category": "Radiology", "chartdate": "2150-08-07 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 920905, "text": " 9:26 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: HIV,ELAVATED BILIRUBINE\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and CD4 less than 50. CMV colitis, Cryptosporidium,\n esoph. candidiasis, C. diff colits, rising tbili, ap\n REASON FOR THIS EXAMINATION:\n RUQ ultrasound,\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Liver and gallbladder ultrasound.\n\n CLINICAL HISTORY: 40-year-old man with HIV, CMV colitis, Cryptosporidium,\n esophageal candidiasis, C. diff colitis, rising bilirubin.\n\n FINDINGS: Right upper quadrant ultrasound was performed on .\n Comparison made to prior study dated .\n\n The hepatic parenchymal echotexture is within normal limits. No focal hepatic\n lesions are identified. There is no intrahepatic biliary ductal dilatation.\n The common bile duct is dilated, measuring up to 10 mm, and tapering in the\n pancreatic head. No pancreatic masses are identified. There is marked\n gallbladder wall thickening, measuring up to 11 mm in thickness. No\n gallstones are identified. Degree of gallbladder wall thickening is increased\n compared to prior study, although this could be secondary to decreased\n gallbladder distension.\n\n IMPRESSION: Extrahepatic biliary ductal dilatation and markedly thickened\n gallbladder wall. The combination of findings is concerning for HIV\n cholangiopathy, given the patient's clinical history:\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 920269, "text": " 12:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for cardiopulmon process\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO M with advanced AIDS, crypto, pancytopenic, scabies neutropenic, with\n hypotension, concern for SIRS, with new productive cough\n REASON FOR THIS EXAMINATION:\n please evaluate for cardiopulmon process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Advanced age, crypto-----pancytopenic, _____, neutropenic, concern\n for SIRS with new productive cough. Question cardiopulmonary process.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The heart is not enlarged. There is triangular opacity at the right base,\n though cardiac and diaphragmatic silhouettes are preserved. Appearance is\n compatible with atelectasis -- question subsegmental or segmental. There is\n new accentuation of interstitial markings at the left infrahilar,\n retrocardiac, and left base regions, compared to . No CHF, frank\n consolidation, or effusion is identified. A right subclavian PICC line is\n present, tip in region of SVC/RA junction, unchanged. No pneumothorax is\n detected.\n\n IMPRESSION: Atelectasis at right base. Increased interstitial markings at\n left base, more pronounced than on . Question early infectious\n infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 921039, "text": " 11:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute bleed,\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with progressive HIV, pancytopenia, scabies, on ARVs, with\n change in mental status\n REASON FOR THIS EXAMINATION:\n acute bleed,\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of progressive HIV, pancytopenia, scabies, change in\n mental status. Evaluate for acute bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage.\n The -white matter differentiation appears grossly preserved. There is\n slight prominence of the ventricles and sulci that may be related to volume\n loss. The basal cisterns appear patent. Imaged paranasal sinuses appear\n clear.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921246, "text": " 10:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/ PNA, pulmonary edema\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO M with advanced AIDS, crypto, pancytopenic, scabies neutropenic, with\n hypotension, concern for SIRS, with new productive cough\n REASON FOR THIS EXAMINATION:\n r/ PNA, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n INDICATION: Hypertension. Productive cough.\n\n COMPARISON RADIOGRAPH: and .\n\n The heart size is normal. There is a persistent area of opacity in the right\n lower lobe with associated displacement of the fissure suggestive of\n atelectasis. There is a new area of opacity in the left retrocardiac region\n with air bronchograms, concerning for infectious pneumonia or aspiration.\n There is a persistent small right pleural effusion and there is a new small\n left pleural effusion.\n\n IMPRESSION:\n\n Persistent right lower lobe opacity, most likely atelectasis. New left\n retrocardiac opacity, concerning for infectious pneumonia or aspiration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 919912, "text": " 4:38 PM\n CHEST (PA & LAT) Clip # \n Reason: R/o infectious or infiltrative processPt needs mask. Is on T\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 yo M c HIV p/w progressive pancytopenia\n\n REASON FOR THIS EXAMINATION:\n R/o infectious or infiltrative processPt needs mask. Is on TB precautions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV and progressive pancytopenia, evaluate for infectious or\n infiltrative process.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: The right-sided PICC is in place with tip terminating in mid SVC,\n in unchanged position. Heart size and mediastinal contours are within normal\n limits. The lungs are clear. There is no pleural effusion or pneumothorax.\n Osseous structures appear within normal limits.\n\n IMPRESSION: No evidence of acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-31 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 919981, "text": " 8:38 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Pt has very high Alk Phos. Pls evaluate for abdominal proces\n Admitting Diagnosis: THROMBOCYTOPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and CD4 less than 50. CMV colitis, Cryptosporidium,\n esoph. candidiasis, C. diff colits.\n REASON FOR THIS EXAMINATION:\n Pt has very high Alk Phos. Pls evaluate for abdominal process. U/S has to be\n done in room. Pls follow Scabies and TB precautions!!!!\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with HIV, CD4 less than 50, CMV colitis,\n cryptosporidiosis and esophageal candidiasis. Patient now with elevated\n alkaline phosphatase. Evaluate.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: The liver parenchyma is normal in echotexture. A few\n scattered areas of increased echogenicity near the right liver dome likely\n represent biliary hamartomas. No focal nodules or masses are detected. There\n is no intrahepatic biliary ductal dilatation. A moderate amount of sludge is\n seen within a non-distended gallbladder. The gallbladder wall is slightly\n thickened at 3 mm. The common bile duct dilated at 8 mm. The right kidney\n measures 9.3 cm. The left kidney measures 8.9 cm. A 10 x 6 x 8 mm cyst is\n seen within the interpolar, lateral left kidney. No hydronephrosis, stones,\n masses are seen bilaterally. The spleen is not enlarged at 9.0 cm. The\n pancreas and aorta are poorly visualized secondary to overlying bowel gas.\n\n IMPRESSION: Minimal thickened gallbladder wall with intraluminal sludge and\n slightly dilated common bile duct. These constellation of findings are\n concerning for HIV cholangiopathy.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-02 00:00:00.000", "description": "Report", "row_id": 1452478, "text": "NPN 7a-7p\nNeuro: Pt. alert and oriented-able to communicate needs. Pt. verbalilzed he understands DNR/DNI.\n\nResp: On 4L NC with sats 96-98%. CXR shows RML pna. Has congested cough but unalbe to cough sputum out. Breath sounds clear bilaterally. Was seen by ENT who obtained culture swabs. Thought tissued looked \"healthy\" but dry.\n\nCV: Unable to wean pressors-remains on dopa 20mcg levo 0.15 with BP 80-90/60 MAP 60's. Has had 4 L LR. Will be switching maintenance IVF. K 2.7, repeat 4.5 but was possibly contaminated by IVF running in. Will repeat. Was repleted with 40KCL and K phos and Mag.\n\nGI: Hypoactive bowel sounds. Had 3 episodes of diarrhea-stool for c-diff sent. TPN on hold.\n\nGU: Foley intact. Urine output 50-100cc/hr.\n\nEndo: insulin per ss\n\nID: Temp increased to 95. Bear hugger on. On broad spectrum antibiotics and isolation precautions for WBC 0.4. Antiretrovirals restarted.\n\nSkin: Scabies rash with some oozing of serosanquinous drainage.\n\nSocial: Family in to visit most of the day. Trying to get pt's mother here from .\n\nPlan\n-check k\n-monitor BP wean pressors as tolerated\n-IVF as ordered\n-monitor plts and replete as needed\n-stool sample to be sent for chem.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452479, "text": "micu-west npn 1900-0700\n***Code status: DNR/DNI\n\n**Allergies: Iodine\n\n*Precautions: Contact for Scabies/Droplet for ?TB\n\nin Brief: A 40 yo male w/ PMH: HIV; CD4=17. Also, significant for cryptosporidium, CMV colitis, C-Dif, esophogeal Yeast, malnutrition, Abnormal TFTs, H/o pancreatitis, scabies, anal candylomata, and panocytopenia/anemia - came to initially f0r treatment for anemia, FTT, and Panocytopenia (PLT < 7) thought to be caused by HAART medication. On pt. condition worsened becoming hypotensive while on floor, sbp 40s and tx w/ Dopamine and 3 L IVF w/ bump to sbp 60s, and this time pt. was transferred to MICU for maintenance of BP/?TB vs viral laryngitis.\n\nNeuro: Pt. is pleasant, able to follow commands, alert and oriented to person, place, and time, pupils pearl 2mm brisk, able to move all four extremeties on bed, gross muscle atrophy present in extremeties, pt. complains of weakness. Pt. sips H20 and swallows crushed meds.\n\nResp: Pt. is on 2L NC, O2 sats 98-100%, LS clear in upper lobes and diminished in lower lobes, occasional dry cough, CXR shows right mid-lobe PNA, ENT consult : multiple samples sent, no nodules visualized indicating doubtful of TB, although pt. remains on droplet precautions at this time.\n\nCV: Pt. received on Dopamine @ 20mcg/kg/min and Levophed @ 0.15mcg/kg/min w/ sbp=88-94, Map=58-70 and HR 110-140s. Around 0400, pt. Dopamine decreased to 10mcg/kg.hr and Levophed increased to 0.28mcg/kg/hr. Pt. sbp 95-106 and HR 125-135 NSR, no ectopy. Pulses palpable in all four extremties, though extremeties cool and dry. Right PICC Line - double lumen currently infusing D5W 1/2NS w/ 50mEq NaHCO3 @ 100cc/hr for 1 Liter. 4gm Ca+Glu repleted today for ICa+=0.9. K+ repletion HELD for K+ of 4.5. Peripheral IV WNL. Blood Cult- growing gram neg rods/pos cocci.\n\nGU/GI: Abd soft/firm/nontender, BS hypoactive, TPN on HOLD since , loose green stool x 4 medium amounts, Foley drainng 50-100cc/hr yellow/sediment urine.\n\nID: Pt. WBC =0.4, Lactic Acid=3.4, receiving steroids, Temp 95-97.5, bair hugger applied as needed, Abx Flagyl for C.Dif/Vanco/Cefepime.\n\nSkin: Pt. has highly contagious scabies from head to toe, tx. w/ Permetherine @ 00:00 and has patches of severe dry skin, tx w/ Eucerin @ .\n\nEndo: FSBS 130-150, follow SS\n\nSocial: Dr. met w/ pt. and pt. code status changed from Full Code to DNR/DNI tonight, cousins visited tonight, and family is coming from , will be here in about a week.\n\nPlan: Please obtain stool sample/C. Dif?\n Follow-up on morning labs ie: electrolyte repletion\n TPN?/ address nutrition needs\n TB? Need for Droplet precautions\n Follow-up on sputum cultures/blood cult\n Wean Dopamine/Levophed keeping MAPS>60.\n Await Enfuvurtide - arriving this evening\n Wash off premetherine this AM\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452480, "text": "NPN MICU-7 7AM-7PM\nEVENTS: PLT-9, started with lrge amts dark brown watery stool this AM, that advanced to BRB watery stool that required a recatl tube placed, and rec'd several blood products. Able to wean of Dopa Gtt but continues on Levo. Gtt.\n\nC/V: pt on Dopa and Levo Gtts, able to wean and d/c Dopa, but Levo continues @ 0.232 mcq/min/kq down from .280mcq. BP-86-96/60's, HR has come down from 140's ST to 98-105's with Dopa being off. K+-3.5, rec'd 40mEq KCL, and Mag+ repletion.\n\nRespir: Remains on 2-3L NP's with O2 sats 97-100%, but with RR 30-40's, appears to be tiring. Does not have an aline. Has no cough, remains on repsir precautions.\n\nGI:HEME; PLT Ct-9, is in DIC, INR-1.9, had dark red watery stool this AM but has advanced to BRB watery stool late morning. Rec'd 2 units PLT's, and 1 FFP, to rec PC's one unit when available from BB. No N/V noted. Rectal bag was placed but had to have a mushroom cath placed. Still having lrge amts Melena well over a 1200cc noted. Will transfuse with PC's then repeat levels. Is NPO.\n\nGU: U/O 50-70cc/hr with Bun/CRE-46/1.0. IVF's D5W with 3 amps Bicarb @50cc/hr started this afternoon.\n\nID: Temps 97-95.6 PO heating Bair hugger blanket was off for some of the day, but will be replaced this evening. WBC-0.4, continues on several IV antibx's which times have needed to be re-scheduled due to IV access difficulty. Still awaiting arrival of Enfurvirtide from Pharmacy.\n\nSkin: As MD's skin is improved, still on contact precautions. Applying skin cream's as ordered. Has two skin tears on buttocks, duoderms were applied.\n\nNeuro: A&Ox3, is very pleasant and cooperative is aware of how grave is prognosis is.\n\nIV access: Only has double lumen PICC line in place is difficult to administer all IV's, as ordered, has discussed with team the issue, but with PLT of 9 and bleeding cannot place an additional line.\n\nA/P: Continue to attempt to wean pressors, follow u/o. Assess bleeding and monitor HCT's,PLT Ct and administer blood products as needed. Assess lytes and replete as needed. Continue with IV antibx's, monitor temps use bair hugger blanket to keep temp 97 po.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-03 00:00:00.000", "description": "Report", "row_id": 1452481, "text": "NPN ADDENDUM 7AM-7PM\nS/O: SOCIAL: Code Status was disussed with pt and with HCP and with Cousin was questions about reverseing the DNR/DNI status but after discussing the situation with the pt and family members adn fully explaining his grave condition pt dicided to remain a DNR/DNI. Will continue full aggressive treatment and will hopefully make it until his mother and brother arrive in a few days.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-04 00:00:00.000", "description": "Report", "row_id": 1452482, "text": "micu west 1900-0700 npn\n****Code status: dnr/dni\n***Allergy: Iodine\n** Precautions: Contact for Scabies and Droplet for question TB\n\nSignificant Events: Pt. received TOTAL 3 units PRBCS for HCt=19 @ 1900, 1 unit FFP, and 1 unit Platlets for PLT=10. Also, total 60mEq of Potassium was repleted for K+=2.5.\n\nNeuro: Pt. is alert and oriented,able to follow commands and verbalize needs, voice hoarse, and pt. tires during effort to speak, pupils 3mm brisk, able to move all four extremeties on bed, although weak w/ gross muscle wasting, cough is very weak secondary to fatigue.\n\nResp: Pt. is on 2-3L NC, 02sats 98-100%, LS clear to diminshed in bases, cough effort is very weak/nonproductive, pt does not/is unable to expectorate any sputum.\n\nCv: Pt. is currently receiving Levophed 0.235 mc/kg/hr, sbp 90-115, MAP>60, HR 90-140 NS/ST no ectopy, HR decreasing from 140 to 100 since IVF and blood products infusing, suggesting need for hydration/volume, Dopamine OFF now for 24 hrs. Pt. received 1 L of D5W w/ 50mEq BiCarb, IVF was switched, and D5W is currently infusing @ rate of 200cc/hr for 1 L.\n\nGu/Gi: Foley draining yellow to drk yellow sediment urine 35-100cc/hr, urine sent for PH to determine Bicarb levels, abd soft/nontender, BS present, Mushroom cath draining increasing gross bloody liquid stool.pt has been NPO for 24hrs, does not take PO meds due to gross bloody liquid stool/GU bleed, TPN needed but there is currently no designated port available as Abx and Blood products are infusing via LICC -double lumen. Access has not been obtained as of now due to decreased PLT.\n\nId: Temp 95.7-99.5 for shift, Bair Hugger adjusted accordingly, Vanco Dc'd, ABX: Cefepime/Flagyl/Levofloxacon/Veroconizole\n\nEndo: FSBS covered per SS\n\nSkin: Applied Eucerin on dry areas/neck, coccyx abrasion/breakdown protected w/ duoderm, Scabies present on skin.\n\nSocial: Friends visited today/Health Care Proxy came and will visit tomorrow morning, Dr. met w/ pt. and discussed code status and disease process.\n\nPlan: **Access for TPN needed/check PLT count/consider Precautions and pt. tenous condition before any transport\n Monitor PLT/HCT/K+/Mg; replete blood product/electrolytes as\n needed\n Monitor INR/bleeding\n Wean Levophed, maintaining Maps>60\n Social work consult today to discuss end of life issues\n One more sputum needed to r/o TB\n Permetherine (skin ointment) due Thursday\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-04 00:00:00.000", "description": "Report", "row_id": 1452483, "text": "Nursing Note:0700-1900\n\nCode Status:DNR/DNI\nAllergies:Iodine\nPrecautions: Scabies and Droplet question of TB.\n\n40 yo M with a hx of AIDSon salvage HAART admitted for tx of anemia, FTT, pancytopenia. On pt's condition worsened;hypotensive, SBP:40's. Transferred to MICU. Last night\npt. recieved 3units PRBC's bumping up HCT to 28.2 and recieved KCL repletion. Potassium 2.7.\n\nNeuro:A&Ox3, articulates well, follows commands, PERRL, labored MAE, cachectic, weak cough.\n\nResp: LS cta dim @ bases,SpO2:97-100%,RR 30's,weak, nonproductive cough, Sputum sent for 3rd TB.\n\nCV:Pt. recieved of Norepinephrine 0.235 mcg/kg/hr weaned to 0.093 mcg/kg/hr.\nTolerated well. D5W 200 ml/hr continuous. HR82-107 bpm, SBP:95-122,\nTemp:96-96.3, Pt requested removal of bearhugger.Potassium down to\n2.6 from 2.7/to be repleted.\n\nID:Temp:96-96.3,Bear hugger refused, ABX;Cipro q12h, Cefepime,Voriconazole. Levofloxacin D/C'd. Pt unable to swallow PO meds and cannot take HAART meds including subcut. unless all meds are administered, Dr notified.\n\nGI/GU:Foley draining adequate amount of clear amber urine. Mushroom cath draining liquid bloody stool/GI Bleed. Pt unable to take PO meds and all antiviral meds. Nutrition consult:Diet chg'd to Full Liquids; supplement, boost resource fruit beverage B/L/D. Pt continues to obsess about caloric intake/TPN/boost, he prefers the dietary chg to a more invasive procedure.\n\nEndo:Insulin SS protocol.\n\nAccess:PICC R ac. Dressing chg'd, patent.\n\nInteg:Scabies throughout body. Cream applied to neck and underarms.\nAbrasion breakdown on coccyx area, replaced 2 Duoderms. Skin flakes off. Frequent bed changes.\n\nSocial:Discussed end of life issues. Pt. is \"at peace\" and has come to an acceptance of disease process.\nFamily and friends visiting throughout the day. Very supportive.\nSocial work in to meet with pt and family. Pt.'s mother coming from on Thursday.\n\nPlan:Monitor patient for internal hemorrhage/INR/PLT. Replete blood products with HCT of 21. Current HCT 28. Monitor electrolytes.\nReplete prn.Continue to wean levophed. Ivermectin due .\nPermethrin due .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-05 00:00:00.000", "description": "Report", "row_id": 1452484, "text": "micu west 1900-0700 npn\n****Code Status: DNR/DNI\n***Allergy: Iodine\n*Precuations: Droplet for question TB and Contact for scabies\n\nSignificant Events: Pt. received (two) infusions of 60mEqKCl in 1 Liter D5W, for a K+ of 2.6 and received 150mEq Bicarb in 1 Liter D5W.\nAlso, anti-retroviral medications DC'd.\n\nNeuro: Pt. is alert and oriented, pupils 3m brisk, pt. is very weak w/ gross atrophy, but able to move extremeties well on bed. Pt. cough is weak, gag reflex impaired. Pt. is able to sip water, but is NOT taking the majority of his PO medication, but is able to sip medication crushed in water. **Of note: Antiretrovirals are rendered inactive when crushed/ in addition all the anti-retrovirals must be taken for effectiveness/also, pt has not been very responsive to anti-retrovirals for some time, so Dr. and pt. agreed to D'C anti-retroviral mediction as effectiveness and absorption is in question. Pt voice is much stronger/less hoarse than previous, and pt. appears to be less lethargic since RBC/PLt/FFP transfusion.\n\nResp: Pt. received on 2L NC, O2 sat=98-100%, around 00:00 was able to D'C the NC w/ O2 sat=94-98%. Pt. cough is increasing in productivity, last sputum to r/o TB was sent , but lab cancelled specimen. Pt. does not complain of SOB, RR=20-30, decreased from 40s, and becoming more regular rather than shallow.\n\nCV: HR 75-90 NSR, Levophed has been weaned from 0.93 to 0.75 w/ sbp maintaining 90-115 MAp>65 (goal >60). Pt. received 1 Liter D5W w/ 150MEq Bicarb, and is currently receiving D5W @ 200cc/hr for maintenance fluid (continue for total 4L). In addition, pt. has received 1 L D5W w/ 60mEq K+Cl for K+=2.6 and an additional 1 L D5W w/ 60mEq K+Cl is currently infusing. Hct 28 (@2200) goal HCt>21.\n\nGU/GI: Foley draining 100-300cc/hr yellow/sedimenty urine, abd is firm, nontender, BS present, Mushroom cath draining large volumes of brown liquid stool, red tinged but significantly less frank blood than previous. Pt. is able to sip water and able to take Boost/Fruit nectar for calorie.\n\nID: Temp 95.7 Bair Hugger on, Levofloxacin DC'd/Cipro added/Flagl Dc'd\nBlood Culture for Psuedomonas.\n\nEndo: FSBS covered according to SS.\n\nSocial: Friend called tonight and informed pt/nurse that pt's mother will visit Thursday morning as well as four colleuges/friends from where pt. received PhD.\n\nPlan: Permetherine Ointment due/Ivermectin due as well\n cont. to monitor K+ and replete\n PLT=11 (trending down) Goal?\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-05 00:00:00.000", "description": "Report", "row_id": 1452485, "text": "NPN 7a-7p\nEVENTS: Levophed weaned off since 1100. MAPs>60. Pt has received total of 100mEq KCL and will get 60mEq more. Pt also received 2g Mg. Plts dropped to 8, and received 1u Plts-post plt count 53.\n\nNEURO: Pt is A@O, very pleasant man. Pt seems to be somewhat depressed today, anxious about his mother coming tomorrow and fears about what he looks like. Emotional support provided. Social worker also spoke with pt. Pt very weak, needing help moving around in bed. Pt refusing PO meds.\n\nCV: NSR 60s-90s. BP 80s-108/60s-70s, MAPs>60. Levophed off, as stated above. PM lytes to be checked @ MN.\n\nRESP: LS coarse upper, diminished @ bases. Pt has nonproductive cough. 3rd AFB pnding, 2 smears negative. Sats>96% on RA. RR 20s-30s.\n\nGI/GU: ABD is firm, +BS. Mushroom cath draining green liquid stool, guiac +. No visual blood. Pt taking occas sips of water and boost. 1500cc stool out @ 1200. Foley draining ample urine, 140-480cc/hr. D5W maintenance @100cc/hr-on 3rd out of 4L.\n\nENDO: BS have been 200s-300s, D5W. On humalog SS.\n\nID: Tmax 96.3, bear-hugger on most of day. +pseudomonas in blood. Pt also has scabies.\n\nSOCIAL: Pt has had many visitors today, including relatives. Pts mother will be flying in from tomorrow.\n\nPLAN: Continue to monitor BP, support as needed to maintain MAP>60. Continue skin care with creams and ointments for scabies. F/U with pm labs, replete lytes prn. Goal plts 10. Monitor for bleeding.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-06 00:00:00.000", "description": "Report", "row_id": 1452486, "text": "micu west npn 1900-1077\nDNR/DNI\n\nallergy: Iodine\n\nPrecaution: Contact for Scabies/Droplet for ?TB\n\nEvents: Pt. met w/ DSr. and has decided take PO medication, including HAART meds (anti-retrovirals), Pt. repleted 60mEq K+Cl for K+=3.5 and 15mmol Phosp repleted for Phos=1.7, and 500cc FB for sbp 90 and HR 120-140s, HR decreased to 9\\85-93 w/ FB.\n\nNeuro: Pt. is alert and oriented, given 2 tab Percocet for anxiety w/ good effect, pt. able to sleep for remainder of the night. Pt. is bale to move all extremeties on bed, despite complaints of weakness, gross muscle atrophy present in all four extremeties. Pupils 3mm brisk, cough weak, nonproductive and gag reflex intact, pt. is able to swallow pills whole and sip boost w/ no coughing.\n\nResp: Pt. LS are coars to clear in upper lobes and diminshed in bases, O2 sats 97-98% RA, RR was in 40s earlier this evening, but settled to 20-30 following fluid bolus, no complaints of SOB or difficulty breathing. Sputum 3 of 3 for ACB came back negative.\n\nCV: At 2100 pt. appeared to becoming more tachycardic/tachypneic, HR 110-120, 500cc FB given and HR decreased to 80-95 and RR decreased from 40 BPM to 20-30 BPM. Currently, HR 85-100 NSR, sbp 90-100 MAP.60.. Pt. has been off Levophed since @ 1100am. Pulses are palpbale in all four extremeties, 2+ edema noted in LE. K= 3.5 tx w/ 60MEqKCl in 1L D5W repletion, Phos=1.7 tx w/ 15mmol/20mEq K+Phos in 500ml D5W. 4 of 4 Liters D5W @ 100cc/hr IN @ 0600.\n\nHEME: hct 28/PLT 27 (post 1 unit PLT infusion )\n\nGU/GI: Foley draining 50-300cc/hr amber/yellow sediment urine, abd firm/slight tenderness noted on exam, mushroom cath draining approx 2L of brown to tan liquid stool, appearing tan following several sips of boost and PO medication. Pt has decided to take HAART medications as well as other PO medications, and has swallowed PO medication/Boost successfully.\n\nSkin: applied at midnight (dose 2 of 2).\n\nID: t=95-97.5, bair hugger on, ABX: Cefepime/Cipro\n\nEndo: FSBS covered SS\n\nSocial: Friends visited last night, will return this AM for rounds, mother to come today from , and health care proxy may come today as well. Pt. provided emotional support this evening, as he was deciding whether or not to take HAART medication. Ultimately, pt. decided to continue w/ HAARTs.\n\nPlan: Monitor BP, FB w/ NS for MAP>90\n Monitor PLT (GOAL>10), currently 27.\n Monitor electrolytes and replete as necessary\n ** PSYCH CONSULT for support\n Please START HAART medications in AM, as pt. requested taking them @ 0800\n Please rinse OFF pt. skin and apply Eucerin\n Allow friends/family visit, providing rest for pt per his request\n Cont. Potassium Phosphate infusion, running @ 80cc/hr\n Maintenance fluids?\n Please encourage BOOST/high calorie intake as tolerated by pt.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-06 00:00:00.000", "description": "Report", "row_id": 1452487, "text": "Nursing Note:0700-1900\n\nCode Status:DNR/DNI\nPrecautions:Contact and \nAllergies:Iodine\n\nNeuro:Calm, Cooperative Male,A&Ox3,PERRL,Pt OOB to Chair with\n2 assists; tolerated well. Pt. in good spirits today. MAE; pt at risk for falls, very weak. Pt. denies pain.Emotional support provided.\n\nResp:Coarse to clear LS dim at bases, weak cough effort. RR 26-38,\nSpO2:96-99%. Respiratory Precautions D/C'd. CO2-14\n\nCV:HR:89-111 ST/NSR, SBP:100-111,Mean:73-95,\nFluid goal 1 to 1 1/2 L positive, pedal pulses positive.\nCalcium Gluconate repletion. Ionized calcium:1.11\nPotassium 2.7, HCT 28.3, Hgb 10.2, Plt's 23, RBC's 3.27.\nPotassium to be repleted.Pending labs\n\nGI/GU:Pt has thrush and is being treated with antifungal, Vericonazole. Diet;full liquids, boost. Abd firm to palpation, bs+,\nMushroom catheter no longer in place, sphincter muscle has lost tone,\nunable to place rectal bag d/t continue flow of stool. Pt has padding and diaper on; chg'd q1hr. Urine specimen sent. Foley draing adequate\namounts of clear yellow urine. Lg quantity of liquid,brown stool outputfor shift\n\nEndo:Insulin SS protocol.\n\nInteg:Breakdown coccyx area, duoderms replaced multiple times d/t\ncontinual stooling.Breakdown on neck and underarms treated with Urea cream throughout day.\n\nSocial: multiple visitors and phone calls all day. very supportive family. Mother to arrive tomorrow. pt happy to be out of bed and into a chair today for visitors. Pt cousin, is contact person. Please refer callers and visitors to her for information.\n\nDispo: continue to replete lytes prn\nMonitor labs closely, Fluid goal 1 1/2 L positive,\ncontinue treating skin with urea cream.\ncont. to assess bp,temp. Monitor FS\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-07 00:00:00.000", "description": "Report", "row_id": 1452488, "text": "NURSING NOTES: 1900-0700\n40Y/O MALE ADMITTED FOR THROMBOCYTOPENIA\n\nPMH: HIV/AIDS \n CRYPTOSPIRIDIUM, CMV COLITIS, CDIFF COLITIS\n ESOPHAGEAL CANDIDIASIS, MALNUTRITION, ABNORMAL TFTS\n PANCREATITIS, SCABIES, ANAL CONDYLOMATA, PANCYTOPENIA, ANEMIA\n\nDNR/DNI\n\nIODINE ALLERGY.\n\nSIGNIFICANT EVENTS: LYTES REPLETION.\n\nNEURO. PATIENT REMAINS TO BE ALERT AND ORIENTED X3. MAE.3MM PERRLA/BSK. DENIES ANY PAIN. NO SEIZURE ACTIVITY NOTED ON THIS SHIFT.\n\nCV. NSR TO ST WITH HR BETWEEN 76-105 NO ECTOPY NOTED. SBP BETWEEN 102-112. PALPABLE PULSES NOTED ON ALL EXTREMETIES. HCT 30.4 FROM 28.3. K OF 2.7 REPLETED WITH 80 MEQS OF IV KCL AND 20MEQS PO KCL. K IN AM WAS 3.3 WILL REPLETE WITH 60MEQS MORE IV KCL. MG 1.7 TO BE REPLETED WITH 4 GMS OF MAGNESIUM SULFATE IV. NA 141 DOWN FROM 150 POST WATER BOLUSES. LAST PLATELET WAS 23.\n\nRESP. ON ROOM AIR SATTING BETWEEN 98-100% WITH CLEAR BIL BREATH SOUNDS WITH SLIGHTLY DIM BS AT THE BASES. EUPNEIC AT 26-30 NOT IN DISTRESS.\n\nGI/GU. HYPERACTIVE BOWEL SOUNDS. STILL DRAINING LARGE AMT OF LIQUID STOOLS. DIAPER IN PLACE. PATIENT NOT ON PPI AS PPI INCREASE CHANCE OF THROMBOCYTOPENIA PER DR. . FOLEY CATH DRAINING TO 50-200CC/HR CLEAR YELLOW URINE.\n\nID. TMAX 96.2 ON RETROVIRAL MEDS, CEFTRI AND CEFEPIME LAST WBC 11.3.\n\nSKIN. DRY/SCALY/FLAKING SKIN. STILL WITH SCABBIES. TOPICAL OINTMENTS APPLIED.\n\nACCESS. RT PICC LINE WNL.\n\nPLAN. MONITOR LYTES AND REPLETE IF NECESSARY. GOAL TO BE 1.5L POSITIVE. PLT GOAL OF >10. MONITOR FOR HYPOTENSION AND FLUID BOLUS IF NECESSARY. CHECK Q1-2 HOUR AND CHANGE DIAPER AS NECESSARY.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-09 00:00:00.000", "description": "Report", "row_id": 1452493, "text": "micu Nursing note \n\nNeuro pt awake and alert this am, at 1400 woke pt to turn was confused didn;t understand why i was turning him even after explaining it to pt took 10 min to reorient pt to what we were doing, pt follows commands but seem to have periods on confusion.\n\nCv pt through most of the day hr 70-90 sr at 1400 pt turned hr ^ 130 st called resident Bp stable at the time pt boluses with 500 cc n/s , hr dropped back to the 80's while getting bolus then after bolus finished hr back up into 120's Ivf changed to 1/2 ns at 150 hr, labs sent at that time ( and pending ) now\n\nGi abd soft nontender, pt still has flexflow rectal tube system passing green lig stool 800 cc this shift pt continues on octotide and opium for loose stool, pt taking poor intake incouraged to eat and drink but still has poor po intake,\n\n pt passing clear yellow urine via foley 100-200 cc hr.\nId pt hypothermic again was in bear hugger x5 hr pt remain on iv antibiotics and antivirals hct 27, wbc 14 plt 38 this am\nSkin pt still picking at skin pulling off scabs on neck and head told that he must stop because skin below and is bleeding , scalp washed andcream applied to head and body, scale covered with cap in order to remind pt not to pick at skin, pt remains on multi skin creams for dry skin and scabes,\n\nSocial spoke with family today about pt and that he does have periods of confusion they would like to speak with hiv specialist tomorrow to have a time line about therapy of new drug, also we need social service andcase worked to see pt about what type of care will be needed and if pt should be dischaged back to a long term care facility or a medical floor, at present pt talking a large amount of nursing time for care and would be to much care for nursing on floor, with need for lyte replacement and nutrition support and dirrehea control along with the fact pt will need a privite room, Right now is the time we need to balance the needs of the psycosocial along with medical, have the most amount of freedom and least restrictive enviornment, with the need for medical care will address this again with house staff tomorrow and also need to speak with id about long term needs, for isolation,\n\nA/p follow up with social services, care worked, Hiv and id, follow up with labs tonight may need replacement lytes and now looks to need more iv fluids, follow mental status and would talk with hiv speicalist about mental status and what meds may be part of making pt more confused\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452494, "text": "MICU 7 1900-0700 NPN\n\nPlease see flowsheet for objective data.\n\nNeuro: Patient's mental status fluctuates. When asked yes/no questions he answers appropriately, yet when RN administer's care he presents with confusion not understanding why care is being done even though POC has been explain previously. Early and Late in shift patient was lethargic. He was able to answer questions but did not take an interest in completing his oral medications. Upper and lower extremities are very weak and was not able to help in his turns.\n\nCV: Patient continues to be ST with no ectopy. 250cc bolus given and HR recovered to NSR. 60mEq PO of KCL, and 40mEq IV of KCL were ordered for correction of a Potassium level of 2.9. However patient would only take 20mEq of the PO KCL. need to replete remaining PO KCL via IV.\n\nResp: Patient continues to maintian >95% O2 sats on RA. Lung sounds remain clear throughout. Increased work of breathing and RR noted late in shift. 250 cc FB given, RR decreased to low 20's with occassional jumps to high 30's. Patient cough remains weak and patient states that he is not moving secretions.\n\nGI/GU: Patient remains on soft diet. No appetite noted this shift. Bowel sounds present, and flexitube inplace and draining green liquid stool. There is some leaking at rectum around tube, placed new kurlex and pads to absorb leakage and applied double guard cream to buttocks to protect skin. Patient continues to be on opium to correct excessive output of liquid stool. Foley is intact and draining large amounts of clear yellow urine. Urine output has significantly increased in the last 24 hours from 30cc/hr to 100-200cc/hr.\n\nID: Remains on contact precautions for scabies. Skin continues to be treated with multiple skin creams at bedside. Skin is very fragile at head and neck. Patient continues with bear hugger therapy due to low temps.\n\nSocial: Family into visit at 0000 after patient placed call to family.\n\nPlan: Continue to monitor hemodynamic status, follow electrolytes and replete when appropriate. Monitor fluid balance, team wants patient to be positive. ? mental status changes, is it r/t hemodynamic status, medications, or both. ? Long term plan for patient and plan for HIV MD consult requested by family.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452495, "text": "MICU 7 1900-0700 Addendum\n\n0600 FS 24, Amp of D50 given. At 0630 FS was up to 189. Very Lethargic this AM. Unable to take PO medication. D5 started at 100cc/hr. PICC port was clotted off, 1 cc of TPA was given with good effect.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452496, "text": "Micu Nursing note \n\nNeuro to very lathargic this am when bp 80/50 pt fluid boluses with 1l n/s and 1 liter Bp improved over an hr pt became more responsive when sbp > 100/. pt required multi lyte replacements durring the day and still passing lg amount of lig green stool hem pos, > 2 liters of stool this shift , u/o 400-500 cc hr. Family called in this am because pt was doing poorly.\nThis afternoon pt asked to speak with me in reguards to his care, after 45 min dicussion where pt was very clear, he stated that he didn't want this type of care any more would like to go home. wanted to be cmo,\nCall had aready been placed to Dr his Hiv md who did come in this evening also the icu fellow was called and informed about pt decision case mannagement was called and told of pt decision, a fmily discussion with DR , myself the family and the icu fellow. The family's concern is should go home with hospice or to a nursing home with hospice decause of the amount of nursing care,\n again verbalized to family his wishes for cmo, and case mannagement will work on dischage planning tomorrow,\nPlan is for pt to be transfered out to home /nh on hospice\nwill provide supportive care for pt and family\n" }, { "category": "Nursing/other", "chartdate": "2150-08-10 00:00:00.000", "description": "Report", "row_id": 1452497, "text": "NURSING NOTE \nPT HAD VERBALIZED CONCERNS REGARDING WILL. PAGE TO AT SOCIAL SERVICES MADE IN AN ATTEMPT TO FIND OUT PROPER CHANNELS FOR MAKING ARRANGEMENTS- ADVISED TO GET IN TOUCH WITH LEGAL COUNSEL- DISCUSSED CASE WITH FROM LEGAL WHO INFORMED THIS RN THAT UNFORTUNATELY, THE HOSPITAL IS UNABLE TO REPRESENT PT IN REGARDS TO THESE MATTERS AND TO ADVISE PT TO MAKE ARRANGEMENTS WITH FAMILY AND HCP REGARDING HIRING PRIVATE COUNSEL AND AT THE HAVING HCP WRITE DOWN WISHES AND SIGN PAPER UNTIL LEGAL PREPARATIONS HAVE BEEN MADE. WILL DISCUSS AT LENGTH WITH THE PATIENT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-11 00:00:00.000", "description": "Report", "row_id": 1452498, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nCODE STATUS: CMO\n\nTHIS IS A 39 Y/O M WITH , NORWEGIAN SCABIES, END STAGE AIDS, CHORNIC DIARRHEA CRYPTOSPORIDIUM, C-DIFF AND CMV COLITIS, PANCYTOPENIA, ELECTROLYTE ABNORMALITIES WHO WAS ADMITTED FROM CC7 FOR HYPOTENSIVE CRISIS WITH SBP IN THE 40'S. AFTER A LONG, DETAILED DISCUSSION WITH PT, DR. (PRIMARY ID PHYSICIAN) AND MICU PT HAS ADVANCED CODE STATUS TO CMO AS OF AT 6PM.\n\nNEURO: PT IS BECOMING MORE SLEEPY THROUGH THE SHIFT. HAD BEEN ALERT AND ORIENTED X 3- LUCID AND NEUROLOGICALLY INTACT ENOUGH TO TAKE CARE OF LAST WILL AND TESTAMENT WHICH WAS WITNESSED AND NOTARIZED AT THE BEDSIDE. PT HAS BEEN VERY ANXIOUS ABOUT HIS COMFORT NEEDS AS HE BECOME MORE LETHARGIC, CONFUSED AND UNABLE TO VERBALIZE HIS PAIN MEDICATION NEEDS. SPOKE WITH THE PATIENT AT LENGTH ASSURING HIM THAT HE IS BEING CLOSELY MONITORED AND THAT COMFORT IS OUR PRIMARY ISSUE WITH HIM. PT HAS AN ORDER FOR PRN MORPHINE 2-10MG Q 1 HOUR AS NEEDED. AFTER LENGTHY DISCUSSION AND PT HAS BEEN VERY COMFORTABLE AND ABLE TO REST. PT HAS VERBALIZED THAT HE \"DOES NOT WANT TO PROLONG HIS LIFE AT ALL\". PERRLA, 3/BRISK. PT C/O CONSTANTLY BEING COLD- CURRENTLY HAS BAIR HUGGER ON FOR COMFORT. NO SEIZURE ACTIVITY NOTED. SPEECH REMAINS CLEAR AND HE IS FOLLOWING COMMANDS WITHOUT ANY DIFFICULTY.\n\nRR: PT CURRENTLY O2L NC. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES. PT C/O OF SOME SOB AT TIMES WHICH IS RELIEVED BY MORPHINE. SP02 > OR = TO 95%. BILATARAL CHEST EXPANSION NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-80'S WITH NO SIGNS OF ECTOPY. SBP > OR = TO 100. WEAKLY PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT IS STILL RECEIVING BICARB GTT AT 200CC/HR BUT AS PER DR. - WE ARE NOT TREATING ELECTROLYTES.\n\nGI: PT CONTINUES TO HAVE MASSIVE DIARRHEA- GREEN, LIQUID STOOL NOTED. PT HAS SECURE AND INTACT FECAL INCONTINENCE BAG. SOME SEEPAGE AROUND SITE- BUT FOR THE MOST PART STOOL IS CONTAINED. PT WOULD LIKE TO KEEP BAG ON.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: PT KNOWN TO HAVE NORWEGIAN SCABIES. CARE PROVIDERS AND ANY VISITORS MUST WEAR SHOE COVERS, CAP, GOWN AND GLOVES PRIOR TO ENTERING. PT NOTED TO HAVE DRY, SCALY SKIN THROUGHOUT BODY.\n\nSOCIAL: LARGE AMOUNTS OF FAMILY IN TO VISIT. PT ALSO ABLE TO TAKE PHONE CALLS. MOM AT BEDSIDE. ALL QUESTIONS ANSWERED.\n\nPLAN: CMO. D/C TO HOSPICE ASAP. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2150-08-08 00:00:00.000", "description": "Report", "row_id": 1452491, "text": "MIcu Nursing note \n\nNeuro pt is awake and alert following commands, this morning pt sent for head ct which was neg for a bleed, they felt his mental staus was slighly off, pt knows place sometimes is unable to state month.\n\nCv pt hemeodymanically stable, pulses weak but palp, bilaterally, pt\nhad 2 episodes where hr down in the 40's when asleep, bp stable at that time. pt remains on d5w at 100/hr Na still ^, pt still havving large amounts of loose brown which has now turned yellow this afternoon, pt needing lyte replacment , repeat lytes this afternoon K 3.0 and cal 7.2 house staff to put in orders to replace lytes.\n\nResp pt on Ra sats 96-100% lungs cta. pt has slight cough non productive.\n\nGi pt started on brat diet tonight, has been given 2 doses of opium po for loose stool bsx4, flexflow system patent,\n\nGu u/o low 10-20 cc hr amber urine\nId pt hypothermic placed on bearhugger this afternoon at 1500 temp 95.6 blood culture sent of picc today\nendo bs 148-152 requiring coverage at 6 pm 2 units reg sq.\nskin neck scalp with crusty scabs, and open areas because is picking skin told nt to pick scabs because underneight is very frigile and will try to wash scaple tomorrow.\n\nsocial asked pt today if he still wanted full treatment he said yes , told him that we need to treat dirrehea and that, if he wanted to be treated that this issue must be addressed and stated that the opium kills his appetite told hiwe understand but that liguid still in the amounts he has must be treated. her agreed to take opium tonight.\n\nA/P opium q6, repleat lytes , uncourage po's and continue with brat diet.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-09 00:00:00.000", "description": "Report", "row_id": 1452492, "text": "MICU 1900-0700 NPN\n\nPlease refer to flowsheet for all objective data.\n\nNeuro: Patient A/O x3 for most of shift. At times patient seemed confused when RN would respond to call bell. However patient could be reoriented quickly. MAE's, but stregnth is weak.\n\nCV: HR has been ST with no ectopy this shift. Pedal pulses are palpable bilaterally. 60 mEq of KCL was given for a potassium of 3.4. 2 grams of calcium gluconate was given to correct for a calcium of 7.1. Morning labs still pending.\n\nResp: Patient continues to sat at 95-100% on RA. Cough remains weak and nonproductive.\n\nGI/GU: Patient continues to have no appetite. Has requested water several times tonight. BS are present. Fecal bag remains intact and draining clear liquid stool. Foley remains intact and is draining amber colored urine.\n\nID: Remains on contact precautions for scabbies. Tmax this shift was 98.3. Patient continues to require bear hugger at times for hypothermia.\n\nSocial: Patients family was in to visit at the start of shift.\n\nPlan: Continue to monitor hemodynamic status. Continue contact precautions and topical ointments for skin. Follow lytes and replete when appropriate. ? call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-07 00:00:00.000", "description": "Report", "row_id": 1452489, "text": "NPN MICU-7 7AM-7PM\n41 YO MALE WITH +HIV/AIDS, WITH Cryptospiridum, CMV Colitis, C-diff Colitis, Esophageal Cnadidiasis, Anal Condylomata, Pancytopenia, Anemia, S/P Sepsis, and Scabies.\n\nEvents: Not as Alert today, and poor PO's.\n\nNeuro: Alert but extremely tired and sleepy, but easily arousable. Appears mildly confused @times, but is aware of time.date and place. Did not want to get out of bed today.\n\nC/V: BP stable to 98-110/60, HR 70's-80's SR with no ectopy noted. AM K+-3.3, rec'd 60mEq IV, Ca 7.5, MagS+ 1.7, was repleted. Repeat Lytes sent are PND.\n\nHEME: HCT-stable @ 30.4, PLT-29, PT/PTT 14/30.0 INR- 1.2. No s/s bleeding, no transfusions needed.\n\nGI: Continues having copious amts brown Liquidy stool, Flexi-seal stool bag was placed but is still leaking around the rectal area, but is better contained. Is very tired today not wanting any PO's today except for OJ this AM. T Bili-6.8. Was ordered for U/S but has not been done as yet.\n\nRESPIR: Remains on RA with O2 sats 98-100%, RR 24-28, L/S clear.\n\nGU: U/O 60-80cc/hr, BUN/CRE 37/0.8. Rec'ing IVF- NS 125cc/hr, Na+-141, T CO2-19.\n\nID: Temp 96-95.6, WBC-11.3. Continues on several IV antibx's and anti-virals.\n\nSkin: Seen by Derm. skin appears to be improving, rec'ing creme's as ordered. Has duoderm on two open areas on buttocks. Head and neck and back still with flaking off skin in lrge amts.\n\nSocial: Mother and Brother arrive from today, have been in/out visiting today. Dr discussed issues with the family.\n\nA/P: Continue to replete Lytes as needed, and continue IVF's as ordered. Assess GI output, and assess for re-bleeding, check HCT, and PLT's . Apply skin cream's, as ordered. Monitor I&O's, as replete fluids as needed. Continue IV antibx's. Update family as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-08 00:00:00.000", "description": "Report", "row_id": 1452490, "text": "NURSING NOTES 1900-0700\n39 Y/O MALE ADMITTED FOR DIAGNOSIS OF THROMBOCYTOPENIA\n\nPMH: HIV/AIDS \n CRYPTOSPIRIDIUM, CMV COLITIS\n CDIFF COLITIS, ESOPHAGEAL CANDIDIASIS,\n MALNUTRITION, ABNORMAL TFTS, H/O OF PANCREATITIS, SCABIES,\n ANAL CONDYLOMATA, PANCYTOPENIA, ANEMIA.\n\nINITIAL ADMISSION CC7 FOR TX OF ANEMIA, FTT AND PANCYTOPENIA (PLT DOWN TO 7), THOUGHT TO BE MYELOSUPPRESSION FROM HAART MEDS AND MALNUTRITION. ON PT. WORSENING HYPOTENSION SBPS 40'S, DOPA AND 3L OF IV FLUID ADMINISTERED WHICH BROUGHT SBP TO 60'S, HENCE ADMIT TO MICU.\n\nDNR/DNI\n\nALLERGY: IODINE\n\n\nSIG EVENTS: LYTES REPLACEMENT, PATIENT SPOKE WITH MOTHER. VERBALIZED WANTING TO TALK WITH SOCIAL SERVICES AND ETHICS COMMITTEE, ALLOWED TO SLEEP FOR 4-5HRS WITH PLANNED CARE INTERRUPTIONS.\n\n\nNEURO. REMAINS ALERT AND ORIENTED X 3 WITH GENERAL WEAKNESS. MAE. PERRLA 3MM/BSK. DENIES OF ANY PAIN OR DISCOMFORT. NO SEIZURE ACTIVITY NOTED. PATIENT WAS ASSURED THAT HE HAS AN ADVOCATE THROUGH HIS NURSES IF HE EVER FEELS ALONE. PT OPEN TO SUGGESTION TO TALKING WITH SOCIAL SERVICES AND ETHICS COMMITTEE.\n\n\nCV. NSR HR BETWEEN 78-97 WITH NO ECTOPY NOTED. STRONG PALPABLE PULSES NOTED ON ALL EXTREMETIES. SBP 97-111. K=3.2 REPLACED TOTAL OF 100MEQS OF KCL, CO2=20 REPLACED WITH 100MEQS OF BICARB IN 1L OF D5W. HCT STABLE AT 30.1. LYTES RESULTS PENDING POST REPLETION.\n\n\nRESPI. ROOM AIR SATTING BETWEEN 95-100% EUPNEIC WITH RR BETWEEN 18-30. CLEAR BIL BREATHSOUNDS NOTED ON AUSCULTATION. OCCASSIONAL COUGHING NOTED, ENCOURAGED PATIENT TO TURN MORE OFTEN, AMENABLE.\n\nGI/GU. ON FULL LIQUID DIET. PLS ENCOURAGE. HYPERACTIVE BOWEL SOUNDS NOTED ON AUSCULTATION.PATIENT CONTINUES TO OOZE GREENISH LIQUID STOOL VIA FLEXI SEAL BAG. SYSTEM INTACT, FLEXI SEAL BALLOON REINFORCED WITH ADDTL 15CC SALINE TOT 45CC. TOTAL OF 1L EMPTIED IN LESS THAN 12 HOURS. PATIENT STARTED ON OCTREOTIDE, OPIUM TINCTURE AND LOPERAMIDE BUT REFUSED LOPERAMIDE AND OPIUM TINCTURE DESPITE OF ENCOURAGEMENT. FOLEY CATH DRAINING TO OF 30-100CC/HR..\n\nENDO. FSS COVERED BY SLIDING SCALE \n\nSKIN. DRY FLAKY SKIN. TOPICAL OINTMENTS ADMINISTERED. ENCOURAGED NOT TO SCRATCH. HAS NOWRWEGIAN SCABIES WHICH IS BEING TREATED WITH PERMETHRINE OINMENT ONCE EVERY 2 WEEKS. POSITIVE SKIN BREAKDOWN IN COCCYX.\n\nID. TMAX 95.9 BAIR HUGGER AND WARM PACKS OFFERED BUT REFUSED. EXTRA BLANKETS PROVIDED. WBC 14.1. PT CONTINUES TO BE ON RETROVIALS AND ANTIBIOTICS.\n\nPLAN. MAINTAIN PLT >10, CONT TO MONITOR LYTES AND REPLETE IF NECESSARY. HAVE SOCIAL WORKER AND ETHICS COMMITTEE TOUCH BASE WITH PATIENT. START CALORIE COUNT. PROVIDE EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452501, "text": "NURSING NOTES 0700-1900\n39 Y/O MALE PT WITH END STAGE AIDS, NORWEGIAN SCABBIES, CHRONIC DIARRHEA, CMV COLITIS, CDIFF,CRYPTOSPORIDIUM AND ELECTROLYTE ABNORMALITIES. INITIALLY ADMITTED AT CC7 FOR ANEMIA, FTT AND PANCYTOPENIA HAD HYPOTENSIVE CRISIS WITH SBP IN THE 40'S THUS TRANSFER TO MICU.\n\nPATIENT HAS DECIDED HIMSELF TO BE ON COMFORT MEASURES LAST /O6. PATIENT IS CURRENTLY ON MORPHINE DRIP AT 5MG/HR REQUIRING RESCUE DOSES AT TIMES FOR PAIN/GEN DISCOMFORT MOSTLY FROM HIS COCCYX. HE IS LUCID, LETHARGIC BUT VERY MUCH ORIENTED X 3.\n\nPATIENT HAS BEEN ST WITH HR RATE IN THE 120'S WITH SBP BETWEEN 85-90'SMMHG.\n\nCONTINUES TO BE ON ROOM AIR, EUPNEIC RR IN THE 20'S SATTING BETWEEN 95-100%.\n\nOF NOTE PATIENT HAS A PHD DEGREE IN ECONOMICS AND IS VERY MUCH LOVED BY A LOT OF FRIENDS AND FAMILY. MOTHER AND BROTHER FLEW IN FROM . PATIENT VALUES A LOT THAT HIS WISHES WOULD NOT BE REVERSED WHEN HE IS NOT LUCID ANYMORE AND THAT HE WOULD DIE WITH DIGNITY.\n\nPLEASE PROVIDE PATIENT AND FAMILY EMOTIONAL/SPIRITUAL SUPPORT DURING THE DYIN/GRIEVING PROCESS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452502, "text": "NURSING NOTES ADDENDUM 0700-1900\nPT AT 140S WITH SATS AROUND THE 80'S WITH LABORED BREATHING, TALKED WITH PATIENT, REQUESTING FOR FAMILY TO BE AROUND, WAS ABLE TO SPEAK WITH (COUSIN), THEY WILL BE IN ASAP. NURSE WITH PATIENT.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452503, "text": "Transfer to the floor is on hold.\nAgonal breathing, sats in the 60's. Morphine gtt was increased to 10 mg/h at 1715.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452504, "text": "PT PASSES AWAY AT ON , DR PRONOUCED. FAMILY AWARE, PT'S BELONGES SENT WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2150-08-11 00:00:00.000", "description": "Report", "row_id": 1452499, "text": "Nsg Progress Note 0700-1900\n\nCV - Pt hemodynamically stable. IVF dc'd. HR NSR with no ectopy although it is becoming slightly irregular.\n\nResp - No O2. O2sats excellent on RA and no c/o SOB or difficulty breathing. BS cl bilat. Dry spont cough. Pt did have 3 short episodes of nose bleed from left nares only. Bleeding stopped spontaneously. No episodes since 1300.\n\nGI - Pt has no interest in eating. Abd soft with positive BS. Mushroom cath placed for large amt green liquid stool.\n\nGU - foley cath draining mod - large amt clear yellow urine. Urine is occasionally blood tinged but clears on its own.\n\nNeuro - Pt very awake in the morning and able to help with turns and care. A&O x3 and very aware of surroundings. Pt requesting more pain med and as the day progressed - he is sleeping more and takes longer to orient self to place and time. He is still oriented and appropriate and stated that he just wants to sleep and not be awake anymore.\n\nSocial - Mother, brother and in all day. They have been updated on condition by attending and case manager and social worker. They are all in agreement with patient's wishes. They would prefer to keep patient in hospital if death looks imminent but they are also comfortable with patient being transferred to hospice if necessary.\n\nCode status - Pt remains a CMO and antibiotics and IVF's have been dc'd. Pt receiveing MSO4 as requested to keep him comfortable. He responds well to 5 mg IVP q 3-4 hours.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-08-12 00:00:00.000", "description": "Report", "row_id": 1452500, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM DAY SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVRIONMENT SECURED FOR SAFETY.\n\nTHIS IS A 39 Y/O MALE W/ NORWEGIAN SCABIES, END STAGE AIDS, CHRONIC DIARRHEA CMV COLITIS, C-DIFF AND CRYPTOSPORIDIUM, PANCYTOPENIA AND ELECTROLYTE ABNORMALITIES THAT WAS INITIALLY ADMITTED FROM CC7 IN HYPOTENSIVE CRISIS; SBP 40-60'S. AFTER A LONG, DETAILED DISCUSSION WITH FAMILY, PRIMARY CARE- DR. AND MICU PT ADVANCED HIS CODE STATUS TO CMO AS OF . SOCIAL SERVICES IS ACTIVELY ATTEMPTING TO ARRANGE PLCMT INTO HOSPICE NH.\n\nPT HAS BEEN COMFORTABLE FOR MOST OF SHIFT. CURRENTLY RECEIVING IVP OF 10MG MORPHINE Q 2-3 HOURS FOR COMPLAINTS OF GENERALIZED DISCOMFORT. REMAINS LUCID- ORIENTED X 3- LETHARGIC AT TIMES. PROVIDING CONSTANT REASSURANCE THAT HIS DISCOMFORT WILL NOT GET OUT OF CONTROL. MOTHER HAS BEEN SPENDING THE NIGHT AT THE BEDSIDE. PLAN IS FOR PLCMT IN HOSPICE NH- AND MANAGING DISCOMFORT WITH MORPHINE DURING TRANSITION. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n" } ]

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On hospital day number one, the intra-aortic balloon pump remains in place. The patient is stable. He had a head CT scan which showed chronic lacunar infarcts and cisterna magna. Cardiology was consulted who agreed with the patient's therapy and also recommended the cardiac surgery consultation for possible coronary artery bypass graft in the future. Neurology was consulted for the patient's finding on the CT scan. Neurology's opinion was that the patient's findings were due to old long-standing hypertension and there were no clinical signs or symptoms concerning for embolic ischemic cerebrovascular disease at the time of examination. The patient had some signs and symptoms of Parkinson's, however, that was not an acute issue and would not warrant any evaluation at that time. On hospital day number three, the patient had carotid Duplex Doppler which was within normal limits. The patient was taken to an Operating Room on , where a coronary artery bypass graft times three with saphenous vein graft to left anterior descending, left internal mammary artery to diagonal and saphenous vein graft to obtuse marginal was performed. The operation went without complications. Pacing wires as well as mediastinal and pleural tubes were placed. Postoperative day number one, the patient had to be bolused a few times to keep his cardiac index in an acceptable range. The patient was weaned off Propofol and was alert and arousable. On postoperative day number two, intra-aortic balloon pump was removed; the patient was extubated. He had an episode of atrial fibrillation which responded to Amiodarone bolus. The patient was started on an Amiodarone drip which was discontinued later in the morning. Electrophysiology Service was consulted who suggested that the patient may need a pacer at some point in the future. On postoperative day number three, the patient had episodes of bradycardia arrhythmia and a couple of episodes of atrial fibrillation which responded to Amiodarone boluses as well. The chest tube was successfully removed. On postoperative day number four, the patient continued to go in and out of atrial fibrillation. When he is in atrial fibrillation his rate is about 90. When the patient is in normal sinus rhythm, his rate is anywhere from 60 to 70. On postoperative day number five, the patient had a few episodes of rate controlled atrial fibrillation converted spontaneously, so it was decided not to start the patient on Lopressor or Amiodarone due to the possibility of a block. He was started on anti-coagulation for his atrial fibrillation. Postoperative day number six, the patient continues to go in and out of rate controlled atrial fibrillation. On postoperative day number seven, again rate controlled atrial fibrillation. The patient was transferred to the floor in stable condition. On the floor overnight, the patient had a six second asystolic episode when transitioned from rate controlled atrial fibrillation to normal sinus rhythm. The patient was asymptomatic at that time. His blood pressure remained stable. He was seen again by Electrophysiology Service who at this point recommended a pacemaker placement. The patient's warfarin and heparin were held overnight. On postoperative day number eight, Lopressor was discontinued. He continues going in and out of atrial fibrillation, rate controlled, and had a couple of episodes of brady arrhythmia which resolved spontaneously. On postoperative day number nine, the patient was taken to Electrophysiology Laboratory where a dual chamber rate responsive pacemaker was placed. The patient had some blood loss and it was recommended by Electrophysiology Service to hold all his anti-coagulation for a few days. The patient was also started on a few doses of Cefazolin per Electrophysiology Service protocol. Also, on postoperative day number five, urinalysis was done which showed a urinary tract infection for which the patient was treated with a five day course of Ciprofloxacin. At this point, the patient has no complaints, no active issues. The issue of anti-coagulation will be decided between the Cardiothoracic and the Electrophysiology Services before the patient is discharged and will be discussed with him and his family.

LUNGS CLEAR - COARSE AFTER TCDP AND INSENTIVE SPEROMETRY. There is a hazy opacity involving the left base consistent with a pleural effusion. Small left sided pleural effusion with associated atelectatic changes. Right bundle-branch block with left anterior fascicular block.Compared to the previous tracing of no significant change.TRACING #1 I believe this finding represents a so-called cisterna magna, as opposed to a retrocerebellar cyst. 3) Minimal nonspecific hazy increased density persists in both lung bases. Left atrial abnormality. Note is made of a small hiatal hernia. There is a right apical opacity as well as a patchy opacity within the right middle lobe. The left lung demonstrated a small left sided pleural effusion with associated atelectatic changes. The trachea is deviated to the right of the chest and there is effusion versus pleural thickening most marked at the right apex and to a lesser degree at the left apex. There are bibasilar parenchymal opacities, unchanged from prior study. Rightbundle-branch block with left anterior fascicular block. Note is made of a calcified granuloma in the left upper lobe. 2) Left sided pleural effusion. There is right apical and right middle lobe opacity probably representing atelectasis and/or scarring. The prominence in the chest radiograph most likely represented a tortuous ectatic aorta. Additionally, there is a very large cerebrospinal fluid space posterior to the cerebellum, but without apparent mass effect. There is ectasia of the aorta with calcification consistent with atherosclerotic disease. There is coronary calcifications. However, there are multiple tiny areas of low density within the head of the left caudate nucleus, the right lentiform nucleus and the cerebellar hemispheres bilaterally, consistent with chronic lacunar infarcts. FINDINGS: Duplex and color Doppler demonstrate normal carotid systems bilaterally. There is a dual lead left sided pacemaker with leads appropriately positioned. Sinus rhythm. Sinus rhythm. Sinus rhythm. Since the previoustracing of ST-T wave changes are decreased. Right bundle-branch block with leftanterior fascicular block. Sinus rhythm- borderline first degree A-V blockRBBB with left anterior fascicular blockST-T changes consider ischemiaQRS changes in lead V3 - ? The previously noted endotracheal tube, Swan Ganz catheter, NG tube, and chest tubes have been removed. There are sternal wires and clips overlying the cardiac silhouette consistent with a previous CABG. There are bilateral pleural effusions. The right lung is decreased in volume. There is still minimal nonspecific increased density in both lung bases. LS DIMINISHED AT BASES. Cardiac and mediastinal contours are unchanged. RA=91%.ABD SOFT WITH + BS. DUODERMS INTACT ON BACK/COCCYX.2+PEDAL EDEMA.SKIN EXTREMELY DRY/FLAKY. The ET tube, bilateral chest tubes, right swan ganz catheter, and numerous mediastinal clips and wires are essentially unchanged in position. This other mediastinal drain are less likely a right chest tube terminating adjacent to the right mediastinum. A right cordis remains in place, its tip in the distal right internal jugular vein. The aorta is tortuous and a radiopaque marker of the intra-aortic balloon pump is 7.3 cm below the most superior aspect of the aortic arch. PT DOES APPEAR COMF EXTUB. PT UPDATE PT IS S/P CABG X3 YEST. BILOUS DRG. Reversing paralytics currently.GU: UOP very low in OR. C/O naseau once, Zofran given. Resp: O2 on at 1L NC. Nursing Note 7A-7PNeuro: Arouses to voice, awake oriented to person, place, disoriented to time or day. REMAINS ON NTG (SEE FLOW SHEET FOR EXACT DOSEAGES). CXR-IABP placement better per , PA. 1st units PRBC going in now. UOP improving currently.GI: OG to LCWS, bilious drainage. Lungs clear.NEURO: Propfol still infusing. During day, pt stated place was , , Sitchuit. POST-EXT. HEPARIN GTT CONT. IABP 1:1, poor wave form, fling, team notified, attempted to fix. Will vpace 100%, but CO still low. R IJ IABP CONT. Passing gas, requested bedpan once but no BM.ENDO: BG wNL.SKIN: Arms still edematous, cordis in place. Iapb on 1:1 all night with good augmentation.GI: ogt patent drianing bilious fluid.GU: urjine outputs adequate.skin: incisions clean and dry no drainage. TO HAVE GOOD DIASTOLIC AUGMENTATION AND SYS UNLOADING, SEE FLOW SHEET FOR EXACT #'S. IN TO ASSESS PT A FEW MINUTES AGO AND WANTS PT MORE AWAKE TO EXTUB. Ntg gtt started for HTN at that time. DOPPLERABLE PULSES BILT., FEET COOL TO TOUCH.RESP: BS CLEAR BILT., O2 WEANED DOWN TO 2L NP WITH SAT'S >95%.GI/GU: HOURLY URINES CONT. GI: OGT-LCWS. GIVEN 1 DOSE OF MAGSO4 (2GM'S), K LEVEL WNL. SHIFT UPDATE.PT. SHIFT UPDATE.PT. TO BE IN NSR WITH AT TIMES PERIODS OF 1 DEGREE AV BLOCK WITH PR INTERVALS OF >.24, MULTIFOCAL PVC'S NOTED THRU-OUT NIGHT. EXTUB. IV Lasix given, good diuresis.GI: Hypo bowel sounds. Epicardial pacing wires attached to pacer, back up rate of 60 set.PULM: Wean off O2, room air now with good sats. TO OOZE VERY SM. SX FOR OLD BL. CV: At beginning of shift, junctional vs CHB. CV: NSR, occass to rare PVC's. REPOSITIONED, U/O IMPROVING. TINGE-SCANT AMT. BS CLEAR, DECREASED IN BASES. BP stable. IABP advanced by , PA, waiting CXR results.PULM: CT's draining sanginous fluid, no airleak. Giving reversal agents presently. pt presented to csru- awake, alert,pleasant, on iv ntg and integrilin. HCT STABLE-28. BP stable at this time but CO low. When pacer turned down, NSR rate 70's. NODAL B/P STABLERESP CONTINUES TO REQUIRE FREQ ENCOURAGMENT TO LEAVE O2 ON DEEP BREATHING AND COUGHING WELL COARSE BS WITH SOME UPPER AIRWAY CONGESTIONLABS K COVERED X2 WITH 20MEQ IV KCL BS 121 NO COVERAGEGU/GI GOOD U/O WITH DECEASING AMTS IN AM MD AWARE NO PO FLUIDS MOUTH CARE FREQPLAN CONTINUE TO MONITOR EKG FOR CHANGES MAINTAIN WORKING PACER AMT, DSG CHANGED AND NEW PRESSURE DSG APPLIED. Extremely labile BP initially, treated with 3L LR and one unit PRBC so far. d/c iapb later today. CI 1.8-1.9 range, also treated with the fluid so far. EP consulted. IABP 1:1. Will tx low CI with 2 units PRBC.

35

[ { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 765678, "text": " 6:26 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate ? anterior mediastinal mass\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man pre-op CABG\n REASON FOR THIS EXAMINATION:\n evaluate ? anterior mediastinal mass\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Question anterior mediastinal mass.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the upper abdomen. 100 cc of optiray were given because of patient's\n debility. There are no previous examinations available for comparison.\n\n A chest X-ray performed on was used.\n\n There is ectasia of the aorta with calcification consistent with\n atherosclerotic disease. The heart is normal in size. There is coronary\n calcifications. There is no paracardial effusion. A filling defect is seen\n throughout the descending aorta consistent with the intraaortic balloon pump.\n There is no mediastinal or hilar lymphadenopathy. No mediastinal mass is\n identified. There is a right apical opacity as well as a patchy opacity\n within the right middle lobe. This is suggestive of atelectasis and/or\n scarring. The right lung is decreased in volume. There is no evidence of\n lung resection. There is evidence of pleural thickening at the right base, as\n well. There are right posterior rib fractures. The left lung demonstrated a\n small left sided pleural effusion with associated atelectatic changes. No\n nodules or masses are identified. Note is made of a calcified granuloma in\n the left upper lobe.\n\n Note is made of a small hiatal hernia. There is a simple right renal cyst\n that measured 3.4 x 3.2 cm. The patient has a appropriately positioned IVC\n filter.\n\n IMPRESSION:\n\n There is no anterior mediastinal mass or lymphadenopathy. The prominence in\n the chest radiograph most likely represented a tortuous ectatic aorta.\n\n There is right apical and right middle lobe opacity probably representing\n atelectasis and/or scarring. This causes decreased volume within the entire\n right lung.\n\n Small left sided pleural effusion with associated atelectatic changes.\n\n (Over)\n\n 6:26 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate ? anterior mediastinal mass\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 765636, "text": " 10:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pt with vagues h/o dizziness and needs CABG. Please eval for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD, HTN\n REASON FOR THIS EXAMINATION:\n Pt with vagues h/o dizziness and needs CABG. Please eval for presence of\n strokes/other lesions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dizziness; preoperative for coronary artery bypass.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no intracranial hemorrhage or shift of normally midline\n structures.\n\n However, there are multiple tiny areas of low density within the head of the\n left caudate nucleus, the right lentiform nucleus and the cerebellar\n hemispheres bilaterally, consistent with chronic lacunar infarcts.\n\n Additionally, there is a very large cerebrospinal fluid space posterior to the\n cerebellum, but without apparent mass effect. I believe this finding\n represents a so-called cisterna magna, as opposed to a retrocerebellar\n cyst. Considering patient age, there is only minor involutional change of the\n brain identified.\n\n CONCLUSION: Multiple chronic lacunar infarctions. cisterna magna.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765760, "text": " 3:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/IABP check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/IABP check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG and intraaortic balloon placement.\n\n Status post CABG. The chest is markedly rotated to the right. Endotracheal\n tube is 6 cm above carina. The tip of Swan-Ganz catheter overlies main\n pulmonary artery segment. Because of the rotation tip of intraaortic balloon\n is not clearly identified on this film. NG tube is present with distal end\n also not localized. Chest tube is present in the left lower hemithorax. No\n pneumothorax. There is biapical pleural thickening/effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765602, "text": " 2:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate IABP placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n REASON FOR THIS EXAMINATION:\n Evaluate IABP placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease with intra-aortic balloon pump.\n\n FINDINGS: There are no old films available for comparison. The trachea is\n deviated to the right of the chest and there is effusion versus pleural\n thickening most marked at the right apex and to a lesser degree at the left\n apex. The aorta is tortuous and a radiopaque marker of the intra-aortic\n balloon pump is 7.3 cm below the most superior aspect of the aortic arch.\n This other mediastinal drain are less likely a right chest tube terminating\n adjacent to the right mediastinum. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-12 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 765648, "text": " 12:39 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: CAD, DIZZINESS\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Coronary artery disease, dizziness.\n\n FINDINGS: Duplex and color Doppler demonstrate normal carotid systems\n bilaterally. There is also normal antegrade flow in both vertebral arteries.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 766533, "text": " 10:35 AM\n CHEST (PA & LAT) Clip # \n Reason: check lead placement and rule out pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CABG, and new pacemaker on left side\n REASON FOR THIS EXAMINATION:\n check lead placement and rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New pacemaker placement.\n\n Two views of the chest are compared to a previous study dated .\n\n There is a dual lead left sided pacemaker with leads appropriately positioned.\n There are sternal wires and clips overlying the cardiac silhouette consistent\n with a previous CABG. There is no pneumothorax. There is a hazy opacity\n involving the left base consistent with a pleural effusion. There is\n significant tortuousity of the aorta and enlargement of the heart. The\n patient is status post right upper lobectomy with staples in the hilar region.\n The right lung is otherwise clear.\n\n IMPRESSION:\n\n 1) Appropriately positioned left sided dual lead pacemaker.\n 2) Left sided pleural effusion.\n 3) No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765769, "text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check IAB placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD\n\n REASON FOR THIS EXAMINATION:\n check IAB placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89 y/o man with coronary artery disease status post intra aortic\n balloon pump placement.\n\n Portable AP supine view of the chest performed at 17:56 hours.\n Comparison film performed same day at 15:34 hours.\n\n Multiple lines and tubes overlie the visualized chest and abdomen. The ET\n tube, bilateral chest tubes, right swan ganz catheter, and numerous\n mediastinal clips and wires are essentially unchanged in position. An intra\n aortic balloon pump is not clearly visualized. There are bilateral pleural\n effusions. There are bibasilar parenchymal opacities, unchanged from prior\n study.\n\n IMPRESSION:\n\n 1. An intra aortic balloon pump is not clearly visualized. A follow up repeat\n radiograph with good positioning, removal of the overlying wires and tubes,\n and good inspiration should be performed for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2148-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765983, "text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man s/p cabg and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal.\n\n PORTABLE CHEST: Comparison is made to film from two days earlier. The\n previously noted endotracheal tube, Swan Ganz catheter, NG tube, and chest\n tubes have been removed. A right cordis remains in place, its tip in the\n distal right internal jugular vein. Cardiac and mediastinal contours are\n unchanged. There is stable pleural-based density in both lung apices, with no\n change in a more vertically oriented band-like density which projects over the\n left apex medially. There is no evidence of pneumothorax. There is still\n minimal nonspecific increased density in both lung bases.\n\n IMPRESSION:\n\n 1) Status post removal of all tubes and catheters as described, with a right\n Cordis now in place.\n\n 2) No evidence of pneumothorax.\n\n 3) Minimal nonspecific hazy increased density persists in both lung bases.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2148-08-23 00:00:00.000", "description": "Report", "row_id": 136683, "text": "Tracing taken with a magnet. Sinus rhythm. Right bundle-branch block with left\nanterior fascicular block. Intermittent paced beats.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-08-23 00:00:00.000", "description": "Report", "row_id": 136684, "text": "Sinus rhythm. Right bundle-branch block with left anterior fascicular block.\nCompared to the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 136685, "text": "Sinus rhythm. Left atrial abnormality. Marked left axis deviation. Right\nbundle-branch block with left anterior fascicular block. Since the previous\ntracing of ST-T wave changes are decreased.\n\n" }, { "category": "ECG", "chartdate": "2148-08-11 00:00:00.000", "description": "Report", "row_id": 136686, "text": "Sinus rhythm\n- first degree A-V block\nRBBB with left anterior fascicular block\nProbable anterior infarct - age undetermined\nLateral T wave changes offer additional evidence of ischemia\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 136687, "text": "Sinus rhythm\n- borderline first degree A-V block\nRBBB with left anterior fascicular block\nST-T changes consider ischemia\nQRS changes in lead V3 - ? position\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-18 00:00:00.000", "description": "Report", "row_id": 1380969, "text": "Pt. alert and answers all questions appropriately. Needs orientation to day but otherwise has good recall of recent events.\nPt. having several episodes of incontinence despite having penile appliance on. Pt. had episode of afib at 0400. that was reported to Dr. . HR <100 with good bp. K+ with a.m. labs was 3.3. kcl 20 meq po given. Nsr restored without intervention.Pt. swallowing with some discomfort in his throat. Says that his throat is sore.\nPlan: monitor rhythm; keep electrolytes wnl. slowly increase po diet as tol. OOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-18 00:00:00.000", "description": "Report", "row_id": 1380970, "text": "NEURO ALERT ORIENTED GOOD EQUAL STRENGHTS NO DEFECITS NOTED\n\nC/V NSR NO ECT UNTIL 1810 CONVERT TO AFIB HR 90S B/P 98/47 NO C/O MD AWARE NO TREATMENT AT THIS TIME\n\nRESP NC 1L SATS 99% RA SATS 92-94% LUNGS CLEAR\n\nGU/GI URINARY POUCH REAPPLIED GOOD U/O BAG INTACT ABD SOFT POSITIVE FLATUS TOL PO FAIR C/O SORE THROAT MD AND SOFT FOODS GIVEN\n\nACTIVITY OOB TO CHAIR X2 ASSISTS TOL WELL GOOD WEIGHT BEARING\n\nPLAN INCREASE ACTIVITY AS TOL MONITOR EKG CHANGES\n" }, { "category": "Nursing/other", "chartdate": "2148-08-19 00:00:00.000", "description": "Report", "row_id": 1380971, "text": "8-11/11P-7A\n\nNEUROLOGICALLY INTACT. FOLLOWING COMMANDS.MAE, ALTHOUGH VERY STIFF.NSR WITH STABLE BP. LS DIMINISHED AT BASES. 1.5LNC SATS=97%. RA=91%.\nABD SOFT WITH + BS. URINE COLLECTION POUCH INTACT AND WORKING GREAT. CLOUDY YELLOW URINE. DUODERMS INTACT ON BACK/COCCYX.2+PEDAL EDEMA.\nSKIN EXTREMELY DRY/FLAKY. -OIL APPLIED ALL OVER.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-19 00:00:00.000", "description": "Report", "row_id": 1380972, "text": " 7a-7p Addendum to transfer note:\nOn transfer but no beds available.\nStable with improvement to bp 100-140's/50-59; Sats 97-98% on 1.5 via nc. DB&C / IS encouraged. OOB to chair with improving mobility. Eating small amts from meal trays. Total 575 cc cloudy urine (7a-7p).\n" }, { "category": "Nursing/other", "chartdate": "2148-08-20 00:00:00.000", "description": "Report", "row_id": 1380973, "text": "D PATIENT ALERT AND ORIENTED MOVING ALL EXTREMETIES NSR MOST OF THE SHIFT BUT WENT INTO AFIB WITH A HR OF 90 -120 TOLERATED WELL CONVERTED BACK TO NSR ON OWN AT PRESENT WITH OUT ECTOPI. PATIENT UNABLE TO SUCCESSFULLY USE THE URINAL. A URINE POUCH WAS PUT IN PLACE TO COLLECT THE URINE. CLEAR YELLOW URINE. ABD SOFT WITH BOWEL SOUNDS. LUNGS CLEAR - COARSE AFTER TCDP AND INSENTIVE SPEROMETRY. MOVING . SAT REMAIN >94. ON 1.5 L NC. TURNED FREQUENTLY .\n SKIN INTEGRITY DRY WITH POOR TURGER. LOTION APPLIED TO LEGS. DOUDERM REMAINS ON BACK AND COCCYX PRESSER SITES .\nA PATIENT STABLE. HAS PERIODS OF AF WHICH HE TOLERATEDS WELL.SKIN INTEGRITY IS POOR.\nR TURN FREQUENTLY. INCOURAGE TCDP AND INSENTIVE SPEROMETRY.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380957, "text": "89 y.o. male readmitted to CSRU after CABG x 3 using the LIMA and SVG. Difficult intubation in OR due to limited range of motion of neck. Received 3 units PRBC in OR. Otherwise uneventful OR time. Extremely labil BP first 3 hours in unit but now stabilizing.\n\nCV: NSR, long PR interval, rate 60's. Apaced, rate 80 currently. 2Atrial and 2Ventrical epicardial wires attached to pacer. Still warming. Extremely labile BP initially, treated with 3L LR and one unit PRBC so far. CI 1.8-1.9 range, also treated with the fluid so far. Waiting for team to decide on latest CI. IABP 1:1, poor wave form, fling, team notified, attempted to fix. IABP advanced by , PA, waiting CXR results.\n\nPULM: CT's draining sanginous fluid, no airleak. Lungs clear.\n\nNEURO: Propfol still infusing. Reversing paralytics currently.\n\nGU: UOP very low in OR. UOP improving currently.\n\nGI: OG to LCWS, bilious drainage. No bowel sounds.\n\nENDO: BG WNL so far.\n\nSKIN: Right fem IABP site not bleeding, dsg changed. Multiple central lines/alines.\n\nPLAN: Waiting for team to view CXR, decide on tx for low CI. Giving reversal agents presently.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380958, "text": "Will tx low CI with 2 units PRBC. CXR-IABP placement better per , PA. 1st units PRBC going in now.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380959, "text": "Neuro: propofol weaned off pt wakes with stimulation, following commands nodding head to questions but still sleepy.\nResp: Pt remained vented overnight, good abg's weaning vent at present with plans to extubate this am with anesthesia present 2nd to difficult intubation.Chest tubes patent draining serous sanguinious fluid.\nC/V: pt a paced underlying rhythm sinus with rat in the low 70's but bp dips with this rhythm. pt required 2 units of pc's 2u ffp and 1l hespan for volume 2nd to low cardiac index. svo2 prior to volume 71 but ci 1.7 post volum index >2. Iapb on 1:1 all night with good augmentation.\nGI: ogt patent drianing bilious fluid.\nGU: urjine outputs adequate.\nskin: incisions clean and dry no drainage. Iabp no oozing. pt heels reddened.\nPlan wean to extubate ? d/c iapb later today.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380954, "text": "SHIFT UPDATE.\nHOURLY URINES DROPPING TO 10CC X3/HR'S, CCU RESIDENT NOTIFIED AND AWAITING TO EVALUATE PT. NO INTERVENTION GIVEN AT THIS TIME. VSS CONT. TO BE STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380955, "text": "CV: NSR, occass to rare PVC's. AFebrile. IABP 1:1. Balloon alarming gas leakage almost constantly this a.m. Team notified, while preparing pt to go to cath lab to change out balloon, alarm quit. Decided not to change it. Only change had been in pt's position. Site is oozing blood, hematoma present but unchanged from previous shift.\n\nPULM: 2L/NC, sats 98%. Strong cough. Lungs clear. Pt going to CAT scan for CT of chest now for \"mass seen on mediastinum\" NP.\n\nNEURO: Alert, oriented. No c/o CP today. Agrees to CABG tomorrow. CT of head and doppler of carotids done today.\n\nGU: 250cc fluid bolus and MIVF restarted due to low UOP. UOP seems to increase when BP is higher. Small amt bloody drainage from catheter.\n\nGI: Ate 75% breakfast, 25% lunch. C/O naseau once, Zofran given. No CP at that time.\n\nPLAN: CT scan of chest now.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-13 00:00:00.000", "description": "Report", "row_id": 1380956, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, OR PROCEDURE REVIEWED WITH PATIENT. APPEARS TO BE UNDERSTANDING POST-OPERATIVE BYPASS SURGERY. GIVEN 5MG PO AMBIEN AT BEDTIME, PT. SLEEPING ALL NIGHT, EASILY AROUSABLE BUT AT TIMES DID APPEAR TO BE CONFUSED BUT EASILY RE-ORIENTED BACK TO PLACE AND TIME. LOG ROLLED SIDE TO SIDE BUT D/T IABP CONSISTENTLY GAS LEAKAGE WHILE ON SIDES PT. LEFT ON BACK AND FLAT IN BED.\nCARDIAC: CONT. TO BE IN NSR WITH OCCASSIONAL PVC'S, LABS CHECKED AND TREATED AS NEEDED. R GROIN IABP CONT. TO OOZE FROM AROUND SITE, PRESSURE DSG'S CHANGED X2, SITE CONT. TO HAVE A HEMATOMA NOTED BUT HAS NOT EXPANDED PAST MARKER OUTLINE. DOPPLERABLE PULSES, FEET COOL TO TOUCH. CONT. TO HAVE GOOD DIASTOLIC AUGMENTATION AND SYS UNLOADING, SEE FLOW SHEET FOR EXACT #'S. NTG GTT REMAINS ON AT 100MCG/MIN KEEP SYS ~90-120 WITH MAP'S IN THE 70'S. HEPARIN GTT CONT. TO BE TITRATED TO KEEP PTT AROUND 60'S, PREVIOUS PTT IN THE 70'S AND GTT DECREASED TO 700U/HR, PTT PENDING. IVF D/C'D AT 2200PM.\nRESP: BS SLIGHTLY DIMINISHED IN BASES, O2 ON AT 2L NP WITH SAT'S >96%.\nGI/GU: HOURLY URINES ACCEPTABLE, CONT. TO HAVE DRAINAGE FROM AROUND MEATUS, CLEANED SEVERAL TIMES, STAT U/A SENT LAST EVENING. + BS THRU-OUT, TOLERATING SUPPER AND PT. MADE NPO AFTER MN.\nSOCIAL: SON AND INTO VISIT, UPDATES GIVEN REGARDING PENDING SURGERY AND QUESTIONS ANSWERED REGARDING CXRAY FINDINGS (MASS NOTED IN MEDIASTINUM) AND FOLLOW UP CHEST CT (WHICH RESULTS STILL PENDING), PT. ALSO AWARE OF CXRAY FINDINGS.\nSURGERY: UA SENT, BATH SCRUB DONE AND TYPE AND SCREEN SENT TO BB. ALSO FULL CHEM 7, COAGS, CBC/DIFF SENT TO LAB THIS AM, PRE-OP CHECK LIST ALSO STARTED.\nPLAN: CABG THIS AM WITH DR. , RESULTS OF CHEST CT, PTT LEVEL.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-16 00:00:00.000", "description": "Report", "row_id": 1380965, "text": "NEURO ALERT CONFUSED TO PLACE AND TIME AWARE OF PERSON ONLY MOVES ALL EXTREMTIES NO WEAKNESS NOTED INCREASE AGITATION DURING NOC PULLING AT LINES EKG CABLES WHEN ATTEMTED TO ORIENT PT \"GO JUMP IN A \" HALDOL 2MG GIVEN WITH GOOD EFFECT DECREASE AGITATION SLEEPING IN NAPS\n\nC/V NSR WITH PACS B/P INCREASE AT TIMES RESPONDS WELL TO IV NITRO ON AND OFF DURING NOC GOOD DOPPLER PULSES EPI WIRES INTACT BACKUP RATE OF 60 NOT NEEDED\n\nRESP NC4L WITH SATS 98-99% LUNGS CLEAR MUCH IMPROVED PRODUCTIVE FOR SMALL AMTS CLEAR SECRETIONS\n\nPLAN CONTINUE TO MONITOR CARDIAC STATUS MAINTAIN CURRENT STATUS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-08-16 00:00:00.000", "description": "Report", "row_id": 1380966, "text": "CV: NSR, no ectopy. Approx 1430, pt in and out of afib, highest rate seen is 111. BP stable. Hydralazine po ordered but not given yet due to parameters set for med. AFebrile. Epicardial pacing wires attached to pacer, back up rate of 60 set.\n\nPULM: Wean off O2, room air now with good sats. Lungs clear.\n\nNEURO: Disoriented to place, answers year correctly every time and knows people. Pt very drowsy today. Woke up to eat breakfast but asleep since. Wakes to noxious stimuli. No pain meds given. OOB with max assitance x 2, pt barely moves feet.\n\nGU: Pt pulled on Foley, urine became bloody and had clots in it. Irrigated catheter, urine now clear with small amt bloody sediment. IV lasix as scheduled.\n\nGI: Ate half of breakfast, no lunch. Passing gas, requested bedpan once but no BM.\n\nENDO: BG wNL.\n\nSKIN: Arms still edematous, cordis in place. Waffle boots on while in bed. Duoderm on coccyx.\n\nPLAN: Monitor rhytm, BP. No pain meds due to drowsiness. Will stay in ICU until rhythm settles and more alert.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-17 00:00:00.000", "description": "Report", "row_id": 1380967, "text": "Neuro: pt easy to arouse, able to state year, place and some events but thinks he is in . slept well through night.\nResp: Breath sounds clear, on 1l np with sats 96-98%\nC/V: pt heart rate most of night sinus with intermittent bouts of afib controlled rate 90-105. pt converts back to sinus rhythm on own. Presently in afib. blood pressure stable on hydralazine.\nGi: tolerat ing water with pills without issues.\nGU: foley sluggish with minimal drainage and leaking around cath. area cleansed and tube reposition and balloon reinflated with improvement in urine output.\nSkin: Heels reddened, duoderm present on coccyx.\nPlan: ? transfer to floor this weekend if rhythm remains stable.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-17 00:00:00.000", "description": "Report", "row_id": 1380968, "text": "Nursing Note 7A-7P\nNeuro: Arouses to voice, awake oriented to person, place, disoriented to time or day. PERL, moves all extremities. C/V: NSR rate in the 70's no ectopy noted. Pacer wires remain attached rate set at 60. Resp: O2 on at 1L NC. Lung sounds clear. Sat=96-98%. GU: Foley D'cd (see flow sheet). Voiding in urinal in small amts. GI: Positive BS, no stools. Diet taken well. Activity: OOB to chair X2 for Bkft and lunch. Skin: Duoderm ramains on coccyx removed from back. Social: Family members visited and updated to patients status. Plan: Continue to monitor cardiac status, transfer to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-11 00:00:00.000", "description": "Report", "row_id": 1380952, "text": "post cath\nD: pt adm with csru post cath on CCU service- pt ccu- results noted in history- iabp placed as well as pacing wire due to pt r/I for ant mi- severe 3 vessel dx- surgery consulted- surgery request pt have head ct , and doppler studues of carotids prior to surgery- pt no going to or tomorrow thus tests to be performed monday am.\n pt presented to csru- awake, alert,pleasant, on iv ntg and integrilin. site of iabp/and fem-arterial and venous sheath ozzing with bright red blood- cath team aware as well as ccu team. site out line over hardened area on groin.\nA: integrilin d/c and changed to heparin per ccu team- initial ptt >70- thus heparin started at 600u without a bolus.\nR: eventually ozzing subsided, no inc in hardened area over right fem.\nD: pt denies c/o pain except in right fem area when turning, c/o nausea- given protonix and zofran with some relief, tol sips of ginger ale.\nsocial: pt married with 4 children- wife and he live alone in situate- daughter in .\nplan: pt for possible CABG on tues- after ct and doppler studies okayed.--keep iabp\n\naddem; pt sbp intially 130-145/70 with map >100- inc iv ntg until map <75- iv ntg up to 160mcq/min.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-12 00:00:00.000", "description": "Report", "row_id": 1380953, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, C/O \"NOT BEING ABLE TO GET COMFORTABLE\" TURNED AND REPOSITIONED FREQUENTLY. GIVEN 5MG PO AMBIEN WITH GOOD EFFECT. PT. ABLE TO SLEEP IN LONG NAPS. MOVING ALL EXTREMITIES TO COMMANDS. DENIES ANY CHEST PAIN.\nCARDIAC: CONT. TO BE IN NSR WITH AT TIMES PERIODS OF 1 DEGREE AV BLOCK WITH PR INTERVALS OF >.24, MULTIFOCAL PVC'S NOTED THRU-OUT NIGHT. GIVEN 1 DOSE OF MAGSO4 (2GM'S), K LEVEL WNL. R IJ IABP CONT. TO HAVE FAIR DIASTOLIC AUGMENTATION AND GOOD SYS UNLOADING, WAVE FORM TIMMING DIFFICULT ESPECIALLY IF PT. HAVING FREQUENT PVC'S, SLIGHTLY DAMPENED WAVE FORM. R IJ GROIN SITE, CONT. TO OOZE VERY SM. AMT, DSG CHANGED AND NEW PRESSURE DSG APPLIED. R FEMORAL HEMATOMA SITE CONT. TO BE STABLE FROM PREVIOUS OUTLINE MARK, NO PROGRESSION NOTED, SITE REMAINS TENDER TO PALPATION, HCT STABLE. REMAINS ON NTG (SEE FLOW SHEET FOR EXACT DOSEAGES). HEPARIN GTT TITRATED TO KEEP PTT ~60, CURRENTLY AT 800U/HR, WILL PLAN ON RECHECKING IN AM. V-WIRE ATTACHED BUT PACER OFF. DOPPLERABLE PULSES BILT., FEET COOL TO TOUCH.\nRESP: BS CLEAR BILT., O2 WEANED DOWN TO 2L NP WITH SAT'S >95%.\nGI/GU: HOURLY URINES CONT. TO BE AROUND 25CC, INITIALLY URINE CLOUDY WITH LOTS OF SEDIMENT, FOLEY IRRIGATED X1, FOR 1/HR OF MINIMAL URINE, PT. REPOSITIONED, U/O IMPROVING. PT. ALSO NOTED TO HAVE SOME BLOODY DISCHARGE FROM AROUND MEATUS. + BS THRU-OUT, TOLERATING SIPS OF LIQUIDS WELL, ABLE TO TAKE PO PILLS WITHOUT DIFFICULTY.\nPLAN: KEEP PTT AROUND 60, MONITOR U/O AND HEMODYNAMICS, PLAN FOR CABG POT. ON TUESDAY. IAPB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380963, "text": "NEURO REMAINS ALERT LETHARGIC EASILY AROUSABLE MOVES ALL EXTREMETIES\n\nC/V CO/CI WHILE V PACED 2.02 TO 1.84 IMPROVED WITH CONVERT TO NSR 70S CI INCREASE TO 2.4 ATTEMPTED TO A IN NSR UNABLE TO CAPTURE WITH A WIRES BACKUP VWIRES AT 60 TOL WELL 615AM CONVERT AFIB FLUTTER WITH EPISODES OF HR 30S V WIRE NON CAPTURE WITH PATIENT ON L SIDE MA INCREASE TO 16 FOR CAPTURE HR 30S AMIODERONE BOLUS REPEATED REMAINS IN AFIB FLUTTER PACER SET TO 45 MD WITH FREQUENT EPISODES OF PACED 45 ? NODAL B/P STABLE\n\nRESP CONTINUES TO REQUIRE FREQ ENCOURAGMENT TO LEAVE O2 ON DEEP BREATHING AND COUGHING WELL COARSE BS WITH SOME UPPER AIRWAY CONGESTION\n\nLABS K COVERED X2 WITH 20MEQ IV KCL BS 121 NO COVERAGE\n\nGU/GI GOOD U/O WITH DECEASING AMTS IN AM MD AWARE NO PO FLUIDS MOUTH CARE FREQ\n\nPLAN CONTINUE TO MONITOR EKG FOR CHANGES MAINTAIN WORKING PACER\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380964, "text": "CV: At beginning of shift, junctional vs CHB. BP stable at this time but CO low. Apacing not capturing 100%. Will vpace 100%, but CO still low. Dr. wants pt AV paced, which does capture 100% and CO good. Ntg gtt started for HTN at that time. EP consulted. When pacer turned down, NSR rate 70's. Stayed in NSR until evening when he started flipping between controlled afib rate 80's, junctional 40's, NSR 80's, this is his current rhythm. EP at beside during this episode, will watch rhythm for 72 hours then reevaluate. Pt has 2atrial and 2 vent epicardial pacing wires. Afebrile.\n\nPULM: Decreased to 2L/NC, sats 97%. Strong cough, able to raise thin, tan sputum, very small amts. Lungs clear. CT's draining small amts serosang fluid, no airleak.\n\nNEURO: Lethargic all day. Confusion increased during day. In morning, pt oriented except to year. During day, pt stated place was , , Sitchuit. Has not gotten year correct. OOB to chair with max assistance. On way back to bed, almost had to total lift pt to bed. No pain meds today.\n\nGU: Foley. IV Lasix given, good diuresis.\n\nGI: Hypo bowel sounds. Ate small amts jello at lunch and half of custard at dinner and drank mighty shake. No swallowing problems. bm.\n\nSKIN: Red area on coccyx, turned pt side to side as tx. Heels red, waffle boots bil. Cordis in, no PIV, arms too swollen.\n\nPLAN: Watch rhythm for 72 hours then decide on perm pacer. Pulm toilet. OOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380960, "text": "PT UPDATE\n PT IS S/P CABG X3 YEST.\n\n NEURO: PT HAS BEEN OFF PROP SINCE 12MN. HAS RECEIVED NO SEDATION TODAY. PT WAS VERY DROWSY THIS AM. PT IS MORE AWAKE THIS AFTERNOON-BUT NEEDS TO BE MORE AWAKE TO EXTUB. MAE, AND FOLLOWING COMMANDS CONSISTENTLY. APPEARS TO UNDERSTAND WHAT IS SAID TO HIM.\n\n RESP: PT HAS BEEN ON CPAP SINCE 0600. ABG GOOD. FIO2 DOWN TO 40% THIS AM WITH SATS 98-99. BS CLEAR, DECREASED IN BASES. SX FOR OLD BL. TINGE-SCANT AMT. PT WAS A DIFFICULT INTUB. IN TO ASSESS PT A FEW MINUTES AGO AND WANTS PT MORE AWAKE TO EXTUB.\n\n CARDIAC: IABP WEANED DOWN TO 1:3 THIS AM AND D/C'D. CI REMAINS EXCELLENT-3.0 AT 1330. PT REMAINS AP 80-VERY LITTLE RHYTHM UNDERNEATH. BP STABLE OFF ALL PRESSORS. SOMEWHAT HIGHER AT THIS TIME AS PT IS MORE AWAKE AND SEEMS A LITTLE ANXIOUS.\n\n GU: PT RECEIVED LG AMTS VOLUME (BLD PRODUCTS AND CRYST) OVERNIGHT. WEIGHT UP 10 KG. U/O MARGINAL. GIVEN 20MG IVP LASIX JUST NOW.\n\n GI: OGT-LCWS. BILOUS DRG.\n\n LAB: K 4.2-HAS NOT NEEDED K OR CA REPLACEMENT TODAY. HCT STABLE-28. RECEIVING SS INSULIN AS PER PROTOCOL.\n\n OTHER: PT HAS PULSES PT/DP BILAT. RT FOOT COOLER THAN LEFT THIS AM-STILL SLIGHTLY COOLER; BUT WARMER THAN EARLIER TODAY. RT GROIN DSD INTACT FROM IABP SITE-NO OOZING.\n\n WIFE AND SON IN TO VISIT TODAY. WIFE IS ANXIOUS FOR PT TO BE EXTUB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-14 00:00:00.000", "description": "Report", "row_id": 1380961, "text": "PT UPDATE\n PT MORE AWAKE THIS AFTERNOON. EXTUB. AT 1500. PT STILL SOMEWHAT LETHARGIC WHEN LEFT ALONE. POST-EXT. ABG GOOD. SATS 98. BS SOMEWHAT COARSE. PT ENCOURAGED TO COUGH AND DEEP BREATH. PT TURNED SIDE TO SIDE AND GIVEN CPT-DID NOT TOL TOO WELL. PT NEEDS MUCH ENCOURAGEMENT TO TAKE A DEEP BREATH-NOW AFTER CPT, HAS HAD A FEW GOOD COUGHS. ATTEMPTED TO HAVE PT USE I.S.-BUT PT SEEMS UNABLE TO DO IT. MED WITH SMALL DOSE SC MSO4 FOR INCISIONAL PAIN TO ASSIST IN PT'S ABILITY TO COUGH. PT DOES APPEAR COMF EXTUB.\n" }, { "category": "Nursing/other", "chartdate": "2148-08-15 00:00:00.000", "description": "Report", "row_id": 1380962, "text": "NEURO LETHERGIC AWAKE AT TIMES EASILY AROUSABLE ORIENTED X3 MOVES ALL EXTREMETIES EQUAL STRENGHTS\n\nRESP LUNGS COARSE ALL FIELDS DEEP BREATHING AND COUGHING WITH ENCOURAGMENT WITH SOME CLEARING OF CONGESTION REMOVES AEROSAL MASK FREQUENTLY WITH SATS DECREASING TO 90 NC 4L ON TO MAINTAIN SATS WHEN MASK REMOVED WITH GOOD EFFECT SATS 96-99% MOUTH BREATHS BENEFITS FROM MASK WITH MIST\n\nC/V MP A PACED 80S AT 8PM OCC NON CAPTURED BEAT UNDERLYING INITIALLY DIFFICULT TO ASSESS DUE TO POOR SENSING OF A WIRES AND CONTINUED PACING WITH LOWER RATE HR 30S TO 40S ? SB 10PM WHILE MOVING AND BED AND COUGHING A WIRES NON CAPTURE WITH PAUSE OF APPROX 3 SECONDS ? UNDERLYING PATTERN AFIB UNABLE TO APPROPRIATLY OR CAPTURE WITH WIRES MD AWARE V PACING WITH GOOD CAPTURE AND SENSING AMIODERONE 150MG BOLUS GIVEN WITH GOOD EFFECT UNDERLYING PATTERN SB 30-40 HOWEVER STILL UNABLE TO A NONCAPTURE AT FULL MA CONTINUES TO SENSE INAPPROPRIATELY POLARITY CHANGED WITH NO EFFECT PT CONTINUED TO MD DECREASE WITH INDEX 2.02 B/P STABLE\n\nPLAN CONTINUE TO MAINTAIN HEMODYNAMICS CLOSE MONITOR OF EPICARDIAL WIRES FOR EFFECTIVE HR\n" } ]

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1. Congestive heart failure - The patient with significantly volume overloaded on admission with severe lower extremity edema from volume overload seen on chest x-ray. The patient was aggressively diuresed with Lasix initially on admission. Initially Foley catheter was placed to monitor ins and outs and creatinine was followed very closely. The crackles in the left lobe were improved and the patient had evidence of becoming dry with an increase in creatinine by . At that time his Lasix was held as his pulmonary status was stable. However, on , the patient became hypotensive which continued to be a problem over the next 24 hours. This was possibly secondary to urosepsis and required large fluid boluses to maintain his blood pressure. In the setting of this increased intravenous fluid, the patient's congestive heart failure worsened and he was transferred to the Intensive Care Unit. In the Intensive Care Unit, the patient was once again aggressively diuresed using Lasix and prn Metolazone. On , the patient was able to return to the floor for continued care. He was diuresed throughout the remainder of this hospital stay with a good result. His creatinine has remained stable during this time. hose were applied to the legs bilaterally and his legs and right arm were kept elevated. The patient will be discharged on a standing Lasix dose. 2. Coronary artery disease - The patient was found to have a new right bundle branch block on admission. Laboratory data revealed an elevated MB index and slightly elevated troponin 0.4 to 0.6. These findings were thought to be most likely ___________related. The patient was monitored on telemetry without _________________during the early parts of admission. An echocardiogram was repeated to evaluate for new wall defect and provide further ______________ regarding the patient's congestive heart failure. Echocardiogram on showed in left ventricular function of greater than 55 percent. The left and right atrium are moderately dilated. There is symmetric left ventricular hypertrophy with a normal ventricular cavity size. Regional and ventricular wall motion was normal. Mild aortic valve stenosis, periventricular and preventricular, mild 1+ mitral regurgitation. Mild tricuspid regurgitation 1+, mild pulmonary _____________________. The patient was continued on aspirin and beta blocker throughout her admission. 3. Atrial fibrillation - The patient is on Coumadin for anticoagulation at home and a beta blocker for rate control. On admission, his INR was supertherapeutic at 3.6. Therefore his Coumadin was held to allow the INR to trend down. His Coumadin was then restarted with goal INR ranged between 2 and 3. The patient is therapeutic at this time. He continues on beta blocker with good rate control. 4. Infectious disease - The patient showed no evidence of infection on admission. However, on , he became hypotensive with a systolic blood pressure of 70. This was responsive to intravenous fluids. The patient was pancultured and was found to have urosepsis with 10:100,000 of Enterobacter ACA grown on culture. The patient required transfer to the Intensive Care Unit on for blood pressure support and diuresis consistent with congestive heart failure. Thereupon he was started on a course of Ciprofloxacin and will complete a ten day course for his urosepsis. Blood cultures have been negative during admission. At this time he is afebrile with a normal white blood cell count. 5. Renal - The patient had acute and chronic renal failure at the time of presentation. His creatinine was followed closely as he diuresed. During admission, he did have an increase in creatinine during which time his Lasix was held. However, his Lasix was now trended down and he is tolerating daily diuresis with a creatinine below his baseline. 6. Myeloid dysplastic syndrome - The patient is pancytopenic at baseline thought to be secondary to myeloid dysplastic syndrome, although this has not been confirmed with a bone marrow biopsy. On admission, he was transfused three units of packed red blood cells. His hematocrit and platelets have been fairly stable within the range since that time. His hematocrit has been followed closely with a goal transfusion for hematocrit less than or equal to 28. 7. Rehabilitation - Physical therapy has been working extensively with the patient. They have recommended discharge to a rehabilitation facility. 8. Code - The patient is full code.

Vanco stopped.Heme: Pt with stable hct this AM and plt count 90. Pts LLE > in edema than R. Adequate u/o. head CT at 2200 negative.RESP: B/L BS diminished, occasional I wheeze relieved w/ nebs. MSICU NSG COVERAGE 0700-1100Periods of lethargy alt w/periods on being barely arousable. remains intubated overnoc on A/C. PT does desat to high 70's when O2 removed. Pt in ARF, BUN/Cr is 71/1.9.HEM: HCT/HGB down from 33.7/9.7 to 30.2/8.7. Mg=2.0.GI: NPO sec to lethargy. Cardiac: Remains in af..100-110.no vea. Hypotensive at start of shift, SBP in 80's; resolved spon. Lytes repleated.Resp: Pt extubated on .4 FT. BS clear bilaterally, pts cough weak. +BM (small), +BS, abd tender upon palpation.GU: Pt anasarcic. NPO sec to lethargy. PLT 83 sec to chronic condition.ID: afebrile, WBC down to 12. on abx.HEM: 1U PRBC tx for HCT 28, tol well, no s/s of reaction. +glaucoma, R exothalmosis. Awaiting AM labs.GI: Abd distended, soft, +BSX4. B/L BS present, coarse, w/rales. Pt became hypotensive, Neo restarted at 0.50mcq/kg/min. Pt has R nare NGT placed. MAE.CV- HR 100-116, afib, no ectopy. AM ABG: 7.31/74/66/6/39. Resp Care,Pt. Abd soft, distended, +ventral hernia. GI: Taking liqs well started on soft solids..tolerated ok Neuro: Alert,orientated able to follow commands..limited rom d/t edema. NPNMICUPLEASANT YR OLD MALE ADM WITH CHF,AFIB AND UROSEPSIS....HOSP COURES C/B HYPOXIA AND HYPERCAPNEA ..REQUIRING INTUBATION ..AND BRIEF PRESSOR SUPPORT ..S NO COMPLAINTSO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATACV REMAINS IN AFIB ..RATES IN THE 110-120'S...AMIODARONE INFUSION DECREASED TO .5MG/KG...LOPRESSOR RESTARTED AT LOWER RATE ..SBP 110-130'S/60'S..VIA RIGHT RADIAL ALINE ..CVP 10-12RESP RIGHT >LEFT PLEURAL EFFUSION..PER CXR ON ..NON-PROD COUGH ..RR 22-24..UNLABORED ...LUNGS CLEARGI TOLERATING SIPS OF CLEAR LIXS..COUGH WITH SWALLOWING ..GU ..URINE OUTPUT 30-40 CC Q1 ...REMAINS 3RD SPACED ...ID ON CEFTRIAXONE FOR UROSEPSIS ...RIGHT IJ TLC ..FLUSHED AND INTACT ...A HEMODYN STABLENEEDS BETTER RATE CONTROLDIURESISHEPARIN VS COUMADIN FOR AFIBPT CONSULT AM ABG: 7.38/56/115/6/34/97.8. BS coarse w/ rales bibasilar. Awaiting CXR, cont to follow w/ team.GI- Abd soft and distended, +BS, sm BM. Weaned neo to off. lungs essentially clear on auscultation but diminished at the bases . Pt remains lethargic this AM though arouses at time to voice, tactile, and localizes. O2 sat 97-98%.GI: Pt remains NPO except for meds. BP remains 110-130 on neo drip at .75mcg/kg/min. NPN 1900-0700NEURO: AXOX3, DIFFACULT TO UNDERSTAND , ACCENT AND SPEECH IMPAIRED BY WHAT APPEARS TO BE OLD FACIAL CVA DEFECEIT.RESP: LCTA, DIMINISHED AT BASES, 02 2L W/ SATS MID 90'SC/V: AFIB, AMIODORONE DECREASED TO .5MG /MIN .RECIEVED 80MG LASIX BOLUS,W/ BRISK EFFECT. No fentanyl needed today.Cardiac: Pt remains in AF, HR 106-120, CVP 3-6, lopressor dc'd, Neo weaned off, started on amio gtt at 1mg/min unitl 2100, minimal effect on HR or BP. pt transfered top 11r. No c/o pain.RESP: B/L BS diminished w/ rales, coarser at L base. Lopressor 5mg IV X1 w/ no effect. +dry cough. BP tolerated dose. ABG sent, results 7.26/78/69/4/37. IMPRESSION: 1) Stable appearance of LV failure with a left pleural effusion. IMPRESSION: Left ventricular failure with small pleural effusions. There is mild symmetric left ventricular hypertrophy. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. A left pleural effusion is present.Conclusions:1. There is mild aorticvalve stenosis. There ismild aortic valve stenosis. There is a moderate amount of periventricular and subcortical white matter hypoattenuation consistent with chronic small vessel ischemia and gliosis. PATIENT/TEST INFORMATION:Indication: Left ventricular function.BP (mm Hg): 108/70HR (bpm): 78Status: InpatientDate/Time: at 15:42Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is a persistent left lower lobe opacity consistent with atelectasis or consolidation. CHEST AP: There is cardiomegaly with small bilateral pleural effusions. Trace aortic regurgitation is seen.4. Note is made of prominent soft tissue edema. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is interval placement of a right IJ central line with the tip in the low SVC. There is mild pulmonary artery systolic hypertension.6. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is a trivial/physiologic pericardial effusion.GENERAL COMMENTS: Compared with the findings of the prior study, there hasbeen no significant change. Sinus rhythmFirst degree A-V blockRBBB with left anterior fascicular blockInferior T wave changes are nonspecificLow QRS voltages in limb leadsSince previous tracing, atrial fibrillation absent; inferior T wave changesnoted IMPRESSION: Findings consistent with mild CHF. Small, old lacunar infarcts and chronic small vessel ischemic gliosis. Distribution of the pulmonary vascularity and the septal lines consistent with an interval worsening of CHF or fluid overload. There are persistent bibasilar infiltrates/atelectasis and small bilateral pleural effusions. There is a trivial pericardial effusion.7. Worsening of CHF, or fluid overload. A left pleural effusion remains present. If a nasogastric tube has indeed been placed, it may be within the oro- and hypopharynx ( regions which are not included on this study). IMPRESSION: 1) Endotracheal tube in satisfactory position. Regional left ventricular wall motion isnormal. Patchy atelectasis in both lower lobes. The left atrium is moderately dilated.2. FINDINGS: There are low lung volumes. There are degenerative changes of the thoracic spine which are unchanged when compared to the previous study. There are bilateral small pleural effusions. Compared with the findings of the prior report (tape unavailable forreview) of , tricuspid regurgitation is less. There is calcification of the aorta. Degenerative changes are noted in the thoracic spine. Left ventricular systolic function is hyperdynamic (EF>75%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are moderately thickened. Mild (1+) mitralregurgitation is seen.5. Again demonstrated are bilateral pleural effusions, right greater than left. Again seen is a left lower lobe opacity. Query worsening of CHF. Left lower lobe atelectasis/consolidation. Compared to the previous tracing of rightbundle-branch block patterning was previously present and is no longer present.Arrhythmia persists as before.

30

[ { "category": "Nursing/other", "chartdate": "2160-03-26 00:00:00.000", "description": "Report", "row_id": 1562063, "text": "MSICU NSG ACCEPTANCE/PROGRESS NOTE\n\n yo man,w/ h/o MDS and new urosepsis, transferred from 11R w/hypoxia/hypercapnea,hypotention and CHF.\n\nLethargic/fatigued but follows commands (very HOH). No episodes of hypotention upon arrival and given 80mg Lasix and started on low-dose IV NTG. BP remained stable. Given 5mg IV Lopressor. Foley cath inserted. Initial urine pale yellow. Now it is sl pink at times.He is currently ~700cc neg since ICU admit. On 50% neb FT his O2sats are mid 90s. No further ABGs drawn. Denies pain. No c/o SOB. Family in with pt all day. NPO except for meds as he is lethargic. ?more Lasix this eve. MD to re-evaluate.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 1562064, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Lethargic at start of shift. More alert as night progressed. Did not sleep. Very HOH. +glaucoma, R exothalmosis. Ointment and gtt at bedside. PERRLA, 2 brisk. MAE, generalized weakness, X4. Mostly russian speaking. Able to communicate approp w/ limited english. O X3. Speech slurred at times, baseline. No c/o pain.\n\nRESP: B/L BS diminished w/ rales, coarser at L base. +dry cough. Pt tachhypneic, no other s/s of distress. O2 sat 95-100% O2 weaned to 2L NC, tolerating. O2 sat 100%.\n\nCV: A-Fib, no ectopy. Accelerated throughout night, 100-120. No s/s of cardiac distress. HO aware. Started on PO lopressor 25mg TID. Lopressor 5mg IV X1 w/ no effect. No additional interventions. Nitro at 0.25mcq/hr to decrease preload. SBP 100-140. +anasarca, pitting, +. +PP. Slightly hyperkalemic at 5.2 sec to ARF, HO aware. Mg=2.0.\n\nGI: NPO sec to lethargy. Able to swallow pills w/ pudding when more awake. Aspiration precaution. Abd soft, distended, +ventral hernia. Small Bm X3, brown, soft, guiac neg.\n\nGU: Foley catheter w/ no urine at start of shift. Catheter and meatus w/ scant amt of serosanguinous drainage. Flushed catheter w/ no effect, irrigant dispelled from urethral meatus. D/C'd foley, blood clots evident at tip. Attempted to insert 16 Fr w/ no effect. Met no resistence upon insertion, but yielded no urine. Bladder scan w/ portable device, no urine in bladder. Lasix 60mg IV as per HO, yielded no results. Urology consulted by Ho. Ho attempted to insert Coude catheter w/o effect, inserted w/ no resistence, though resistence met during inflation of balloon. As per urology, apply condom catheter, and monitor for bladder distention, will come in AM. Passing small amts of blood clots, HO aware. No discomfort nor bladder distention throughout shift. As per ultrasound, bladder w/ 300cc of urine at 0500. Pt in ARF, BUN/Cr is 71/1.9.\n\nHEM: HCT/HGB down from 33.7/9.7 to 30.2/8.7. PLT 83 sec to chronic condition.\n\nID: afebrile, WBC down to 12. On abx.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562067, "text": "MSICU NSG COVERAGE 0700-1100\n\n\nPeriods of lethargy alt w/periods on being barely arousable. SBP 77 after being turned and remained low despite IVB. ABG 7.30 PCO2 71 PaO2 83 on Bipap. Intubated for airway protection d/t alt mental status. BP required Neo post intubation and additional IVBs. SBP appears to be stabilizing. Plan to wean Neo as tol.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-30 00:00:00.000", "description": "Report", "row_id": 1562075, "text": " 4 ICU nursing progress note:\n Respiratory: RR 20's..sats 98% changed to 2l nc..sats mid 90's. No cough. Decreased BS.\n Cardiac: Remains in af..100-110.no vea. Given 150mgm amioderone bolus this am...gtt increased to 1mgm/min for next 24hrs. Also given 80 lasix late this afternoon...45cc out thus far. Has 3+ pitting edema in lower extremites.\n GI: Taking liqs well started on soft solids..tolerated ok\n Neuro: Alert,orientated able to follow commands..limited rom d/t edema.\n Lines: RIJ and R radial aline..peripheral ivs dc'd...day #3\n Social: Multiple family members in to visit..updated on pt condition.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 1562065, "text": "PMICU Nursing Progress Note 7a-7p\nEvents\n\n Pt did not make urine all morning, cont only to have a few bloody clots out until a new cath placed. At 1300, urologist placed 20 F coude double lumen cath. Pt immediately put out 450 cc dark red urine. Cath was then manually flushed until return was pink, light and clear. Pt then recieved 80 mg of lasix to assist w/ diuresis for CHF. Following cath placement, pt fell asleep. He became increasingly lethargic as afternoon went on. HO notified as pt became more difficult to arouse. ABG sent, results 7.26/78/69/4/37. Pt then placed on BIPAP in attempt to improve ventilation. Family at bedside throughout, updated on status by nsg and team.\n\nReview of Systems\n\nNeuro- Changes in MS mentioned above, this am pt was alert and oriented x2 which according to Pt's daughter (also his HCP) is his baseline. Denied pn throughout day when asked. MAE.\n\nCV- HR 100-116, afib, no ectopy. SBP 105-150, lopressor increased to 37.5 PO. Cont on Nitro gtt @ .25 mcg/kg/min. Unable to take evening cardiac meds for afib due to lethargy, HO notified. Evening labs checked, K 4.7, Na 143, Ion Ca 1.20, lactic acid 1.2, HCT 28.\n\n Pt presently on BIPAP 10/5, TV 200-400 (problems w. leaking- RT presently working on), sats 98%, RR 18-20. LS coarse, diminished bases. Pt had insp wheeze this am, recieved atrovent nebs q 4 hrs today, improvement noted. PT does desat to high 70's when O2 removed. Awaiting CXR, cont to follow w/ team.\n\nGI- Abd soft and distended, +BS, sm BM. NPO until pt is more awake.\n\nGU- Current FB - 920, goal - 1 L. Urine yellow and clr, plan to manually flush if output decreases or it darkens.\n\nID- Afebrile, cont on Vanco and ceftriaxone IV. Pt does have gram neg rods in urine.\n\nPlan- Cont supportive medical care.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562068, "text": "NPN 11AM-7PM:\nNeuro: Pt initially agitated after intubation requiring fentanyl 25-50mcg IV Q1hr times two. Since then pt is able to be awake without too much agitation/discomfort and has received small doses of fentanyl 25mcg IV PRN. Pt now seems alert and interactive with family, nodding yes and no to simple questions and assisting with turns and position changes. Tolerating suctioning/turning well. MAE\n\nCV: Remains in RAF rates 110-120 and due to hypotension has not been able to get lopressor doses. Required neo drip to maintain SBP goal of 120 or above. Currently at .75mcg/kg/min infusing via new central line inserted after intubation. Pt also has a-line with good waveform, draws easily. Pt received 1 liter NS IVF boluses after intubation and after central line insertion was given additional 500cc's for CVP3-5. Currently CVP 6-7.\n\nResp: Pt intubated for airway protection and hypercarbia and hypotension. Remains on AC 20, TV 500, FIO2 40% with 5cm peep with good sats. Lungs coarse with deminished sounds at bases. Bronch done at bedside and washings sent for culture.\n\nID: Afebrile. Some antibiotic changes done. Vanco stopped.\n\nHeme: Pt with stable hct this AM and plt count 90. No s/s bleeding noted. Given dose of procrit as ordered.\n\nGI: OGT inserted for meds. Pt has +BS small oozing of soft brown stool.\n\nGU: Foley draining clear yellow urine in adequate amts.\n\nIV access: Pt has two PIV's flushed with NS and new triple lumen central line in right IJ.\n\nSkin: Looks to be in good shape. Heels slightly reddened bilaterally as well as coccyx. No open areas noted.\n\nSocial: Family are aware of the intubation and line placements. Have been at his bedside talking to him for most of the afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562069, "text": "Patient intubated due to bad ABG mental status change. Bronchoscopic procedure done today lung tissue appears normal. ABG improves patient slightly more alert will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-31 00:00:00.000", "description": "Report", "row_id": 1562076, "text": "NPN 1900-0700\n\nNEURO: AXOX3, DIFFACULT TO UNDERSTAND , ACCENT AND SPEECH IMPAIRED BY WHAT APPEARS TO BE OLD FACIAL CVA DEFECEIT.\n\nRESP: LCTA, DIMINISHED AT BASES, 02 2L W/ SATS MID 90'S\n\nC/V: AFIB, AMIODORONE DECREASED TO .5MG /MIN .RECIEVED 80MG LASIX BOLUS,W/ BRISK EFFECT. STARTED ON LASIX GTT . CURRENTLY 1200CC NEG FOR 24HRS. CONT TO HAVE + EDEMA OF HANDS AND FEET.\n\nF/E/N: NA+ STILL ELEVATED @ 146, CONT TO HAVE FREQUENT THIRST. UO NOW DOWN TO ~ 200CC /HR.SMEARS OF STOOL OVERNOC. ??INCREASE BOWEL REGIMEN?\n\nPLAN: CONT AMIODODRNE GTT FOR AFIB, CONT LASIX GTT W/ GOAL OF 1.5 LITERS NEG FOR 24/HR.MONITOR LYTES.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-31 00:00:00.000", "description": "Report", "row_id": 1562077, "text": "d: pt a&o x3 . follows simple commands appropriately. o2 at 2l/m nc with o2 sats> 95%. lungs essentially clear on auscultation but diminished at the bases . hemodynamically very stable. remains in afib with hr in the 80's. amioderone gtt at 0.5 mg/hr d/c'd and pt changed to amioderone 200 mg po tid. abd soft and nontender with pos bowel sounds on auscultation. no sotol output today, pt takin free water wll. will continue to gently diures pt with goal of i& o to be neg about 500cc's. r arm more swollen then l. medical team aware and to have u/s done to r/o dvt. also plan to restart pt on po coumadin. pt transfered top 11r. will continue with present medical management. pt's daughter at bedside and was updated by nursing staff.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562066, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Pt found stuperous at start of shift. Unresponsive since 1600 sec to hypercapnea. Pt remains lethargic this AM though arouses at time to voice, tactile, and localizes. Able to make eye contact when aroused. Incomprehensible sounds. Generalized weakness, equal strength throughout. R eye glaucoma, exothamosis, pupil 1, slugg, L pupil 2, slug. No s/s of pain. head CT at 2200 negative.\n\nRESP: B/L BS diminished, occasional I wheeze relieved w/ nebs. BS coarse w/ rales bibasilar. Weaned O2 to 2L mask when off Bipap. ABG improved at 2100. Placed on Bipap post head Ct. Tol well, sats upper nineties on 30% Rate 18 PS 10 PEEP 5. AM ABG: 7.31/74/66/6/39. More hypercapneic and hypoxic. PEEP increased to 8, FIO2 to 40% as per HO. Tol well.\n\nCV: A-Fib, accelerated rate, 110-120. Hypotensive at start of shift, SBP in 80's; resolved spon. Lopressor 5mg, then 7.5mg IV given as per HO w/ 2-3 hr effect, rate 90-105. Anasarca. PP palp. ECG done, unchanged. Awaiting AM labs.\n\nGI: Abd distended, soft, +BSX4. NPO sec to lethargy. +BM, mod brown, neg.\n\nGU: Foley C/D/I. +hematuria, pink tinged, sediment. No clots. Patent. Adequate amts/hr. Pt I/O -1618 for shift.\n\nID: afebrile. on abx.\n\nHEM: 1U PRBC tx for HCT 28, tol well, no s/s of reaction. HCT 35.2 this AM.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-03-28 00:00:00.000", "description": "Report", "row_id": 1562070, "text": "MICU NPN Addendum 7PM-11PM:\nPt's vital signs remain unchanged. Pt remains in RAF 110-130. Pt given 5mg IV lopressor to try to control rate without much effect. BP tolerated dose. BP remains 110-130 on neo drip at .75mcg/kg/min. UO remains 45-60/hr. CVP 6-8. Hematology results this eve are unchanged from this AM and ABG is good on current vent settings. Pt slightly restless at times and treated with small doses of IV fentanyl with good effect. Decision made to hold off on starting tube feeds due to possibility of trying to extubate if vital signs are stable tomorrow. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562071, "text": "NPN SHIFT 2300-0700: Assessment unchanged since picking up pt at 2300. See previous notes. Weaned neo to off. Cardizem 10mg IV given as per HO for RAF, rate 110-130. Rate controlled to 80-90, but improvement in HR did not improve BP. Pt became hypotensive, Neo restarted at 0.50mcq/kg/min. SBP 90-120. HCT stable at 32. No s/s of bleed. PLT= 90 sec to MDS. Afebrile. WBC=3.54. Na+=152, HO made aware, no interventions. K=3.6, no repletion sec to ARF. Mg+=1.8. Phos=2.6. BUN/Cr=65/1.3. I/O=pos 683.8. Good urine output. B/L BS present, coarse, w/rales. No cough, scant secretions. No resp distress. AM ABG: 7.38/56/115/6/34/97.8. Satting 100%. +BS, no BM, kept NPO as MD.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562072, "text": "Resp Care,\nPt. remains intubated overnoc on A/C. No vent changes this shift. RSBI not obtained due to apnea. Maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-29 00:00:00.000", "description": "Report", "row_id": 1562073, "text": "M/SICU Nursing Progress Note\nNeuro: PT A&O x3. MAE, weak however. Pt c/o pain on palp in RLQ of abd. No fentanyl needed today.\n\nCardiac: Pt remains in AF, HR 106-120, CVP 3-6, lopressor dc'd, Neo weaned off, started on amio gtt at 1mg/min unitl 2100, minimal effect on HR or BP. BP stable 110-120 sys. Lytes repleated.\n\nResp: Pt extubated on .4 FT. BS clear bilaterally, pts cough weak. O2 sat 97-98%.\n\nGI: Pt remains NPO except for meds. Pt has R nare NGT placed. +BM (small), +BS, abd tender upon palpation.\n\nGU: Pt anasarcic. Pts LLE > in edema than R. Adequate u/o. Pt started on 250cc q3 free H2O bolus for hypernatremia.\n\nID: Pt remains afebrile on ceftriaxone.\n\nSocial: Multiple family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2160-03-30 00:00:00.000", "description": "Report", "row_id": 1562074, "text": "NPN\nMICU\nPLEASANT YR OLD MALE ADM WITH CHF,AFIB AND UROSEPSIS....HOSP COURES C/B HYPOXIA AND HYPERCAPNEA ..REQUIRING INTUBATION ..AND BRIEF PRESSOR SUPPORT ..\nS NO COMPLAINTS\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV REMAINS IN AFIB ..RATES IN THE 110-120'S...AMIODARONE INFUSION DECREASED TO .5MG/KG...LOPRESSOR RESTARTED AT LOWER RATE ..SBP 110-130'S/60'S..VIA RIGHT RADIAL ALINE ..CVP 10-12\nRESP RIGHT >LEFT PLEURAL EFFUSION..PER CXR ON ..NON-PROD COUGH ..RR 22-24..UNLABORED ...LUNGS CLEAR\nGI TOLERATING SIPS OF CLEAR LIXS..COUGH WITH SWALLOWING ..\nGU ..URINE OUTPUT 30-40 CC Q1 ...REMAINS 3RD SPACED ...\nID ON CEFTRIAXONE FOR UROSEPSIS ...\nRIGHT IJ TLC ..FLUSHED AND INTACT ...\nA HEMODYN STABLE\nNEEDS BETTER RATE CONTROL\nDIURESIS\nHEPARIN VS COUMADIN FOR AFIB\nPT CONSULT\n" }, { "category": "Echo", "chartdate": "2160-03-21 00:00:00.000", "description": "Report", "row_id": 60382, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 108/70\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 15:42\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Left ventricular systolic function is hyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmild aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Compared with the findings of the prior study, there has\nbeen no significant change. A left pleural effusion is present.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%).\n3. The aortic valve leaflets are moderately thickened. There is mild aortic\nvalve stenosis. Trace aortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is mild pulmonary artery systolic hypertension.\n6. There is a trivial pericardial effusion.\n7. Compared with the findings of the prior report (tape unavailable for\nreview) of , tricuspid regurgitation is less.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824815, "text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with new fever and increased hypoxemia. Evaluate\n for infiltrate.\n\n AP single view of the chest is compared to .\n\n FINDINGS: There are low lung volumes. The cardiac and mediastinal contours\n are unchanged. There is calcification of the aorta. Distribution of the\n pulmonary vascularity and the septal lines consistent with an interval\n worsening of CHF or fluid overload. Patchy opacity in the left lower lobe but\n could represent pneumonia or atelectasis.\n\n IMPRESSION:\n 1. Worsening of CHF, or fluid overload.\n 2. Patchy opacity in the left base could represent pneumonia or atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825110, "text": " 7:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval volume status\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n eval volume status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever with increased oxygen requirement. Evaluate for pulmonary\n edema or infiltrate.\n\n COMPARISON: .\n\n CHEST AP: There is cardiomegaly with small bilateral pleural effusions. Again\n seen is a left lower lobe opacity. The mediastinal contours are unremarkable.\n\n Degenerative changes are noted in the thoracic spine.\n\n IMPRESSION: Left ventricular failure with small pleural effusions. Left lower\n lobe atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 824342, "text": " 4:14 PM\n CHEST (PA & LAT) Clip # \n Reason: SOB ? WORSENING chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with\n REASON FOR THIS EXAMINATION:\n SOB ? WORSENING chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old male with shortness of breath. Query worsening of CHF.\n PA and lateral views of the chest are compared to .\n\n The heart is increased in size consistent with cardiomegaly, but no\n significantly unchanged in the interval. The aorta is tortuous and calcified.\n The mediastinal and hilar contours are unchanged. There is upper zone\n redistribution of the pulmonary vascularity which is consistent with mild CHF,\n but there is no overt pulmonary edema. There are bilateral small pleural\n effusions. No focal consolidations to suggest pneumonia. There are\n degenerative changes of the thoracic spine which are unchanged when compared\n to the previous study.\n\n IMPRESSION:\n Findings consistent with mild CHF.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825289, "text": " 5:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old man with new fever and increased O2 requirement.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared to\n the previous study of yesterday.\n\n The NGT is coiled within the pharynx.\n\n There is increased congestive heart failure with cardiomegaly and bilateral\n pleural effusions. There is increased patchy atelectasis in both lower lobes.\n The patient has been extubated. The right jugular IV catheter remains in\n place.\n\n IMPRESSION:\n 1) Coiling of the NGT in the pharynx.\n 2) Increased congestive heart failure with cardiomegaly and small bilateral\n pleural effusions. Patchy atelectasis in both lower lobes.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825190, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check for R IJ central line placement & NG tube placement\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n check for R IJ central line placement & NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A -year-old man with new fever and increased oxygen\n requirement. Now status post right IJ central line placement and NG tube\n placement.\n\n AP semi-upright single view of the chest is compared to .\n\n FINDINGS: There is an ET tube located in good position unchanged when compared\n to the previous study. There is interval placement of a right IJ central line\n with the tip in the low SVC. There is no evidence of pneumothorax. There has\n been placement of a feeding tube with the tip extending beyond the limits of\n the diaphragm in the stomach.\n\n IMPRESSION: Right IJ central line and feeding tube are in satisfactory\n position. Otherwise, unchanged appearance of the chest x-ray when compared to\n the study done two hours earlier on the same day.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 824925, "text": " 9:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulm edema\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n Evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New fever and hypoxia.\n\n COMPARISON: .\n\n FINDINGS: AP portable semi-upright view. Cardiomegaly with congestive heart\n failure is again noted, and changed since the prior status. A left pleural\n effusion remains present. There is a persistent left lower lobe opacity\n consistent with atelectasis or consolidation. Degenerative changes are noted\n within the thoracic spine.\n\n IMPRESSION:\n\n 1) Stable appearance of LV failure with a left pleural effusion.\n 2) Stable left lower lobe atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 825074, "text": " 1:25 PM\n RENAL U.S. PORT Clip # \n Reason: r/o hydroneprhosis\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with MDS, diastolic dysfunction, CRF now w/ no urine outpt x 10\n hours w/ minimal UO despite new foley\n REASON FOR THIS EXAMINATION:\n r/o hydroneprhosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MDS, diastolic dysfunction, no urine output for 10 hours.\n\n FINDINGS: The left kidney measures 10.4 cm. The right kidney measures 11.0.\n There is a 2.3 cm simple cyst within the lower pole of the left kidney. There\n is also a 2.5 cm simple cyst in the upper pole of the left kidney. The\n bladder is collapsed with a Foley in place.\n\n IMPRESSION: No evidence of hydronephrosis or stones.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825393, "text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval fluid status\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please\n evaluate for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n please eval fluid status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever and increasing oxygen requirement.\n\n AP UPRIGHT CHEST: Compared with , there is slightly better lung\n inflation. There are persistent bibasilar infiltrates/atelectasis and small\n bilateral pleural effusions. Persistent vascular congestion and cardiomegaly.\n No pneumothorax. The right central venous catheter is unchanged.\n\n IMPRESSION: 1) Persistent CHF. 2) Slight improvement in the bibasilar\n infiltrate/atelectasis, which could represent pneumonia if clinically\n consistent.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-31 00:00:00.000", "description": "R US EXTREMITY NONVASCULAR RIGHT", "row_id": 825448, "text": " 2:14 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: RUE SWELLING, R/O DVT\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new RUE edema w/ R. radial a-line and R. IJ TLC\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper extremity edema with right radial A-line and right\n internal jugular catheter.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the\n right internal jugular, subclavian, axillary, brachial, basilic and cephalic\n veins were performed. Normal flow, compressibility, augmentation, and wave\n forms are demonstrated. No intraluminal thrombus is identified. Note is made\n of prominent soft tissue edema.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2160-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825176, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS ETT PLACEMENT, FAILED NGT PLACENET\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with new fever and increased O2 requirement. Please evaluate\n for infiltrate and pulm edema.\n REASON FOR THIS EXAMINATION:\n assess ETT placement and NGT placement in y/o male now intubated for\n hypotension decreased ms\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared to previous study of one day earlier.\n\n CLINICAL INDICATION: Evaluate endotracheal tube and nasogastric tube\n position.\n\n An endotracheal tube is in satisfactory position. No nasogastric tube is\n identified. Cardiac and mediastinal contours appear stable in the interval.\n Again demonstrated are bilateral pleural effusions, right greater than left.\n There is persistent left retrocardiac opacity, not significantly changed.\n\n IMPRESSION:\n\n 1) Endotracheal tube in satisfactory position.\n\n 2) No nasogastric tube identified. If a nasogastric tube has indeed been\n placed, it may be within the oro- and hypopharynx ( regions which are not\n included on this study).\n\n" }, { "category": "Radiology", "chartdate": "2160-03-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 825113, "text": " 8:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute change in mental status, h/o CVA, chronic afib, coumad\n Admitting Diagnosis: ANEMIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with chf, uti, afib\n REASON FOR THIS EXAMINATION:\n acute change in mental status, h/o CVA, chronic afib, coumadin has been held in\n house\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: CHF, A fib, acute mental status changes.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial noncontrast head CT.\n\n CT HEAD WITHOUT CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalus, shift of normally midline structures or edema. There is a\n moderate amount of periventricular and subcortical white matter\n hypoattenuation consistent with chronic small vessel ischemia and gliosis.\n Small lacunar infarcts are also identified within bilateral basal ganglia,\n and there is a small left parietal chronic infarction.\n\n The paranasal sinuses are well aerated. There is proptosis on the right with\n an irregular contour to the globe posteriorly.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n 2. Small, old lacunar infarcts and chronic small vessel ischemic gliosis.\n 3. Proptosis of the right orbit with an irregular configuration to the\n posterior portion of the right globe. This may represent previous trauma to\n the globe with rupture. Clinical correlation is recommended.\n\n\n\n" }, { "category": "ECG", "chartdate": "2160-03-27 00:00:00.000", "description": "Report", "row_id": 107770, "text": "Atrial flutter-fibrillation. Axis minus 30 degrees. ST segment elevations in\nleads V2-V3 (probably early repolarization). Low voltage in the limb leads and\nprecordial leads. Compared to the previous tracing of right\nbundle-branch block patterning was previously present and is no longer present.\nArrhythmia persists as before.\n\n" }, { "category": "ECG", "chartdate": "2160-03-21 00:00:00.000", "description": "Report", "row_id": 107771, "text": "Possible atrial flutter (P in lead V1) with variable block versus atrial\nfibrillation\nLeft axis deviation\nBorderline left anterior fascicular block\nRight bundle branch block\nSince previous tracing, atrial flutter present\n\n" }, { "category": "ECG", "chartdate": "2160-03-20 00:00:00.000", "description": "Report", "row_id": 107772, "text": "Sinus rhythm\nFirst degree A-V block\nRBBB with left anterior fascicular block\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing, atrial fibrillation absent; inferior T wave changes\nnoted\n\n" } ]

97,243

129,107

Pt was admitted to neurosurgery service and underwent a right frontal craniotomy for tumor resection on . Pt tolerated this procedure very well with no complications. Post operatively he was transferred to the ICU for continued care including q1 neuro checks and strict blood pressure control. On post op exam he is AOx3, following commands and moving all ext with full strength, he has no change from his baseline. A post op head ct showed good resection of lesion with no acute hemorrhage. Pt was transferred to the floor on , his diet was advanced, his foley was removed and he was sdeemed fit for discharge on the morning of as he was ambulatory in the hallways without assistance. He as given instructions for followup and discharged on the afternoon of

Imaged portion of paranasal sinus and mastoid air cells appear within normal limits. Limited study for a preoperative planning demonstrates stable appearance of bifrontal enhancing lesions with surrounding vasogenic edema, left greater than right. Note is again made of a T1 hyperintense subcutaneous nodule, which is unchanged in size and most consistent in imaging appearances with lipoma. The right frontal enhancing mass appears unchanged. Again seen is an enhancing right frontal focus with an apparent necrotic component. The enhancing lesion seen in the right frontal lobe, 2:22, is better evaluated on last MR. CONCLUSION: Status post resection of left frontal lobe mass with expected post-operative changes. Again identified is a right occipital scalp lipoma. There is stable mass effect on the frontal of the left lateral ventricle. T1 hyperintense well-circumscribed subcutaneous nodule over the right occiput, most consistent with lipoma. TECHNIQUE: MP-RAGE, coronal T1, sagittal T1, axial T1 images were acquired. FINDINGS: Again seen are bifrontal metastases with marked surrounding vasogenic edema, left greater than right. FINDINGS: The patient is status post a left frontal craniotomy for resection of the previously demonstrated parenchymal mass. Again seen is extensive left frontal edema. no large acute hemorrhage. Sagittal MP-RAGE imaging was performed and reformatted in axial and coronal orientations. Enhancing lesion at the right frontal lobe better evaluated on recent MRI. Post-surgical changes at the left frontoparietal region with expected pneumocephalus and tiny blood products. The ventricles and sulci are normal in size and configuration. FINAL REPORT HISTORY: Left parietal lesion; status post craniotomy for resection. COMPARISON: Multiple prior MRIs, most recently . IMPRESSION: 1. IMPRESSION: 1. Fiducial markers are in place over the scalp. The dural venous sinuses are patent. Comparison to brain MRs and . Please obtain between 2130 and 2230 No contraindications for IV contrast WET READ: IPf FRI 9:18 PM post-surgical changes at the left frontal lobe. Overall, this appears slightly improved since the pre-operative study. Elsewhere -white differentiation is preserved. There is persistent soft tissue edema in the left frontoparietal white matter, 2:20. The orbits are normal in appearance. Sagittal and axial short TR, short TE spin echo imaging was performed through the brain. FINDINGS: Status post resection of left parietal mass with post-surgical changes at the surgical bed, with pneumocephalus and tiny blood products. The ventricles are stable in size. There is stable 2-mm shift of midline structures, 2:15. COMPARISON: MR . No new lesions are detected. No new lesions are detected. Persistent vasogenic edema at the left frontal lobe. The globes are intact. No new foci are appreciated. Evaluate postoperative change. Following the administration of contrast. TECHNIQUE: Contiguous axial images were obtained through the brain. The visualized paranasal sinuses are unremarkable. No new enhancing foci are seen. Note that the high intensity of the hemorrhage will somewhat limit detection of small amounts of enhancing tumor. These are similar in size compared with the prior with the largest on the left measuring approximately 1.8 x 1.6 cm. There is no large acute hemorrhage or large acute territorial infarction. 2. 2. No intravenous contrast administered. After administration of 16 cc of Magnevist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, long TR, long TE fast spin echo, short TR, short TE spin echo, and diffusion technique. There is hemorrhage at the surgical site, with no evidence of residual enhancing tumor. 9:19 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change in patient with left craniotomy Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: MAGNEVIST Amt: 16CC MEDICAL CONDITION: 79 year old man with left parietal lesion s/p craniotomy for resection REASON FOR THIS EXAMINATION: evalaute for post-op change in patient with left craniotomy for resection No contraindications for IV contrast FINAL REPORT MR HEAD WITHOUT AND WITH CONTRAST HISTORY: Status post left parietal craniotomy for tumor resection. 7:47 PM CT HEAD W/O CONTRAST Clip # Reason: evalaute for post-op change. 3. Please obtain between 2130 and Admitting Diagnosis: BRAIN TUMOR/SDA MEDICAL CONDITION: 79 year old man with left parietal lesion s/p craniotomy for resection REASON FOR THIS EXAMINATION: evalaute for post-op change. 12:12 PM MR HEAD W/ CONTRAST Clip # Reason: for surgical mapping Contrast: MAGNEVIST Amt: 17 MEDICAL CONDITION: 79 year old man with brain tumor REASON FOR THIS EXAMINATION: for surgical mapping No contraindications for IV contrast FINAL REPORT CLINICAL INFORMATION: A 79-year-old male with history of melanoma and brain metastasis.

3

[ { "category": "Radiology", "chartdate": "2147-03-10 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1176429, "text": " 12:12 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: for surgical mapping\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with brain tumor\n REASON FOR THIS EXAMINATION:\n for surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: A 79-year-old male with history of melanoma and brain\n metastasis.\n\n COMPARISON: Multiple prior MRIs, most recently .\n\n TECHNIQUE: MP-RAGE, coronal T1, sagittal T1, axial T1 images were acquired.\n Following the administration of contrast.\n\n FINDINGS: Again seen are bifrontal metastases with marked surrounding\n vasogenic edema, left greater than right. These are similar in size compared\n with the prior with the largest on the left measuring approximately 1.8 x 1.6\n cm. No new foci are appreciated. Elsewhere -white differentiation is\n preserved. The ventricles and sulci are normal in size and configuration.\n Fiducial markers are in place over the scalp. Note is again made of a T1\n hyperintense subcutaneous nodule, which is unchanged in size and most\n consistent in imaging appearances with lipoma. The orbits are normal in\n appearance. The visualized paranasal sinuses are unremarkable. The dural\n venous sinuses are patent.\n\n IMPRESSION:\n 1. Limited study for a preoperative planning demonstrates stable appearance\n of bifrontal enhancing lesions with surrounding vasogenic edema, left greater\n than right. No new enhancing foci are seen.\n\n 2. T1 hyperintense well-circumscribed subcutaneous nodule over the right\n occiput, most consistent with lipoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-03-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176507, "text": " 7:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalaute for post-op change. Please obtain between 2130 and\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left parietal lesion s/p craniotomy for resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change. Please obtain between 2130 and 2230\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf FRI 9:18 PM\n post-surgical changes at the left frontal lobe. no large acute hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left parietal lesion; status post craniotomy for resection.\n Evaluate postoperative change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast administered.\n\n COMPARISON: MR .\n\n FINDINGS: Status post resection of left parietal mass with post-surgical\n changes at the surgical bed, with pneumocephalus and tiny blood products. The\n enhancing lesion seen in the right frontal lobe, 2:22, is better evaluated on\n last MR. There is persistent soft tissue edema in the left frontoparietal\n white matter, 2:20. There is stable mass effect on the frontal of the\n left lateral ventricle. There is stable 2-mm shift of midline structures,\n 2:15.\n\n The ventricles are stable in size. There is no evidence of hydrocephalus.\n There is no large acute hemorrhage or large acute territorial infarction.\n Imaged portion of paranasal sinus and mastoid air cells appear within normal\n limits. The globes are intact.\n\n IMPRESSION:\n 1. Post-surgical changes at the left frontoparietal region with expected\n pneumocephalus and tiny blood products.\n 2. Persistent vasogenic edema at the left frontal lobe.\n 3. Enhancing lesion at the right frontal lobe better evaluated on recent MRI.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-03-12 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1176657, "text": " 9:19 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change in patient with left craniotomy\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 16CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left parietal lesion s/p craniotomy for resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change in patient with left craniotomy for resection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST \n\n HISTORY: Status post left parietal craniotomy for tumor resection.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. After administration of 16 cc of Magnevist intravenous contrast,\n axial imaging was performed with gradient echo, FLAIR, long TR, long TE fast\n spin echo, short TR, short TE spin echo, and diffusion technique. Sagittal\n MP-RAGE imaging was performed and reformatted in axial and coronal\n orientations. Comparison to brain MRs and .\n\n FINDINGS: The patient is status post a left frontal craniotomy for resection\n of the previously demonstrated parenchymal mass. There is hemorrhage at the\n surgical site, with no evidence of residual enhancing tumor. Note that the\n high intensity of the hemorrhage will somewhat limit detection of small\n amounts of enhancing tumor. Again seen is extensive left frontal edema.\n Overall, this appears slightly improved since the pre-operative study. Again\n seen is an enhancing right frontal focus with an apparent necrotic component.\n No new lesions are detected.\n\n Again identified is a right occipital scalp lipoma.\n\n CONCLUSION: Status post resection of left frontal lobe mass with expected\n post-operative changes. No new lesions are detected. The right frontal\n enhancing mass appears unchanged.\n\n\n" } ]

29,488

147,767

Cardiac catherterization showed 99% LM, IABP was placed, and she was taken emergently to the operating room where she underwent a CABG x 2. She was transferred to the ICU in critical but stable condition. She was extubated and her IABP was removed on POD #1. She was transferred to the floor on POD #3. She did well postoperatively, she was seen by PT and was ready for discharge home on POD #5.

There is an RSR' pattern in lead V1 which is probably normal.Non-specific anterior and anterolateral ST-T wave changes. given percocet 1tab po w/sip of h2o->n/v shortly after. d/c CTs in am. Normal ascending aorta diameter. Percoets d/c'd and Darvocet given this am. percocet 1 tab given x2 w/good effect. PATIENT/TEST INFORMATION:Indication: CAD, unstable angina,Height: (in) 66Weight (lb): 130BSA (m2): 1.67 m2BP (mm Hg): 100/40HR (bpm): 72Status: InpatientDate/Time: at 18:07Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is a right internal jugular central venous line in place terminating within the expected region of the cavoatrial junction. SINGLE VIEW CHEST, AP UPRIGHT: The cardiac size is on the upper limits of normal. cxray done. The mitral valveappears structurally normal with trivial mitral regurgitation. The endotracheal and left chest tube have been removed in the interim. Normal aortic arch diameter. There are simple atheroma in the descendingthoracic aorta. ct's & epicardial wires d/c'd. Normal RV systolic function.Mild improvement in previously hypokinetic apical anterior and anteroseptalsegments.Minimal MR and minimal TR. vent weaned. PP palpable.RESP: Pt on 4L NC. o2 weaned to 2l nc. FINAL REPORT PROCEDURE: Chest portable line placement on . iabp weaned tolerated well->d/c'd by dr . wean ntg as tolerates. ntg restarted d/t sbp>130 by aline, nibp 10pt lower. Neuro: pt oriented following commands.Resp: pt on 2 L NP tolerating well with O2 sats 95-98%C/V: vss pt in sinus rhythm with stable BP . There is mild regional left ventricular systolic dysfunctionwith focalities in the apical anteroseptal and anterior wall. zofran order/more freq reglan order. There is asmall pericardial effusion. Plan to place on Cpap wean for possible extubation.C/V: pacer turned down, pt in sinus rhythm rate 70-80's no ectopy. Hct 31.1. tolerating po lopressor. Mild regional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - hypo; anterior apex - hypo; septal apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. CT draining min amt serosang fluid. The patient is status post median sternotomy and CABG. The patient is status post median sternotomy and CABG. I ABP inserted and pt sent to OR. abd soft +bs. +palp pp bilat.resp: lungs clear but dim in bases. Thepatient appears to be in sinus rhythm. 6am lasix dose held d/t low cvp, given at 11a per team w/fair diuresis.endo: fs treated w/ssri per protocol.id: last dose of vanco given. sat's>94%.gi/gu: og->lws w/billious drainage, d/c'd w/extubation. Lytes repleated prn.SKIn: Skin WDI, afebrile, t-max 98.6.PLAN: Monitor VS, resp status, CT and u/o. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). n/v as noted above. +pp bilat. Left ventricular wall thicknesses arenormal. Baseline postop examination showing a new left lower lobe atelectasis and small left pleural effusion. pacer placed on a demand of 60. pt became hypertensive nitro started and titrated up to 3 with MAP staying up in the 90's and SBP by IABP 130's. The cardiac silhouette remains at the upper limits of normal. a&o x3 post extubation. CVP 0-3 most of shift, MD aware. There is improved aeration of the left base associated with partial interval resolution of the left basilar atelectasis noted on the prior examination. +bs. Sinus rhythm. Sinus rhythm. c/o nausea w/pain med & requesting reglan w/pain med->nauseous dispite med zofran given w/good effect. oob->chair w/assist of 2 tol well.cv/skin: nsr. Normal LV cavity size. FINDINGS: In the interim, a new endotracheal tube has been placed with distal tip terminating approximately 3 cm above the carina bifurcation. c/o incisional pain medicated w/morphine->n/v x1 reglan given. team aware of ^'d need of ntg, to order lopressor. Arrived here on Propofol and Neo 0.2mcg pt 100% apaced on arrival. shift update:neuro: oriented x3. shift update:neuro: , , follows commands. Cannot rule out myocardialischemia. k+, ca & magnesium repleted. LS clear, diminshed in bases. tolerating sips of clears. Focal calcifications in aorticarch. FINDINGS: A single portable image of the chest was obtained and compared to the prior examination dated . Neo weaned off.Neuro: pt sedated with propofol overnight. magnesium repleted.resp: lungs clear but dim in bases. pt reports n/v from morphine. Focal calcifications inascending aorta. FINDINGS: A single portable image of the chest is compared to the prior examination dated . The left ventricular cavity size is normal. Wake and wean vent good diuresis after lasix.endo: insulin gtt per protocol. reglan x1. -airleak/crepitus.GI/GU: +BS, pt nauseous/-vomitting: given reglan Q6; pt requesting more often ? zofran?CV: pt in NSR 70s-80s, with no ectopy noted. Note is made of bilateral humeral head replacements. Cont with pulmonary toileting. Radial aline tracing with fling SBP up to 160's. pt given reglan Q6 for nausea-> ? sat's>94. There are focalcalcifications in the aortic arch. encouraged to cdb & use is, cough weak & only able to get is to 250.gi/gu: abd soft. The heart size is mildly enlarged expected from a postoperative procedure. IMPRESSION: 1. A line d/c'd after lost waveform and could not draw off; NIBP 100s-120s, MAP 60s-70s. Comfort and support pt. Foley to be d/c'd in am.Skin: Incisions clean and dry no drainage or redness noted.Pain: pt complains of incision pain requesting percocet and something for nausea at same time. The right hemithorax is clear. The cardiomediastinal silhouette is stable. The cardiac silhouette is grossly unchanged. sbp stable. dr aware, no new orders. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Focal calcifications inaortic root. ^ diet and activity as tol by pt.

13

[ { "category": "Radiology", "chartdate": "2122-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002592, "text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p urgent CABG\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: A 72-year-old status post urgent CABG.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . The endotracheal and left chest tube\n have been removed in the interim. In addition, the nasogastric tube has been\n removed. Otherwise, no significant interval change. The patient is status\n post median sternotomy and CABG. Persistent left basilar streaky opacities\n are seen likely reflect underlying atelectasis, difficult to exclude\n pneumonia. The right hemithorax is clear. The cardiac silhouette is grossly\n unchanged. The cardiac silhouette remains at the upper limits of normal.\n There is a right internal jugular central venous line in place terminating\n within the expected region of the cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1002419, "text": " 8:41 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumotnorax.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumotnorax.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable line placement on .\n\n Chest radiograph from at 14:21.\n\n HISTORY: 72-year-old woman with CABG, evaluate for effusion, edema or\n tamponade.\n\n FINDINGS: In the interim, a new endotracheal tube has been placed with distal\n tip terminating approximately 3 cm above the carina bifurcation. A new right\n IJ central line terminating at the atrial/caval junction. A new feeding tube\n is placed terminating in the stomach. There is an intraaortic balloon pump at\n a distance of 8 cm from the superiormost portion of the aortic arch. A new\n left lower lobe atelectasis with a small left pleural effusion is also noted\n on today's examination. The right lung is clear. The patient is status post\n cardiothoracic surgery with multiple sternotomy wires with no associated wire\n complication. The heart size is mildly enlarged expected from a postoperative\n procedure.\n\n IMPRESSION:\n\n 1. Baseline postop examination showing a new left lower lobe atelectasis and\n small left pleural effusion.\n\n 2. Lines and tubes and catheters are in appropriate location as described\n above.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002452, "text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72F severe left main dz s/p emergent CABGx2\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 72-year-old female with severe left main disease status\n post emergent CABG x2.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination dated . The patient is status post median sternotomy and\n CABG. The supporting lines are stable and in satisfactory positions. There\n is improved aeration of the left base associated with partial interval\n resolution of the left basilar atelectasis noted on the prior examination. No\n new focal opacities are seen. The cardiomediastinal silhouette is stable.\n\n\n" }, { "category": "Echo", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 76251, "text": "PATIENT/TEST INFORMATION:\nIndication: CAD, unstable angina,\nHeight: (in) 66\nWeight (lb): 130\nBSA (m2): 1.67 m2\nBP (mm Hg): 100/40\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 18:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. No left ventricular\naneurysm is seen. There is mild regional left ventricular systolic dysfunction\nwith focalities in the apical anteroseptal and anterior wall. Right\nventricular chamber size and free wall motion are normal. There are focal\ncalcifications in the aortic arch. There are simple atheroma in the descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is a\nsmall pericardial effusion. Dr. was notified in person of the results\non patient .\n\nPost_Bypass:\nLVEF 50%.\nThoracic aortic contour is intact. Normal RV systolic function.\nMild improvement in previously hypokinetic apical anterior and anteroseptal\nsegments.\nMinimal MR and minimal TR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-02-23 00:00:00.000", "description": "Report", "row_id": 1644511, "text": "Neuro: pt oriented following commands.\nResp: pt on 2 L NP tolerating well with O2 sats 95-98%\nC/V: vss pt in sinus rhythm with stable BP . CVP 2-4. palpable pedal pulses.\nGI: pt having intermittent bouts of nausea associated with pain medication treated with Zofran 4mg with fair relief but not lasting more then several hours. IV Reglan given with good effect.\nEndo: blood sugars treated with sliding scale insulin.\nGU: pt receiving lasix 10mg ivp with fair response. Foley to be d/c'd in am.\nSkin: Incisions clean and dry no drainage or redness noted.\nPain: pt complains of incision pain requesting percocet and something for nausea at same time. pt given Zofran and percocet 1 tab but developed dry heaves several hours later.Pt stated that she gets nauseous after taking percocets. Percoets d/c'd and Darvocet given this am. Pt sleeping at present.\nPla: Remove floey, increase activity and transfer to floor when bed available\n" }, { "category": "Nursing/other", "chartdate": "2122-02-22 00:00:00.000", "description": "Report", "row_id": 1644509, "text": "NEURO: Pt A&Ox3, MAE and follows commands. Pt c/o severe () pain @ CT site. Given 0.50mg Dilaudid IV Q4, with min effect, however pt falls asleep. Pt c/o nausea most of shift, especially when given pain medicine (immediate nausea). pt given reglan Q6 for nausea-> ? zofran?\n\nCV: pt in NSR 70s-80s, with no ectopy noted. Epicardial wires: 2As/2Vs, Vs do not sense or capture appropriately. A line d/c'd after lost waveform and could not draw off; NIBP 100s-120s, MAP 60s-70s. CVP 0-3 most of shift, MD aware. Given 250cc NS fluid bolus for low u/o and CVP. Hct 31.1. PP palpable.\n\nRESP: Pt on 4L NC. LS clear, diminshed in bases. Pt not C&DB well. Uses IS<250. CT draining min amt serosang fluid. -airleak/crepitus.\n\nGI/GU: +BS, pt nauseous/-vomitting: given reglan Q6; pt requesting more often ? zofran order/more freq reglan order. Standing order Lasix 10mg TID with + diuresis for few hours. Give 250cc NS bolus for low u/o-->?hold lasix in am. ^ diet as pt tol, pt refused PM meds, food & H2O d/t N/V.\n\nENDO: Lasix gtt off d/t BS 76; BS WNL since, will tx prn with SC insulin. Lytes repleated prn.\n\nSKIn: Skin WDI, afebrile, t-max 98.6.\n\nPLAN: Monitor VS, resp status, CT and u/o. Comfort and support pt. ^ diet and activity as tol by pt. Cont with pulmonary toileting. ? d/c CTs in am. OOC to chair\n" }, { "category": "Nursing/other", "chartdate": "2122-02-22 00:00:00.000", "description": "Report", "row_id": 1644510, "text": "shift update:\n\nneuro: oriented x3. mae. c/o incisional pain on scale 1-10. dilaudid 0.5mg ivp x1 given w/reglan per pt request w/fair effect per pt, but pt found sleeping. percocet 1 tab given x2 w/good effect. oob->chair w/assist of 2 tol well.\n\ncv/skin: nsr. no vea. sbp stable. tolerating po lopressor. ct's & epicardial wires d/c'd. cxray done. +pp bilat. magnesium repleted.\n\nresp: lungs clear but dim in bases. o2 weaned to 2l nc. sat's>94. encouraged to cdb & use is, cough weak & only able to get is to 250.\n\ngi/gu: abd soft. +bs. c/o nausea w/pain med & requesting reglan w/pain med->nauseous dispite med zofran given w/good effect. tolerating sips of clears. 6am lasix dose held d/t low cvp, given at 11a per team w/fair diuresis.\n\nendo: fs treated w/ssri per protocol.\n\nid: last dose of vanco given. afebrile.\n\nsocial: niece into visit & update given.\n\nplan: pain management. cont to monitor vs, labs, i&o. encourage pulmonary toilet. increase activity & diet as tolerates. transfer to 6 when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644507, "text": "pt arrived last evening around from the OR s/p Cabg x2 done emergently after found to have tight left main. I ABP inserted and pt sent to OR. Arrived here on Propofol and Neo 0.2mcg pt 100% apaced on arrival. Pt had been oozy in OR chest tubes draining small amounts Fibrogen 128 pt received Cryoprecipitate on arrival. Neo weaned off.\nNeuro: pt sedated with propofol overnight. This am opening eyes with stimulation, moving all extremities and following commands.\nResp: pt on CMV overnight with good ABG's Fio2 weaned down to 40%. Peep increased to 8 last night after chest xray showed lower left based possible collaspse. Plan to place on Cpap wean for possible extubation.\nC/V: pacer turned down, pt in sinus rhythm rate 70-80's no ectopy. pacer placed on a demand of 60. pt became hypertensive nitro started and titrated up to 3 with MAP staying up in the 90's and SBP by IABP 130's. Radial aline tracing with fling SBP up to 160's. Monitoring BP by fiberoptic and Iabp aline. CVP 8-9 pt given lopressor total 5mg ivp for elevated BP with out effect, hydralazine 5mg ivp given with good effect Map down below 85 and nitro weaned off. IABP on 1:1 all night with good augmentation and unloading. Pedal pulses palpable in bilateral feet, warm to touch.\nGI: OGT draining dark bilious fluid overnight. no bowel sounds heard as of yet.\nEndo: Insulin gtt started for BS of 150's off this am.\nGU: adequate urine output.\nSkin: Dsg clean and dry no drainage.\nPain: pt given morphine 2mgs ivp for perceived pain through ight. pt nods yes to pain this am after turning.\nPlan: wean IABP prepare for possible remaoval. Start lasix. Wake and wean vent\n\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644508, "text": "shift update:\n\nneuro: , , follows commands. c/o pain medicated w/morphine 2mg at 0800 w/good effect. a&o x3 post extubation. c/o incisional pain medicated w/morphine->n/v x1 reglan given. pt reports n/v from morphine. given percocet 1tab po w/sip of h2o->n/v shortly after. dr aware, no new orders. remains on bedrest until 1830 per cardiology d/t iabp d/c'd.\n\ncv/skin: nsr->st w/rare pac's. ntg restarted d/t sbp>130 by aline, nibp 10pt lower. iabp weaned tolerated well->d/c'd by dr . team aware of ^'d need of ntg, to order lopressor. pacer set for ademand at 60, sensing & capturing appropriately. ct drainage minimal. k+, ca & magnesium repleted. +palp pp bilat.\n\nresp: lungs clear but dim in bases. vent weaned. extubated to 50% oft->weaned to 4lnc. sat's>94%.\n\ngi/gu: og->lws w/billious drainage, d/c'd w/extubation. n/v as noted above. reglan x1. abd soft +bs. good diuresis after lasix.\n\nendo: insulin gtt per protocol. see flowsheet for details.\n\nsocial: niece into visit, updated. niece requesting that her phone number be given out to anyone calling to check on pt.\n\nplan: pain management. bedrest until 1830. ?start po lopressor. wean ntg as tolerates. cont to monitor vs labs & i&o. increase diet as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2122-02-21 00:00:00.000", "description": "Report", "row_id": 1644506, "text": "Respiratory care note:\nPt received from OR around 7:30 PM on A/C 550/12/5 with 100%. X-ray revealed some atelectasis, peep increased to 8. Good ABGs, FiO2 and peep weaned to 40% and 5.\nPlan: Continue to monitor.\nRSBI=69.5\n" }, { "category": "Radiology", "chartdate": "2122-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002376, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest pain resolved\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n chest pain resolved\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n COMPARISONS: None.\n\n SINGLE VIEW CHEST, AP UPRIGHT: The cardiac size is on the upper limits of\n normal. There are no focal pulmonary opacities and the pulmonary vasculature\n is within normal limits. There is no pneumothorax or definite pleural\n effusion. Note is made of bilateral humeral head replacements.\n\n IMPRESSION: No acute cardiopulmonary disease.\n\n\n" }, { "category": "ECG", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 185883, "text": "Sinus rhythm. There is an RSR' pattern in lead V1 which is probably normal.\nNon-specific anterior and anterolateral ST-T wave changes. Compared to the\nprevious tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 185884, "text": "Sinus rhythm. Anterolateral ST-T wave changes. Cannot rule out myocardial\nischemia. Compared to the previous tracing of anterolateral\nST-T wave changes are new. Clinical correlation is suggested.\n\n" } ]

1,747

109,552

MICU transfer: 42 yo alcoholic male with h/o DTs and withdrawal seizures who initially admitted to medicine serivice on after a witnessed tonic-clonic seizure secondary to EtOH withdrawal. Per reports, the seizure lasted a few minutes and the patient was post-ictal and incontinent of urine upon arrival to ED. On arrival to ED T 101.8, HR 120, BP 113/69, RR 18, O2 sat 95%. Blood alcohol level of 80. In ED he received IV hydration with D5NS, thiamine, and ativan per CIWA scale for withdrawl. He denied hallucinations, CP, SOB, Fever, Chills, N/V/D, belly pain, HA, nightsweats. Reports chronic minially productive cough, no hemoptysis. . After arrival to the floor, the patient was managed with Valium initially at 10 mg po q1-2 hrs per CIWA protocol and Haldol prn for agitation. On the evening of the day of admission, code purple was called after the patient started ripping his IV and attempting to leave AMA. The patient was delirius and did not have decisional capacity to leave AMA. . He received a total of over 170 mg of Valium since arrival to medical floor. The patient was transferred to MICU today for management of EtOH withdrawal in the setting of high benzodiazepine requirement and increasing agitation. Psychiatry was concerned re: paradoxical reaction to Benzodiazepines. At the time of transfer, the patientn is delirius and is unable to provide hitory. History is obtained from the chart review. . On admission to the MICU, the patient was started on an aggressive CIWA scale with 20mg Ativan q10 minutes initially as needed for a CIWA scale greater than 10. The patient initially required frequent dosing and large requirements, recieving int he first 12 hours 240mg of Diazepam. The patient appeared o respond well with decreased agitation and decreased benzo needs. An attempt was made to control the patient's agitation with increased Haldol and less benzo's, but patient responded with increased agitation again, indicating that the patient had large and ongoing Benzodiazepine requirements for ETOH withdrawal. Since admission to the MICU the patient has remained afebrile and had no additional seizures. He has been maintained with a 1:1 sitter as needed and required ongoing point restraints for agitation and attempts to get out of bed. . 1. EtOH withdrawl/seizure. He reports last drink was 1 day PTA but had negative serum EtOH in ED. Suspect that seizure due to withdrawl. LFTs c/w EtOH abuse (AST > AlT). - CIWA scale with valium was continued after transfer from MICU. Patient did not require more than 3 doses overnight after transfer. - thiamine, folate were continued throughout the hospitalization. - Does not report a history of cirrhosis and no ascites on exam. - 1 day after transfer from MICU, patient decided to leave the hospital AMA, and was in the opinion of the housestaff and medical attending capable of making that decision for himself. The patient left the hospital against medical advice.

1:1 sitters d/c'd.cv: monitor shows sb-nsr with rare pvc noted.resp: ls coarse throughout. NEW IV PLACED RL POSTERIOR ARM.DISPO- REMAINS IN MICU FOR DT TX.PLAN- VALIUM 10-20MG IV Q 10MIN PRN CIWA > 10. diaphoritic at times with DT'S. adequately sedated from previous shift(s) IV Valium doses. labs pending.Resp: on RA, pulse ox 96-99%, lungs clear.GI/ENDO: abd soft,nontender,nondistended. +bs noted. uo marginal...dr aware. Baseline artifactSinus tachycardiaOtherwise normal ECGNo previous tracing available for comparison Pt medicated as ordered with 10-30mg Valium IV according to CIWA scale. micu note 2300-0700S; incomprehensible, mumbling.O; Please see carevue for VS and objective dataNeuro; Pt. +perrla noted. bowel sounds +, no BM on this shift. BS CLEAR.CARDIAC- HR 100-ONE TWENTIES. HE FEELS HE IS IN A MONITORED SETTING WITH GOOD O2 SATS ON RA. Valium20 ivp given, total of at least 240mg ivp q shift. Arrived in EW post ictal and had urinary incontinence. PERL, 2mm, sluggish. tol sips of clears.gu: foley intact and patent. MICU team aware of level of sedation and last dose Valium. 1:1 sitter this shift.CVS; Hemodynamically stable with HR 50-60's, NSB/NSR. Treated w/IVF and IV ativan in EW, had - head CT and tox screen had zero ETOH level. PATIENT HAD 1:1 SITTER THIS AM. HALDOL GIVEN 5MG IV X1. WAS CALLED AND A SITTER WAS REINSTITUTED. SBP 130-160'S. CIWA scale still >10.Cardiac: ST 100-110's, no ectopy. FOCUS; NURSING PROGRESS NOTE42 YEAR OLD GOING THROUGH ETOH WITHDRAWAL.REVEIW OF SYSTEMS-NEURO- PATIENT IS ORIENTED TO PERSON ONLY. Received 160mg valium until he became somulent. BP ranges 109-130's/60-70.Resp; Room air sats 97-100%, Lungs clear bil. neuro: a+o to person and place. MICU NPN Neuro: pt sedated, has recieved 280mg Valium IV today, last dose at 1830. motehr called x1. Abdomen soft with active bowel sounds, no stool this shift. Last dose 11/3 1830. initially extremely agitated and medicated with prn valium x2 for ciwa scale >10 with +efffect. CIWA scale 3 most of shift. HE BECAME QUITE AGGITATED WHEN VALIUM WAS HELD TO TRY HALDOL. AND THINKS IT IS 'S. He tried to leave AMA overnight and Code Purple was called. Foley to drainage with clear, amber urine, u/o 30-45cc/hour.ID; afebrileA: adequately sedated from previous shift IV Valium while in acute DTs.P: Cont to monitor neuro and CIWA scale, assess for further DTs, IV Valium as needed by CIWA. remains in 3 point restraints. DR HERE AT THE TIME AND WANTS THE PATIENT TO CONT ON VALIUM 10-29MG Q 10MIN PRN FOR CIWA > 10. ?IV: #18 in right AC. REPEAT TO BE DRAWN AT 1700.GI- ABD SOFT WITH POS BS. #20 angio placed on left hand and medicated w/Valium. K+ 3.4, received 40meq ivpb on this shift. Opened eyes briefly to nailbed pressure. +mae noted. RESP 16-21. MG WAS 1.8 TX WITH 2GMS MAG. LOWEST CIWA HAS BEEN 8.RESP- ON RA SATS HAVE BEEN 98-99%. fingersticks q 6hr. Arousable to name and sternal rub with a mumbling of incomprehensible sounds only. 35-50ml/hrSkin/ID: intact, afebrile. HE IS NPO. TX WITH 40MEQ IV KCL. CIWA scale remains >10 when awoken to assess CIWA scale. shift note 1900-700Events: Pt continues to withdrawal and active DT's, hallucinating, discorieted and aggitated. had witnessed seizure on admission in EW, no seizure activity this shift. denies sob or resp distress.gi: abd soft and nontender. Pt. Sitter present in room.CV: HR 54-60's SB/NSR, BP 108-130/60.ID: afebrile.A/P: Pt without need for further Valium over past 4 hrs, cont to monitor. Pt initially medicated w/5mg IM haldol as IV on right lower arm was infiltrated. remains on ra. DOWN TO THE 90'S WHEN CIWA 8. HE WAS ON VALIUM IV FOR CIWA > THAN 10 THIS AM. NEW IV PLACED THIS AM IN LEFT HAND WHICH PATIENT WAS ABLE TO GET OUT. pt updated on status and plan of care. Follow up with am labs, IVF when banana bag complete, remains NPO. cough/gag intact. VSS. HAS BEEN REORIENTED A NUMBER OF TIMES THIS AM. REPEAT 3.6. No vea noted. THINKS HE IS . oriented to self. replete electrolytes as needed. PSYCHE WAS BY AND FELT HE WAS BENZO TOXIC. SBP 140-150's. mouthcare x 2, but difficulty to do mouthcare, which pt needs. THE PATIENT HAS IN TOTAL RECEIVED 160MG OF VALIUM IV TODAY. NPO.GU: foley with clear amber urine. RR 16-20, sats 98% on RA, occ coughing. eye care given x 2, may have conjuntivitis? OLD ECCHYMOSIS ON LEFT THIGH. D5 1/2ns with 20 kcl infusing @ 120 cc/hr.i-d: afebrile.psy-soc: c/o medical floor awaiting bed. ON PPI.GU- FOLEY PATENT DRAINING AMBER CLEAR URINE AT 30-100CC/HR.SKIN- SKIN INTACT. Comfort and emotional support to Pt. K THIS AM WAS HEMOLYZED AT 5.5. pt non-complient and uncoorperative. Snoring at intervals.GI;GU; NPO, IVF with banana bag from previous shift at 100cc/hour. sedated, no N/V, tremors/seizures, no diaphoresis. Please see FHPA for further details. HE WAS SEDATED FOR A SHORT TIME AFTER THIS BUT 1.5 HOURS AFTER RECEIVING NO VALIUM HE HAD A CIWA OF 21. No cough. No N/V. lethargic most of shift but easily arousable. sitter at bedside.Neuro: confused and disoriented to event,place,time. Pt has had sitter at bedside since.Pt arrived to MICU via ambulance accompanied by sitter, disoriented, combative, profusly diaphoretic with auditory and visual hallucinations. receiving banana bag at 100ml/hr, and then d51/2 at 100ml/hr.Plan: continue to monitor for DT's, sedation PRN for pt's safety. SITTER WAS DC'D BY AS THIS NURSE HAD ONE PATIENT AND PATIENT WAS RELATIVELY CALM WHEN SHE WAS HERE. No audible or visual hallucinations noted. no stools this shift. no Nausea or vomiting. Not following commands. SHE STATES HE HAS WITHDRAWAL SEIZURES MULTIPLE TIMES IN THE PAST. NO STOOL TODAY. Pt in EW 21 hours then transfered to floor where he received large doses of valium as well as intermittent haldol to control his withdrawal symptoms of agitation, tremulousness, tachycardia and hypertension. no seizure activity.

7

[ { "category": "ECG", "chartdate": "2175-09-27 00:00:00.000", "description": "Report", "row_id": 202249, "text": "Baseline artifact\nSinus tachycardia\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284190, "text": "shift note 1900-700\nEvents: Pt continues to withdrawal and active DT's, hallucinating, discorieted and aggitated. Valium20 ivp given, total of at least 240mg ivp q shift. no seizure activity. remains in 3 point restraints. sitter at bedside.\n\nNeuro: confused and disoriented to event,place,time. oriented to self. hallucinating, seeing people in room, thinks he is at work,in the car, at the bar, ect. aggitated, but increasing becoming easier to communicate with patient and listens more throughout shift. unable to comprehend whereabouts and unable to keep oriented. speech comprehensible but slurred, will use profanity. had witnessed seizure on admission in EW, no seizure activity this shift. CIWA scale still >10.\n\nCardiac: ST 100-110's, no ectopy. SBP 140-150's. Replete MG on days with 4 grams, which bumped his mg level to 2.5. K+ 3.4, received 40meq ivpb on this shift. labs pending.\n\nResp: on RA, pulse ox 96-99%, lungs clear.\n\nGI/ENDO: abd soft,nontender,nondistended. bowel sounds +, no BM on this shift. fingersticks q 6hr. no Nausea or vomiting. NPO.\n\nGU: foley with clear amber urine. 35-50ml/hr\n\nSkin/ID: intact, afebrile. mouthcare x 2, but difficulty to do mouthcare, which pt needs. pt non-complient and uncoorperative. diaphoritic at times with DT'S. eye care given x 2, may have conjuntivitis??\n\nIV: #18 in right AC. receiving banana bag at 100ml/hr, and then d51/2 at 100ml/hr.\n\nPlan: continue to monitor for DT's, sedation PRN for pt's safety. replete electrolytes as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284191, "text": "FOCUS; NURSING PROGRESS NOTE\n42 YEAR OLD GOING THROUGH ETOH WITHDRAWAL.\nREVEIW OF SYSTEMS-\nNEURO- PATIENT IS ORIENTED TO PERSON ONLY. THINKS HE IS . AND THINKS IT IS 'S. HAS BEEN REORIENTED A NUMBER OF TIMES THIS AM. HE WAS ON VALIUM IV FOR CIWA > THAN 10 THIS AM. PSYCHE WAS BY AND FELT HE WAS BENZO TOXIC. HALDOL GIVEN 5MG IV X1. HE WAS SEDATED FOR A SHORT TIME AFTER THIS BUT 1.5 HOURS AFTER RECEIVING NO VALIUM HE HAD A CIWA OF 21. DR HERE AT THE TIME AND WANTS THE PATIENT TO CONT ON VALIUM 10-29MG Q 10MIN PRN FOR CIWA > 10. HE FEELS HE IS IN A MONITORED SETTING WITH GOOD O2 SATS ON RA. THE PATIENT HAS IN TOTAL RECEIVED 160MG OF VALIUM IV TODAY. LOWEST CIWA HAS BEEN 8.\nRESP- ON RA SATS HAVE BEEN 98-99%. RESP 16-21. BS CLEAR.\nCARDIAC- HR 100-ONE TWENTIES. DOWN TO THE 90'S WHEN CIWA 8. SBP 130-160'S. K THIS AM WAS HEMOLYZED AT 5.5. REPEAT 3.6. TX WITH 40MEQ IV KCL. MG WAS 1.8 TX WITH 2GMS MAG. REPEAT TO BE DRAWN AT 1700.\nGI- ABD SOFT WITH POS BS. NO STOOL TODAY. HE IS NPO. ON PPI.\nGU- FOLEY PATENT DRAINING AMBER CLEAR URINE AT 30-100CC/HR.\nSKIN- SKIN INTACT. OLD ECCHYMOSIS ON LEFT THIGH.\n MOTHER CALLED AND WAS UPDATED BY THIS NURSE. SHE STATES THAT THE PATIENT HAS BEEN DRINKING SINCE AGE 13. IF HE IS WORKING HE DOES WELL IF HE ISN'T WORKING HE DRINKS HEAVILY. SHE STATES HE HAS WITHDRAWAL SEIZURES MULTIPLE TIMES IN THE PAST. PATIENT HAD 1:1 SITTER THIS AM. SITTER WAS DC'D BY AS THIS NURSE HAD ONE PATIENT AND PATIENT WAS RELATIVELY CALM WHEN SHE WAS HERE. HE BECAME QUITE AGGITATED WHEN VALIUM WAS HELD TO TRY HALDOL. HE WAS ATTEMPTING TO CRAWL OOB. SWINGING LEGSOVER THE SIDERAIL. WAS CALLED AND A SITTER WAS REINSTITUTED. SITTER PRESENTLY AT BEDSIDE.\nPATIENT ALSO HAS SAFETY DEVICES ON WRISTS TO PREVENT HIM FROM PULLING AT TUBES AND LINES.\nACCESS- HAS RIGHT ANTECUB IV. NEW IV PLACED THIS AM IN LEFT HAND WHICH PATIENT WAS ABLE TO GET OUT. NEW IV PLACED RL POSTERIOR ARM.\nDISPO- REMAINS IN MICU FOR DT TX.\nPLAN- VALIUM 10-20MG IV Q 10MIN PRN CIWA > 10.\n" }, { "category": "Nursing/other", "chartdate": "2175-09-28 00:00:00.000", "description": "Report", "row_id": 1284192, "text": "MICU NPN \nNeuro: pt sedated, has recieved 280mg Valium IV today, last dose at 1830. Pt has been sleeping, snorring. RR 16-20, sats 98% on RA, occ coughing. Sitter present in room.\nCV: HR 54-60's SB/NSR, BP 108-130/60.\nID: afebrile.\nA/P: Pt without need for further Valium over past 4 hrs, cont to monitor. VSS.\n" }, { "category": "Nursing/other", "chartdate": "2175-09-29 00:00:00.000", "description": "Report", "row_id": 1284193, "text": "micu note 2300-0700\nS; incomprehensible, mumbling.\nO; Please see carevue for VS and objective data\nNeuro; Pt. adequately sedated from previous shift(s) IV Valium doses. Last dose 11/3 1830. CIWA scale 3 most of shift. Pt. sedated, no N/V, tremors/seizures, no diaphoresis. No audible or visual hallucinations noted. PERL, 2mm, sluggish. Arousable to name and sternal rub with a mumbling of incomprehensible sounds only. Opened eyes briefly to nailbed pressure. Not following commands. MICU team aware of level of sedation and last dose Valium. Soft hand restraints remain in place for safety of IVs. 1:1 sitter this shift.\nCVS; Hemodynamically stable with HR 50-60's, NSB/NSR. No vea noted. BP ranges 109-130's/60-70.\nResp; Room air sats 97-100%, Lungs clear bil. No cough. Snoring at intervals.\nGI;GU; NPO, IVF with banana bag from previous shift at 100cc/hour. Abdomen soft with active bowel sounds, no stool this shift. No N/V. Foley to drainage with clear, amber urine, u/o 30-45cc/hour.\nID; afebrile\nA: adequately sedated from previous shift IV Valium while in acute DTs.\nP: Cont to monitor neuro and CIWA scale, assess for further DTs, IV Valium as needed by CIWA. Follow up with am labs, IVF when banana bag complete, remains NPO. Comfort and emotional support to Pt. and family\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-29 00:00:00.000", "description": "Report", "row_id": 1284194, "text": "neuro: a+o to person and place. initially extremely agitated and medicated with prn valium x2 for ciwa scale >10 with +efffect. lethargic most of shift but easily arousable. pt with increased alertness this afternoon and more appropriate than in am. +mae noted. cough/gag intact. +perrla noted. 1:1 sitters d/c'd.\ncv: monitor shows sb-nsr with rare pvc noted.\nresp: ls coarse throughout. +prod cough thick yellow secretions. remains on ra. denies sob or resp distress.\ngi: abd soft and nontender. +bs noted. no stools this shift. tol sips of clears.\ngu: foley intact and patent. uo marginal...dr aware. D5 1/2ns with 20 kcl infusing @ 120 cc/hr.\ni-d: afebrile.\npsy-soc: c/o medical floor awaiting bed. motehr called x1. pt updated on status and plan of care.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-09-27 00:00:00.000", "description": "Report", "row_id": 1284189, "text": "Nursing Admit\n42 yo man w/history of alcohol abuse with history of DTs w/withdrawal seizures presents to MICU from 12 with escalating drug requirements for ETOH withdrawal.\nPt presented to EW via ambulance after witnessed seizure. Arrived in EW post ictal and had urinary incontinence. Treated w/IVF and IV ativan in EW, had - head CT and tox screen had zero ETOH level. Pt in EW 21 hours then transfered to floor where he received large doses of valium as well as intermittent haldol to control his withdrawal symptoms of agitation, tremulousness, tachycardia and hypertension. He tried to leave AMA overnight and Code Purple was called. Pt has had sitter at bedside since.\nPt arrived to MICU via ambulance accompanied by sitter, disoriented, combative, profusly diaphoretic with auditory and visual hallucinations. Pt initially medicated w/5mg IM haldol as IV on right lower arm was infiltrated. #20 angio placed on left hand and medicated w/Valium. Pt medicated as ordered with 10-30mg Valium IV according to CIWA scale. Received 160mg valium until he became somulent. CIWA scale remains >10 when awoken to assess CIWA scale. Please see FHPA for further details.\n\n" } ]

5,877

172,786

She was admitted to on for a Whipple Procedure. This was complicated by a Portal Vein injury with an estimated 2000cc blood loss. She received 6 Units of PRBCs. She was admitted to the SICU post-operatively and remained intubated. She was stable post-op and extubated the next morning.

Resp Care,Pt. Left lower lobe atelectasis is noted. FRONTAL CHEST RADIOGRAPH: Right IJ line is terminating in distal SVC. Nasogastric tube is seen terminating in the left upper quadrant. ABG WNL, see carevue. IMPRESSION: Tubes and lines as described above. Plan to extubate this am. Placed on SBT. Three small radiodense opacities in the upper abdomen, probably representing clips. Three small linear densities are seen, probably representing surgical clips. Drainage tube is noted, overlying the mid abdomen. Drainage tube is noted overlying the left upper quadrant. Nasogastric tube is coursing down below the left hemidiaphragm, with the tip in left mid quadrant. Cardiac and mediastinal contours are within normal limits. T wave abnormalities.Since the previous tracing of the rate is somewhat slower. TECHNIQUE: Portable abdominal radiograph. Comparison is made with the prior abdominal CT dated . Sinus tachycardia.. Borderline low limb lead voltage. Clinicalcorrelation is suggested. admitted from OR intubated #7.5 taped at 21@lip. Endotracheal tube is terminating 3 cm above the carina. TheQRS voltage is decreased and T wave abnormalities are more marked. IMPRESSION: Somewhat limited study. Tol well. 6:47 PM ABDOMEN (SUPINE ONLY) IN O.R. follows commandsCARDIO:hr 100-110'S; On neo for a short period, now off since 4am and SBP>100EKG unchanged post-opRESP:weaned to extubation by 4am; RSBI 25. pt awake and wanting tube outvery ready for extubation.GI/GU:good urine outsPOC:EXTUBATECONTINUE TO FOLLOW PATHWAY The evaluation is somewhat limited on this film which does not include the peripheral portion of the left abdomen. Clip # Reason: MISSING MATERIALS ? BS clear. awoke calm and moves all extremities. 8:16 PM CHEST PORT. Admitting Diagnosis: PANCREATIC CA/SDA FINAL REPORT INDICATION: 63-year-old woman with question missing material. No other radiodense foreign body. No other radiodense material is noted. No evidence of pneumothorax. condition updateS/P WHIPPLE PROCEDURE W/PORTAL BLEED.NEURO:sedated on propofol, given 2 doses of pain med and shut off propofol around 2am for more thorough neuro exam and vent wean. 4am RSBI 25, awake and alert. No evidence of pneumothorax is noted on this radiograph.

5

[ { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1339245, "text": "condition update\nS/P WHIPPLE PROCEDURE W/PORTAL BLEED.\nNEURO:\nsedated on propofol, given 2 doses of pain med and shut off propofol around 2am for more thorough neuro exam and vent wean. awoke calm and moves all extremities. follows commands\nCARDIO:\nhr 100-110'S; On neo for a short period, now off since 4am and SBP>100\nEKG unchanged post-op\nRESP:\nweaned to extubation by 4am; RSBI 25. pt awake and wanting tube out\nvery ready for extubation.\nGI/GU:\ngood urine outs\nPOC:\nEXTUBATE\nCONTINUE TO FOLLOW PATHWAY\n" }, { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1339246, "text": "Resp Care,\nPt. admitted from OR intubated #7.5 taped at 21@lip. BS clear. 4am RSBI 25, awake and alert. Placed on SBT. Tol well. Plan to extubate this am. ABG WNL, see carevue.\n" }, { "category": "ECG", "chartdate": "2103-09-27 00:00:00.000", "description": "Report", "row_id": 201016, "text": "Sinus tachycardia.. Borderline low limb lead voltage. T wave abnormalities.\nSince the previous tracing of the rate is somewhat slower. The\nQRS voltage is decreased and T wave abnormalities are more marked. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2103-09-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 934240, "text": " 8:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: sp whipple\n Admitting Diagnosis: PANCREATIC CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with panc ca\n REASON FOR THIS EXAMINATION:\n sp whipple\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with pancreatic cancer, status post Whipple\n procedure.\n\n FRONTAL CHEST RADIOGRAPH: Right IJ line is terminating in distal SVC.\n Endotracheal tube is terminating 3 cm above the carina. Nasogastric tube is\n coursing down below the left hemidiaphragm, with the tip in left mid quadrant.\n Drainage tube is noted, overlying the mid abdomen. No evidence of\n pneumothorax is noted on this radiograph. Cardiac and mediastinal contours\n are within normal limits. Left lower lobe atelectasis is noted.\n\n IMPRESSION: Tubes and lines as described above. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-27 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 934228, "text": " 6:47 PM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: MISSING MATERIALS ?\n Admitting Diagnosis: PANCREATIC CA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with question missing material.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n Comparison is made with the prior abdominal CT dated . The\n evaluation is somewhat limited on this film which does not include the\n peripheral portion of the left abdomen. Nasogastric tube is seen terminating\n in the left upper quadrant. Drainage tube is noted overlying the left upper\n quadrant. Three small linear densities are seen, probably representing\n surgical clips. No other radiodense material is noted.\n\n IMPRESSION: Somewhat limited study. Three small radiodense opacities in the\n upper abdomen, probably representing clips. No other radiodense foreign body.\n\n\n" } ]

55,973

164,256

Primary Reason for Hospitalization: 60F with PMH pancreatic and renal transplants, DM type II, diastolic CHF, HTN, and hypothyroidism, recently admitted for CHF exacerbation who presents with weakness, fevers, and hypotension suggestive of urosepsis.

Moderateregional LV systolic dysfunction. There is moderate regional left ventricular systolic dysfunction withakinesis of the apex and hypokinesis of the distal segments of the LV. There is a trivial/physiologicpericardial effusion. No echocardiographicsigns of tamponade.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium is mildly dilated. Traceaortic regurgitation is seen. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Left atrial abnormality. There is moderatepulmonary artery systolic hypertension. The left ventricular cavity is mildlydilated. Compared to tracing #1 sinustachycardia is absent.TRACING #2 Left bundle-branch block.Compared to the previous tracing of ST segment depression is lesspronounced in lead V6.TRACING #1 Possible left atrial abnormality. Mildly dilated LV cavity. INDICATION: Urosepsis with poor IV access. : (in) 67Weight (lb): 138BSA (m2): 1.73 m2BP (mm Hg): 86/43HR (bpm): 90Status: InpatientDate/Time: at 10:20Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is continued perihilar haziness with vascular indistinctness compatible with mild pulmonary edema. Moderate to severe (3+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Patchy opacities at the lung bases likely reflect atelectasis. Sinus tachycardia. Sinus tachycardia. Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH This is a power pick FINAL REPORT (Cont) The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cannot exclude LV mass/thrombus. The main renal artery and vein are patent with normal waveforms. Sinus rhythm. IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions, similar compared to the prior study. Perinephric fluid or hydronephrosis. OPERATORS: Drs. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Small bilateral pleural effusions are similar when compared to the prior study. The mediastinal and hilar contours are unchanged. Incorrectly transcribed PFI. Incorrectly transcribed PFI. The mitral valve leaflets are mildly thickened.Moderate to severe (3+) mitral regurgitation is seen. Under aseptic conditions and son guidance, a micropuncture needle was placed in the right basilic vein. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. The diameters ofaorta at the sinus, ascending and arch levels are normal. Mild to moderate [+] TR.Eccentric TR jet. IMPRESSION: 1. Resistive indices in the upper, mid and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively, previously ranging from 0.78 to 0.81. UPRIGHT AP VIEW OF THE CHEST: The heart size remains mildly enlarged. Timeout was performed as per protocol. The left atrium is elongated. FINAL REPORT PICC PLACEMENT. Tissue Doppler imagingsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Left bundle-branch block. Pulmonary pressures are worse. COMPARISON: . COMPARISON: . Leftventricular wall thicknesses are normal. Bibasilar air space opacities likely reflect atelectasis. REASON FOR THIS EXAMINATION: Please place PICC line. Wire was removed and sheath peeled away. Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH This is a power pick ********************************* CPT Codes ******************************** * PICC W/O PORT * * * **************************************************************************** MEDICAL CONDITION: 60 year old woman s/p pancreas and renal transplant w/ dCHF and CAD, p/w with urosepsis, and poor IV access. No AS. A 0.018 caliber wire was placed via the needle and advanced into the IVC. Appropriate dressing was applied. Appropriate measurements were made. , , and . Otherwise,no significant change. The tricuspidregurgitation jet is eccentric and may be underestimated. There are no echocardiographic signs of tamponade.Compared with the findings of the prior study (images reviewed) of ,the focal left ventricular dysfunction described above is new. Hypotension, fever. Rightventricular chamber size and free wall motion are normal. CONTRAST: None. A PICC was attempted to be placed over the wire via the peel-away sheath; however, we were unsuccessful in passing the catheter past the axillary - subclavian vein junction. 2. 2. 2. 2. 2. Status post pancreas and renal transplant. The degree ofmitral regurgitation has increased slightly. No acute osseous abnormalities are seen. TDI E/e'>15, suggesting PCWP>18mmHg. SEDATION: None. (Over) 2:23 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line.

8

[ { "category": "Radiology", "chartdate": "2181-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1202157, "text": " 9:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: The heart size remains mildly enlarged. The\n mediastinal and hilar contours are unchanged. There is continued perihilar\n haziness with vascular indistinctness compatible with mild pulmonary edema.\n Small bilateral pleural effusions are similar when compared to the prior\n study. Patchy opacities at the lung bases likely reflect atelectasis. No\n pneumothorax is present. No acute osseous abnormalities are seen.\n\n IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions,\n similar compared to the prior study. Bibasilar air space opacities likely\n reflect atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-08-06 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1202962, "text": " 2:23 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line.\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n This is a power pick\n ********************************* CPT Codes ********************************\n * PICC W/O PORT *\n * *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p pancreas and renal transplant w/ dCHF and CAD, p/w with\n urosepsis, and poor IV access.\n REASON FOR THIS EXAMINATION:\n Please place PICC line.\n ______________________________________________________________________________\n FINAL REPORT\n PICC PLACEMENT.\n\n OPERATORS: Drs. , , and . Dr.\n , attending physician was present throughout the procedure.\n\n INDICATION: Urosepsis with poor IV access. Status post pancreas and renal\n transplant.\n\n SEDATION: None.\n\n CONTRAST: None.\n\n PROCEDURE: Patient was placed supine on the imaging table in the\n interventional suite. Procedure was explained to the patient. Timeout was\n performed as per protocol.\n\n Under aseptic conditions and son guidance, a micropuncture needle was\n placed in the right basilic vein. A 0.018 caliber wire was placed via the\n needle and advanced into the IVC. The needle was exchanged over the wire with\n a peel-away sheath. Appropriate measurements were made. A PICC was attempted\n to be placed over the wire via the peel-away sheath; however, we were\n unsuccessful in passing the catheter past the axillary - subclavian vein\n junction. Multiple attempts were made with various catheters. Venogram was\n not performed due to renal insufficiency. We were subsequently successful in\n advancing a 4-French 34 cm Glidecath into the lower SVC. Wire was removed and\n sheath peeled away. Glidecath port was secured to the skin by a StatLock.\n Appropriate dressing was applied. The patient tolerated the procedure well\n and no immediate post-procedure complications were seen.\n\n IMPRESSION: Successful placement of a 34 cm 4-French C2 Glidecath via the\n right basilic vein with its tip in the lower SVC. Please note that multiple\n attempts were made to pass a standard 4-French PICC but were unsuccessful.\n Results were discussed with Dr. at around 5:10 p.m. on\n .\n (Over)\n\n 2:23 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line.\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n This is a power pick\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2181-08-01 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1202282, "text": " 3:00 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ?hydronephrosis\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hx DMI s/p renal tx/pancreatic tx, urosepsis, fever\n REASON FOR THIS EXAMINATION:\n ?hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): WED 9:13 PM\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n\n Incorrectly transcribed PFI. Correct read discussed with Dr. at 9 pm\n on via telephone.\n PFI VERSION #1 WED 4:39 PM\n 1. Perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with history of diabetes, status post renal\n transplant, urosepsis and fever.\n\n COMPARISON: .\n\n RENAL ULTRASOUND: The transplanted kidney measures 11.3 cm. No evidence of\n hydronephrosis or perinephric fluid collection. The main renal artery and\n vein are patent with normal waveforms. Resistive indices in the upper, mid\n and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively,\n previously ranging from 0.78 to 0.81.\n\n The bladder is collapsed about the Foley and could not be well evaluated in\n this study.\n\n IMPRESSION:\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n Findings discussed with Dr. at 9 pm on via telephone\n\n" }, { "category": "Radiology", "chartdate": "2181-08-01 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1202283, "text": "2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78. Page: 2\n\n , F 60 () \n , MED 3:00 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ?hydronephrosis\n Admitting Diagnosis: URINARY TRACT INFECTION;SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hx DMI s/p renal tx/pancreatic tx, urosepsis, fever\n REASON FOR THIS EXAMINATION:\n ?hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n 1. No perinephric fluid or hydronephrosis.\n 2. Resistive indices in the upper, mid and lower poles of the transplant\n kidney range from 0.75 to 0.78.\n\n Incorrectly transcribed PFI. Correct read discussed with Dr. at 9 pm\n on via telephone.\n\n" }, { "category": "Echo", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 63959, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension, fever.\n: (in) 67\nWeight (lb): 138\nBSA (m2): 1.73 m2\nBP (mm Hg): 86/43\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nregional LV systolic dysfunction. Cannot exclude LV mass/thrombus. TDI E/e'\n>15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nakinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nEccentric TR jet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is mildly\ndilated. There is moderate regional left ventricular systolic dysfunction with\nakinesis of the apex and hypokinesis of the distal segments of the LV. The\nremaining segments contract normally (LVEF = 35-40 %). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. The tricuspid\nregurgitation jet is eccentric and may be underestimated. There is moderate\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe focal left ventricular dysfunction described above is new. The degree of\nmitral regurgitation has increased slightly. Pulmonary pressures are worse.\n\n\n" }, { "category": "ECG", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 125673, "text": "Sinus rhythm. Left bundle-branch block. Compared to tracing #1 sinus\ntachycardia is absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2181-08-01 00:00:00.000", "description": "Report", "row_id": 125674, "text": "Sinus tachycardia. Possible left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing of ST segment depression is less\npronounced in lead V6.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2181-07-31 00:00:00.000", "description": "Report", "row_id": 125675, "text": "Sinus tachycardia. Left atrial abnormality. Left bundle-branch block.\nCompared to the previous tracing of heart rate is increased. Otherwise,\nno significant change.\n\n" } ]

20,680

166,134

1) Rhythm - The patient was shocked twice to convert him to A fib rhythm. He was put on a lidocaine drip at 2 mg/min and transferred to . His rhythm spontaneously converted to bradycardic sinus rhythm within 6 hours of arrival, and the lidocaine drip was discontined. He was put on heparin 6 hours post cardiac catheterization but this was discontinued within 6 hours as well, as the sinus rhythm continued. He remained borderline sinus bradycardic during the remainder of hospitalization, with rates from 45-60, but was asymptomatic. He was transferred to the VA for pacer/AICD placement. 2) Pump - Initial EF during catheterization was calculated at 28%. He was monitored overnight with a swan-ganz catheter, which showed slightly increased RA and pulmonary pressures (see cath report). This was removed in the morning before extubation. His EF was 35% by echocardiogram, which also showed a dilated LV. He was put on captopril 6.25 TID which can be titrated as tolerated. His BP was stable at 110's-130's the day of discharge. A CHF workup can be pursued at the VA including TSH, iron studies, SPEP/UPEP, and an HIV test. 3) Coronaries - He has no coronary artery disease by cardiac catheterization. 4) Neurological - His short term memory was decreased immediately post extubation, but improved gradually during hospitalization. It is presumably due to the transient cerebral hypoxia. It should be followed up. His long term memory was intact. 5) Respiratory - The patient was intubated by the EMS, and extubated the morning after admission without incident.

There is moderateglobal left ventricular hypokinesis. There is moderate global leftventricular hypokinesis. follows commands, otherwise neuro status per baseline.resp: 2l nc o2 to ra tol well, o2 sats stable. denies sob/distress.cv: hr in nsr to sinus brady, couple rare episodes of ectope, pvc's noted. Right ventricular chamber size is normal.There is borderline global right ventricular free wall hypokinesis. cont in sr w/good bp.p- cont. fx/pt updated on pt progress, yesterday's events and plan.a- s/p arrest with clean cs on cath, low ef. +BPPP. Extubated yesterday and hemodynamically stable since.EPS possibly todayPossible call out to floor k- 3.7, mg 1.9 both replaced. CLEAR SECRETIONS.CARDIAC: ON ADM. TO CCU HR 50-53 AFIB, NO ECTOPY. Foley patent and draining adequate amounts of CYU. 1/2NS 100CC/HR X5HRS GIVEN FOR POST-CATH FLUIDS.GI: NPO. ccu npno- id- afebrile to 99.1po.cv- hr 50-60s sr, occ 40s, no vea. SX FOR MIN. OGT IN PLACE FOR MEDS. PLACEMENT CONFIRMED BY CXR. BS CLEAR BUT DIMINISHED AT BASES. safety prec prn. VS stable upon transfer HR 40-60 SR SB. S/P VF arrest.Height: (in) 66Weight (lb): 160BSA (m2): 1.82 m2BP (mm Hg): 117/94HR (bpm): 60Status: InpatientDate/Time: at 10:58Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. bs present, belly soft, nt/nd. pulses palp dp/pt bilat. The patient has been extubated in the interval. Sinus bradycardiaLeft bundle branch blockSince pervious tracing, no significant change to monitor hr, bp, ryhthm. BS+. ~0430 BECAME HYPOTENSIVE WITH SBP 77. nursing prog. Left ventricular wall thicknesses arenormal. ABG 7.42/39/166/26 99%. hct 32.7. aline d/c'd this pm. FINDINGS: Single portable AP view of the chest shows successfully placed ETT in good position. Cardiomegaly with slight cardiac failure. Improved cardiomegaly. TO BE SEEN BY EP->PACER/AICD. about 1000cc day.gi- abd soft, no pain, pos. Hemodynamically stable overnight. Pt to CCU intubated, fully vent supported. HR 50-57 SB, NO ECTOPY.BP 97-129/55-76. Overall left ventricular systolic function ismoderately depressed.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. There is minimal linear atelectasis in the left retrocardiac region. NG tube is noted with its tip and side port past the GE junction. Denies difficulty breathing. Denies chest pain dizziness, or lightheadedness. venous sheath d/c'd this pm by fellow, r groin d+i. BP m120-130/40-60. Otherwise neuro intact. The leftventricular cavity is mildly dilated. VENOUS SHEATH & SWAN IN R. GROIN WHICH IS D&I. There is mild pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. DISTENDED. RSBI this am 25 when sedation decreased. The left ventricular cavity is mildly dilated. Groin CDI with palpable pulses distal. Sinus bradycardiaLeft bundle branch block ADMISSION NOTEMR. The mitral valve leaflets are structurally normal.There is mild pulmonary artery systolic hypertension. Overall left ventricular systolicfunction is moderately depressed. Since the previous tracingof no significant change. bowel sounds. LIDO 2MG GTT.PAD 15->10, C0 4.4->4.3, CI 2.2->2.15. Sinus bradycardia. The aorticvalve leaflets (3) appear structurally normal with good leaflet excursion andno aortic regurgitation. IMPRESSION: Successful placement of ETT. MAEs. U/O 100-200CC/HR->5-40CC/HR. Cuff leak present prior to extubatation. Little changes overnoc on vent, remained sedated. There is left ventricular enlargement with slight upper zone redistribution of pulmonary vascular markings. RR 12/12. Low grade temps. NOT FOLLOWING COMMANDS.RESP: ON VENT: 40%/TV 600/AC 12/PEEP 5. no residual effect from hypoxemia other than noted short term memory deficit. note significant short term memory deficit, becoming apparent throughout morning with pt. ABD. SL. npo after 12am.ms- forgetful, oriented to person, date, occ. ls clear bilat and to bases. Breath sound clear. O2 SAT 100%. NSR/SB with no ectopy noted. PATIENT/TEST INFORMATION:Indication: Left ventricular function. bp 120-140s/ this pm. TO BE SEEN BY EP.NEURO: SEDATED ON PROPOFOL 10-20MCG/KG. See flowsheet for further pt data.Plan: Extubate. Left bundle-branch block. Follow simple commands. O2 sat on RA 100%. CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier. reorient prn, repeat teaching as needed. repeats self in converstaion topics. "SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSsO-A/O/X/3. R. GROIN ARTERIAL SHEATH D/C'D BY FELLOW SHORTLY AFTER COMING TO CCU. Resp CarePt extubated with no stridor noted tol well with spo2 in the upper 90s on 50% coo aerosal. This may indicate slight cardiac failure. bp slightly hypertensive this am, pt refused dose of captopril this am, after discussion w/ Dr. pt willing to take med, given at 1500. trace edema to ble.gi/gu: had remained npo for tentative aicd placement, currently restarted on low sodium diet, tol well at present. had liquids, pudding, to solids, tol well. OFF BRIEFLY, MAE & EXTREMELY AGITATED. There is mild cardiac enlargement which has improved since the prior study. RESPIRATORY CARE:61 yo m adm to CCU s/p cath (after vfib arrest in field). HR DOWN TO 45.500CC NS BOLUS & ATROPINE .5MG GIVEN->SBP 90'S & HR 55. IMPRESSION: No evidence of congestive heart failure. noteneuro: alert, oriented x3, moving all extrem. MVO2 65->60%. The lungs are otherwise clear. GIVEN NS BOLUS FOR HYPOTENSION, & WATCHING U/O.ID: ABEBRILE.AM LABS PENDING.PLAN: WEAN->EXTUBATE(WILL HAVE TO BE DONE QUICKLY--VERY AGITATED WHEN AWAKE). PLEASE SEE FHP FOR DETAILS OF PMH & EVENTS OF CURRENT ADMISSION. NO STOOL.GU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. Tolerating POs well with good intake. Denies SOB chest discomfort over sternum probably due to defibrillation, chest compressions. No repeative questions or response noted. heparin/lido d/c'd in am.resp- propofol d/c'd and extubated this am to 50% face tent with bag 7.38,41,81. sats 95-100. u/o adeq, i+o pos. NPO after MN for possible EP study in morning. O2Sats > 95% on 2LNP.

13

[ { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533761, "text": " 1631\n\nPt transfered to hospital for evaluation and placement of AICD. Transfered via ALS ambulance crew. VS stable upon transfer HR 40-60 SR SB. BP m120-130/40-60. O2 sat on RA 100%. Denies SOB chest discomfort over sternum probably due to defibrillation, chest compressions. Denies chest pain dizziness, or lightheadedness. PG 1,2 Discharge summary and cath reports sent with ambulance crew to hospital. Patient aware of transfer and happy with plan.\n" }, { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533759, "text": "CCU NPN:\nS:\"I am very interested in research!\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSs\n\nO-A/O/X/3. Pleasant and cooperative with care. Asking appropriate questions. No repeative questions or response noted. Follow simple commands. MAEs. Otherwise neuro intact. Hemodynamically stable overnight. NSR/SB with no ectopy noted. Groin CDI with palpable pulses distal. Breath sound clear. O2Sats > 95% on 2LNP. Denies difficulty breathing. Foley patent and draining adequate amounts of CYU. Tolerating POs well with good intake. NPO after MN for possible EP study in morning. Low grade temps. On no current abx treatment.\nSister visiting for most evening going home. Contact numbers for daughter and sister in room.\n\nA/P: 61 yo s/p vf arrest with defibrillation times two to NSR and intubated. Extubated yesterday and hemodynamically stable since.\n\nEPS possibly today\nPossible call out to floor\n" }, { "category": "Nursing/other", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 1533760, "text": "nursing prog. note\nneuro: alert, oriented x3, moving all extrem. note significant short term memory deficit, becoming apparent throughout morning with pt. follows commands, otherwise neuro status per baseline.\n\nresp: 2l nc o2 to ra tol well, o2 sats stable. ls clear bilat and to bases. denies sob/distress.\n\ncv: hr in nsr to sinus brady, couple rare episodes of ectope, pvc's noted. bp slightly hypertensive this am, pt refused dose of captopril this am, after discussion w/ Dr. pt willing to take med, given at 1500. trace edema to ble.\n\ngi/gu: had remained npo for tentative aicd placement, currently restarted on low sodium diet, tol well at present. bs present, belly soft, nt/nd. foley patent for concentrated yellow urine, qs, catheter d/c'd at 1500.\n\nendo: bg stable, no insulin coverage needed.\n\nid: afebrile, wbc stable.\n\nsocial: daughter present, friends in to visit. case mgmt in to discuss plans for transfer to VA facility this afternoon/evening if bed available, insurance/veterans benefits situation resolved.\n\na/p: pt s/p vf arrest, doing well at present. no residual effect from hypoxemia other than noted short term memory deficit. continue monitoring as per protocol, plan for aicd placement at va facility within next couple days after hopeful transfer tonight.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533755, "text": "ADMISSION NOTE\nMR. IS A 61 YR OLD SELECTMAN WHO HAD A VFIB ARREST AT THE TOWN MEETING LAST EVENING. PLEASE SEE FHP FOR DETAILS OF PMH & EVENTS OF CURRENT ADMISSION. DIRECT ADMISSION TO CATH LAB->NL CORONARIES WITH EF~30%. TO BE SEEN BY EP.\n\nNEURO: SEDATED ON PROPOFOL 10-20MCG/KG. OFF BRIEFLY, MAE & EXTREMELY AGITATED. NOT FOLLOWING COMMANDS.\n\nRESP: ON VENT: 40%/TV 600/AC 12/PEEP 5. ABG 7.42/39/166/26 99%. MVO2 65->60%. RR 12/12. O2 SAT 100%. BS CLEAR BUT DIMINISHED AT BASES. SX FOR MIN. CLEAR SECRETIONS.\n\nCARDIAC: ON ADM. TO CCU HR 50-53 AFIB, NO ECTOPY. ~0145 HAD ~4.5 SEC.\nPAUSE, THEN CONVERTED TO SR AT RATE OF 50. HR 50-57 SB, NO ECTOPY.\nBP 97-129/55-76. ~0430 BECAME HYPOTENSIVE WITH SBP 77. HR DOWN TO 45.\n500CC NS BOLUS & ATROPINE .5MG GIVEN->SBP 90'S & HR 55. LIDO 2MG GTT.\nPAD 15->10, C0 4.4->4.3, CI 2.2->2.15. R. GROIN ARTERIAL SHEATH D/C'D BY FELLOW SHORTLY AFTER COMING TO CCU. VENOUS SHEATH & SWAN IN R. GROIN WHICH IS D&I. NO EVIDENCE BLEEDING/HEMATOMA. +BPPP. 1/2NS 100CC/HR X5HRS GIVEN FOR POST-CATH FLUIDS.\n\nGI: NPO. OGT IN PLACE FOR MEDS. PLACEMENT CONFIRMED BY CXR. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 100-200CC/HR->\n5-40CC/HR. GIVEN NS BOLUS FOR HYPOTENSION, & WATCHING U/O.\n\nID: ABEBRILE.\n\nAM LABS PENDING.\n\nPLAN: WEAN->EXTUBATE(WILL HAVE TO BE DONE QUICKLY--VERY AGITATED WHEN AWAKE).\n TO BE SEEN BY EP->PACER/AICD.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533756, "text": "RESPIRATORY CARE:\n\n61 yo m adm to CCU s/p cath (after vfib arrest in field). Pt to CCU intubated, fully vent supported. Little changes overnoc on vent, remained sedated. RSBI this am 25 when sedation decreased. See flowsheet for further pt data.\nPlan: Extubate.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533757, "text": "Resp Care\nPt extubated with no stridor noted tol well with spo2 in the upper 90s on 50% coo aerosal. Cuff leak present prior to extubatation.\n" }, { "category": "Nursing/other", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 1533758, "text": "ccu npn\no- id- afebrile to 99.1po.\ncv- hr 50-60s sr, occ 40s, no vea. bp 120-140s/ this pm. k- 3.7, mg 1.9 both replaced. hct 32.7. aline d/c'd this pm. venous sheath d/c'd this pm by fellow, r groin d+i. pulses palp dp/pt bilat. echo done in am, ef 35%, etc. heparin/lido d/c'd in am.\nresp- propofol d/c'd and extubated this am to 50% face tent with bag 7.38,41,81. sats 95-100. u/o adeq, i+o pos. about 1000cc day.\ngi- abd soft, no pain, pos. bowel sounds. no n/v, no bm. had liquids, pudding, to solids, tol well. npo after 12am.\nms- forgetful, oriented to person, date, occ. hard time remembering what hospital he is in. repeats self in converstaion topics. mae.\nsocial- fx in, sister, then dtr and her fx. fx/pt updated on pt progress, yesterday's events and plan.\na- s/p arrest with clean cs on cath, low ef. cont in sr w/good bp.\np- cont. to monitor hr, bp, ryhthm. reorient prn, repeat teaching as needed. safety prec prn. npo after 12am, ?eps, ?icd tomorrow.\n\n" }, { "category": "Echo", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 76911, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P VF arrest.\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nBP (mm Hg): 117/94\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:58\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. There is moderate global left\nventricular hypokinesis. Overall left ventricular systolic function is\nmoderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. There is moderate\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is moderately depressed. Right ventricular chamber size is normal.\nThere is borderline global right ventricular free wall hypokinesis. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve leaflets are structurally normal.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841047, "text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for acute cardiopulmonary process\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p V.fib arrest, clean coronary arteries with increased sob\n\n REASON FOR THIS EXAMINATION:\n assess for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P VIFB arrest with increased shortness of breath.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier.\n The patient has been extubated in the interval. The Swan-Ganz catheter has\n also been removed as has the nasogastric tube. There is mild cardiac\n enlargement which has improved since the prior study. There is minimal linear\n atelectasis in the left retrocardiac region. The lungs are otherwise clear.\n There is no evidence of congestive heart failure.\n\n IMPRESSION: No evidence of congestive heart failure. Improved cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2112-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 840862, "text": " 11:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate tube placement, for infiltrate, CHF\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p V.fib arrest, clean coronary arteries\n REASON FOR THIS EXAMINATION:\n please evaluate tube placement, for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P V-FIB arrest, evaluate tube placement.\n\n COMPARISON: None.\n\n FINDINGS: Single portable AP view of the chest shows successfully placed ETT\n in good position. There is left ventricular enlargement with slight upper zone\n redistribution of pulmonary vascular markings. This may indicate slight\n cardiac failure. A transfemoral Swan-Ganz catheter is seen with its tip in the\n pulmonary artery trunk. NG tube is noted with its tip and side port past the\n GE junction. The osseous structures are unremarkable.\n\n IMPRESSION: Successful placement of ETT. Cardiomegaly with slight cardiac\n failure.\n\n" }, { "category": "ECG", "chartdate": "2112-09-01 00:00:00.000", "description": "Report", "row_id": 183989, "text": "Sinus bradycardia. Left bundle-branch block. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 183990, "text": "Sinus bradycardia\nLeft bundle branch block\nSince pervious tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2112-08-31 00:00:00.000", "description": "Report", "row_id": 183991, "text": "Sinus bradycardia\nLeft bundle branch block\n\n" } ]

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The tube was sutured in place with 0-Prolene. Mild (1+) mitral regurgitationis seen. Mild(1+) aortic regurgitation is seen. The right brachial vein was selected for venipuncture. Focal calcifications in aortic root.Mildly dilated ascending aorta. Atrial fibrillation with a controlled ventricular response. The intravascular length of the catheter was determined. Borderline PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. The catheter and puncture access site were overlaid with a Tegaderm occlusive dressing. Ultrasound was used to identify right brachial vein, which was patent and compressible. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 68Weight (lb): 150BSA (m2): 1.81 m2BP (mm Hg): 150/76HR (bpm): 62Status: InpatientDate/Time: at 15:52Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The ascending aorta is mildly dilated. Underlying rhythm is atrial fibrillation. Catheter is ready to employ. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Atrial fibrillation. Probable underlying atrial fibrillation.Compared to the previous tracing of no diagnostic change. There isborderline pulmonary artery systolic hypertension. Under ultrasound guidance, right brachial vein was punctured, and 0.018-guidewire was inserted over the needle. The mitral valve leaflets are mildlythickened. Mild thickening of mitral valve chordae. The aortic root ismoderately dilated. Right upper arm was prepped and draped in usual sterile fashion. Pre- and post-ultrasound images obtained. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's anterior abdominal wall was prepped and draped in a sterile fashion. Calcified tipsof papillary muscles. The guide wire was advanced by way of the access needle and steered to the superior vena cava under fluoroscopic visualization. Tip position is in caudal superior vena cava. Atrial fibrillation with underlying left bundle-branch block and secondaryST-T wave abnormalities. Once satisfactory positioning was confirmed, both lumens of the catheter were flushed and heparin locked. Mild mitralannular calcification. This demonstrated the gastric remnant to be of decent size and directly below the anterior abdominal wall. Baseline artifactVentricular paced rhythmUnderlying atrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change The catheter was tailored at the 37-cm mark and delivered using modified Seldinger technique to the level of the caudal superior vena cava. Insufflation of the patient's current NG tube was performed in conjunction with review of a recent CT scan. NURSING VSS, AFEBRILE OVERNIGHT. 11:18 AM PICC LINE PLACMENT SCH Clip # Reason: please place PICC Admitting Diagnosis: ILEUS,ABDOMINAL PAIN ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. OPERATORS: , M.D. A catheter or pacing wire isseen in the RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Compared to theprevious tracing of ventricular pacing is no longer present. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root. Once the above were accomplished, the patient was positioned in supine fashion on a special procedures/angiography table with the right arm abducted and externally rotated. Bipap weaned to off, and placed on face mask and 02 weaning. The right arm in turn was prepped and draped from the axilla to the antecubital fossa. The proximal port which is for gastric aspiration, was left within the gastric remnant, the distal port, 80 cm in the efferent limb for tube feeding. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF 60%). The line was finally StatLocked. Focal calcifications in ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Final catheter length is 37 cm. Normal tricuspidvalve supporting structures. Uneventful one- wall venipuncture was achieved under ultrasound guidance using a 21-gauge micropuncture needle. The final fluoroscopic image was obtained to confirm the location of the line. Left bundle-branch blockwith secondary ST-T wave abnormalities. wire and Kumpe catheter were used to manipulate into the patient's efferent loop. Atrial sensed ventricular pacedNo previous tracing available for comparison Needs PICC and TPN. Needs PICC and TPN. FINAL REPORT HISTORY: Gastric outlet obstruction in a patient with a Billroth II procedure. MD aware of 5.4 K. skin intact. MORPHINE GTT STARTED, ANTIBIOTICS DC'D, VENODYNES REMOVED, O2 APPLIED WITH NASAL CANNULA FOR PATIENT COMFORT. K 5.4 (up from ), kayexalate given as ordered. , M.D. DR. IV access required for TPN and blood draws. TITRATE MORPHINE GTT TO PATIENT COMFORT. bolused x2, lasix given on floor. Atrial sensed ventricular pacedSince previous tracing of , no significant change Atrial fibrillation with a rapid ventricular response. Responsive only to pain and with transfer to bed. IN AND SPOKE WITH PATIENTS HEALTH CARE PROXY. This loop was confirmed both with contrast and passage of a 150-cm wire. The catheter-wire combination were manipulated approximately 100 cm into the efferent limb, after which the wire was exchanged for an Amplatz wire. Underlying leftbundle-branch block and secondary ST-T wave abnormalities. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Please place GJ tube. Tourniquet was applied to the upper arm. REASON FOR THIS EXAMINATION: please place GJ tube tube with G port to vent stomach & J port into efferent jejnual limb for tube feedings... Needle was exchanged with peel-away sheath, and 31 cm 5 French double lumen PICC line was inserted over the wire using flouroscopic guidance, with the tip terminating in distal SVC. IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this patient's gastric remnant, proximal port within the remnant, distal port approximately 80 cm within the efferent limb in this patient who is status post a Billroth II procedure. REASON FOR THIS EXAMINATION: Please place PICC FINAL REPORT PROCEDURE: 5 French dual-lumen PICC line placement via right brachial vein approach.

18

[ { "category": "Echo", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 105314, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 150\nBSA (m2): 1.81 m2\nBP (mm Hg): 150/76\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 15:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Mild to moderate [+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 60%). No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2189-09-08 00:00:00.000", "description": "Report", "row_id": 309881, "text": "Ventricularly paced rhythm at 60 beats per minute with probable underlying\natrial fibrillation. Compared to the previous tracing of the\nventricular pacing is new.\n\n\n" }, { "category": "ECG", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 309882, "text": "Atrial fibrillation with underlying left bundle-branch block and secondary\nST-T wave abnormalities. No change compared to the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2189-08-31 00:00:00.000", "description": "Report", "row_id": 309883, "text": "Atrial fibrillation with a controlled ventricular response. Underlying left\nbundle-branch block and secondary ST-T wave abnormalities. Compared to the\nprevious tracing of ventricular pacing is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2189-09-22 00:00:00.000", "description": "Report", "row_id": 309877, "text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch block\nwith secondary ST-T wave abnormalities. Compared to the previous tracing\nof no change.\n\n" }, { "category": "ECG", "chartdate": "2189-09-18 00:00:00.000", "description": "Report", "row_id": 309878, "text": "Atrial fibrillation. Left bundle-branch block. Compared to the previous tracing\nthe paced rhythm is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2189-09-14 00:00:00.000", "description": "Report", "row_id": 309879, "text": "Baseline artifact\nVentricular paced rhythm\nUnderlying atrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2189-09-13 00:00:00.000", "description": "Report", "row_id": 309880, "text": "Ventricular paced rhythm. Underlying rhythm is atrial fibrillation. Compared to\nthe previous tracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2189-08-28 00:00:00.000", "description": "Report", "row_id": 310092, "text": "Ventricularly paced rhythm, rate 60. Probable underlying atrial fibrillation.\nCompared to the previous tracing of no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2189-08-28 00:00:00.000", "description": "Report", "row_id": 310093, "text": "Atrial fibrillation with ventricular pacing, rate 60. Since the previous\ntracing of the technical artifacts are improved. Positional changes are\nnoted, particularly over the lateral precordium.\n\n" }, { "category": "ECG", "chartdate": "2189-08-27 00:00:00.000", "description": "Report", "row_id": 310094, "text": "Atrial sensed ventricular paced\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2189-08-26 00:00:00.000", "description": "Report", "row_id": 310095, "text": "Atrial sensed ventricular paced\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2189-09-17 00:00:00.000", "description": "GUID WIRES INCL INF", "row_id": 930437, "text": " 2:32 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please place GJ tube tube with G port to vent stomach & J po\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 30CC\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86M s/p bilroth 2, with delayed gastric emptying & need for feeding tube.\n REASON FOR THIS EXAMINATION:\n please place GJ tube tube with G port to vent stomach & J port into efferent\n jejnual limb for tube feedings...\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gastric outlet obstruction in a patient with a Billroth II\n procedure. Please place GJ tube.\n\n TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's\n anterior abdominal wall was prepped and draped in a sterile fashion.\n Insufflation of the patient's current NG tube was performed in conjunction\n with review of a recent CT scan. This demonstrated the gastric remnant to be\n of decent size and directly below the anterior abdominal wall. Hence, after\n insufflation, two T-fasteners were placed along the greater curvature of the\n stomach, after which the Seldinger technique was used to place a 5 French\n sheath within the gastric remnant lumen. wire and Kumpe catheter\n were used to manipulate into the patient's efferent loop. This loop was\n confirmed both with contrast and passage of a 150-cm wire. The catheter-wire\n combination were manipulated approximately 100 cm into the efferent limb,\n after which the wire was exchanged for an Amplatz wire. -Coons\n gastrojejunostomy tube was shortened (regularly 100 cm, shortened to\n approximately 80 cm) with additional sideholes placed and then advanced into\n the efferent limb after tract dilatation. The proximal port which is for\n gastric aspiration, was left within the gastric remnant, the distal port, 80\n cm in the efferent limb for tube feeding. The tube was sutured in place with\n 0-Prolene. As well, it contains a mushroom tip for internal anchoring.\n\n IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this\n patient's gastric remnant, proximal port within the remnant, distal port\n approximately 80 cm within the efferent limb in this patient who is status\n post a Billroth II procedure. No complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-08-27 00:00:00.000", "description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)", "row_id": 927850, "text": " 11:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: POOR ACCESS, NEEDS TPN AND LAB DRAWS\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with poor nutrition for 14 days. Needs PICC and TPN.\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 5 French dual-lumen PICC line placement via right brachial vein\n approach.\n\n CLINICAL HISTORY: 86-year-old man with poor nutrition. IV access required\n for TPN and blood draws.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were accomplished, the patient was positioned in\n supine fashion on a special procedures/angiography table with the right arm\n abducted and externally rotated. The right arm in turn was prepped and draped\n from the axilla to the antecubital fossa. Tourniquet was applied to the upper\n arm. Ultrasound was used to assess the veins of the upper arm. The right\n brachial vein was selected for venipuncture. The skin was infiltrated with\n approximately 2-3 cc of 1% Xylocaine for local anesthesia. Uneventful one-\n wall venipuncture was achieved under ultrasound guidance using a 21-gauge\n micropuncture needle. (Hard copy son images of the venipuncture were\n obtained in hard copy fashion.) The guide wire was advanced by way of the\n access needle and steered to the superior vena cava under fluoroscopic\n visualization. The intravascular length of the catheter was determined. The\n catheter was tailored at the 37-cm mark and delivered using modified Seldinger\n technique to the level of the caudal superior vena cava. Once satisfactory\n positioning was confirmed, both lumens of the catheter were flushed and\n heparin locked. The catheter was statlocked and positioned for security. The\n catheter and puncture access site were overlaid with a Tegaderm occlusive\n dressing. The patient tolerated the procedure well. No immediate\n complications were encountered. Estimated blood loss was minimal.\n\n IMPRESSION:\n 1. Status post successful placement of 5 French dual-lumen PICC line via\n right brachial vein approach. Final catheter length is 37 cm. Tip position\n is in caudal superior vena cava. Catheter is ready to employ.\n\n\n\n (Over)\n\n 11:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: POOR ACCESS, NEEDS TPN AND LAB DRAWS\n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)", "row_id": 928586, "text": " 11:18 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC \n Admitting Diagnosis: ILEUS,ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with poor nutrition for 14 days. Needs PICC and TPN.\n\n REASON FOR THIS EXAMINATION:\n please place PICC \n ______________________________________________________________________________\n FINAL REPORT\n\n 1\n INDICATION: 86-year-old male with poor nutrition.\n\n RADIOLOGIST: Drs. and , the attending\n radiologist, who was present throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography table.\n Right upper arm was prepped and draped in usual sterile fashion. Ultrasound\n was used to identify right brachial vein, which was patent and compressible.\n Pre- and post-ultrasound images obtained. Under ultrasound guidance, right\n brachial vein was punctured, and 0.018-guidewire was inserted over the needle.\n Needle was exchanged with peel-away sheath, and 31 cm 5 French double lumen\n PICC line was inserted over the wire using flouroscopic guidance, with the tip\n terminating in distal SVC. Peel-away sheath is removed, the wire is removed.\n The line was flushed, capped, and heplocked. The line was finally StatLocked.\n The final fluoroscopic image was obtained to confirm the location of the line.\n The patient tolerated the procedure without any immediate complication. The\n line is ready for use.\n\n IMPRESSION: Successful placement of 31 cm 5 French double lumen PICC line\n with the tip terminating in distal SVC from right brachial vein. The line is\n ready for use.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-22 00:00:00.000", "description": "Report", "row_id": 1437453, "text": "nursing note\nPt admitted from 10 after being found unresponsive and nt suctioned for fecal contents. Pt admitted and placed on bipap mask secodnary to o2sat's in 80's. Responsive only to pain and with transfer to bed. LS coarse, suctioned for thick brown fecal smelling contents. Bipap weaned to off, and placed on face mask and 02 weaning. o2 sat 97% on 80%fio2. , NGT to lws with brown fecal smelling contents. abd soft,nt. JT clamped, GT to gravity with brown fecal smelling output. foley patent dark yellow urine, minimal output, urine lytes sent. bolused x2, lasix given on floor. K 5.4 (up from ), kayexalate given as ordered. MD aware of 5.4 K. skin intact. Family spoke with MD and reiterated DNR/DNI, plan to await rest of family beofre making further decisions.\n\nPLAN:Bipap prn, wean o2, monitor I+O, DNR/DNI, monitor lytes.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-23 00:00:00.000", "description": "Report", "row_id": 1437454, "text": "NURSING\n VSS, AFEBRILE OVERNIGHT. FAMILY IN ATTENDENCE ALL NIGHT AT BEDSIDE. ALL GRANDCHILDREN ARRIVED BY MIDNIGHT. DR. IN AND SPOKE WITH PATIENTS HEALTH CARE PROXY. DNR/ CHANGED TO CMO STATUS AT MIDNIGHT. MORPHINE GTT STARTED, ANTIBIOTICS DC'D, VENODYNES REMOVED, O2 APPLIED WITH NASAL CANNULA FOR PATIENT COMFORT. PATIENT HAD COMPLAINED OF PAIN PRIOR TO GTT BEING STARTED, GTT STARTED AT 5 MG/HR. CURRENTLY REMIANING AT 5. APPEARS COMFORTABLE, MINIMAL RESPONSE TO STIMULI, OPENS EYES WHEN TURNED. PACER CONTINUES TO PACE A NORMAL SINUS RHYTHM WITH FREQUENT PACED BEATS AND OCCASIONAL PAC'S.PACER IS ATRIAL SENSED, VENTRICULAR PACED, SET AT A RATE OF 60.\n CONTINUE TO PROVIDE COMFORT MEASURES, SUPPORT TO FAMILY. TITRATE MORPHINE GTT TO PATIENT COMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-23 00:00:00.000", "description": "Report", "row_id": 1437455, "text": "Pt expired with family at bedside. Emotional support was given throughout the shift.\n" } ]

12,838

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1. GI: The patient presented with coffee ground emesis. She was initially guaiac negative in the Emergency Room but on transfer to the floor developed melena. On the following morning she was found to be with persistent melena and hypotensive with a blood pressure to 60/40, heart rate was 80 and her mental status had declined. She was transfused and then transferred to the MICU for further management and discussion of GI work-up. The GI team was consulted and it was decided that she would undergo an EGD when hemodynamically stable. Later that evening she developed acute respiratory distress. Chest x-ray showed an opacification in the left lung. Her arterial blood gases were consistent with a severe respiratory acidosis. The patient had stated clearly, prior to this event, that she wished to be DNR, DNI and the situation was also discussed with her power of attorney, who was in at the time. C-PAP was attempted but did not lead to an improvement in her symptoms. After discussions between the MICU team and the patient's daughter, it was decided to move to comfort measures only. The patient subsequently passed away on at 1:50 a.m. , M.D. Dictated By: MEDQUIST36 D: 13:53 T: 16:47 JOB#:

A nasogastric tube has been removed in the interval. There is interval removal of NG tube. Interval removal of NG tube. Sinus rhythmPossible inferior infarct, age indeterminateSince last ECG, increased anterolateral ST-T abnormalities There is some patchy alveolar opacity in the left mid lung zone centrally. FINAL REPORT HISTORY: Acute ventilatory failure. There is interval worsening of consolidation in the left base, obscuring the left hemidiaphragm. Sinus rhythmPossible inferior myocardial infarctInferolateral ST-T abnormalities less markedSince last ECG, , no significant change CLINICAL INDICATION: Decreased oxygen saturation. There is interval decrease in diffuse granular opacities throughout both lungs and slight interval decrease in bilateral pleural effusions. 3) Probable small left pleural effusion. HR/BP dropping quickly and pronounced by resident at 0120. grandaughter called. out of sync with mask vent and placed on NRB. dopa d/c'd. The distal most aspect of the intramedullary nail is not imaged. The right lung is clear except for discoid atelectasis at the right base. Diffuse pulmonary edema is resolved. However, a focal area of consolidation in the left mid lung is unchanged. stat CXR done, ABG 6.86/PO2 47. pt. There has been interval development of complete collapse of the left lower lobe. IMPRESSION: 1) Interval development of complete collapse of left lower lobe. at 2230 slightly less responsive but still with good air movement, responding to name. Minimal scarring or linear atelectasis in the right base. less responsive again, brady to 50, BP drop to 60/. Right internal jugular central venous catheter is again noted. taken off mask vent. There is moderate prominence of ventricles and sulci consistent with moderate brain atrophy. The cardiomediastinal silhouette is within normal limits. IMPRESSION: Moderate brain atrophy, otherwise negative study. discussed with resident, taken off mask to NRB for comfort. and ambu bag , given NS IVB. Pts O2 sat decreasing, abg very poor, Pt placed on bipap with 20 PS; causing Pts BP to drop. Question aspiration pneumonia in LLL.GI: Pts abd con't to be firm, with melena stool'sGU: Poor urine ouptutID: Pt started on Levo and flagyl for ? attending aware and in agreement.- at 0100, MSO4 gtt started at 2mg/hr. ABG on NRB: 7.18/46/101 at 2200. check on pt. Noted is dextroscoliosis of the thoracic spine, associated with degenerative disc disease of thoracic spine. 1:38 PM CT HEAD W/O CONTRAST Clip # Reason: s/p fall with injury to hip. Today while being disimpacted, passed large black tarry stool and dropped bp to 60/40, given 2L bolus of NS and 1U prbc and bp ^ 85 sys. mental status changes FINAL REPORT CLLINICAL INFORMATION: Status post fall with hip injury now with mental status changes. Recommend repeat film to exclude injury involving the distal aspect of nail. also given .2mg flumazenil IV in case of prolonged effects of sedation given earlier today. NBP found to be 10-15pts > than aline: 90/50 MAP 66. dopa weaned to 17mcq.ABG on 15 PS/5peep: 7.24/42/91. The aorta is calcified and tortuous. IMPRESSION: Healing right intertrochanteric fracture. Status post transfusion, assess for pulmonary edema. decesion made to place back on PS.- at 2300, placed back on CPAP , pt. Pt started on Dopa @ 4mcg with a bp ^ high 80-90;s.Pt then had CVL and ALINE placed which thereafter scoped at bedisde. patient with oxygen decompensation not a candidate for intubation placed on face-mask 15/5-1.0. Suspect pneumonia (vs. less likely atelectasis) in the left mid lung and left lung base. Dopa in creased to 12mcg, currently.Pt is DNR/DNI.PLAN:Continue to monitor BP and resp statusEGD showed "Kissing duodenal ulcer" plan for tx IV protonix and serum H-pyloriSerial H/H q6h HR 70's SR, BP 60-80's/50. 11:11 PM CHEST (PORTABLE AP) Clip # Reason: poor air movement and desaturation on CPAP MEDICAL CONDITION: 89 year old woman with above, requesting CXR for further eval REASON FOR THIS EXAMINATION: poor air movement and desaturation on CPAP FINAL REPORT Portable chest obtained compared to previous study earlier the same day. Pt to continued to pass tarry stools which then turned maroon in color and transferred here for bp support.PMH: NHL (s/p Xrt to neck),HTN, Hyperthyroidism, R hip fx w/ hip screw placement x 1 MONTH AGOCCU COURSE: Pt tx to CCU alert and confused but following commands. There is probably a small left pleural effusion present as well. 12:18 AM CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # Reason: 89 yo female with acute ventilatory failure. During procedure given 0.5mg of versed intially and another 0.5mg as pt became more agitated. pneumonia. DR. . Addendum to CCU Admittion noteNeuro: Pt becoming much more awake and aggitated.Cardiac: Pt remains on 12 mcg dopa to keep maps >60. Serial H&H, next at .Resp: Pt Remains on bipap with ABG's greatly improving! ABG metabolic acidosis will switch patient intermittently from mask ventilation to non rebreathe mask.

11

[ { "category": "ECG", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 298536, "text": "Sinus rhythm\nPossible inferior myocardial infarct\nInferolateral ST-T abnormalities less marked\nSince last ECG, , no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-11-07 00:00:00.000", "description": "Report", "row_id": 298750, "text": "Sinus rhythm\nPossible inferior infarct, age indeterminate\nSince last ECG, increased anterolateral ST-T abnormalities\n\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430943, "text": "Addendum to CCU Admittion note\nNeuro: Pt becoming much more awake and aggitated.\n\nCardiac: Pt remains on 12 mcg dopa to keep maps >60. Serial H&H, next at .\n\nResp: Pt Remains on bipap with ABG's greatly improving! Question aspiration pneumonia in LLL.\n\nGI: Pts abd con't to be firm, with melena stool's\n\nGU: Poor urine ouptut\n\nID: Pt started on Levo and flagyl for ? pneumonia.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430944, "text": "patient with oxygen decompensation not a candidate for intubation placed on face-mask 15/5-1.0. ABG metabolic acidosis will switch patient intermittently from mask ventilation to non rebreathe mask.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-09 00:00:00.000", "description": "Report", "row_id": 1430945, "text": "CCU NPN 1900-\nO: SBP 70/40 initially via radial aline at 1900. per team, dopa increased up to 20mcq to maintain MAPS >60. NBP found to be 10-15pts > than aline: 90/50 MAP 66. dopa weaned to 17mcq.\nABG on 15 PS/5peep: 7.24/42/91. pt. awake and moaning, appearing uncomf. with mask on. discussed with resident, taken off mask to NRB for comfort. pt. awake, speaking with garbled speech. saying name. RR ~ 20. responding to name. ABG on NRB: 7.18/46/101 at 2200. check on pt. at 2230 slightly less responsive but still with good air movement, responding to name. decesion made to place back on PS.\n- at 2300, placed back on CPAP , pt. less responsive again, brady to 50, BP drop to 60/. taken off mask vent. and ambu bag , given NS IVB. HR/BP coming up within ~ 5min. resident called. stat CXR done, ABG 6.86/PO2 47. pt. out of sync with mask vent and placed on NRB. HR 70's SR, BP 60-80's/50. also given .2mg flumazenil IV in case of prolonged effects of sedation given earlier today. no effect.\n- during this time, resident calling and speaking to fellow oncall as well as attending. in addition, calls/messages left with family, proxy. granddaughter(proxy in ) ~ 0030 and updated on condition, she agreed with idea for comfort only. attending aware and in agreement.\n- at 0100, MSO4 gtt started at 2mg/hr. dopa d/c'd. HR/BP dropping quickly and pronounced by resident at 0120. grandaughter called.\n" }, { "category": "Nursing/other", "chartdate": "2197-11-08 00:00:00.000", "description": "Report", "row_id": 1430942, "text": "CCU Nsg Admission Note\nCC: 87 yo was admitted to hospital on after being found down in facility covered in \"coffee ground emesis.\" Pt admitted to floor and followed by team. Today while being disimpacted, passed large black tarry stool and dropped bp to 60/40, given 2L bolus of NS and 1U prbc and bp ^ 85 sys. Pt to continued to pass tarry stools which then turned maroon in color and transferred here for bp support.\n\nPMH: NHL (s/p Xrt to neck),HTN, Hyperthyroidism, R hip fx w/ hip screw placement x 1 MONTH AGO\n\nCCU COURSE: Pt tx to CCU alert and confused but following commands. BP 70 sys, given 500x 2 Ns bolus and addt'l unit of prbc with a bp ^ 80's, BS present abd firm and passing lagre melana stools. U/O 10 -20cc/hr, amber in color and clear. Pt started on Dopa @ 4mcg with a bp ^ high 80-90;s.Pt then had CVL and ALINE placed which thereafter scoped at bedisde. During procedure given 0.5mg of versed intially and another 0.5mg as pt became more agitated. Pts O2 sat decreasing, abg very poor, Pt placed on bipap with 20 PS; causing Pts BP to drop. Dopa in creased to 12mcg, currently.Pt is DNR/DNI.\n\nPLAN:\nContinue to monitor BP and resp status\nEGD showed \"Kissing duodenal ulcer\" plan for tx IV protonix and serum H-pylori\nSerial H/H q6h\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 744703, "text": " 1:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p fall with injury to hip. mental status changes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with injury to hip. mental status changes\n ______________________________________________________________________________\n FINAL REPORT\n CLLINICAL INFORMATION: Status post fall with hip injury now with mental\n status changes.\n\n Contiguous axial images.\n\n No priors.\n\n FINDINGS:\n\n There is no mass, hemorrhage, diplacement of normally midline structures or\n extraaxial accumulation. There is moderate prominence of ventricles and sulci\n consistent with moderate brain atrophy. The bone images show no definite\n evidence fo calvarial fracture and the visualized paranasal sinuses are clear.\n\n IMPRESSION: Moderate brain atrophy, otherwise negative study.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-07 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 744705, "text": " 1:46 PM\n PELVIS (AP ONLY) Clip # \n Reason: s/p fall with injury to hip\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with injury to hip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89 year old female status post fall with hip pain.\n\n COMPARISON: .\n\n SINGLE AP PELVIS: A compression screw and intramedullary nail in the right\n femur is unchanged with no evidence of hardware failure proximally. There is\n increased callus formation about the fracture site. The distal most aspect of\n the intramedullary nail is not imaged. The sacroiliac joints, pubic\n symphysis, and left hip are normal.\n\n IMPRESSION: Healing right intertrochanteric fracture. No evidence of new\n fracture. However, distal aspect of intramedullary nail is not imaged.\n Recommend repeat film to exclude injury involving the distal aspect of nail.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744746, "text": " 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement, check placement, actively GI bleeding s/p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above\n REASON FOR THIS EXAMINATION:\n s/p NGT placement, check placement\n actively GI bleeding s/p 4 units fluid please assess for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post NG tube placement in this patient with active GI\n bleeding. Status post transfusion, assess for pulmonary edema.\n\n Single frontal view of the chest: Comparison is made to film obtained 9 hours\n ago. Right internal jugular central venous catheter is again noted. There is\n interval removal of NG tube. The cardiomediastinal silhouette is within\n normal limits. The aorta is calcified and tortuous. There is interval\n decrease in diffuse granular opacities throughout both lungs and slight\n interval decrease in bilateral pleural effusions. However, a focal area of\n consolidation in the left mid lung is unchanged. There is interval worsening\n of consolidation in the left base, obscuring the left hemidiaphragm. No\n pneumothorax is seen. Noted is dextroscoliosis of the thoracic spine,\n associated with degenerative disc disease of thoracic spine.\n\n IMPRESSION: Consolidation in the left mid lung and worsening consolidation in\n the left base are suspicious for pneumonia. Diffuse pulmonary edema is\n resolved. Interval removal of NG tube.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744788, "text": " 12:18 AM\n CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: 89 yo female with acute ventilatory failure.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above, requesting CXR for further eval\n REASON FOR THIS EXAMINATION:\n 89 yo female with acute ventilatory failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute ventilatory failure.\n\n SINGLE FRONTAL VIEW OF THE CHEST. Comparison is made to film obtained 1 hour\n ago. There has been no significant interval change. There is no pneumothorax.\n\n IMPRESSION: No significant change from film obtained 1 hour ago. Suspect\n pneumonia (vs. less likely atelectasis) in the left mid lung and left lung\n base. Minimal scarring or linear atelectasis in the right base.\n\n DR. . \n" }, { "category": "Radiology", "chartdate": "2197-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744786, "text": " 11:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: poor air movement and desaturation on CPAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with above, requesting CXR for further eval\n REASON FOR THIS EXAMINATION:\n poor air movement and desaturation on CPAP\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest obtained compared to previous study earlier the same\n day.\n\n CLINICAL INDICATION: Decreased oxygen saturation.\n\n A central venous catheter remains in satisfactory position. A nasogastric\n tube has been removed in the interval.\n\n The heart size is within normal limits for technique. There has been interval\n development of complete collapse of the left lower lobe. There is probably a\n small left pleural effusion present as well. There is some patchy alveolar\n opacity in the left mid lung zone centrally. The right lung is clear except\n for discoid atelectasis at the right base.\n\n IMPRESSION:\n\n 1) Interval development of complete collapse of left lower lobe.\n\n 2) Persistent alveolar opacity in the left perihilar region, which may\n relate to pneumonia.\n\n 3) Probable small left pleural effusion.\n\n" } ]

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The patient was admitted to , where he was transferred from an outside institution. He was initially started on oral Levaquin and Flagyl for his toe ulceration. Angiogram was scheduled for the day after admission and he was subsequently hydrated gently overnight. He was given the Mucomyst protocol. The Glucophage and Lasix were held prior to angiogram. The creatinine was 1.6. The hematocrit at that time was noted to be 25. On hospital day #1, noninvasive studies were also obtained. These revealed a limited study due to the examination being technically difficult as the patient declined having the cups placed for the volume recordings at any location other than the ankles. EBIs were noted to be inaccurate due to extensive vessel compressibility. The angiogram revealed no significant proximal inflow disease from the level of the renal arteries to the knee. The anterior tibial artery was the only continuously patent leg vessel and it was severely stenosed in its first and few centimeters. A patent dorsalis pedis artery was noted. No plantar arteries were opacified. Based on this information the patient was taken to the operating room on , where a left superficial femoral to dorsalis pedis artery bypass was performed with the use of nonreverse saphenous vein graft. At that time a left fourth toe open amputation was also performed. Details of this procedure are dictated in a separate operative note. The patient did fairly well hemodynamically, postoperatively and was transferred up to the Vascular Intensive Care Unit. PA catheter was placed, which revealed significant pulmonary hypertension. This was noted on preoperative echocardiogram. These were obtained from the Medical records. A Cardiolite imaging study revealed a large fixed hypoperfusion defect involving the inferior apical and inferolateral regions. It was suggestive of an area of prior myocardial infarction with no significant residual ischemia. On gated images the left ventricle was moderately enlarged with moderately reduced systolic function due to wall-motion abnormalities. The right ventricle was also noted to be enlarged. The pulmonary was noted to be approximately 56 mmHg and a left ventricular ejection fraction was noted to be approximately 30%. On postoperative day #2, the patient's pulmonary artery catheter was pulled out to monitor CVP. He was able to get out of bed to a chair and he was started on a regular diet. He did have some nausea, which was relieved with Reglan and Compazine. Consultation was sought by his medical internist, Dr. at that time. On postoperative day #3, the CVP line was changed over to central-venous catheter. He was transferred to the floor and he started to ambulate with physical therapy. After that time, he did extremely well and progressed very rapidly. His wound was left open, however, it did continue to show evidence of healing with pink granulation tissue. He had a palpable dorsalis pedis graft pulse. He was seen by the Department of Physical Therapy routinely throughout the hospital stay and he was eventually cleared for discharge home. He was sent home with a walker and he was only going to need VNA care for his left fourth toe amputation site. On postoperative day #4, he did have some nausea, while on the floor. However, an EKG was obtained and revealed no significant changes from previous EKGs. On postoperative day #5, the patient was discharged to home on PO Keflex. It was to be continued for approximately ten days. The patient was instructed by Dr to followup in his office in ten days to two weeks.

Please Contrast: OPTIRAY Amt: 210 FINAL REPORT (Cont) On the left, the left superficial femoral artery is patent. Pull back pressures were measured at the level of the distal aorta, left common iliac and left external iliac arteries. At the foot level, the dorsalis pedis artery is patent and shows a tortuous course. The left peroneal artery is occluded in its middle third and reconstitutes distally. With the catheter in the left external iliac artery, serial arteriograms covering the entire left lower extremity were obtained. It presents, however, significant stenosis in its first and last few centimeters. The catheter was pulled down into the infrarenal aorta and an oblique pelvic arteriogram was acquired. Please Contrast: OPTIRAY Amt: 210 ********************************* CPT Codes ******************************** * INTRO AORTA FEM/AXIL ABDOMINAL A-GRAM * * EXT UNILAT A-GRAM IV CONSCIOUTIOUS SEDATION PRO * * NON-IONIC 200 CC SUPPLY * **************************************************************************** MEDICAL CONDITION: 66 year old man with gangrene of left foot X 2weeks. A 0.035 guidewire was inserted through the needle and advanced up to the abdominal aorta. An AP abdominal aortogram was obtained. Manual compression of the left groin was applied until hemostasis was achieved. Patent dorsalis pedis artery. The needle was exchanged for a 4-French straight multi- sidehole catheter which was advanced to the suprarenal aorta. FINDINGS: The right and left renal arteries are widely patent. 225 ml of nonionic contrast intra-arterially. Diffuse ST-T waveabnormalities consistent with conduction abnormality. Sinus bradycardiaMarked left axis deviationIntraventricular conduction defect Anterolateral inferior ST elevation consider related to Intraventricularconduction delay or injury Lateral T wave changes may be due to myocardial ischemiaClinical correlation is suggested Sinus rhythmMarked left axis deviationIntraventricular conduction defectDiffuse nonspecific ST-T abnormalitiesSince previous tracing, no significant change After sterile draping and prepping, local anesthesia was administered in the left groin and the left common femoral artery was punctured by using a 19 gauge needle. The internal and external iliac arteries and the common femoral arteries are patent on both sides. There are several narrowings in branches of the left profunda femoris artery, two of which are moderate-to-severe. MEDICATIONS: Lidocaine 1% for local anesthesia. The anterior tibial artery is the only continuously patent leg vessel and is severely stenosed in its first and last few centimeters. Sinus rhythm. DR. D' Please due left leg with runuff and AP and LAT views of foot. The left popliteal artery shows several short mild-to- moderate narrowings in its above-knee portion, all of which appear to be less than 50% reductions in diameter. Incomplete left bundle-branch block. Please do left leg runoff with AP and Lat views of foot. RADIOLOGISTS: Drs. The patient was then transferred to the recovery room and the catheter was removed. There is mild tortuosity of the infrarenal aorta and common iliac arteries, without significant narrowing at those levels. No significant proximal inflow disease from the level of the renal arteries to the knee. 30 mg of papaverine were injected intraarterially for vasodilation when imaging the distal leg and foot. The left anterior tibial artery is the only leg artery which is patent in its entirety. (Over) 7:52 AM UNI-LAT FEMORAL Clip # Reason: 66 yr old male with gangrene of left foot X 2weeks. A total of 2.5 mg of Versed and 125 micrograms of fentanyl were administered intravenously in divided doses under continuous hemodynamic monitoring for conscious sedation. REASON FOR THIS EXAMINATION: 66 yr old male with gangrene of left foot X 2weeks. 7:52 AM UNI-LAT FEMORAL Clip # Reason: 66 yr old male with gangrene of left foot X 2weeks. It supplies at least four different intermetatarsal arteries. Compared to the previoustracing of no interval change. No posterior tibial artery nor plantar arteries can be opacified, even after intraarterial injection of 30 mg of papaverine. CONCLUSIONS: 1. As mentioned above, no plantar artery can be opacified, even after pharmacologic vasodilation test. FINAL REPORT INDICATION: Nonhealing ulcer and gangrene of the fourth left toe for three weeks in a 66 year old male patient. Dr. , the staff radiologist, was present for the whole procedure. 2. PROCEDURE/TECHNIQUE: The procedure with its potential risks and benefits were explained to the patient and informed signed consent was obtained. No plantar artery opacified. 3. and .

4

[ { "category": "ECG", "chartdate": "2130-02-06 00:00:00.000", "description": "Report", "row_id": 175441, "text": "Sinus rhythm. Incomplete left bundle-branch block. Diffuse ST-T wave\nabnormalities consistent with conduction abnormality. Compared to the previous\ntracing of no interval change.\n\n" }, { "category": "ECG", "chartdate": "2130-02-05 00:00:00.000", "description": "Report", "row_id": 175442, "text": "Sinus rhythm\nMarked left axis deviation\nIntraventricular conduction defect\nDiffuse nonspecific ST-T abnormalities\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2130-02-01 00:00:00.000", "description": "Report", "row_id": 175443, "text": "Sinus bradycardia\nMarked left axis deviation\nIntraventricular conduction defect\n Anterolateral inferior ST elevation consider related to Intraventricular\nconduction delay or injury\n Lateral T wave changes may be due to myocardial ischemia\nClinical correlation is suggested\n\n" }, { "category": "Radiology", "chartdate": "2130-02-01 00:00:00.000", "description": "ABDOMINAL A-GRAM", "row_id": 751522, "text": " 7:52 AM\n UNI-LAT FEMORAL Clip # \n Reason: 66 yr old male with gangrene of left foot X 2weeks. Please\n Contrast: OPTIRAY Amt: 210\n ********************************* CPT Codes ********************************\n * INTRO AORTA FEM/AXIL ABDOMINAL A-GRAM *\n * EXT UNILAT A-GRAM IV CONSCIOUTIOUS SEDATION PRO *\n * NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with gangrene of left foot X 2weeks. Please do left leg runoff\n with AP and Lat views of foot.\n REASON FOR THIS EXAMINATION:\n 66 yr old male with gangrene of left foot X 2weeks. Please due left leg with\n runuff and AP and LAT views of foot.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nonhealing ulcer and gangrene of the fourth left toe for three\n weeks in a 66 year old male patient.\n\n RADIOLOGISTS: Drs. and . Dr. \n , the staff radiologist, was present for the whole procedure.\n\n MEDICATIONS: Lidocaine 1% for local anesthesia. 225 ml of nonionic contrast\n intra-arterially. A total of 2.5 mg of Versed and 125 micrograms of fentanyl\n were administered intravenously in divided doses under continuous hemodynamic\n monitoring for conscious sedation. 30 mg of papaverine were injected\n intraarterially for vasodilation when imaging the distal leg and foot.\n\n PROCEDURE/TECHNIQUE: The procedure with its potential risks and benefits were\n explained to the patient and informed signed consent was obtained. After\n sterile draping and prepping, local anesthesia was administered in the left\n groin and the left common femoral artery was punctured by using a 19 gauge\n needle. A 0.035 guidewire was inserted through the needle and advanced up to\n the abdominal aorta. The needle was exchanged for a 4-French straight multi-\n sidehole catheter which was advanced to the suprarenal aorta. An AP abdominal\n aortogram was obtained. The catheter was pulled down into the infrarenal aorta\n and an oblique pelvic arteriogram was acquired. Pull back pressures were\n measured at the level of the distal aorta, left common iliac and left external\n iliac arteries. With the catheter in the left external iliac artery, serial\n arteriograms covering the entire left lower extremity were obtained. The\n patient was then transferred to the recovery room and the catheter was\n removed. Manual compression of the left groin was applied until hemostasis was\n achieved.\n\n COMPLICATIONS: No immediate complication occurred.\n\n FINDINGS: The right and left renal arteries are widely patent. There is mild\n tortuosity of the infrarenal aorta and common iliac arteries, without\n significant narrowing at those levels. The internal and external iliac\n arteries and the common femoral arteries are patent on both sides.\n\n (Over)\n\n 7:52 AM\n UNI-LAT FEMORAL Clip # \n Reason: 66 yr old male with gangrene of left foot X 2weeks. Please\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n On the left, the left superficial femoral artery is patent. There are several\n narrowings in branches of the left profunda femoris artery, two of which are\n moderate-to-severe. The left popliteal artery shows several short mild-to-\n moderate narrowings in its above-knee portion, all of which appear to be less\n than 50% reductions in diameter.\n\n The left anterior tibial artery is the only leg artery which is patent in its\n entirety. It presents, however, significant stenosis in its first and last few\n centimeters. The left peroneal artery is occluded in its middle third and\n reconstitutes distally. No posterior tibial artery nor plantar arteries can be\n opacified, even after intraarterial injection of 30 mg of papaverine.\n\n At the foot level, the dorsalis pedis artery is patent and shows a tortuous\n course. It supplies at least four different intermetatarsal arteries. As\n mentioned above, no plantar artery can be opacified, even after pharmacologic\n vasodilation test.\n\n CONCLUSIONS:\n 1. No significant proximal inflow disease from the level of the renal arteries\n to the knee.\n 2. The anterior tibial artery is the only continuously patent leg vessel and\n is severely stenosed in its first and last few centimeters.\n 3. Patent dorsalis pedis artery. No plantar artery opacified.\n\n DR. D' \n" } ]

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He was given 10 cc per kilogram normal saline for poor perfusion and pallor. 1. RESPIRATORY: The baby's initial chest x-ray showed low volume and hazy lung fields consistent with surfactant deficiency. He was intubated and given a total of three doses of surfactant with excellent response. He was transitioned to CPAP and subsequently to nasal cannula by day of life number four. He subsequently weaned to room air on . He has had no apnea and bradycardia.

NPN DAYSRESP DISTRESS:REMAINS IN RA, MAINTAINS O2 SATS IN MID 90'S.LUNGS CLEAR, RR 40-60'S WITH OCCASIONAL MILD SUBCOASTALRETRACTIONS. NPN 1900-0730#1 Problem resolved, lungs clear and well aerated to baseswith mild baseline SC retractions. P: Continue to monitor andsupport developmental needs.REVISIONS TO PATHWAY: 7 Hyperbilirubinemia; resolved MOM INDEPENDENT WITHBF. Mom agreeable to VNA. CONTINUE CURRENTFEEDING PLAN. REVIEWED SOME D/CTEACHING. UPDATED AT BEDSIDE. NPN 7a-1215p, discharge note is a former 37 1/7wk infant now DOL 10, corrected at 38 4/7wks. 10:46 PM BABYGRAM (CHEST ONLY) Clip # Reason: ? Is NPO, maintaining d/s's. PLEASE SET UP VNATOMORROW PRIOR TO D/C. Dr. did speak with pedi and gave update. BP stable. TYLENOLGIVEN AFTER CIRC. Capgas 7.36, pCo2 45 26/0. Mom very . NPN 1900-0730#1 Lungs are clear and well aerated to bases with mildtachpnea and little/no WOB. Waking ~q4hrs for feeds. CONTINUE TOMONITOR RESP STATUS CLOSELY FOR ANY DESATS. NOEPISODES OF APNEA OR BRADYCARDIA OR DESATS. SHE IS INDEPENDENTWITH CARES AND BF. HEARING SCREEN PASSED THIS MORNING. RRR, without murmur, pulses 2+ and symmetrical. asking appropriate questions, were updated oninfant's continued required vent support. Infant is s/p circ. RR 50's-70's, mild intercostalretractions. P: Continue to update and support.FEN: BW= 3625kg, CW= 3345kg ^5gms. 24h lytes139/4.5/105/19. Lytes 143/4.6/110/20. Updated on pt condition.A=Involved.P= Support.#4 F/N- Abd soft,+bs no loops.Remains NPO. A:NPO,dstick stable. alert with cares, settlesbetween cares.Font. BSclear. 99.1-99.4 swaddled. LSclear, SC retractions present. To treat for 48h. Abdomen bneign. P: Continueantibiotics as ordered. Bilirubin 8.1/0.3. received intubated on SIMV, 22/6, rate of 18.Pt. BS present. Comfoprtavble appearing. completed transfusion of PRBC after critof 22.2 with retic of 8.2. O: Wt. Remains in NCo2. WIll repeat this am. O:Pt. O:Pt. O: pt. O: Pt. extubated and placed on prong CPAp around 0300 afterCBG, 7.38/32. Mild SC retractions. maintaining temp. TF at 80 cc/k/d. swaddled on offwarmer, temp. P:Cont to support and update.#4 O: NPO. A: AGA. Dstick 103. A:Weaning rate today. No bradys.A:Weaned toCPAP.P: Continue to monitor resp. Pt. Pt. Pt. Hct 37. Abdomen benign; voiding 3.0cc/kg/h in 12h. NeonatologyDoing well. Bili 3.5/0.2/3.3. HC stable at 35.5cm; isnoted at 35 at time of delivery. NPN#1 Resp- Remains on Prong CPAP of 7cms in 30-38% o2. LS clear and=. Soft belly with + BS. status.#2Potential sepsis. Initial CBCwithout shift. BC - todate. continue to monitor/wean O2 as tolerated.3. Initial Hct 35. A: NPO. BP in good range. RR 40-60s since placed on CPAP, FiO2 35-40. Will continue on cpap and follow. On IV dextrose. Respiratory CareBaby continues on cpap 7, fio2 32-40%, Bs clear, rr 40-70's. DS 133, 68 when PIV turnedoff to let PRBC's infuse through it. Neonatology AttendingDay 3Remains on CPAP with fio2 0.28-0.32. P: Cont to monitor.#2 O: Infant remains on amp and gent as ordered. NoA&B's noted. Ptreceived Survanta x 1. Pt continues with IC/SubC retractions. Continue to wean O2 as pt.tolerates.#3. CBG after intubation was7.37/43/28/26. CXR c/w mild RDS per Dr. . Respiratory O: Pt. P-Cont to assess resp needs.#2 O/A- CBC DONE AT 1220 WITH PEDING REULTS.aMPI AND GENT AT1320 AFTER BC SENT.tEMP STABLE. Abdomen benign.Ad feeds being tolerated.Hct 49.5Will discuss possibility of retrotx with . UPDATED ATBEDSIDE. P: Continue tomonitor respiratory status. Admitted to NICU at 1120 viaincubater with blby02. He isvoiding/ stooling QS. P: Cont tomonitor.G&D: Temps 99.1-99.9 on open warmer, warmer weaned x 1. LS clear/=, mild SC retractions. IVF is D10W via PIV. A/P: Cont tomonitor resp status.3. P-Cont to assess cv needs.#1O/AReceived with 100% blby 02 with cpap 7 at 1140 with abgat 1320 of 7.39,39 c02,35 p02.Dr. NPN#1 cont in NC O2. Cap refill secs. SPoek with primary pedi who has priviledges at NWH. STOOL GUIAC NEG. Nursing NICU Note#1. He is currently on low flow NC, 100cc flow, Fio2100%. A: Pt. A: Pt. He has begun towean back from 100cc flow now. A-Cv needs wnl with paoloron admission. POa BM/E20. Weaning to RA. On BM ad . NeonatologyIn NCo2 at 100% 1oo cc. Bp 71/49 mean 61. aware of above withno changes in setting .Chest x ray at 1230 with reverealedMild RDS from Dr. . Nrsg Addendum Note-1818 remains with f102 25-30 % on npcpap 7 with rr 40-70-'s with occassional retractions with gd aeration noted. P: Cont to monitor.G&D: Temps stable in , pt dressed/swaddled. d/t PrematurityP:Cont. Nosupplement given. Amp and gent d/c'd. Updated on pt condition. Stable on CPAP cont to follow P: Cont tomonitor and wean from NC as tolerated.FEN: Birth wgt was 3625g. soft,pos bs,noloops or spits.Voiding and stooling guiac negativestool.A:Stable P:Cont. Off antibiotics, very active withhandling, appearing comfortable once settled. R to L shunting). in Resp. to assess resp. Neonatology fellow noteAwake and alert, NADAFOF, mildly jaundicedRRR, I/VI SEMOn NC, CTA bilaterally, good air entry, no retractionsAbd soft, active bowel sounds, fullWWP, MAEE, good tone Updated atbedside. A: Remainingin NC o2. LS = and clear,still exhibiting poor "reserve". p= Support.#4 F/N- Abd soft,+bs, no loops.Remains NPO. LS clear/=.No retractions. Neonatology fellow noteSleeping, NADAFOF, mildly jaundicedRRR, no murmursCTA bilaterally on CPAP, good aeration, mild retractionsAbd soft, active bowel sounds, non-distendedWWP, MAEE, good tone Settles well withpacifier or feeding. A: AGA.P: Cont to support development.#7 O: Coloring jaundiced. to support growth and dev.Hyperbili:Infant appears jaundice.Bili level sent awaitingresults. Med spit x 1. held awhile and were updated. Wgt tonight is 3430g, down 120g.Pt is ad lib feeding BM20/PE20, needing to be woken Q4hr toeat. LS clear and=. Respiratory CareBaby continues on cpap 7, fio2 28-31%, bs clear, rr 40-60's. Lungs fairly well aerated bilaterally despite grunting, heart RRR s murmur, abd soft s HSM. P: Contto monitor.#5 O: Infant maintaining temp in . WIll wean further today as tolerated. Mild retractions.RR= 40-70's.#3 Mom called x1.

63

[ { "category": "Radiology", "chartdate": "2154-05-02 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 791926, "text": " 12:04 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: eval lung fields, heart size\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress, O2 req s/p c-s at 37 wks\n REASON FOR THIS EXAMINATION:\n eval lung fields, heart size\n ______________________________________________________________________________\n FINAL REPORT\n CHEST DATED \n\n CLINICAL INDICATION: Infant with respiratory distress. Evaluate lung fields.\n\n FINDINGS: Lung volumes are small. The chest has a slight bell-shape,\n suggesting a slightly small thorax. Please correlate clinically. Hazy\n opacifications throughout both lungs suggest surfactant deficiency. No focal\n pulmonary parenchymal process. The study is otherwise unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2154-05-02 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 791978, "text": " 10:46 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ? ETT position; evaluate lungs\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, 37 weeks, now intubated\n REASON FOR THIS EXAMINATION:\n ? ETT position; evaluate lungs\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n HISTORY: Infant with RDS.\n\n FINDINGS: The film is submitted for interpretation on . The baby has\n been intubated. The tip of ETT is 1 cm above carina. The lungs are hazy in\n keeping with hyaline membrane disease. The lung volumes are greater than on\n film number 1. There is no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2154-05-04 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 792117, "text": " 1:08 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: 37 week infant with RDS, persistent respiratory distress\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above.\n REASON FOR THIS EXAMINATION:\n 37 week infant with RDS, persistent respiratory distress\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST \n\n HISTORY: 37 week infant with RDS. Persistent respiratory distress.\n\n FINDINGS: Since the study performed , the endotracheal tube has been\n removed. The lung aeration is normal. The minimal granular opacities\n consistent with hyaline membrane disease appear similar. The heart and\n mediastinal contours are normal. The pulmonary blood flow is within normal\n limits.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992293, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992294, "text": "NPN DAYS\n\n\nALT IN RESP:RECEIVED BABY IN NASAL CANNULA O2, 100%, 75CC.\nBABY WEANED OUT OF O2 AT10AM THIS MORNING WHILE BF. HE HAS\nREMAINED IN RA ALL DAY. MAINTAINS O2 SATSIN MID 90'S. NO\nEPISODES OF APNEA OR BRADYCARDIA OR DESATS. CONTINUE TO\nMONITOR RESP STATUS CLOSELY FOR ANY DESATS. RETURN TO NASAL\nCANNULA IF HE DOES NOT MAINTAIN O2 SATS 94% OR GREATER.\n\nALT IN NUTRITION:TOL FEEDS WELL, ON AD DEMAND SCHEDULE\nOF BM20. HE BF WITH MOM AT 9:30AM FOR 1HR AND BOTTLED 30CC,\nAND ALSO AT 1PM. AT 5PM HE BF FOR 1HR AND FELL ASLEEP, DID\nNOT NEED BOTTLE. ABD EXAM BENIGN, NO LOOPS, NO SPITS.\nVOIDING AND STOOLING WELL. STOOL GUIAC NEG. CONTINUE CURRENT\nFEEDING PLAN. MOM WILL NOT BE HERE TONIGHT, BOTTLE AD .\n\nALT IN GROWTH AND DEVELOPMWNT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WLL BTW FEEDS. WAKES AND DEMANDS ABOUT Q4HRS.\nMAINTAINS TEMP IN OPEN CRIB. NEEDS HEARING SCREEN AND CAR\nSEAT TEST, AND CIRC SOON.\n\nALT IN PARENTING:MOM IN TO VISIT ALL DAY. SHE IS INDEPENDENT\nWITH CARES AND BF. UPDATED AT BEDSIDE. REVIEWED SOME D/C\nTEACHING. CONTINUE TO SUPPORT AND UPDATE. MOM WILL BRING IN\nCAR SEAT TOMORROW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992295, "text": "NPN 1900-0730\n\n\n#1 Lungs are clear and well aerated to bases with mild\ntachpnea and little/no WOB. RR's 50-70's. Sats are\ngenerally >95% in RA with rare drifts to 92 while sleeping.\nWill cont to follow exam closely and offer supplemental O2\nas needed.\n\n#3 Mom called x1 for update, pleased with his progress and\nthat he's remained out of oxygen. No new questions or\nconcerns voiced. She plans to be in around 0830 for\nfeeding.\n\n#4 Weight up 65gms to 3385 on full enteral feeds of BM20 ad\n demand. Took 112cc/k/d plus breastfeeding yesterday.\nVoiding and stooling well with benign abdominal exam.\nWaking every four hours or so to eat, taking 120cc each\ntime.\n\n#5 Temps remain stable in open crib dressed and swaddled.\nWaking for feeds as above. Alert and active with cares,\nsettles off quickly to sleep. Needs help bringing hands to\nface and enjoys snug swaddling. will cont to support growth\nand development as able.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992296, "text": "Neonatology Attending\nDOL 10\n\nHas been in room air for 24 hours. No apneas/bradycardias/desaturations.\n\nNo murmur.\n\nWt 3385 (+65) on breastfeeding during the day and bottling well overnight. Voiding and stooling normally.\n\nPassed hearing screen.\n\nA&P\n37-1/7 infant with resolved surfactant deficiency\n-We will monitor respiratory status for another 24 hours then consider discharge home\n-Car seat testing today\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992297, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and slightly jaundiced. Abd benign, no HSM. active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-12 00:00:00.000", "description": "Report", "row_id": 1992298, "text": "NPN DAYS\n\n\nRESP DISTRESS:REMAINS IN RA, MAINTAINS O2 SATS IN MID 90'S.\nLUNGS CLEAR, RR 40-60'S WITH OCCASIONAL MILD SUBCOASTAL\nRETRACTIONS. NO EPISODES OF APNEA OR BRADYCARDIA OR DESATS,\nEVEN WHILE BOTTLING OR BREASTFEEDING. CONTINUE TO MONITOR\nRESP STATUS CLOSELY FOR DESATS.\n\nALT IN NUTRITION:TOL FEEDS WELL ON AD DEMAND SCHEDULE OF\nBM20. BABY BF WITH MOM AT 10AM FOR 1HR. NO SUPPLEMENT. AT\n1:30-2:30PM BABY BOTTLED 120CC. AT 6PM MOM BF FOR 40MINS AND\nHE BOTTLED 30CC. ABD EXAM BENIGN, NO LOOPS, NO SPITS.\nVOIDING AND STOOLING WELL. STOOL GUIAC NEG. CIRC COMPLETED\nBY DR. AT 8PM USING INJECTED LIDOCAINE. TYLENOL\nGIVEN AFTER CIRC. NO BLEEDING. CONTINUE CURRENT FEEDING\nPLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. WAKING AND DEMANDING Q3-4HRS.\nMAINTAINS TEMP IN OPEN CRIB. CAR SEAT TEST PASSED THIS\nAFTERNOON. HEARING SCREEN PASSED THIS MORNING. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 10AM. THEY ARE\nINDEPENDENT WITH CARES. BATH DONE. MOM INDEPENDENT WITH\nBF. BABY IS READY FOR D/C TOMORROW. PLEASE SET UP VNA\nTOMORROW PRIOR TO D/C. MOM KNOWS TO MAKE PEDI APPOINTMENT\nFOR WEDNESDAY. CONTINUE TO REVIEW D/C TEACHING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992299, "text": "NPN 1900-0730\n\n\n#1 Problem resolved, lungs clear and well aerated to bases\nwith mild baseline SC retractions. Transient tachypnea to\nthe upper 60's at times with sats >97% in RA.\n\n#3 Mom called x1 for update, very excited to bring \nhome today. No new questions or concerns voiced.\n\n#4 Weight up 25gms to 3410 on full enteral feeds of BM20 ad\n demand. Took 126cc/k/d yesterday plus BF'ing. Belly is\nunremarkable, voiding and stooling well. Taking >4oz. every\nfour hours.\n\n#5 Temps are stable in open crib, waking Q4-5hrs to eat.\nAlert and active with cares, settles easily to sleep. Circ\nsite is clean with scant blood tinged drainage on gauze.\nTylenol given every six hours for pain with good relief\nseen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992300, "text": "Neonatology Attending Progress Note\n\nNow day of life 10 for this 37 week gestation infant.\n\nRR 40-70s - now in RA for 2 days.\nNo apnea and bradycardia.\nHR 130-140s\nBP 78/44 54\n\nWt. 3410gm up 25gm on ad demand feedings of breastmilk\n Baby is also taking bottle feedings well.\nTotal yesterday 126cc/kg/d plus breastfeeding.\n\nCirc healing well - performed yesterday.\n\nAssessment/plan:\nVery nice progress continues.\nWill plan on discharge to home today.\nVNA to be set up.\nAppointment with pediatrician to be set up within 2 days.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992301, "text": "Neonatology fellow note\nWell-appearing, crying but consolable, NAD\nAFOF, pink\nred reflex ou, palate intact\nRRR, no murmurs, 2+ femoral pulses\nCTA bilaterally, no retractions\nAbd soft, good bowel sounds, non-distended, no HSM\nCirc'd male, testes descended bilaterally\nPatent anus, no dimple\nHips stable, WWP\nMAEE, reflexes intact, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-13 00:00:00.000", "description": "Report", "row_id": 1992302, "text": "NPN 7a-1215p, discharge note\n is a former 37 1/7wk infant now DOL 10, corrected at 38 4/7wks. Infant has been in RA since Sat , easily maintaining sats >/=95%. RR stable 40-60. No retractions noted. BBS cl/=. No apnea/brady spells noted. Hr stable- 140-160. No murmur. BP stable. Infant remains pink and well perfused. Current wt 3410. Has been ad demand feeding BM20. Waking ~q4hrs for feeds. Mom in this am and breastfed infant for over 45mins. Infant has strong suck, and feeds very well. Mom did offer supplemental bottle of 35cc to settle infant. No spits. Abd soft, +, no loops. Voiding and stooling. Infant is s/p circ. Tip of penis is red, no active bleeding noted. Sm spot of pink noted on gauze this am. Vaseline applied to tip of penis and front of diaper. Sm bruise noted on upper left base of penis r/t injection site from circ. Mom aware and will monitor for changes at home. No difficulty voiding. Tylenol given x1 for pain this am. Mom discussed Tylenol with Dr. and will follow her recommendations. Reviewed circ care with Mom and written info given. also conts to maintain stable temps while swaddled in an open crib. He is alert and active with cares. Waking on own for feeds. Settles easily. MAE. Fonts soft/flat. He has passed his hearing screen and carseat tests. Reviewed proper positioning of infant in carseat, and gave Safe Travels handout. Dad did put infant in carseat correctly. Mom spoke with pedi, Dr. and will be taking infant to pedi office upon d/c from NICU per pedi's request. Dr. did speak with pedi and gave update. Fellow to have d/c summary faxed to pedi. VNA referral called in and faxed. Will be seen by Care Group VNA tomorrow. Mom agreeable to VNA. Reviewed all d/c teaching with . Mom plans to exclusively breastfeed. Will cont to pump and give bottles of BM20 at times, as needed. Mom very . with care of infant and feeding. did not have L&D tags on them, but both provided positive MA ID's. D/C exam done and order in chart. Infant d/c'ed home with in carseat.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992285, "text": "npn 1900-0730\n\n7 Hyperbilirubinemia\n\nRESP: Recieved infant on 50cc of 100% FiO2, currently infant\nweaned down to 25cc of 100% FiO2. Sats=>94%, with no desats\nnoted. RR=40-60'S, with mild baseline subcostal retractions.\nLSC/=. No s/s of increased WOB noted thus far. No spells\nthus far. P: Continue to monitor respiratory status and\ncontinue to wean O2 as tolerated.\n\nPAR: No contact from thus far, unable to assess\nfuther at this time. P: Continue to update and support\n.\n\nFEN: BW= 3625kg, CW= 3345kg ^5gms. Infant is an ad \ndemand feeder, waking 2-3.5hrs bottling 75-90cc of BM/E20.\n also BF during the day, when mom is in to visit.\nInfant tolerating po feeds well, no spits. TF for past\n24hrs= 64cc/kg/d + volumes from Breast feeding. Abd benign,\nsoft, no loops, +BS. Voiding and stooling, guiac negative.\nP: Continue w/ current feeding plan and monitor wt gain.\n\nDEV: Temp stable in , while infant dressed and swaddled.\nInfant wakes for feeds. Alert and active with cares. Sucks\non pacificer vigorously. Brings hands to side of face to\ncomfaort himself. Brings hands to mouth and midline. \ncan become irritiable at times but calms easily w/ pacificer\nor being held. MAE. AFSF. AGA. P: Continue to monitor and\nsupport developmental needs.\n\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992259, "text": "NPN 7A-7P\n\n\n#1 Infant remains on CPAP 7, Fi02 35-40%. Has Sa02 drifts\nwith irritability/crying and slowly returns to baseline once\ncalmed. LS = clear. RR 50's-70's, mild intercostal\nretractions. CRX done earlier in day, no changes made. Cap\ngas 7.36, pCo2 45 26/0. Will con't to monitor respiratory\nstatus closely for increased respiratory distress.\n\n#2 Remains on map and gent, blood cultures negative to date.\nStill requiring CPAP support, will determine length of\nantibiotic course tomorrow.\n\n#3 in to visit x 2 today, also brought in visitors.\n asking appropriate questions, were updated on\ninfant's continued required vent support. Mom informed of\nprobability that ifnant will not be discharged with her to\nhome on Monday and was appropriately teary but is glad that\nhe somewhat improved. Will con't to update and support. Plan\nfor Family Meeting on Monday prior to mom's discharge from\npost-partum.\n\n#4 Remains NPO, PIV infusing well, D/S:74. Is slightly\nedematous, voiding well, no stool this shift but has mec\nlast evening. Con't to assess respiratory status to\ndetermine start of feeds.\n\n#5 Three day old 37 weeker still requiring vent support for\nRDS. Is NPO, maintaining d/s's. Active with handling but\nsettling well. On antibiotics, voiding and stooling. Con't\nto monitor closely.\n\n#6 Is pink, repeat Hct today 37.5. BP 60/39 m:47. Problem\nd/c'd.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992260, "text": "6 Alteration in CV status\n\nREVISIONS TO PATHWAY:\n\n 6 Alteration in CV status; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992261, "text": "RESPIRATORY CARE NNOTE\nBaby received on Prong CPAP 7 FiO2 30-38%. RR 40-70's breath sounds are clear. Suctioned orally for mod amt of white secretions. Baby looks comfortable on CPAP will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992262, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 7cms in 30-38% o2. BS\nclear. Mild retractions.RR= 40-70's.\n#2 Sepsis- Remains on Amp+ Gent.\n#3 Mom here to visit x1. Updated on pt condition.A=\nInvolved.P= Support.\n#4 F/N- Abd soft,+bs no loops.Remains NPO. PIV patent\ninfusing at 80cc/kg/day.Voiding in adeq amts.Sm stool x1.Wt\ndown 5 gms.Lytes=143/4.6/110/20.\n#5 Dev- Alert+ active w/cares. Sleeping in between.Swaddled\non off open warmer w/adeq temps.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992263, "text": "Neonatology Attending\n\nDay 3\n\nRemains on CPAP with fio2 0.28-0.32. Clear breath sounds. Blood gas 7.35/45. Doesn't tolerate being off CPAP. HR 130-50s. BP mean 46. Hct 37. Weight 3615 gms (-5). TF at 80 cc/kg/d. On IV dextrose. Lytes 143/4.6/110/20. Blood glucose 85. Bilirubin 8.1/0.3. Stable temperature on warmer.\n\nResolving hyaline membrane disease. Will continue to wean CPAP as allowed. Monitoring cardio-respiratory status closely. Metabolically fine. Physiologic bilirubin. Will follow. Plan to stop antibiotics today. Hct is fine now. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992256, "text": "NPN 1900-0700\n\n\n#1Resp. O:Pt. received intubated on SIMV, 22/6, rate of 18.\nPt. extubated and placed on prong CPAp around 0300 after\nCBG, 7.38/32. RR 40-60s since placed on CPAP, FiO2 35-40. LS\nclear, SC retractions present. Pt. suctioned with cares for\nmoderate white secretions via ett. Maintaining sat 90 and\nabove with occasional drifts to 80s. No bradys.A:Weaned to\nCPAP.P: Continue to monitor resp. status.\n\n#2Potential sepsis. O:Pt. maintaining temp. swaddled on off\nwarmer, temp. 99.1-99.4 swaddled. MAP BP 45 and 54. Pt.\ncontinues on ampicillin and gentamycin as ordered. BC - to\ndate. A: No increasing signs of sepsis noted. P: Continue\nantibiotics as ordered. Check blood culture results, monitor\nfor increasing signs of sepsis.\n\n#3Parenting. O: Mom here during evening for visit, updated\nat bedside. Mom has called for updates during night.\nA:Involved family. P: Continue to update and support family.\n\n#4Fen. O: Wt. 3620, up 5 gms, currently at BW. Pt NPO, on TF\nof 80cc/kg/day receiving D10 with lytes via PIV at\n12.1cc/hr. Dstick 103. Abd. soft, active bowel sounds, no\nloops, voiding with each care, meconium stool x1. A:NPO,\ndstick stable. P: Continue to monitor I/O, monitor dstick.\n\n#5Dev. O: pt. initially on open warmer set at lowest setting\nof 34 degrees, temp. 99.5-100 on warmer. Warmer now off, pt.\nswaddled and maintaining temp. Pt. alert with cares, settles\nbetween cares.Font. soft and flat, MAE.A: AGA. P: Support\ndevelopmental needs.\n\n#6CV status. O: Pt. completed transfusion of PRBC after crit\nof 22.2 with retic of 8.2. Pt. pale pink, brisk cap refill\nafter transfusion. HR 150-160. BP 77/43, MAP 54. No murmur\nnoted. A: Post transfusion for low crit, poor perfusion.\nP:Monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992257, "text": "Neonatology Attending Progress Note:\n\nDOL #2\nextubated last pm to CPAP 6 increased to 7 this am. FiO2=40%\nRR=40-80's\ncrit=37.5%\nmean BP=45\nbili=3.5\nwt=3620g\nNPO\ndstx=74\nurine output > 2 cc/kg/hr\n\nPE: moderate respiratory distress on CPAP, active, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally, mod ic/sc retx, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: x-37 week infant s/p blood loss at time of delivery, HMD--continuing with respiratory distress, and r/o sepsis.\n--obtain ABG\n--CXR in setting of persistent respiratory distress\n--to decide course of antibiotics depending on CXR\n--may need to reintubate if persistent\n--lytes and bili in am.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992258, "text": "Respiratory Care\nBaby continues on cpap 7, fio2 32-40%, Bs clear, rr 40-70's. Cpap increased to 7, for increased fio2 requirements. CXR with good lung expansion, cbg drawn 7.36/45. Will continue on cpap and follow.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992284, "text": "1. remains in nasal cannula 100% weaned to 50cc flow\nthis am, sats>95, RR 40-70, mild sc retractions, BBS clear,\nequal. continue to monitor/wean O2 as tolerated.\n3. Mom here all day, breast feeding, learning temp taking,\nindependent with diaper changes, spoke with Neo fellow, has\ndecided to stay here vs transfer to community hospital.\ncontinue to provide updates and offer support.\n4. E20/BM /breast feeding ad . BF well plus 30cc BM at\n1000, abd soft, active bowel sounds, no loops, no spits,\nvoiding and passing loose yellow stool. continue to monitor.\n5. wakes ~q4-5h, active and alert, temps stable swaddled in\nopen crib. continue to support growth and development.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992250, "text": "Neonatology fellow note\nSleeping, NAD\nAFOF, pale pink\nRRR, no murmurs\nCTA bilaterally, good aeration, moderate retractions, tachypneic\nAbd soft, good bowel sounds, non-distended\nNl male genitalia, testes descended bilaterally\nno sacral dimple\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992251, "text": "Neonatology\nIntubated last night for increasing distress has received two dose of surfactant. CXR lung fields c/w RDS, but low lung voluems with bell shaped thorax. Ribs appear normal. Consideration to be given to third dose of surf based on clinical status and net settings.\nBP in good range. No evidence of PDA.\n\nPale this am. Initial Hct 35. WIll repeat this am. Not jaundiced. No signs of external losses except minimal phlebotomy.\n\nNo sepsis risk factors, will rx with 48 h r/o but given clincial course and GA will consider treating with extended course of abx over weekend..\n\nWt 3260 down 15. TF at 80 cc/k/d. Abdomen bneign. BS present. Will plan to start feeds as tolerated via gavage this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992252, "text": "Neonatology\nREpeat HCT this am shows HCT of 22. No evdinec of blood loss. Neuro exam non-focal and age appropriate. No sig bogginress of skull. Abdomen soft non-distened. BP in good range. Liver just below RCM. Not enlarged.\n\nSpokje with Dr . Anterior placenta with accretta. ? blood loss at time of delivery.\n\nWill Transfuse with 20 cc/k PRBCs and monitor response. If evidence of ongoing losses will evaluate further including perhaps HUS, abd US.\n\nSpoke with Father at bedside\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992253, "text": "NPN 0700-1900\n\n6 Alteration in CV status\n\n#1 O: Received infant intubated on vent settings of 22/6\nrate 20; weaned to rate of 18 after CBG of 7.38/42. Fio2\n21-40%. RR 40's-90's; very tachypneic at times. LS clear and\n=. Suctioned for lg amounts of thick white secretions from\nETT q 2-3h. Mild SC retractions. No spells but having desats\nto 60's and 70's after being disturbed or while sucking on\npacifier. Received third dose of surfactant;given by RRT. A:\nWeaning rate today. P: Cont to monitor.\n#2 O: Infant remains on amp and gent as ordered. Initial CBC\nwithout shift. To treat for 48h. Bl cx remain neg to date.\nA: No obvious s/s of sepsis. P: Cont to monitor.\n#3 O: Dad in numerous times throughout day; asking a lot of\nappropriate questions. Mom in later today; very sleepy and\nweak. Signed consent for blood transfusion. A: Involved. P:\nCont to support and update.\n#4 O: NPO. TF= 80cc/kg/d. Infant receiving IV fluids of D10\ntoday (added lytes this eve at 1700). Receiving 12.1cc/h via\nPIV. Abdomen benign; voiding 3.0cc/kg/h in 12h. No stool\nthis shift. Soft belly with + BS. DS 133, 68 when PIV turned\noff to let PRBC's infuse through it. 24h lytes\n139/4.5/105/19. Bili 3.5/0.2/3.3. A: NPO. P: Cont to\nmonitor.\n#5 O: Infant noted to be warm this am while on servo mode.\nTaken off servo and switched over to air for a while.\nSheepskin also removed today. Placed prone for most of day\nwith boundaries in place. Infant very agitated throughout\nday having desats when upset. Sucks on pacifier when offered\nbut sometimes also desats with this. HC stable at 35.5cm; is\nnoted at 35 at time of delivery. A: AGA. P: Cont to\nsupport development.\n#6 O: Infant had a repeat Hct drawn at 24 h old today;\nresult was 22.2. Infant was given first transfusion of\nPRBC's of 35cc's over 2h from 1500-1700 today. Second\ntransfusion to be started shortly. BP means 44-52. Pale\ncoloring prior to transfusion; starting to pink up since\nreceiving first transfusion. Poor perfusion noted. To\nttransfuse 2nd aloquot of PRBC's of 35cc's over 2h.\n\nREVISIONS TO PATHWAY:\n\n 6 Alteration in CV status; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992254, "text": "Respiratory Care\nPt recieved on SIMV, rate of 20, pressures of 22/6, with the fio2 23 to 45%. Pt weaned down on ventilator rate from 20 to 18 with good blood gas results. Pt given 3rd dose of surfactant of 14cc, tolerated. Pt to recieved blood. Plan is to follow, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-04 00:00:00.000", "description": "Report", "row_id": 1992255, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 22/6 Rate 18 FiO2 28-30%. Suctioned ETT for mod amt of white secretions. Cap gas PO2 35 Co2 45 PH 7.42 30 3. Baby was extubated at 3am and placed on Prong CPAP 6 FiO2 35%. Baby looks comfortable on CPAP will cont to wean FiO2 as tolerated. Cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992286, "text": "NICU nursing note\nThis RN has assessed pt and agrees with above note.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992287, "text": "Neonatology fellow note\nAwake and alert, crying but consolable\nAFOF, mild jaundice\nRRR, no murmurs\nCTA bilaterally, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992288, "text": "Neonatology\nDoing well. Remains in NCo2. Comfoprtavble appearing. SLowl,y weaning flow. No spells. murmur.\n\nWt 3335 down 5. Took in 63 cc/k/d yesterday with multiple good breast feeds. DOing well from BF.\n\nNeeds hearing screen\nCar seta tes\nNeeds car seat test.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992289, "text": "NPN DAYS\n\n\nALT IN RESP:REMAISNIN NASAL CANNULA O2, 100%. RECEIVED BABY\nIN 25CC. WEANED TO 13CC THIS MORNING, AND HAS REMAINED\nIN 13CC ALL DAY, EVEN WHILE BF. MAINTAINS O2 SATS 94-96%.\nLUNGS CLEAR, RR 40'S WITH MILD SUBCOASTAL RETRACTIONS. NO\nEPISODES OF APNEA OR BRADYCARDIA THIS SHIFT. CONTINUE TO\nMONITOR RESP STATUS CLOSELY AND WEAN O2 AS TOL.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TMEP IN OEPN CRIB.\nCONTINUE DEVELOPMENTAL CARES. WILL ARRANGE HEARING SCREEN\nTHIS WEEKEND, AND POSSIBLE CIRC. WILL DO CAR SEAT TEST WHEN\nBABY IS OUT OF O2.\n\nALT IN PARENTING:MOM IN TO VISIT AT 9AM, AND HAS BEEN HERE\nALL DAY. SHE IS INDEPENDENT WITH CARES, AND BF. UPDATED AT\nBEDSIDE. SHE IS HAPPY THAT IS WEANING DOWN ON HIS O2.\nCONTINUE TO SUPPORT AND UPDATE. BEGIN REVIEWING D/C TEACHING\nWHEN BOTH ARE HERE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-10 00:00:00.000", "description": "Report", "row_id": 1992290, "text": "NPN DAYS CONTINUED\nALT IN NUTRITION: IS ON BM20, AD DEMAND SCHEDULE. HE BOTTLED AT 6:30AM. AT 10AM HE WOKE AND MOM BF HIM FOR 1HR. SHE DID NOT SUPPLEMENT WITH A BOTTLE. AT 12PM HE WOKE AGAIN AND HE BF FOR ANOTHER 20MINS. HE SLEPT UNTIL 4PM AND BF FOR AN HOUR AGAIN, AND THEN BOTTLED 30CC OF BM. HIS ABD EXAM IS BENIGN, NO LOOPS, NO SPITS. VOIDING AND STOOLING WELL. STOOL GUIAC NEG. CONTINUE CURRENT FEEDING PLAN. BOTTLE THROUGH THE NIGHT WHEN MOM IS NOT HERE.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992291, "text": "NPN\n\n\n#1 cont in NC O2. He had some drifting to 70's & 80's\nearly in shift and needed his O2 increased. He has begun to\nwean back from 100cc flow now. LS clear and equal with mild\nSCR noted and slight nasal stuffiness, color pink. A: cont\nto require O2 P: wean as able\n#3 no contaact with family thusfar in shift.\n#4 cont on demand feeds, is waking between 4-5 hrs and\nbottles well taking 105-115 cc BM. Abd benign, soft, no\nloops or distention, vdg qs, no stool. Weight own 25 grams\nA: feeds well P: no change at present\n#5 Stable in open crib, wakes for feeds, sleeps well\nbetween. Sucks some on pacifier. A: AGA P: cont to support\ndevelopment\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-11 00:00:00.000", "description": "Report", "row_id": 1992292, "text": "Neonatology Attending\n\nDOL 8 CGA 38 2/7 weeks\n\nIn NCO2 75 cc then weaned to RA this morning. R 40s-60s. No A/B.\n\nOn BM/E20 ad demand. Feeds well taking 80-115 cc per bottle or breastfeeding. Voiding. Stooling. Wt 3320 grams (down 25).\n\nHct 49.5 on .\n\nMother visiting and up to date.\n\nA: Stable. Weaning to RA. Feeding well.\n\nP: Monitor\n Home when stable in RA\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992278, "text": "Neonatology\nDoing well. Slightly increase Fio2 requirement. No spells. generally comfortable apeparing. No evidence of PDA, Comfortable appearing\n\nWt 3330 down 100. TF at ad lib feeds and doing well.\nAbdomen benign. Will offer pc supplements with BM or formula.\n\nBili in 12 range. Following bili.\n\nAwaiting weaning from O2 and improvem,ent in feeding quantity.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992279, "text": "Neonatology fellow note\nAwake and alert, looking around\nAFOF, mild jaundice\nRRR, no murmur\nCTA bilaterally, no retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992244, "text": "Nrsg Admission Note-0700-1900\n\n1 Term Respiratory Distress\n2 Infant with Potential Sepsis\n3 PARENTING\n\n (male ) born to a 37 y.o G4 now P4 Mom with\nknown acreda. Repeat c section for 37 week gestation male\nborn at 1051 with apgars 7&8. Admitted to NICU at 1120 via\nincubater with blby02. O2 sat 80 (placed on rt ft) and cv\nleads placed.\nCv status- Ap 150 ,rr 70. Bp 71/49 mean 61. Palor noted with\npoor perfusion. Cap refill secs. piv inserted into lt\nhand with nc 10 cc/kg bolus administered over 20 minutes\nwith perfusion improved to 4 secs at 1155 am and color\nremaining pale.Pink at 1200 with bp means ranging 46-61. cbc\nobtained at 1220 with hct 35.9, Dr. aware of above. No\nmurmur noted with ap 140-150's. A-Cv needs wnl with paolor\non admission. P-Cont to assess cv needs.\n#1O/AReceived with 100% blby 02 with cpap 7 at 1140 with abg\nat 1320 of 7.39,39 c02,35 p02.Dr. aware of above with\nno changes in setting .Chest x ray at 1230 with reverealed\nMild RDS from Dr. . Grunting initally with intercostal\nmild retractiosn.occasionally grunts with rr 40-70's.\nAeration gd with color pink from 1200-present. F102 33-50%.1\ndesat to 55 after abg draw. A-Resp needs with chest x ray\nreflective of RDS. P-Cont to assess resp needs.\n#2 O/A- CBC DONE AT 1220 WITH PEDING REULTS.aMPI AND GENT AT\n1320 AFTER BC SENT.tEMP STABLE. A-NO OVERT SEPSIS NEEDS.\n#3o/aMom and dad both visited with complete update\ngiven.Aware of possible intubatioN.Dr. spoke with\nparents. A-Parents aware of status.P-COnt to assess parental\nneeds.\n\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 2 Infant with Potential Sepsis; added\n Start date: \n 3 PARENTING; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992245, "text": "Respiratory Care Note\nThis 37 wk GA male was placed on prong CPAP +7, O2 28% (currently) for grunting and retracting. CXR c/w mild RDS per Dr. . BS clear. Pt continues with IC/SubC retractions. CBG on CPAP 7.39/39.Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992246, "text": "Nrsg Addendum Note-1818\n remains with f102 25-30 % on npcpap 7 with rr 40-70-'s with occassional retractions with gd aeration noted. Dstix 133 at 1800 with d 10w remaining at 80 cc's/kg .Npo status with lge mec x1.DTV. Moving all extrem well with fussiness soothed with sucking on fingers. No plans for repeat chest x ray. No other cbg or abg obtained with Dr. to be notified should fi02 increase to 40 %. Dad and Mom with complete update with both parents aware that adm could be several days in the NICU.( Parents expected 1-2 days in NICU). Plans for report at 1900.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992280, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. received on NC O2 300cc flow Fio2\n~ 40-60%. He is currently on low flow NC, 100cc flow, Fio2\n100%. RR ~30-70's. LS clear/=. No increase work of\nbreathing noted. He has mild SC retractions noted. No\nA&B's noted. A: Pt. is stable on NC O2. P: Continue to\nmonitor respiratory status. Continue to wean O2 as pt.\ntolerates.\n\n#3. O: Mom in throughout the day. She was\nupdated at bedside on pt's current status and daily plan of\ncare. Mom active and independent in cares. A: \n and involved. P: Continue to update, support and\neducate.\n\n#4. FEN O: Pt. is ad lib demand, breastfeeds well.\nAbdomen is soft, pink, +BS, no loops/spits noted. He is\nvoiding/ stooling QS. A: Pt. is tolerating current\nnutritional plan. P: Continue w/ current feeding plan.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. He is alert and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopmet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992281, "text": "NPN NIghts\n\n\n1. O: Received pt on NC 100% 100cc flow. Desats to 80cc with\ndecreased flow. RR 40-70's. Mild subcostal retractions. Occ\ndesats to 80's which QSR. No spells. Ls clear. A/P: Cont to\nmonitor resp status.\n\n3. O: MOm called X1. MOm asking appropriate questions. Rn\nupdated Mom. A/P: Cont to educate and support .\n\n4. O: Wt 3340gms, up 10. POa BM/E20. Pt took 50+ 110cc\nthus far this shift. Voiding and stooling G-. No spits. +bs.\nA/P: Cont to monitor wt, abd, and po intake.\n\n5. O: Temp stable swaddled in open crib. Alert and active\nwith cares. Waking for feeds. A/P: Cont to monitor temp.\nCont to cluster cares.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992282, "text": "Neonatology\nIn NCo2 at 100% 1oo cc. Generally comfortable apeparing but with some desats.\n\nWt 3340 up 10. On BM ad . Abdomen benign.\nAd feeds being tolerated.\n\nHct 49.5\n\nWill discuss possibility of retrotx with . SPoek with primary pedi who has priviledges at NWH. interested in , but given lability in O2 wouls suggest either staying here or transfer to level2.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-09 00:00:00.000", "description": "Report", "row_id": 1992283, "text": "Neonatology fellow note\nWell-appearing, active, NAD\nAFOF, mild jaundice\nRRR, no murmur\nCTA bilaterally, good air entry, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992247, "text": "4 FEN\n5 Development\n\nREVISIONS TO PATHWAY:\n\n 4 FEN; added\n Start date: \n 5 Development; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992248, "text": "1900-0730 NPN\n\n\nRESP: Received pt on Prong CPAP of 7 with FiO2 22-25%. D/T\ncontinuous grunting, pt was placed on SIMV with settings\n22/6, rate of 20. FiO2 on SIMV has been 24-60%. Pt\nreceived Survanta x 1. CBG after intubation was\n7.37/43/28/26. See flow sheet for further details. RR\n33-74, O2 sats >92%. LS clear/=, mild SC retractions. Pt\nsuctioned x 2 for lg cloudy secretions via ETT and no\nsecretions orally. No A/B spells. Desats x 2, requiring\nincrease in O2, see flow sheet for details. P: Cont to\nmonitor and wean vent settings as tolerated.\n\nSEPSIS: Cont on IV Ampicillin and Gentimicin for 48hr r/o.\nBlood cx pending. VSS, no s/s of infection. P: Cont to\nmonitor for s/s of infection and await blood cx results.\n\nFEN: Birth wgt was 3620g. Current wgt is 3615g, down 5g.\nTF=80cc/kg/d. Pt is NPO. IVF is D10W via PIV. D-stick was\n139. Abdominal girths stable at 30.5-31cm. Abdomen soft,\nround, BS active, no loops. Pt is vdg, unable to assess\nurine output this shift d/t lg mec stools x 2. P: Cont to\nmonitor.\n\nG&D: Temps 99.1-99.9 on open warmer, warmer weaned x 1. Pt\nis nested on sheepskin. MAE, alert/active with cares.\nSleeps between cares, with irritability at times. Sucks\npacifier and brings hands to face for comfort, settles well\nwith hand containment. Fontanels soft/flat, sutures smooth.\nAGA. P: Cont to support growth and development.\n\nPARENTING: Mom called x 1, updated by RN, asking\nappropriate questions. P: Cont to support/educate parents.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-03 00:00:00.000", "description": "Report", "row_id": 1992249, "text": "Respiratory care\nBaby received on cpap 7 fio2 ranged from 25-60% when agitated.Decision made to intubate for ^ wob,resp distress.intubated with 4.0 ett @ 10cm with good tube placement , confirmed by cxr.Initial settings r 20 22/6 fio2 as above.Received 2 doses of surf,14 cc,tol well.Sx prior to surf for mod cldy secs.cbg 7.37/43 tried to wean R to 18 but baby became , ^ back to R 20.will follow with rpt gas.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992276, "text": "NPN 0700-1900\n\n7 Hyperbilirubinemia\n\n#1 O: Receeived infant in NC 02 300cc's of flow at 30-50%\nwhere he currently remains while at rest. Needing up to 60%\nwith BF earlier in shift but more recently 40%. LS clear and\n=. RR 40's-70's. No retractions or increased WOB'ing noted.\nO2 sats have been maintained 91-97%. No spells. A: Remaining\nin NC o2. P: Cont to monitor.\n\n#3 O: Both in for family meeting this afternoon.\nThis RN and fellow present. asking appropriate\nquestions and seeming to understand infant's status.\nDiscussed Hep B, car seat test and hearing to all be done\nprior to infant going home. signed consent for circ\nbut aware will not be done until off o2. Mom plans to stay\nover tonight in parent room to be able to BF infant. A:\nInvolved, . P: Cont to support and update.\n\n#4 O: Infant continues on an ad lib demand feeding schedule\nwaking now q 2 1/2-4h and breastfeeding well both sides. No\nsupplement given. Abdomen benign; voiding, no stool. No\nspits. DS this am at 79. A: Tolerating feeds well. P: Cont\nto monitor.\n\n#5 O: Infant maintaining temp in . Awake and alert with\ncares; sleeping well between. Awoke on own for feeds today.\nSwaddled in blanket; sucks on pacifier when offered. A: AGA.\nP: Cont to support development.\n\n#7 O: Coloring jaundiced. Bili to be checked tomorrow am. A:\nHyperbili. P: Cont to monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-08 00:00:00.000", "description": "Report", "row_id": 1992277, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant cont's in NC FIO2 40-60%,flow rate\n300cc's/min.RR 48-80 with mild sc retractions.LS remain\nclear and equal b/l.Infant with no spells thus far.Drifts in\nsats titrating o2 as needed.A:Alt. in Resp. d/t Prematurity\nP:Cont. to assess resp. status and titrate o2 as needed.\n\nParenting:Mom in this eve very and invested.Staying\nin Family Room,does plan to go home tomorrow.Verbalized how\ndifficult it will be leaving her infant.A/P:Cont. to\nsupport,update and educate.\n\nF/E/N:Infant cont's on ad lib demand shedule.Infant BF most\nfeeds.At 2200 mom into BF infant latches on very well.Mom\nskipped following feed to rest prior to going home.Infant\nbottled and took 90cc's of E20 with a Nuk\nnipple.Weight=3.330kg down 100 grams.Abd. soft,pos bs,no\nloops or spits.Voiding and stooling guiac negative\nstool.A:Stable P:Cont. to assess tolerance of feeds.\n\nDEV:AFSF.Infant alert and active with cares.Sleeping quietly\nb/t cares.Infant remains in open crib;presently swaddled\nwith nested boundaries.Bringing hands to face and mouth and\nsucking on pacifier.A:AGA P:Cont. to support growth and dev.\n\nHyperbili:Infant appears jaundice.Bili level sent awaiting\nresults.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-02 00:00:00.000", "description": "Report", "row_id": 1992243, "text": "Admission Note\n37 wk male admitted at ~1.5 hr of age with respiratory distress.\nDelivered via elective repeat c/s this am. EDC \nMom is 37yo G4 P3-4 (1st 3 children are girls); A+/Ab-/RPR NR/RI/GBS ?.\n\nNo fever. ROM at delivery.\nPlacenta accreta noted at delivery; maternal blood loss/transfusion by report\n\nBwt 3625g (LGA); Apgars 7&8. NICU team called for persistent grunting post delivery. Arrived to find pt in RA, pale pink/sl mottled, grunting/flaring/retracting. Pt admitted to NICU for further evaluation/management.\n\nHR 160s, RR 50s (G/F/R), BP mean 50s, T 97.9, sat 100% with 60% BBO2\nD-stick 90\nPE pale pink, active, sl decreased but symmetrical tone. AFOF; no molding. Lungs fairly well aerated bilaterally despite grunting, heart RRR s murmur, abd soft s HSM. Cord clamp noted to have been secured over small amt of skin - removed and replaced. GU AGA male. hips stable.\n\n10cc/kg NS bolus given IV for poor perfusion/pallor\nCBC/Bcx sent\n\nImp/ 37 wk LGA male with resp distress s/p elective c-s - most likely retained fetal lung fluid; possible infection. Pain from cord-clamped skin may have contributed to symptoms (mild incr BP, incr HR, incr glucose, O2 requirement ? R to L shunting). Maternal placenta accreta/blood loss unlikely to have affected baby.\n\nPlan/\ncontinue to monitor cvr status;\nO2 and NCPAP to support resp;\nCXR to evaluate lung fields/heart size;\nABG if distress persists/worsens on CPAP;\nIV amp/gent if indicated by CBC, CXR, or clinical status;\nnpo on IV fluid pending resolution of respiratory symptoms; follow blood sugar given LGA status.\n\nPrimary pedi = ( Medical); in house coverage to be determined by preference of OB \n\nParents updated by in OR.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992271, "text": "NPN/0700-1900\n\n\n#1 RESP: Received infant on prong CPAP 6 with FiO2 ~26%.\nDecreased to 5cm this AM, and then trialed to NC ~2hrs\nlater. Infant remains on 300cc flow NC, 40-50% at rest, ^\nto 60% with breastfeeding. RR 40-60's. LSC/= with no ^\nWOB. Cont. to monitor. Wean O2 as able.\n\n#3 : Mom visiting throughout the day. Updated at\nbedside. Breastfed infant x2 this afternoon. Both mom and\ninfant did well with feedings. Dad and grandparents\nvisiting this afternoon. Very loving towards infant. Mom\nremains in house. Will be up for feeding.\n\n#4 FEN: Received infant NPO with D10 ^ at 100cc/k/d.\nIVF weaned and then dc'd as breastfeeding continued well.\nInfant breastfeeding well Q4hrs. Voiding qs/no stools.\nAbd. benign. DS=82 (on 50cc/k of IVF). Cont. with\nbreastfeeding/ad lib feeds.\n\n#5 DEVELOPMENT: Infant swaddled on off warmer with temps\nstable. Active/irritable with cares. Settles well with\npacifier or feeding. AFOF. AGA. Cont. to support\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992272, "text": "2 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 2 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992273, "text": "1900-0730 NPN\n\n\nRESP: Cont on NC 300cc flow, 30-50% FiO2 (increased to 60%\nfor PO feeding). RR 30's-50's, O2 sats >91%. LS clear/=.\nNo retractions. No A/B spells or desats. P: Cont to\nmonitor and wean from NC as tolerated.\n\nFEN: Birth wgt was 3625g. Wgt tonight is 3430g, down 120g.\nPt is ad lib feeding BM20/PE20, needing to be woken Q4hr to\neat. Pt BF > 10 mins at , and at 2400 took 30cc by\nbottle. D-stick 82. Med spit x 1. Abdomen benign. Pt is\nvoiding, no stool yet this shift. P: Cont to monitor.\n\nG&D: Temps stable in , pt dressed/swaddled. MAE,\nalert/active with cares. Sleeps between cares, not yet\nwaking independently for feeds. Sucks pacifier and brings\nhands to face for comfort. Fontanels soft/flat. AGA. P:\nCont to support growth and development.\n\nPARENTING: Mom in to visit, BF infant. Mom also called x\n1. Mom updated at bedside, asking appropriate questions.\nMom is and invested. P: Cont to support/educate\n.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992274, "text": "Neonatology fellow note\nAwake and alert, NAD\nAFOF, mildly jaundiced\nRRR, I/VI SEM\nOn NC, CTA bilaterally, good air entry, no retractions\nAbd soft, active bowel sounds, full\nWWP, MAEE, good tone\n" }, { "category": "Nursing/other", "chartdate": "2154-05-07 00:00:00.000", "description": "Report", "row_id": 1992275, "text": "Neonatology Attending\nDOL 5\n\nIn NC 300cc/min with no apneas/bradycardias.\n\nNo murmur.\n\nWt 3430 (-120) on ad lib feeds. Voidign and stooling normally.\n\nTemperature stable in open crib.\n\nA&P\nPreterm infant with resolving surfactant deficiency\n-Continue to await resolution of oxygen requirement\n-Monitor for adequacy of enteral intake on ad lib feeds.\n-Otherwise continue current management as above.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992264, "text": "NPN 7A-7P\n\n\n#1 Remains on CPAP 7, Fi02 30% (Fi02 increased with\ncrying/irritability to 40% but able to wean. LS = and clear,\nstill exhibiting poor \"reserve\". Sao2's low-mid 90's. Con't\nto wean Fi02 as tolerated.\n\n#2 Blood culture remains neg, CBC w/ diff unremarkable for\ninfection. Amp and gent d/c'd. Will con't to monitor general\nstatus for S&S of sepsis.\n\n#3 in to visit along with infant's three sisters.\n held awhile and were updated. Will con't to\nsupport. Plan for a Family Meeting tomorrow prior to mom's\ndischarge.\n\n#4 TF remain at 80cc/k/d. Is NPO, abdomen soft and pink with\npositive bowel sounds and likes to suck on pacifier. Is\nvoiding well, no stool. Will remain NPO until respiratory\nstatus improves.\n\n#5 Three day old 37week gestation infant boy on CPAP with\noxygen requirement and poor reserve. Fi02 decreased somewhat\nover the past 24 hrs. Off antibiotics, very active with\nhandling, appearing comfortable once settled. Is swaddled on\n\"off\" warmer (too big for crib. Will con't present\ninterventions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992265, "text": "Respiratory Care\nBaby continues on cpap 7, fio2 28-31%, bs clear, rr 40-60's. Will continue to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-05 00:00:00.000", "description": "Report", "row_id": 1992266, "text": "Neonatal NP-exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infnat active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992267, "text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 7 FiO2 28-32%. RR 40-70's breath sounds are clear. Baby looks comfortable on CPAP. Plan to wean CPAP and transition to nasal cannula soon. Stable on CPAP cont to follow\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992268, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 6 weaned from 7cms in\n26-32%. BS clear. Mild retractions.RR= 40-70's.\n#3 Mom called x1. Updated on pt condition. A=\nInvolved. p= Support.\n#4 F/N- Abd soft,+bs, no loops.Remains NPO. PIV patent\ninfusing at 80cc/kg/day. D/S=85.Voiding+ stooling in adeq\namts.Mec stool x1.Wt down 65gms.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992269, "text": "Neonatology\nDOwn on CPAP from 7 to 6. WIll wean further today as tolerated. Generally comfortable. No murmur.\n\nWT down 65. TF to be increased to 100 cc/k/d.\nAbdomen benign.\n\nHct stable over wekeend.\n\nWIll advance feeds rapidly as tolerated given GA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-05-06 00:00:00.000", "description": "Report", "row_id": 1992270, "text": "Neonatology fellow note\nSleeping, NAD\nAFOF, mildly jaundiced\nRRR, no murmurs\nCTA bilaterally on CPAP, good aeration, mild retractions\nAbd soft, active bowel sounds, non-distended\nWWP, MAEE, good tone\n" } ]

78,814

105,817

77 yo M with history of coronary artery disease s/p CABG , PCI native left circumflex , systolic heart failure, and multiple sclerosis, presented with melena from . Found to be having massive upper GI bleed as well as cholangitis and pneumonia. Suspected source of bleeding was from recent biliary stenting where he had bled in the past. He urgently went to ERCP where he was seen to be bleeding near the duodenal papilla at the site of a prior spincterotomy and bleed. Sclerosis and ligation were unsuccessful at ERCP. IR was called and he went to angio. At angio the gastroduodenal artery was identified as the bleeding source. Embolization was unsuccessful. Surgery was following throughout. After IR could not embolize the source of bleeding, surgery was urgently called to the bedside. Surgery felt the patient was an extremely high operative risk given his CHF, PNA, Afib, MS, and cholangitis on top of his GI bleed. His wife was by surgery and she agreed to defer surgery. The patient was made DNR at that point. He continued to massively hemorrhage. Again his wife was and he was made . He expired shortly thereafter from exsanguination.

Presented in early for bleed at sphincterotomy site which was treated endoscopically as OSH. PPX: -DVT ppx with pneumoboots -Bowel regimen assessment once out of window of GI bleed . PPX: -DVT ppx with pneumoboots -Bowel regimen assessment once out of window of GI bleed . Has had repeated bouts of cholangitis, deemed to be non operative candidate for cholecystectomy, most recently had ERCP in for exchange of stent. ERCP was aborted and trauma line was plaed by anesthesia in ERCP suite prior to patient being transferred back to for stabilization. ERCP was aborted and trauma line was plaed by anesthesia in ERCP suite prior to patient being transferred back to for stabilization. Transfused one unit of PRBC and transferred to for further care. Likely bleeding source is duodenal papilla at site of prior sphincterotomy. Likely bleeding source is duodenal papilla at site of prior sphincterotomy. Of note, patient had a recent admission to from to for elective ERCP during which he had removal of CBD stones as well as a biliary stent placed. Of note, patient had a recent admission to from to for elective ERCP during which he had removal of CBD stones as well as a biliary stent placed. A Trauma line was placed in the right IJ and pt had a left radial aline. A Trauma line was placed in the right IJ and pt had a left radial aline. Selective common hepatic arteriogram. That hospital course was complicated by atrial fibrillation with RVR. That hospital course was complicated by atrial fibrillation with RVR. Based on both clinical and radiologic findings, decision was made to attempt cannulization and embolization of the gastroduodenal artery. Of recurrent bleeding from previous sphincterotomy site. ACCESS: PIV's, trauma line . ACCESS: PIV's, trauma line . Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 160 FINAL REPORT (Cont) notified immediately, including surgical attending Dr. . Per report was taken for ERCP and a large amt of blood was seen in the duodenum with active bleeding noted but visualization was limited and pt was referred to Interventional radiology. Per report was taken for ERCP and a large amt of blood was seen in the duodenum with active bleeding noted but visualization was limited and pt was referred to Interventional radiology. Pt arrived sedated with HR= 110 Afib with occasional PVCs, BP 90-110/60s, intubated and sedated. Pt arrived sedated with HR= 110 Afib with occasional PVCs, BP 90-110/60s, intubated and sedated. Hypoxia: Patient noted in ED to have hypoxia to 70s on room air and was subsequently placed on a non-rebreather. Hypoxia: Patient noted in ED to have hypoxia to 70s on room air and was subsequently placed on a non-rebreather. GI, hepatology, and ERCP were consulted. GI, hepatology, and ERCP were consulted. - Appreciate GI, ERCP, surgery, IR recs - Maintain two large IVs and trauma line - Massive transfusion protocol active - Has anti-E antibodies, so will have to transfuse until the anti-E is consumed by hemolysis - Will continue to trend CBC, coags, and T and S - IR was able to identify bleeding from a branch of the gastroduodenal artery but unable to embolize it. - Appreciate GI, ERCP, surgery, IR recs - Maintain two large IVs and trauma line - Massive transfusion protocol active - Has anti-E antibodies, so will have to transfuse until the anti-E is consumed by hemolysis - Will continue to trend CBC, coags, and T and S - IR was able to identify bleeding from a branch of the gastroduodenal artery but unable to embolize it. He then proceeded to Holy hospital, where he received one unit of blood and ~1 L IVF. He then proceeded to Holy hospital, where he received one unit of blood and ~1 L IVF. Patient's ABG on NRB was 7.46/48/77, indicating a significant A-a gradient. Patient's ABG on NRB was 7.46/48/77, indicating a significant A-a gradient. TITLE: MICU Nursing Critical event note: Pt is a 77yo male adm to ICU with GI bleed and proceeded to ERCP where a bleeding source was visualized but required possible . GI attending in ED felt that source of bleed was likely to be sphincterotomy site as patient had an ERCP in , which was complicated by ulcerative bleed around stent. GI attending in ED felt that source of bleed was likely to be sphincterotomy site as patient had an ERCP in , which was complicated by ulcerative bleed around stent. He was then urgently transferred to for suspected upper GI bleed related to his history of multiple ERCPs. He was then urgently transferred to for suspected upper GI bleed related to his history of multiple ERCPs. Surgery deferred managment decisions to GI and ERCP team. Surgery deferred managment decisions to GI and ERCP team.

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[ { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507265, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male initially adm to ICU via ED from OSH with\n C/O acute abd. pain and melanotic stool. Pt with sig. PMH for COPD,\n IDDM, mult. GIB---mult ERCP for stent placements at sphincterotomy\n site, arrhythmias, CAD, ischemic cardiomyopathy with EF= 25%, CHF, HTN,\n multiple sclerosis, s/p CABG in . Pt with allergies to\n Levofloxacin and quinolones.\n Per report was taken for ERCP and a large amt of blood was seen in the\n duodenum with active bleeding noted but visualization was limited and\n pt was referred to Interventional radiology. During ERCP pt required\n total of 2 units of FFP and 5 units of pRBC via emergency transfusion\n protocol. A Trauma line was placed in the right IJ and pt had a left\n radial aline. BP was reported between 70-120/50-80\ns and IV\n Neosynephrine was infusing at 0.7 mcgs/kg/min. Pt was intubated for\n the ERCP and sedated on Propofol gtt at 33mcgs/kg/min. Pt transferred\n to MICU-6 via ACLS ambulance. Pt arrived sedated with HR= 110 Afib\n with occasional PVC\ns, BP 90-110/60\ns, intubated and sedated. Upon\n arrival to MICU-6 the pt was immediately transported to the IR suite.\n During angiogram a large bleed was seen in a large vessel but all\n attempts by IR team were unsuccessful to embolize or coil the bleed.\n Pt required multiple transfusions during the procedure---transfused\n with total of 3 units pRBC\ns and 1 bag of platelets during IR\n procedure. Neosynephrine gtt was titrated up to 1.0 mcgs/kg/min for\n transient BP dips to 80\ns/60\ns. IV Propofol was increased to\n 50mcgs/kg/min for increased agitation during the case and pt also\n received 2 doses of IV Fentanyl 50mcgs with good effect.\n Returned to MICU-6 and surgical team evaluated pt. Pt not a candidate\n for surgery due to multiple co-morbidities and unstable hemodynamic\n status. Pt bolused with total of 2 liters NS, received 2 more units of\n pRBC\ns ( for a total of 10 units), received 2 more units FFP ( for a\n total of 4 units) and received another bag of platelets (for a total of\n 2 units). Neosynephrine titrated up to 1.2 mcgs/kg/min to maintain\n MAP\ns>60, pt received antibx as ordered, Hct 29, pt passing huge amts\n of melanotic stool and large amts of bright red blood per rectum, color\n ashen with some mottling noted, cool to touch. MICU team and surgical\n teams spoke with pt\ns wife and pt made DNR and then . ALL\n transfusions stopped at 0330, Neo gtt stopped at 0330, bolused with 4\n mg. IV Morphine x 1 and IV Morphine gtt initiated and titrated up to 4\n mg/hr, pt restless/tachypneic/and ? seizing----received 4 mg. IV versed\n x 1 with no effect. Pt received another 4 mg. IV versed bolus dose\n with good effect.\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507268, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male initially adm to ICU via ED from OSH with\n C/O acute abd. pain and melanotic stool. Pt with sig. PMH for COPD,\n IDDM, mult. GIB---mult ERCP for stent placements at sphincterotomy\n site, arrhythmias, CAD, ischemic cardiomyopathy with EF= 25%, CHF, HTN,\n multiple sclerosis, s/p CABG in . Pt with allergies to\n Levofloxacin and quinolones.\n Per report was taken for ERCP and a large amt of blood was seen in the\n duodenum with active bleeding noted but visualization was limited and\n pt was referred to Interventional radiology. During ERCP pt required\n total of 2 units of FFP and 5 units of pRBC via emergency transfusion\n protocol. A Trauma line was placed in the right IJ and pt had a left\n radial aline. BP was reported between 70-120/50-80\ns and IV\n Neosynephrine was infusing at 0.7 mcgs/kg/min. Pt was intubated for\n the ERCP and sedated on Propofol gtt at 33mcgs/kg/min. Pt transferred\n to MICU-6 via ACLS ambulance. Pt arrived sedated with HR= 110 Afib\n with occasional PVC\ns, BP 90-110/60\ns, intubated and sedated. Upon\n arrival to MICU-6 the pt was immediately transported to the IR suite.\n During angiogram a large bleed was seen in a large vessel but all\n attempts by IR team were unsuccessful to embolize or coil the bleed.\n Pt required multiple transfusions during the procedure---transfused\n with total of 3 units pRBC\ns and 1 bag of platelets during IR\n procedure. Neosynephrine gtt was titrated up to 1.0 mcgs/kg/min for\n transient BP dips to 80\ns/60\ns. IV Propofol was increased to\n 50mcgs/kg/min for increased agitation during the case and pt also\n received 2 doses of IV Fentanyl 50mcgs with good effect.\n Returned to MICU-6 and surgical team evaluated pt. Pt not a candidate\n for surgery due to multiple co-morbidities and unstable hemodynamic\n status. Pt bolused with total of 2 liters NS, received 2 more units of\n pRBC\ns ( for a total of 10 units), received 2 more units FFP ( for a\n total of 4 units) and received another bag of platelets (for a total of\n 2 units). Neosynephrine titrated up to 1.2 mcgs/kg/min to maintain\n MAP\ns>60, pt received antibx as ordered, Hct 29, pt passing huge amts\n of melanotic stool and large amts of bright red blood per rectum, color\n ashen with some mottling noted, cool to touch. MICU team and surgical\n teams spoke with pt\ns wife and pt made DNR and then . ALL\n transfusions stopped at 0330, Neo gtt stopped at 0330, bolused with 4\n mg. IV Morphine x 1 and IV Morphine gtt initiated and titrated up to 4\n mg/hr, pt restless/tachypneic/and ? seizing----received 4 mg. IV versed\n x 1 with no effect. Pt received another 4 mg. IV versed bolus dose\n with good effect. Pt extubated and appeared comfortable and expired at\n approx. 0430. MICU resident notified pt\ns family, MICU attending, and\n medical examiner. Medical examiner declined autopsy. Pt has a gold\n watch and eyeglasses and a t-shirt---all to be sent with him to the\n morgue as no family will be coming to the hospital.\n" }, { "category": "Nursing", "chartdate": "2126-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507173, "text": "Pt. presented to OSH with acute onset of sharp abd. Pain this morning\n following episode of maroon stool. Transfused one unit of PRBC and\n transferred to for further care. Surgery, GI teams consulted. Pt.\n has hx. Of recurrent bleeding from previous sphincterotomy site. VSS at\n this time. HR 110\ns-120\ns A-fib, BP 110\ns/60\n Pt. with LLL pna per Xray in ED. On 100% NRB with O2 sat at 99-100%.\n LS with rhoncki with congested cough.\n Abd. Large obese with BS+ hypoactive. No stool while in MICU. NGT in\n place.\n Pt. to go to ERCP tonight.\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Death Note", "row_id": 507259, "text": "TITLE: Death note\n Mr. was made CMO after consultation between his HCP / wife\n . subsequently had pressors discontinued and he was extubated.\n He passed away from exsanguination due to an upper GI bleed. He was\n given morphine and midazolam prior to death to ease his symptoms.\n His case was referred to the Medical Examiner who declined the case. An\n autopsy was refused by his wife/HCP.\n MD\n" }, { "category": "General", "chartdate": "2126-12-07 00:00:00.000", "description": "ICU Event Note", "row_id": 507177, "text": "Clinician: Attending\n 77 yo man with Multiple sclerosis, chronic Afib, h/o CAD, h/o CHF with\n ischemic cardiomyopathy (LVEF 25%), DM2, COPD. Has had repeated bouts\n of cholangitis, deemed to be non operative candidate for\n cholecystectomy, most recently had ERCP in for exchange of stent.\n Presented in early for bleed at sphincterotomy site which was\n treated endoscopically as OSH. Presents now with SOB, abdominal pain,\n maroon stools. Was recently told he has PNA, but has not started\n abtx. Had elevated LFTs in ED with increased alk phos and bili. CXR\n with LLL infiltrate. Also noted to be significantly hypoxemic.\n Transferred to for ERCP. Currently feels mildly SOB. No\n abdominal pain.\n o/e\n dry oropharynx\n no LAD\n lungs: bronchial BS at left base\n CV: irreg, tachy\n abd: soft NT\n ext: no edema, left toe amputations\n Labs:\n ALT: 47 AST: 80 AP: 554 Tbili: 2.7 Lip: 109 INR: 1.3\n A/P:\n cholangitis with intraductal bleed: best explains picture with signs\n of biliary obstruction, and GIB. To get ERCP.\n respiratory distress, hypoxemia: basline long time smoker, COPD, with\n LLL PNA. continue Unasyn for cholangitis plus azithro for LLL PNA.\n Will be intubated for procedure. Hydrate as necessary to support BP\n and urine output.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2126-12-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507229, "text": "TITLE:\n Chief Complaint: abdominal pain, marroon colored stools\n HPI:\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from . Of note,\n patient had a recent admission to from to for\n elective ERCP during which he had removal of CBD stones as well as a\n biliary stent placed. That hospital course was complicated by atrial\n fibrillation with RVR. He then presented on to for additional ERCP to have his previously placed biliary\n stent removed. At time of that procedure, ERCP team\n reported some blood from around the stent at the ampulla, which they\n cauterized to gain hemostasis. Patient was discharged from \n and reports that he was not feeling like he ws back to his baseline at\n any point in . This morning at 0600, he awoke with severe\n mid-abdominal pain and then had urgency to have bowel movement, which\n was described as \"mahagony-colored\". He then proceeded to Holy \n hospital, where he received one unit of blood and ~1 L IVF. Due to poor\n respiratory status, he received furosemide. He was then urgently\n transferred to for suspected upper GI bleed related to his\n history of multiple ERCPs.\n .\n Of note, patient has had upper respiratory sypmtoms for the last 3 to 4\n weeks and presented to his primary care physician several days prior to\n coming in for his acute complaint at this admission. He was prescribed\n an antibiotic of which he does not recall the name. Regardless, he\n never filled the prescription. He notes his breathing is a bit labored\n and though denies acute complaints, later admits that he has had\n increased cough and sputum production in last week.\n .\n Vitals upon presentation to the ED were: T 98, HR 120, BP 100/74, RR\n 16, O2Sat 100% on NRB. Once arriving at , ED obtained NG lavage,\n which failed to clear of blood and noted large amounts of melena.\n Additionally, U/A which showed moderate bacteria and positive nitrite,\n but was without WBCs. Urine culture and blood cultures are pending.\n Patient was given pantoprazole IV as only medical intervention. Patient\n was maintained on a non-rebreather throughout his stay in the ED and\n sats were 100%. He was noted to be in atrial fibrillation with RVR and\n HR was in the 110s to 120s throughout his ED stay with no intervention\n performed. GI, hepatology, and ERCP were consulted. GI attending in ED\n felt that source of bleed was likely to be sphincterotomy site as\n patient had an ERCP in , which was complicated by ulcerative\n bleed around stent. Surgery deferred managment decisions to GI and ERCP\n team. Patient was then transferred to the prior to signout of the\n patient to the admitting medicine ICU team due to need for emergent\n ERCP.\n .\n Patient originally came to and went urgently to ERCP, where was\n quickly noted to be exanguinating from duodenum, though bleeding was\n too brisk to localize further as several units of blood were reported\n to be seen in stomach as well as in the small bowel. ERCP was aborted\n and trauma line was plaed by anesthesia in ERCP suite prior to patient\n being transferred back to for stabilization. Massive transfusion\n protocol was activated and paitent was transfused 5 units PRBC and 2\n units FFP prior to transfer to the MICU for\n stabilization prior to IR attempted angio and embolization.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Levofloxacin\n Rash;\n Quinolones\n Diarrhea;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 06:53 PM\n Azithromycin - 02:33 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n 1) Carbamazepine 200 mg PO QID\n 2) Simvastatin 10 mg PO DAILY\n 3) Zonisamide 100 mg PO DAILY\n 4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea\n 5) Furosemide 20 mg PO DAILY\n 6) Tamsulosin 0.4 mg PO HS\n 7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation \n 8) Metformin 500 mg PO BID\n 9) Sertraline 50 mg Tablet PO DAILY\n 10) Hydromorphone 2 mg PO Q4H:PRN pain\n 11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)\n 12) Pantoprazole 40 mg PO Q12H\n 13) Glyburide 2.5 mg PO DAILY\n 14) Gabapentin 600 mg PO QID\n Past medical history:\n Family history:\n Social History:\n 1) Multiple sclerosis with left hemiparesis/neurogenic bladder\n 2) CAD s/p 2 vessel CABG , PCI LCX \n 3) Chronic systolic heart failure (EF 45-50% with mild hypokinesis of\n the basal to mid inferior and inferolateral segments)\n 4) Atrial fibrillation (complicated by RVR at prior admissions, not on\n anticoagulation)\n 5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ()\n 6) Diabetes mellitus type II\n 7) COPD, on 2L home 02 at night and while ambulatory in summer, no\n current pulmonologist\n 8) Recurrent pseudomonal urinary tract infections\n 9) Recurrent aspiration pneumonia ( and )\n 10) Chronic left ankle fracture c/b non-healing malleolar ulcer\n 11) MRSA colonization\n 12) Hypertension\n 13) Trigeminal neuralgia\n 14) Benign prostatic hypertrophy\n 15) GERD\n Non-contributory\n Occupation: retired electronics tester.\n Drugs: denies\n Tobacco: roughly 120 pack-year history (3 PPD x 40 y)\n Alcohol: denies\n Other: Lives with wife and daughter in , NH\n Review of systems:\n Flowsheet Data as of 03:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.8\nC (96.4\n HR: 109 (97 - 119) bpm\n BP: 87/52(64) {87/52(64) - 121/71(84)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 581 mL\n 2,407 mL\n PO:\n TF:\n IVF:\n 313 mL\n 925 mL\n Blood products:\n 267 mL\n 1,482 mL\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 341 mL\n 2,387 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/56/289/30/4\n Ve: 9 L/min\n PaO2 / FiO2: 482\n Physical Examination\n VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB\n GEN: NAD\n HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient on\n non-rebreather\n NECK: Supple, no \n PULM: CTAB\n CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB\n ABD: obese, BS+, soft, non-tender, non-distended\n EXT: 1+ BLE edema to level of knees\n SKIN: No rashes\n NEURO: Oriented to self, month, year, location. Can not name specific\n day of week. CN II-XII grossly intact. BLE weakness.\n PSYCH: Restricted affect appropriate for clinical situation\n Labs / Radiology\n 230 K/uL\n 11.2 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 26 mg/dL\n 30 mEq/L\n 106 mEq/L\n 3.7 mEq/L\n 141 mEq/L\n 32.1 %\n 10.3 K/uL\n [image002.jpg]\n \n 2:33 A12/19/ 06:18 PM\n \n 10:20 P12/19/ 07:29 PM\n \n 1:20 P12/19/ 08:56 PM\n \n 11:50 P12/19/ 09:38 PM\n \n 1:20 A12/19/ 09:47 PM\n \n 7:20 P12/19/ 10:37 PM\n 1//11/006\n 1:23 P12/20/ 01:08 AM\n \n 1:20 P12/20/ 01:20 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n 10.2\n 10.3\n Hct\n 26.7\n 30\n 28.2\n 29.8\n 32.1\n Plt\n 189\n 250\n 230\n Cr\n 0.6\n 0.8\n TropT\n 0.04\n TC02\n 35\n 30\n 31\n 33\n Glucose\n 176\n 123\n Other labs: PT / PTT / INR:15.3/25.8/1.3, CK / CKMB /\n Troponin-T:21/2/0.04, ALT / AST:36/54, Alk Phos / T Bili:289/9.1,\n Fibrinogen:370 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:145\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from .\n .\n #. Upper GI bleed:\n Massive bleeding seen during ERCP. Likely bleeding source is duodenal\n papilla at site of prior sphincterotomy.\n - Appreciate GI, ERCP, surgery, IR recs\n - Maintain two large IVs and trauma line\n - Massive transfusion protocol active\n - Has anti-E antibodies, so will have to transfuse until the anti-E is\n consumed by hemolysis\n - Will continue to trend CBC, coags, and T and S\n - IR was able to identify bleeding from a branch of the gastroduodenal\n artery but unable to embolize it. Will hopefully go urgently to surgery\n control of his bleeding artery\n .\n #. Cholangitis:\n Patient has had mulitple pseudomonas UTIs in the past and all are\n sensitive to Zosyn. Given that, is reasonable to treat with Zosyn to\n cover his GI flora likely causing his current cholangitis.\n - Trend liver studies\n - ERCP when stable to assure bile duct patency and consider stenting\n - Antibiotic treatment with Zosyn\n .\n #. Hypoxia:\n Patient noted in ED to have hypoxia to 70s on room air and was\n subsequently placed on a non-rebreather. Patient's ABG on NRB was\n 7.46/48/77, indicating a significant A-a gradient.\n - Likely should remain intubated following procedure tonight\n - Post-intubation monitoring of PaO2\n - Antibiotic coverage with Vancomycin/Zosyn/Azithromycin empirically\n pending blood and sputum cultures\n .\n #. Systolic heart failure:\n Recent EF shows hypokinetic LV inferior wall, though EF of 45 to 50%.\n - Hold carvedilol while patient is in window of GI bleed\n .\n #. Atrial fibrillation:\n Patient reported as having atrial fibrillation with RVR during\n hospitalization in and plan at discharge was for cardiology\n follow-up to address anticoagulation; however, it appears that patient\n has not visited a cardiologist following discharge in 9/. At\n presentation to the ICU, HR in the 110s to 120s with stable BP.\n - Assess heart rate response to blood products and fluids\n - Control heart rate rise acutely with IV metoprolol if needed\n - Outpatient follow-up to determine better regimen for rate control and\n to consider patient's candidacy for anticoagulation\n .\n FEN: NPO for now\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen assessment once out of window of GI bleed\n .\n ACCESS: PIV's, trauma line\n .\n CODE STATUS: FULL, per discussion with patient\n .\n EMERGENCY CONTACT: Wife, , or \n .\n DISPOSITION: ICU for stabilization\n ADDEMDUM: Based on surgical risk and discussion with wife and surgery\n team, patient will not go to the OR. I spoke with his wife, , and\n she agreed to DNR. I made her explicitly aware that he will almost\n certainly die of his bleeding. She understood this. We will continue to\n transfuse 1uinit of pRBC per hour for now with 2 units of FFP, and 1u\n PLT. If this does not work after several more hours, we will discuss\n CMO with Mrs. .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:08 PM\n 20 Gauge - 06:08 PM\n Arterial Line - 06:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507240, "text": "TITLE: MICU Nursing Critical event note:\n Pt is a 77yo male adm to ICU with GI bleed and proceeded to\n ERCP where a bleeding source was visualized but required possible .\n Or embolization. Pt adm to MICU-6 emergently for further care.\n Arrived via ambulance and immediately taken to IR suite for possible\n intervention. Pt hemodynamically unstable requiring transfusions of\n total of 5 units pRBC\ns/ 2 units FFP prior to transfer to MICU-6.\n While in IR pt received 3 more units pRBC\ns and 1 bag of platelets. I\n received pt on IV neosynephrine at 0.7 mcgs/kg/min and IV propofol gtt\n at 33 mcgs/kg/min\n" }, { "category": "Physician ", "chartdate": "2126-12-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507233, "text": "TITLE:\n Chief Complaint: abdominal pain, marroon colored stools\n HPI:\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from . Of note,\n patient had a recent admission to from to for\n elective ERCP during which he had removal of CBD stones as well as a\n biliary stent placed. That hospital course was complicated by atrial\n fibrillation with RVR. He then presented on to for additional ERCP to have his previously placed biliary\n stent removed. At time of that procedure, ERCP team\n reported some blood from around the stent at the ampulla, which they\n cauterized to gain hemostasis. Patient was discharged from \n and reports that he was not feeling like he ws back to his baseline at\n any point in . This morning at 0600, he awoke with severe\n mid-abdominal pain and then had urgency to have bowel movement, which\n was described as \"mahagony-colored\". He then proceeded to Holy \n hospital, where he received one unit of blood and ~1 L IVF. Due to poor\n respiratory status, he received furosemide. He was then urgently\n transferred to for suspected upper GI bleed related to his\n history of multiple ERCPs.\n .\n Of note, patient has had upper respiratory sypmtoms for the last 3 to 4\n weeks and presented to his primary care physician several days prior to\n coming in for his acute complaint at this admission. He was prescribed\n an antibiotic of which he does not recall the name. Regardless, he\n never filled the prescription. He notes his breathing is a bit labored\n and though denies acute complaints, later admits that he has had\n increased cough and sputum production in last week.\n .\n Vitals upon presentation to the ED were: T 98, HR 120, BP 100/74, RR\n 16, O2Sat 100% on NRB. Once arriving at , ED obtained NG lavage,\n which failed to clear of blood and noted large amounts of melena.\n Additionally, U/A which showed moderate bacteria and positive nitrite,\n but was without WBCs. Urine culture and blood cultures are pending.\n Patient was given pantoprazole IV as only medical intervention. Patient\n was maintained on a non-rebreather throughout his stay in the ED and\n sats were 100%. He was noted to be in atrial fibrillation with RVR and\n HR was in the 110s to 120s throughout his ED stay with no intervention\n performed. GI, hepatology, and ERCP were consulted. GI attending in ED\n felt that source of bleed was likely to be sphincterotomy site as\n patient had an ERCP in , which was complicated by ulcerative\n bleed around stent. Surgery deferred managment decisions to GI and ERCP\n team. Patient was then transferred to the prior to signout of the\n patient to the admitting medicine ICU team due to need for emergent\n ERCP.\n .\n Patient originally came to and went urgently to ERCP, where was\n quickly noted to be exanguinating from duodenum, though bleeding was\n too brisk to localize further as several units of blood were reported\n to be seen in stomach as well as in the small bowel. ERCP was aborted\n and trauma line was plaed by anesthesia in ERCP suite prior to patient\n being transferred back to for stabilization. Massive transfusion\n protocol was activated and paitent was transfused 5 units PRBC and 2\n units FFP prior to transfer to the MICU for\n stabilization prior to IR attempted angio and embolization.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Levofloxacin\n Rash;\n Quinolones\n Diarrhea;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 06:53 PM\n Azithromycin - 02:33 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n 1) Carbamazepine 200 mg PO QID\n 2) Simvastatin 10 mg PO DAILY\n 3) Zonisamide 100 mg PO DAILY\n 4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea\n 5) Furosemide 20 mg PO DAILY\n 6) Tamsulosin 0.4 mg PO HS\n 7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation \n 8) Metformin 500 mg PO BID\n 9) Sertraline 50 mg Tablet PO DAILY\n 10) Hydromorphone 2 mg PO Q4H:PRN pain\n 11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)\n 12) Pantoprazole 40 mg PO Q12H\n 13) Glyburide 2.5 mg PO DAILY\n 14) Gabapentin 600 mg PO QID\n Past medical history:\n Family history:\n Social History:\n 1) Multiple sclerosis with left hemiparesis/neurogenic bladder\n 2) CAD s/p 2 vessel CABG , PCI LCX \n 3) Chronic systolic heart failure (EF 45-50% with mild hypokinesis of\n the basal to mid inferior and inferolateral segments)\n 4) Atrial fibrillation (complicated by RVR at prior admissions, not on\n anticoagulation)\n 5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ()\n 6) Diabetes mellitus type II\n 7) COPD, on 2L home 02 at night and while ambulatory in summer, no\n current pulmonologist\n 8) Recurrent pseudomonal urinary tract infections\n 9) Recurrent aspiration pneumonia ( and )\n 10) Chronic left ankle fracture c/b non-healing malleolar ulcer\n 11) MRSA colonization\n 12) Hypertension\n 13) Trigeminal neuralgia\n 14) Benign prostatic hypertrophy\n 15) GERD\n Non-contributory\n Occupation: retired electronics tester.\n Drugs: denies\n Tobacco: roughly 120 pack-year history (3 PPD x 40 y)\n Alcohol: denies\n Other: Lives with wife and daughter in , NH\n Review of systems:\n Flowsheet Data as of 03:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.8\nC (96.4\n HR: 109 (97 - 119) bpm\n BP: 87/52(64) {87/52(64) - 121/71(84)} mmHg\n RR: 22 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 581 mL\n 2,407 mL\n PO:\n TF:\n IVF:\n 313 mL\n 925 mL\n Blood products:\n 267 mL\n 1,482 mL\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 341 mL\n 2,387 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.36/56/289/30/4\n Ve: 9 L/min\n PaO2 / FiO2: 482\n Physical Examination\n VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB\n GEN: NAD\n HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient on\n non-rebreather\n NECK: Supple, no \n PULM: CTAB\n CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB\n ABD: obese, BS+, soft, non-tender, non-distended\n EXT: 1+ BLE edema to level of knees\n SKIN: No rashes\n NEURO: Oriented to self, month, year, location. Can not name specific\n day of week. CN II-XII grossly intact. BLE weakness.\n PSYCH: Restricted affect appropriate for clinical situation\n Labs / Radiology\n 230 K/uL\n 11.2 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 26 mg/dL\n 30 mEq/L\n 106 mEq/L\n 3.7 mEq/L\n 141 mEq/L\n 32.1 %\n 10.3 K/uL\n [image002.jpg]\n \n 2:33 A12/19/ 06:18 PM\n \n 10:20 P12/19/ 07:29 PM\n \n 1:20 P12/19/ 08:56 PM\n \n 11:50 P12/19/ 09:38 PM\n \n 1:20 A12/19/ 09:47 PM\n \n 7:20 P12/19/ 10:37 PM\n 1//11/006\n 1:23 P12/20/ 01:08 AM\n \n 1:20 P12/20/ 01:20 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n 10.2\n 10.3\n Hct\n 26.7\n 30\n 28.2\n 29.8\n 32.1\n Plt\n 189\n 250\n 230\n Cr\n 0.6\n 0.8\n TropT\n 0.04\n TC02\n 35\n 30\n 31\n 33\n Glucose\n 176\n 123\n Other labs: PT / PTT / INR:15.3/25.8/1.3, CK / CKMB /\n Troponin-T:21/2/0.04, ALT / AST:36/54, Alk Phos / T Bili:289/9.1,\n Fibrinogen:370 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:145\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 77 yo M with history of coronary artery disease s/p CABG , PCI\n native left circumflex , systolic heart failure, and multiple\n sclerosis, presents with melena from .\n .\n #. Upper GI bleed:\n Massive bleeding seen during ERCP. Likely bleeding source is duodenal\n papilla at site of prior sphincterotomy.\n - Appreciate GI, ERCP, surgery, IR recs\n - Maintain two large IVs and trauma line\n - Massive transfusion protocol active\n - Has anti-E antibodies, so will have to transfuse until the anti-E is\n consumed by hemolysis\n - Will continue to trend CBC, coags, and T and S\n - IR was able to identify bleeding from a branch of the gastroduodenal\n artery but unable to embolize it. Will hopefully go urgently to surgery\n control of his bleeding artery\n .\n #. Cholangitis:\n Patient has had mulitple pseudomonas UTIs in the past and all are\n sensitive to Zosyn. Given that, is reasonable to treat with Zosyn to\n cover his GI flora likely causing his current cholangitis.\n - Trend liver studies\n - ERCP when stable to assure bile duct patency and consider stenting\n - Antibiotic treatment with Zosyn\n .\n #. Hypoxia:\n Patient noted in ED to have hypoxia to 70s on room air and was\n subsequently placed on a non-rebreather. Patient's ABG on NRB was\n 7.46/48/77, indicating a significant A-a gradient.\n - Likely should remain intubated following procedure tonight\n - Post-intubation monitoring of PaO2\n - Antibiotic coverage with Vancomycin/Zosyn/Azithromycin empirically\n pending blood and sputum cultures\n .\n #. Systolic heart failure:\n Recent EF shows hypokinetic LV inferior wall, though EF of 45 to 50%.\n - Hold carvedilol while patient is in window of GI bleed\n .\n #. Atrial fibrillation:\n Patient reported as having atrial fibrillation with RVR during\n hospitalization in and plan at discharge was for cardiology\n follow-up to address anticoagulation; however, it appears that patient\n has not visited a cardiologist following discharge in 9/. At\n presentation to the ICU, HR in the 110s to 120s with stable BP.\n - Assess heart rate response to blood products and fluids\n - Control heart rate rise acutely with IV metoprolol if needed\n - Outpatient follow-up to determine better regimen for rate control and\n to consider patient's candidacy for anticoagulation\n .\n FEN: NPO for now\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen assessment once out of window of GI bleed\n .\n ACCESS: PIV's, trauma line\n .\n CODE STATUS: FULL, per discussion with patient\n .\n EMERGENCY CONTACT: Wife, , or \n .\n DISPOSITION: ICU for stabilization\n ADDEMDUM: Based on surgical risk and discussion with wife and surgery\n team, patient will not go to the OR. I spoke with his wife, , and\n she agreed to DNR. I made her explicitly aware that he will almost\n certainly die of his bleeding. She understood this. We will continue to\n transfuse 1uinit of pRBC per hour for now with 2 units of FFP, and 1u\n PLT. If this does not work after several more hours, we will discuss\n with Mrs. .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:08 PM\n 20 Gauge - 06:08 PM\n Arterial Line - 06:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Attending Addendum:\n Agree with the note above. Please see the event note for full details\n of discussion with the patient\ns wife re-.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:26 ------\n" }, { "category": "General", "chartdate": "2126-12-08 00:00:00.000", "description": "Generic Note", "row_id": 507236, "text": "TITLE: ICU event note:\n After discussions with the surgery consult attending: Dr. as\n described in his note, I spoke with the patients wife over the\n phone and explained to her that the patient continues to have massive\n exanguinating GI bleed in the second duodenum based on the EGD done\n last evening and that IR were able to identify the source of bleeding\n but unable to embolize it and that any surgical intervention at this\n time is associated with very high morbidity and mortality given his\n extensive comorbidities. Based on the above as well as the fact that\n the patient himself had discussed his wishes with his wife few days\n back to be DNR, I informed her that any medical therapy at this time\n including massive blood and blood products transfusion as well as\n vasopressor support will not be able to reverse the ongoing bleeding.\n She understands all what had been mentioned above and all her questions\n have been answered. She made the decision to proceed with CMO at this\n time. Therefore, orders have been entered to discontinue all treatments\n while starting a Morphing IV gtt and titrate to comfort.\n" }, { "category": "ECG", "chartdate": "2126-12-07 00:00:00.000", "description": "Report", "row_id": 243295, "text": "Atrial fibrillation with rapid ventricular response. Right bundle-branch\nblock. Prior inferior wall myocardial infarction. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112928, "text": " 2:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for signs of fluid overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with SOB and GIB, hx of CHF\n REASON FOR THIS EXAMINATION:\n eval for signs of fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with shortness of breath, GI bleed and history of\n CHF.\n\n COMPARISON: Chest radiograph .\n\n CHEST, AP UPRIGHT PORTABLE VIEW: Ill defined left basilar retrocardiac\n opacity is new from prior studies. There is no evidence of pulmonary edema.\n Cardiac silhoette is normal in size. Hilar contours are unchanged.\n Nasogastric tube has been placed. The tip extends beyond the inferior aspect\n of the study. The sternal closure wires are unchanged.\n\n IMPRESSION: Retrocardiac opacity may reflect atelectsis, infection or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1112955, "text": " 9:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line place\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with new trauma line\n REASON FOR THIS EXAMINATION:\n line place\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed seven hours earlier.\n\n Right IJ catheter tip is in the upper SVC. There is no pneumothorax. ET tube\n tip is in standard position, 6.4 cm above the carina. Cardiomediastinal\n silhouette is unchanged. There is worsening left lower lobe opacities,\n consistent with worsening atelectasis or worsening infection. There is no\n evidence of vascular congestion. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "MOD SEDATION, EACH ADDL 15 MIN.", "row_id": 1112957, "text": " 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with massive duodenal bleed.\n REASON FOR THIS EXAMINATION:\n Can angio and embolization be performed for source control?\n ______________________________________________________________________________\n WET READ: AGLc SUN 1:44 AM\n angio showed active extravasation from GDA into 2nd portion of duodenum but\n unable to selectively cannulate GDA for embolization.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male presenting with melena, hypotension and hypoxia,\n found to have massive duodenal bleeding on ERCP. History of cholecystectomy,\n recent plastic biliary stent placement for biliary dilatation due to stones,\n with recent admission at outside hospital 1-2 weeks ago for upper GI bleeding,\n status post stent removal and cauterization at prior sphincterotomy site.\n\n COMPARISON: ERCP images are available from . Images from CT abdomen\n performed at Caritas on are also reviewed on\n PACS.\n\n PROCEDURES:\n 1. Celiac arteriogram.\n 2. Selective common hepatic arteriogram.\n 3. SMA arteriogram.\n\n OPERATORS: Dr. , radiology resident, and Dr. , the\n attending radiologist, who was present and participated throughout the\n procedure.\n\n MEDICATIONS: Moderate sedation was provided by administering divided doses of\n 100 mcg of fentanyl throughout the total intraservice time of 2 hours 45\n minutes, during which the patient's hemodynamic parameters were continuously\n monitored. The patient was also intubated, on propofol. 1% lidocaine was\n also administered for local anesthesia.\n\n (Over)\n\n 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS/PROCEDURE: After discussion of the nature, benefits, risks, and\n alternatives to the proposed procedure, informed consent was given by the\n patient's wife over the phone, which was witnessed by Dr. . The\n patient was then brought to the angiography suite and placed supine on the\n imaging table. The right groin was prepped and draped in the usual sterile\n fashion. Pre-procedural timeout confirmed the patient's identity using three\n patient identifiers, as well as the procedure to be performed.\n\n Using usual sterile technique, 1% lidocaine for local anesthesia, and\n palpatory and fluoroscopic guidance, the right common femoral artery was\n accessed using a 19-gauge needle. An 0.035 wire was then advanced\n through the needle into the abdominal aorta under fluoroscopic guidance. The\n needle was exchanged over the wire for a 5 French vascular sheath, which was\n then connected to a continuous saline sidearm flush. A 5 French C2 Cobra\n catheter was then advanced over the wire into the abdominal aorta. The\n wire was removed. The C2 catheter was then used to access the\n superior mesenteric artery. Arteriogram performed with power injector of the\n SMA in frontal and LAO projections showed no active bleeding.\n\n The C2 Cobra catheter was then dislodged from the SMA, and used to select the\n celiac trunk. Arteriogram of the celiac trunk showed no definite active\n extravasation. Subsequently, a Renegade microcatheter with 0.018 transcend\n wire was advanced through the C2 catheter to selectively cannulate the common\n hepatic artery. Arteriography through the microcatheter showed no active\n extravasation. The microcatheter was removed. Arteriography performed\n through the C2 catheter at the common hepatic artery showed opacification of\n the gastroduodenal artery (GDA), with active extravasation of contrast seen\n from this artery into the second portion of the duodenum.\n\n Based on both clinical and radiologic findings, decision was made to attempt\n cannulization and embolization of the gastroduodenal artery. However, due to\n the tortuous course of the celiac trunk and the angle at the origin of the\n GDA, multiple attempts (Transcend/Fathom wires) to cannulate the GDA were\n unsuccessful. Decision was then made to terminate the procedure and the\n surgical team notified. The wires, catheter, and sheath were then removed and\n hemostasis achieved by manual compression for 20 minutes. A sterile dressing\n was applied. The patient was noted to have continued melena during the\n procedure and was transfused with multiple blood products. Otherwise the\n patient tolerated the procedure without immediate complication.\n\n IMPRESSION:\n 1. Selective common hepatic arteriogram demonstrating active contrast\n extravasation from the gastroduodenal artery (GDA) into the second portion of\n the duodenum. Multiple attempts to gain selective access into the GDA were\n unsuccessful, therefore the procedure was terminated and the surgical team\n (Over)\n\n 10:06 PM\n HEPATIC Clip # \n Reason: Can angio and embolization be performed for source control?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n notified immediately, including surgical attending Dr. .\n 2. SMA arteriogram demonstrating no active extravasation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2126-12-07 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1113118, "text": " 11:14 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP film form - scout only\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with GI bleeding\n REASON FOR THIS EXAMINATION:\n ERCP film form - scout only\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with GI bleeding.\n\n STUDY: Two fluoroscopic images from endoscopy.\n\n FINDINGS: An endogastric tube is noted coursing towards the stomach. Midline\n sternotomy wires are also noted. No endoscope is seen. Per the endoscopy\n report, there was massive GI bleeding. For more details, please see the\n endoscopy note in the online medical record.\n\n\n" } ]

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Patient electively presented and underwent a left occipital craniotomy and resection of mass on . Surgery was without complication and he tolerated it well. He was extubated and transferred to the ICU. Post op Head CT on revealed expected post-operative changes with no evidence of hemorrhage. Patient's diet was advanced and foley removed. He was started on subcutaneous heparin for DVT prophylaxis. Mr. was subsequently transferred to the floor in stable condition. Head MRI on demonstrated post-operative changes with pneumocephalus of left frontal lobe, mild enhancement in upper surgical bed which could represent residual tumor, and post-op cytotoxic edema vs. infarct. Patient will follow up in brain tumor clinic on for re-evaluation, particularly given possible residual tumor post-operatively. He was discharged with prescriptions for keppra 1000mg , dexamethasone taper (4mg TID x1 day -> 4mg BIDx1 day -> 4mg daily until brain tumor clinic follow up), oxycodone, tylenol, and colace. Home ASA was discontinued for now given no absolute need for med (stents etc) and risk of bleeding. ============================ TRANSITION OF CARE: 1. Please consider restarting home ASA 81mg at next follow-up if appropriate Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Dexamethasone 4 mg PO DAILY 2. Doxazosin 2 mg PO HS 3. Lorazepam 0.5 mg PO HS 4. Paroxetine 20 mg PO DAILY 5. Simvastatin 10 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Aspirin 81 mg PO DAILY 8. Cetirizine *NF* 10 mg Oral qday 9. codeine-guaifenesin *NF* 10-100 mg/5 mL Oral unknown Discharge Medications: 1. Dexamethasone 4 mg PO BID Duration: 1 Days Please follow up at Brain Clinic to determine future steroid dosing. RX *dexamethasone 2 mg 2 Tablet(s) by mouth tapered dose Disp #*40 Tablet Refills:*0 2. Dexamethasone 4 mg PO daily Duration: 9 Days Start: After 4 mg tapered dose. Please follow up at Brain Clinic to determine future steroid dosing. 3. Doxazosin 2 mg PO HS 4. Simvastatin 10 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. LeVETiracetam 1000 mg PO BID RX *Keppra 1,000 mg 1 Tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 Tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 Capsule(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain RX *acetaminophen 325 mg Tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 10. Cetirizine *NF* 10 mg Oral qday 11. codeine-guaifenesin *NF* 10-100 mg/5 mL Oral unknown 12. Lorazepam 0.5 mg PO HS 13. Paroxetine 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: left occipital mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Craniotomy for Tumor Excision Dr. ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????You have nylon sutures you may wash your hair and get your incision wet day 7 after surgery. You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ??????If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. We made the following changes to your medications: 1. STOPPED aspirin (increases risk of bleeding - please discuss whether to restart this at your brain tumor clinic follow up) 2. INCREASED dexamethasone to 4mg three times daily for today (), then two times daily tomorrow (), then back to once daily ( until brain tumor clinic follow up) 3. STARTED levetericetam (Keppra) 1000mg twice daily (to prevent seizures) 3. STARTED oxycodone 5mg every 6 hours as needed for pain 4. STARTED acetaminophen (tylenol) 325-650mg every 6 hours as needed for pain 5. STARTED docusate (colace) 100mg twice daily as needed for constipation Followup Instructions: ??????You have an appointment in the Brain Clinic on @ 9:30AM. The Brain Clinic is located on the of , in the Building, . Their phone number is . Please call if you need to change your appointment, or require additional directions.

FINDINGS: The patient is status post left parieto-occipital craniotomy. FINDINGS: The patient is status post left parieto-occipital craniotomy. A small amount of vasogenic edema in the left occipital lobe is similar to MRI . Small extra-axial hematoma is noted adjacent to the surgical bed. Area of pneumocephalus layering along the left frontal lobe appears similar to the CT of . Pneumocephalus layering along the left frontal lobe similar to the prior examination. COMPARISON: MRI and . There is mild enhancement along the anterior aspect of the surgical bed, which may suggest residual tumor, attention on followup imaging is recommended. Slow diffusion along the periphery of the surgical bed may suggest post-op cytotoxic edema versus infarct. FINDINGS: A 2.1-cm transverse x 1.6 cm AP x 1.7 cm CC enhancing lesion within the left occipital lobe with broad-based dural attachment appears most consistent with meningioma (3:11 and 100A:75). IMPRESSION: Expected post-surgical changes after resection of left occipital lesion. Slow diffusion is noted along the periphery of the surgical bed, which may represent post-op cytotoxic edema versus infarct (series 9, image 14). Following the administration of IV contrast, axial T1 images were obtained. A small amount of hyperdense blood is seen in the surgical bed with small pneumocephalus in the left frontal lobe and left occipital lobe. IMPRESSION: 2.1 x 1.6 x 1.7-cm lesion with broad-based dural enhancing lesion with broad-based dural tail within the left occipital lobe appears most consistent with meningioma. Mild enhancement in the upper surgical bed may represent residual tumor. Evaluate for post-operative change and residual lesion. TECHNIQUE: MRI of the brain was obtained with and without the administration of IV contrast. TECHNIQUE: Non-contrast MDCT axial images were acquired through the head. COMPARISON: Outside hospital MRI of the head . Post-surgical changes after resection of left occipital lesion with blood products noted within the surgical bed as well as adjacent extra-axial hematoma and mild adjacent soft tissue hematoma. TECHNIQUE: MRI of the brain was obtained with the administration of IV contrast. COMPARISON: MRI of the brain with contrast . Blood products and hematoma is noted within the adjacent scalp. T1- and T2-hyperintense material within the surgical bed shows blooming on susceptibility images consistent with blood products within the surgical bed. (Over) 8:38 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change and residual lesion Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA Contrast: GADAVIST Amt: 7 FINAL REPORT (Cont) Sagittal T1, axial T1, axial FLAIR, axial T2 and axial susceptibility weighted images were obtained without the administration of IV contrast. Dense atherosclerotic calcifications are seen in the intracranial vertebral arteries. Bilateral mastoid air cells and visualized paranasal sinuses are clear. 8:38 AM MR HEAD W & W/O CONTRAST Clip # Reason: evalaute for post-op change and residual lesion Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA Contrast: GADAVIST Amt: 7 MEDICAL CONDITION: 59 year old man with left occipital lesion s/p resection REASON FOR THIS EXAMINATION: evalaute for post-op change and residual lesion No contraindications for IV contrast FINAL REPORT INDICATION: 59-year-old man with left occipital lesion status post resection. Attention to these areas on followup imaging is recommended. The ventricles and sulci appear normal in size and configuration. Ventricles and sulci are normal in size and symmetric in configuration. -white matter differentiation elsewhere is preserved. Evaluate for postoperative change. The visualized paranasal sinuses and mastoid air cells are clear. Diffusion-weighted and ADC maps were generated and reviewed. Basal cisterns are patent. Please obtain between 1430 and 1530 No contraindications for IV contrast FINAL REPORT CLINICAL HISTORY: 59-year-old man with left occipital lesion status post resection. 5:14 AM MR HEAD W/ CONTRAST Clip # Reason: pre-surgical mapping Contrast: GADAVIST Amt: 7 MEDICAL CONDITION: 59 year old man with left occipital tumor REASON FOR THIS EXAMINATION: pre-surgical mapping No contraindications for IV contrast FINAL REPORT INDICATION: 59-year-old man with left occipital tumor for pre-surgical mapping. Please obtain between 14 Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA MEDICAL CONDITION: 59 year old man with left occipital lesion s/p resection REASON FOR THIS EXAMINATION: evalaute for post-operative change. IMPRESSION: 1. 3:05 PM CT HEAD W/O CONTRAST Clip # Reason: evalaute for post-operative change.

3

[ { "category": "Radiology", "chartdate": "2177-05-29 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1246003, "text": " 5:14 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital tumor\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with left occipital tumor for pre-surgical\n mapping.\n\n COMPARISON: Outside hospital MRI of the head .\n\n TECHNIQUE: MRI of the brain was obtained with the administration of IV\n contrast.\n\n FINDINGS: A 2.1-cm transverse x 1.6 cm AP x 1.7 cm CC enhancing lesion within\n the left occipital lobe with broad-based dural attachment appears most\n consistent with meningioma (3:11 and 100A:75). No other enhancing foci are\n identified. The ventricles and sulci appear normal in size and configuration.\n There is no evidence of acute major vascular territory infarction. There are\n no foci of acute hemorrhage.\n\n Bilateral mastoid air cells and visualized paranasal sinuses are clear.\n\n IMPRESSION: 2.1 x 1.6 x 1.7-cm lesion with broad-based dural enhancing lesion\n with broad-based dural tail within the left occipital lobe appears most\n consistent with meningioma.\n\n" }, { "category": "Radiology", "chartdate": "2177-05-30 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1246172, "text": " 8:38 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change and residual lesion\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital lesion s/p resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-op change and residual lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with left occipital lesion status post resection.\n Evaluate for post-operative change and residual lesion.\n\n COMPARISON: MRI of the brain with contrast .\n\n TECHNIQUE: MRI of the brain was obtained with and without the administration\n of IV contrast. Sagittal T1, axial T1, axial FLAIR, axial T2 and axial\n susceptibility weighted images were obtained without the administration of IV\n contrast. Following the administration of IV contrast, axial T1 images were\n obtained. Diffusion-weighted and ADC maps were generated and reviewed.\n\n FINDINGS: The patient is status post left parieto-occipital craniotomy.\n Small extra-axial hematoma is noted adjacent to the surgical bed. Blood\n products and hematoma is noted within the adjacent scalp. T1- and\n T2-hyperintense material within the surgical bed shows blooming on\n susceptibility images consistent with blood products within the surgical bed.\n Area of pneumocephalus layering along the left frontal lobe appears similar to\n the CT of .\n\n There is mild enhancement along the anterior aspect of the surgical bed, which\n may suggest residual tumor, attention on followup imaging is recommended.\n Slow diffusion is noted along the periphery of the surgical bed, which may\n represent post-op cytotoxic edema versus infarct (series 9, image 14).\n\n IMPRESSION:\n\n 1. Post-surgical changes after resection of left occipital lesion with blood\n products noted within the surgical bed as well as adjacent extra-axial\n hematoma and mild adjacent soft tissue hematoma. Pneumocephalus layering\n along the left frontal lobe similar to the prior examination.\n\n 2. Mild enhancement in the upper surgical bed may represent residual tumor.\n\n 3. Slow diffusion along the periphery of the surgical bed may suggest post-op\n cytotoxic edema versus infarct. Attention to these areas on followup imaging\n is recommended.\n (Over)\n\n 8:38 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evalaute for post-op change and residual lesion\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n Contrast: GADAVIST Amt: 7\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2177-05-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1246079, "text": " 3:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalaute for post-operative change. Please obtain between 14\n Admitting Diagnosis: LEFT OCCIPITAL TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with left occipital lesion s/p resection\n REASON FOR THIS EXAMINATION:\n evalaute for post-operative change. Please obtain between 1430 and 1530\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 59-year-old man with left occipital lesion status post\n resection. Evaluate for postoperative change.\n\n COMPARISON: MRI and .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired through the head.\n\n FINDINGS: The patient is status post left parieto-occipital craniotomy. A\n small amount of hyperdense blood is seen in the surgical bed with small\n pneumocephalus in the left frontal lobe and left occipital lobe. There is no\n large hemorrhage or major vascular territorial infarct. A small amount of\n vasogenic edema in the left occipital lobe is similar to MRI .\n -white matter differentiation elsewhere is preserved. Ventricles and sulci\n are normal in size and symmetric in configuration. Basal cisterns are patent.\n There is no shift of normally midline structures. The visualized paranasal\n sinuses and mastoid air cells are clear. Dense atherosclerotic calcifications\n are seen in the intracranial vertebral arteries.\n\n IMPRESSION: Expected post-surgical changes after resection of left occipital\n lesion.\n\n" } ]

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74M admitted with left side facial swelling. . 1. Facial swelling/angioedema: Patient admitted to ICU for monitoring. Ace inhibitor held-suspected offending . No shellfish etc. (Patient had similar episode in past with shellfish) Treated with benadryl, famotidine. Patient received tow doses of decadron as well. Patient had rpaid improvement in his swelling and angioedema. Decadron discontinued given recent right TKR and concern for septic joint. C1 and C4 complement levels sent. ENT consulted-no evidence of airway compromise. Discharged on 5 days of famotidine/benadryl. Allergy f/u with Dr. scheduled for patient. . 2 Acute renal failure - baseline 1.1, admit 1.3, likely dehydration. Resolved with IVF's. . 3) Right TKR: 2 weeks post replacement. Followed by ortho throughout. Staples removed. Ortho did not feel knee was infected. PT evaluated patient. Lovenox x 10 more days then apsirin as per ortho. F/u with Dr. scheduled. 4)HTN - continued home amlodipine. Ace inhibitor discontinued. Amlodipine titrated to 10mg from 5mg --bp generally well controlled 120's to 130's on amlodipine alone. 5) hyperlipidemia - continued statin. . 6)DM - HISS while inpt, restarted metformin upon discharge. . #PPx - lovenox 40 sc q24 given knee replacement. - bowel regimen not necessary given recent loose bm's in setting of colace. . . #COMM: wife , , sign language interpreter pager .

#DISPO - pending clinical improvement . #DISPO - pending clinical improvement . - f/u C1, C4 - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. Agree with pulse steroids x 3doses, benadryl, zantac. Agree with pulse steroids x 3doses, benadryl, zantac. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. 74 y/o m with PMH CAD & HTN, admitted from EW with difficulty swallowing and facial swelling, likely angioedema r/t reaction to new ace-i, received Solumedrol and Benadryl in EW, pt had a recent right TKR & per ortho pt should not receive steroids. - ENT consult to evaluate airway given ?dysphagia. - ENT consult to evaluate airway given ?dysphagia. - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. - treat with iv benadryl (h1), famotidine (h2) for now as is apparently still getting worse RN. #FEN - liquids for now, pending ENT evaluation, then ok to advance. #FEN - liquids for now, pending ENT evaluation, then ok to advance. d/c lisinopril. d/c lisinopril. Tx with solumedrol, filodipine, benadry. Tx with solumedrol, filodipine, benadry. #HTN - continue home amlodipine. #HTN - continue home amlodipine. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if still in house, can likely remove. # ARF - baseline 1.1, now 1.3, likely dehydration. # ARF - baseline 1.1, now 1.3, likely dehydration. - hydrate with 1L IVF today, encourage PO hydration (pt thirsty) - repeat chem7 in AM. - hydrate with 1L IVF today, encourage PO hydration (pt thirsty) - repeat chem7 in AM. Ortho saw patient, plan to remove staples soon. Lisinopril d/c'd. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 11:30 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: - follow knee exam- appreciate ortho rec will hold off on empiric steroids for now given risk of infection #HTN - continue home amlodipine. - consider allergy consult if not improving. - consider allergy consult if not improving. Action: HO in to assess Response: Per ortho, reluctant to give steroids (post knee)..however with ?increase swelling. # hyperlipid - continue statin. # hyperlipid - continue statin. # hyperlipid - continue statin. Andioedema likley from ACE. - continue home ferrous sulfate. - continue home ferrous sulfate. - continue home ferrous sulfate. #DM - - switch to HISS while inpt, restart metformin upon discharge. #DM - - switch to HISS while inpt, restart metformin upon discharge. #DM - - switch to HISS while inpt, restart metformin upon discharge. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. - prn tylenol for pain, will use ultram for breakthrough pain as oyxcodone caused significant n/v in pt. glaucoma s/p R TKR revision , ( MVA) deafness meningitis no h/o angioedema.

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[ { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 319299, "text": "Chief Complaint: Facial swelling\n 24 Hour Events:\n - steroids d/c'd per ortho, however, developed increased swelling and\n pain with swallowing so restarted\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: minimal pain with swallowing, improved swelling of\n lips\n Gastrointestinal: Diarrhea, day beofre yesterday\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 87 (65 - 93) bpm\n BP: 158/73(90) {139/56(77) - 160/77(97)} mmHg\n RR: 24 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 74 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 74 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -626 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, lips swollen but improved\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: Systolic), II/VI SEM\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, deaf, reads lips\n Labs / Radiology\n 690 K/uL\n 9.5 g/dL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74M admitted with left side facial swelling.\n .\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation.\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - add on serum tryptase (if positive, suggests allergic component).\n - consisder adding on c1, c4 complement levels, though would be send\n outs, however this is is second episode of this type of event.\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids x 24hrs (decadron 10mg q8hr x3 dose)then would switch to\n po steroids for rapid taper (or d/c altogether).\n - ENT consult to evaluate airway given ?dysphagia.\n - consider allergy consult if not improving.\n .\n .\n # ARF - baseline 1.1, now 1.3, likely dehydration.\n - hydrate with 1L IVF today, encourage PO hydration (pt thirsty)\n - repeat chem7 in AM.\n .\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaic stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type event, will hydrate and\n follow in AM.\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n .\n #HTN - continue home amlodipine.\n - add BB or HCTZ if additional control needed.\n .\n # hyperlipid - continue statin.\n .\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge.\n .\n #FEN\n - liquids for now, pending ENT evaluation, then ok to advance.\n - encourage po hydration, no need for IVF.\n .\n #PPx\n - lovenox 40 sc q24 given knee replacement.\n - bowel regimen not necessary given recent loose bm's in setting of\n colace.\n .\n #CODE: FULL\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319302, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319303, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent &\n per ortho pt should not receive steroids.\n" }, { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 319306, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n events noted, received additional dose of decadron yesterday for voice\n change. no stridor at any time.\n subjectively improved lip swelling and voice this am.\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.5\nC (97.7\n HR: 73 (65 - 93) bpm\n BP: 143/62(82) {139/56(77) - 160/77(97)} mmHg\n RR: 17 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 578 mL\n PO:\n 480 mL\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 98 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), no stridor\n Extremities: Right: 1+, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 690 K/uL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible, less likely LMWH. No new foods.\n 1. Andioedema\n likley from ACE. no signs of stridor. Lisinopril d/c'd.\n better with two doses of steroids, benadryl, zantac. Stable.\n 2. S/p right knee surgery - warm to touch, thrombocytosis improved, no\n signs of infection. Ortho saw patient, plan to remove staples soon.\n 3. DM - watch glc with SS and continue metformin\n 4. HTN\n will initiate HCTZ\n Stable to be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2200-04-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 319309, "text": "Chief Complaint: Facial swelling\n 24 Hour Events:\n - steroids d/c'd per ortho, however, developed increased swelling and\n pain with swallowing so given one time dose 4mg decadron IV\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 04:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: minimal pain with swallowing, improved swelling of\n lips\n Gastrointestinal: Diarrhea, day beofre yesterday\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 87 (65 - 93) bpm\n BP: 158/73(90) {139/56(77) - 160/77(97)} mmHg\n RR: 24 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Height: 72 Inch\n Total In:\n 1,570 mL\n 74 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,090 mL\n 74 mL\n Blood products:\n Total out:\n 1,050 mL\n 700 mL\n Urine:\n 1,050 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 520 mL\n -626 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, lips swollen but improved\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: Systolic), II/VI SEM\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, deaf, reads lips\n Labs / Radiology\n 690 K/uL\n 9.5 g/dL\n 129 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 133 mEq/L\n 27.4 %\n 10.3 K/uL\n [image002.jpg]\n 04:29 AM\n WBC\n 10.3\n Hct\n 27.4\n Plt\n 690\n Cr\n 1.0\n Glucose\n 129\n Other labs: Ca++:9.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 74M admitted with left side facial swelling.\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation. Most\n likely culprit ACEI, have d/c\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - f/u C1, C4\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids d/c\nd per ortho for risk of infection, can dose prn for\n symptoms of increased swelling or respiratory compromise\n - ENT consult appreciated\n - consider allergy consult if not improving, should probably arrange\n outpt allergy f/u\n # ARF - baseline 1.1, 1.3 on admission, likely dehydration. Now below\n baseline with fluids.\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaiac stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - overnight drop in HCT likely dilutional\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type eventv recent surgery,\n hydrated and significantly improved this am\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam- appreciate ortho rec\n will hold off on empiric\n steroids for now given risk of infection\n #HTN - continue home amlodipine.\n - will double dose of amlodipine in absence of ACE I\n - can add BB or HCTZ if additional control needed.\n # hyperlipid - continue statin.\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge. .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319316, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 319221, "text": "Chief Complaint: left lower lip, cheek swelling\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 74 yr old male, left lower lip and cheek swelling\n On ACE for 5 yrs. No known new exposure.\n have had similar symptoms a few years ago attributed to shrimp.\n Per wife, lip became more swollen. In ED, sat 100% on RA. Tx with\n solumedrol, filodipine, benadry. Swelling progressed to right lip. No\n stridor at any time. Transferred for close monitoring.\n Patient admitted from: ER\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. DM\n 2. HTN\n 3. deafness d/t meningitis as child\n 4. Anemia\n 5. Prostate ca s/p radiacal prostatectomy\n 6. glaucoma\n 7 hyperlipidemia\n 8. TKR, revision (osteo of right knee d/t MVA 95)\n MEDS PTA\n simvastatin, Fe, amlodipine, lisinopril, lovenox q24h since knee ,\n metformin, tylenol, oxycodone (not taking)\n No angioedema\n Occupation: retired, worked at polaroid\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Nausea, Diarrhea, loose stools yesterday\n attributed to colace and dairy\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 02:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Marked edema of lower lip and left upper lip, edema\n of left cheek, no tongue swelling\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), No stridor\n Extremities: Right: Absent, Left: Absent, right knee warm to touch, no\n erythema, no fluctuance, no drainage\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, deaf, phonates, communicates in sign\n language\n Labs / Radiology\n 825\n 33.2\n 109\n 1.3\n 22\n 4.5\n 7.3\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2\n Fluid analysis / Other labs: Plat were 400 during last admission.\n Wbc Diff: eos 2.6\n Creat baseline 1.1\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible. No new foods.\n 1. Andioedema - no signs of stridor. d/c lisinopril. Agree with pulse\n steroids x 3doses, benadryl, zantac.\n 2. S/p right knee surgery - warm to touch, thrombocytosis but no other\n signs of infection. Will touch base with ortho.\n 3. DM - watch glc with SS and continue metformin\n 4. Code status - full code\n If needed, can be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 319222, "text": "Chief Complaint: left lower lip, cheek swelling\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 74 yr old male, left lower lip and cheek swelling\n On ACE for 5 yrs. No known new exposure.\n have had similar symptoms a few years ago attributed to shrimp.\n Per wife, lip became more swollen. In ED, sat 100% on RA. Tx with\n solumedrol, filodipine, benadry. Swelling progressed to right lip. No\n stridor at any time. Transferred for close monitoring.\n Patient admitted from: ER\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. DM\n 2. HTN\n 3. deafness d/t meningitis as child\n 4. Anemia\n 5. Prostate ca s/p radiacal prostatectomy\n 6. glaucoma\n 7 hyperlipidemia\n 8. TKR, revision (osteo of right knee d/t MVA 95)\n MEDS PTA\n simvastatin, Fe, amlodipine, lisinopril, lovenox q24h since knee ,\n metformin, tylenol, oxycodone (not taking)\n No angioedema\n Occupation: retired, worked at polaroid\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Nausea, Diarrhea, loose stools yesterday\n attributed to colace and dairy\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 02:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Marked edema of lower lip and left upper lip, edema\n of left cheek, no tongue swelling\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), No stridor\n Extremities: Right: Absent, Left: Absent, right knee warm to touch, no\n erythema, no fluctuance, no drainage\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, deaf, phonates, communicates in sign\n language\n Labs / Radiology\n 825\n 33.2\n 109\n 1.3\n 22\n 4.5\n 7.3\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2\n Fluid analysis / Other labs: Plat were 400 during last admission.\n Wbc Diff: eos 2.6\n Creat baseline 1.1\n Assessment and Plan\n 74 yr old male with angioedema, likely from ACE inhibitor. Other\n precipitants possible. No new foods.\n 1. Andioedema - no signs of stridor. d/c lisinopril. Agree with pulse\n steroids x 3doses, benadryl, zantac.\n 2. S/p right knee surgery - warm to touch, thrombocytosis but no other\n signs of infection. Will touch base with ortho.\n 3. DM - watch glc with SS and continue metformin\n 4. Code status - full code\n If needed, can be transferred to floor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2200-04-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 319223, "text": "Chief Complaint: facial swelling\n HPI:\n 74 M h/o DM2, HTN, deaf presents to ED after awakening at 6:45AM with\n left lower lip and cheek swelling. no cp/sob/difficulty swallowing at\n that time, no urticara, pruritis. no recent medications changes (on\n ace-i x 5y), trauma, insect bite, food changes, detergent changes.\n similar type episode in after eating shrimp, though not as\n severe, and resolved within 1-2hrs. per wife, swelling this am\n progressed over minutes, so brought pt to ED. last took lisinopril at\n 10AM .\n .\n Upon arrival to ED 98.5 71 15/55 18 100%RA, pt given solumedrol\n 125mg iv x 1, famotidine 20mg iv x1, benadryl 25mg iv x1 at 0850AM,\n however swelling continued to progress, involving right lower lip, left\n upper lip, and worsening of left cheek swelling. again no cp, sob,\n stridor, though now admits to some difficulty swallowing. Admitted to\n for closer monitoring.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend, Interpreter\n Allergies:\n Ace Inhibitors\n angioedema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n simvastatin 40 mg po qdaily, ferrous sulfate 325mg po qdaily,\n amlodipine 5mg po qdaily, lisinopril 40mg po qdaily, lovenox 40mcg sc\n qdaily, metformin 500mg po bid.\n Past medical history:\n Family history:\n Social History:\n DM2\n HTN\n hyperlipidemia\n anemia\n prostate ca - dx , s/p radical prostatectomy, no chemo/xrt.\n glaucoma\n s/p R TKR revision , ( MVA)\n deafness meningitis\n no h/o angioedema.\n Occupation: retired polaroid factory worker\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Diarrhea\n Neurologic: Numbness / tingling\n Flowsheet Data as of 02:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n BP: 139/56(77) {139/56(77) - 139/56(77)} mmHg\n RR: 17 (17 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, right knee wound c/d/i\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 74M admitted with left side facial swelling.\n .\n # facial swelling - ddx includes angioedema (? ace-i), cellulitis,\n lympedema, svc syndrome, hypothyroid, though angioedema seems most\n likely, no urticarial component, no eosinophila on diff. infectious\n causes seem less likely given lack of fever, wbc elevation.\n - no obvious cause outside of ACE-I, had single similar episode in\n after shrimp exposure.\n - add on serum tryptase (if positive, suggests allergic component).\n - consisder adding on c1, c4 complement levels, though would be send\n outs, however this is is second episode of this type of event.\n - treat with iv benadryl (h1), famotidine (h2) for now as is apparently\n still getting worse RN.\n - iv steroids x 24hrs (decadron 10mg q8hr x3 dose)then would switch to\n po steroids for rapid taper (or d/c altogether).\n - ENT consult to evaluate airway given ?dysphagia.\n - consider allergy consult if not improving.\n .\n .\n # ARF - baseline 1.1, now 1.3, likely dehydration.\n - hydrate with 1L IVF today, encourage PO hydration (pt thirsty)\n - repeat chem7 in AM.\n .\n # anemia - chronic, baseline 32-36, currently 33 s/p recent knee\n replacement, on lovenox. knee is non-tender, but slightly warm, feel\n septic joint is unlikely, but we are starting pt on steroids.\n - guaic stools x 3.\n - continue home ferrous sulfate.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n # thrombocytosis - plts 800s, were 400 last admission, ?related to\n dehydration or reactive to angioedema type event, will hydrate and\n follow in AM.\n - may need outpt f/u.\n .\n # s/p TKR - wound c/d/i, staples still in, now 2wks post procedure, if\n still in house, can likely remove.\n - prn tylenol for pain, will use ultram for breakthrough pain as\n oyxcodone caused significant n/v in pt.\n - follow knee exam, if enlarging consider tap.\n - will let ortho know pt is here.\n .\n .\n #HTN - continue home amlodipine.\n - add BB or HCTZ if additional control needed.\n .\n # hyperlipid - continue statin.\n .\n #DM -\n - switch to HISS while inpt, restart metformin upon discharge.\n .\n #FEN\n - liquids for now, pending ENT evaluation, then ok to advance.\n - encourage po hydration, no need for IVF.\n .\n #PPx\n - lovenox 40 sc q24 given knee replacement.\n - bowel regimen not necessary given recent loose bm's in setting of\n colace.\n .\n #CODE: FULL\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: wife , , sign language interpreter pager\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319280, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with benedryl IV, neg stridor, denies SOB,\n maintaining sats on RA w/o difficulty\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho, ?call out with continued improvement\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R , staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches at home\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, denies knee pain\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319275, "text": "74 y/o m adm from EW with difficulty swallowing and facial\n swelling, likely angioedema d/t ace-i, received solumedrol and benadryl\n in EW, MICU management complicated by recent , ortho pt is not\n to receive steroids, swelling increasing since adm, per pt and this RN\n swelling of lips and face decreased overnight with benedryl\n administration, although pt continues to report some difficulty\n swallowing\n Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with benedryl IV, neg stridor, denies SOB,\n maintaining sats on RA w/o difficulty\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho, ?call out with continued improvement\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R , staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches at home\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, denies knee pain\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319338, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN 406\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319260, "text": " Problem - Description In Comments\n Assessment:\n Pt with facial and lip swelling, reporting some discomfort in throat\n with difficulty swallowing, hx of similar swelling associated with\n shell fish allergy, origin of this instance unknown, currently holding\n steroids per ortho, treating with standing and prn benedryl IV\n Action:\n Monitoring appearance frequently, pt reporting subjective changes, pt\n NPO w/ sips\n Response:\n Swelling/discomfort reported by pt responsive to benedryl adm\n Plan:\n Continue to monitor facial swelling, continue benedryl adm, continue to\n hold steroids per ortho\n Impaired Physical Mobility\n Assessment:\n Pt with recent hx of R TKR, staples in place, area appears well healed\n with minimal swelling, pt ambulating with crutches\n Action:\n Ortho by to assess pt, plan to remove staples tomorrow or Thursday\n Response:\n Pt resting in bed overnight, limited activity, response unknown\n Plan:\n Pt oob in am if appropriate, ?pt consult\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319328, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN $06\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319329, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to\n \n Attending MD:\n \n Admit diagnosis:\n ANGIOEDEMA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 86 kg\n Allergies/Reactions:\n Ace Inhibitors\n angioedema;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: s/p TKR 2wks ago..sutures still in...per wife..less\n swelling\n Pt is DEAF...s/p menningitis at age 8 able to sign and read lips.\n Prefers to have the sign language interpreter present for discussion\n about care.\n recent adm for cp r/o'd for MI and PE\n prostate ca\n Surgery / Procedure and date: TKR ?\n Still with staples in place\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:62\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 689 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:29 AM\n Potassium:\n 4.2 mEq/L\n 04:29 AM\n Chloride:\n 104 mEq/L\n 04:29 AM\n CO2:\n 24 mEq/L\n 04:29 AM\n BUN:\n 23 mg/dL\n 04:29 AM\n Creatinine:\n 1.0 mg/dL\n 04:29 AM\n Glucose:\n 129 mg/dL\n 04:29 AM\n Hematocrit:\n 27.4 %\n 04:29 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: Blackberry at bedside, pt is deaf and he uses the\n device for text messaging\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/SICU FN 406\n Transferred to: RS 1163D\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319319, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n ROS:\n Neuro: pt is deaf, but reads lips well, ASL translators following,\n A&Ox3, MAEW, OOB to chair with minimal assist, ambulating in room to\n toilet with crutches, denies pain at present\n Pulm: LS CTA, SpO2 97-100% RA\n CV: AVSS, please see flowsheet for data\n Integ: right knee incision OTA, staples C/D/I, plan for staples to be\n removed today\n GI/GU: abd soft, NT/ND, BS present, LBM this AM, tolerating heart\n healthy diet without difficulty, voiding qs in urinal and in BR\n Access: #18 angio left AC day #2\n Plan: activity as tolertated, ambulate with crutches, continue to\n monitor until airway edema/facial swelling returns to normal\n" }, { "category": "Nursing", "chartdate": "2200-04-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319253, "text": "74 y/o man with hx of diabetes, htn and deafness, admitted to ICU from\n EW with lip and cheek swelling. Pt woke up early this am with tingling\n and numbness of lips. Given steroids and benadryl in EW and sent to ICU\n for further observation. Pt is also 2 weeks post TRK, still left with\n sutures.\n Problem - Description In Comments\n Assessment:\n Pt admitted with swollen upper lip and puffy left cheek. Over course of\n afternoon, decreased, felt better per pt. By 1800 pt and wife feel\n upper lip is more swollen, by visual..is slightly bigger. No airway\n involvement..Pt is able to eat and drink. Requires no o2.\n Action:\n HO in to assess\n Response:\n Per ortho, reluctant to give steroids (post knee)..however with\n ?increase swelling.\n Plan:\n To get x1 dose of dexa methasone\nContinue to monitor lips and cheek\n swellingl\n Impaired Physical Mobility\n Assessment:\n 2 week post TRK..sutures in. Slight swelling of knee. Per pt and wife,\n knee is much better, Denies pain at this time\n Action:\n Ortho by and assessed pt\n Response:\n To keep sutures in at this time..\n Plan:\n Continue to follow\n .H/O meningitis, other\n Assessment:\n Pt is totally deaf..at age 8 had meningitis.\n Action:\n Use of sign language interpretors..schedule posted in room and on\n chart.\n Response:\n Pt less anxious\n Plan:\n As above..Also speak TO pt so he can see our lips. He is able to lip\n read..\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 319317, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n" }, { "category": "Nursing", "chartdate": "2200-04-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 319318, "text": "74 y/o m with PMH CAD & HTN, admitted from EW with difficulty\n swallowing and facial swelling, likely angioedema r/t reaction to new\n ace-i, received Solumedrol and Benadryl in EW, pt had a recent right\n TKR & per ortho pt should not receive steroids. However, after\n admission to the ICU pt\ns swelling worsened and he received a 1x dose\n of dexamethasone 4mg.\n Impaired Physical Mobility\n Assessment:\n S/p right TKR revision \n Right knee slightly swollen, pt denies pain at present\n OOB toc commode and for AM care with contact guard assist\n Pt ambulating in room with crutches\n Action:\n OOB to chair as pt tolerates\n Ambulate /TID with crutches\n PT evaluation for ROM, strength training\n Response:\n Pt tolerating crutch ambulation and sitting in chair well\n Plan:\n Continue to ambulate pt /TID\n OOB as tolerated\n Problem - Angioedema\n Assessment:\n Pt\ns face and cheeks swollen\n Pt reports improvement in swelling since receiving steroids\n Action:\n Pt continues to get Benadryl and Pepcid\n Response:\n Ongoing assessment\n Plan:\n Continue Benedryl and Pepcid ATC\n Continue to monitor airway edema/facial swelling\n" } ]

64,195

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HOSPITAL COURSE: This is a 58 year old gentleman with a history of recurrent syncope and systolic heart failure (EF 35%) who presented to the ED for pre-syncope w/u and was observed to have a tonic clonic seizure with combative post-ictal state who was intubated for airway protection. . ACTIVE ISSUES: # Seizure: Pt had generalized tonic clonic seizure in ED, most likely withdrawal seizure in setting of EtOH abstinence x2 days and polysubstance abuse (UTox positive for cocaine). Resolved after 5 minutes without any benzodiazepimes. CT head without acute findings. No prior seizure history but has h/o several recent unwitnessed syncopal episodes in setting of EtOH cessation. Patient received one dose of ativan 4mg IV for agitation while still intubated in MICU; after extubation he did not require more ativan over next few hours. He was followed by neurology who initially recommended MRI, EEG and Keppra but retracted these recs once more clear that this was EtOH withdrawal seizure. Patient was continued on CIWA with ativan (can switch to Valium on floor given normal liver synthetic function and fatty liver but no obvious cirrhosis on RUQ ultrasound). He did not require any benzodiazepines on HD2 and he was discharged home. . # Syncope: H/o recurrent pre-syncopal/syncopal events in past year which have all occured in setting of etoh cessation. Some of the events have been witnessed but no evidence of tonic clonic activity during the past, no episodes of blacking out, no loss of bladder control, never had tongue bite or incontinence, or confusion post episode. He was seen in the outpt setting by Neurology who felt his sx were not c/w seizure and ordered a CT scan of his which was unremarkable. Recently had extensive w/u at hospital including TTE and of Hearts which revealed cardiomyopathy and no evidence of malignant arryhthmia. He is followed by both neurology and cardiology at who feel sx c/w likely vasovagal. A follow-up TTE with Valsalva maneuver was negative for a left ventricular outflow tract obstruction. . # EtOH/polysubstance abuse, elevated LFTs: Long h/o EtOH abuse, per wife cut down considerably in recent years w/ recent effort at abstience. Etoh level 0 on arrival, UTox positive for cocaine. Last drink felt to be 2 days ago. LFTs elevated in 2:1 ratio consistent with EtOH hepatitis. Liver synthetic function intact. RUQ ultrasound showed fatty liver, no nodularity. Patient received banana bag in ICU, to be followed by PO folate/MV and 3 days of thiamine 500mg IV BID (given altered mental status which could represent Wernicke's encephalopathy). He was discharged on HD with oral thiamine replacement. . # Coronary Artery Disease: Systolic Heart Failure: Most recent TTE demonstrates global sysolic dysfunction w/ apical hypokinesis and EF 35%. Etiology felt to be multivessel disease versus cardiomyopathy of etoh. Given positive cocaine on UTox, also should consider cocaine cardiomyopathy. In the MICU his home ASA, lisinopril, crestor and metoprolol were continued. He is scheduled for outpatient cards f/u with Dr. on but wife requested earlier f/u if possible given pt noncompliance with appts. Dr. has arranged for cardiac cath in the following 2 weeks. The cath lab will call Mr. with formalized schueduling. The patient was encouraged to follow-up with all his appointments to demonstrate improved compliance. At this time, he was not a candidate for PCI give concern that he would not be faithful to plavix and aspirin. . # Airway Protection: Intubated for airway protection in setting of post-ictal combativeness. In the MICU he received ativan for agitation due to EtOH withdrawal, and was then extubated to room air without further issues, good oxygen sats. . # Memory loss: family reports patient has had progressive memory loss over several years. They reportedly have to leave Post-It notes around the house to remind him to do things. His head CT showed ventricular enlargement worse than expected for his age. Could have Korsakoff psychosis EtOH abuse vs. other form of dementia. Receiving IV thiamine, will need outpatient workup. . # Hypertension: Longstanding hypertension. Wife reports baseline BPs in 180s/80s and previously over 200 systolic. Continued home lisinopril and amlodipine. . # Depression: Stable per wife. Continued home trazodone and sertraline. . TRANSITIONAL ISSUES: - pending labs: blood cx x 2 pending - follow-up: PCP and cardiology - code: full - contact: wife

Stable appearance in comparison to the prior study with no acute intracranial process identified. Sinus rhythm with non-diagnostic repolarization abnormalities. The aorta is of normal caliber but is only partially visualized. The lungs are otherwise without a focal consolidation, pleural effusion, or pneumothorax. The intrahepatic portion of the IVC is unremarkable. Mild left baislar atelectasis. Moderate cardiomegaly. Compared to the previous tracingthere is no significant change.TRACING #2 No biliary dilatation is seen and the common duct measures 0.2 cm. Mild age-inappropriate prominence of the sulci is stable. No acute fractures are identified. Again identified is age-inappropriate prominence of sulci and ventricles. Cardiomediastinal silhouette appears moderately enlarged. No evidence of acute intracranial injury. Compared to the previous tracing there is no diagnostic change.TRACING #3 No previoustracing available for comparison.TRACING #1 The gallbladder is normal. The spleen is unremarkable measuring 10.2 cm. Mild mucosal thickening is noted in the ethmoidal and right maxillary sinuses. No focal liver lesion is identified. FINDINGS: There is no evidence of acute hemorrhage, edema, large vessel territorial infarction, shift of normally midline structures. No hydronephrosis is seen. No ascites is seen in the abdomen. The pancreas is unremarkable, but is only minimally visualized due to overlying bowel gas. Lung volumes are low. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Sinus rhythm with first degree atrio-ventricular conduction delay andnon-diagnostic repolarization abnormalities. COMPARISON: CT head from . COMPARISON: None available. Sinus rhythm. The portal vein is patent with hepatopetal flow. IMPRESSION: 1. IMPRESSION: 1. COMPARISON: No previous exam for comparison. The ventricles and sulci again appear prominent for the patient's age, but stable. -white matter differentiation appears well preserved. FINDINGS: The liver is diffusely echogenic consistent with fatty infiltration. WET READ VERSION #1 FINAL REPORT INDICATION: New seizure. Retraction by 2.0 cm is recommended. 5:06 AM CHEST (PORTABLE AP) Clip # Reason: please eval for tube placement MEDICAL CONDITION: History: 59M now intubated REASON FOR THIS EXAMINATION: please eval for tube placement No contraindications for IV contrast FINAL REPORT INDICATION: Endotracheal tube placement. FINDINGS: Endotracheal tube is in the lower trachea near the carina. IMPRESSION: Echogenic liver consistent with fatty infiltration. 11:35 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: Cirrhosis? The right kidney measures 12.5 cm and the left kidney measures 12.4 cm. 5:09 AM CT HEAD W/O CONTRAST Clip # Reason: please evaluate for intracranial process MEDICAL CONDITION: History: 59M with new onset seizures REASON FOR THIS EXAMINATION: please evaluate for intracranial process No contraindications for IV contrast WET READ: 5:58 AM 1. 2. 2. 2. Endotracheal tube appears in the lower trachea near the carina. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. An enteric tube traverses through the stomach. If clinical suspicion for an acute infarction is high, MR is the recommended study of choice. Multiplanar reformatted images were prepared and reviewed. If clinical suspicion for an acute infarction is high, MRI is the recommended study of choice. FINAL REPORT INDICATION: 59-year-old man with history of ETOH abuse, withdrawal seizure, possible cirrhosis.

6

[ { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244337, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M now intubated\n REASON FOR THIS EXAMINATION:\n please eval for tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement.\n\n COMPARISON: None available.\n\n FINDINGS: Endotracheal tube is in the lower trachea near the carina. An\n enteric tube traverses through the stomach. Lung volumes are low. Mild left\n baislar atelectasis. The lungs are otherwise without a focal consolidation,\n pleural effusion, or pneumothorax. Cardiomediastinal silhouette appears\n moderately enlarged.\n\n IMPRESSION:\n 1. Endotracheal tube appears in the lower trachea near the carina. Retraction\n by 2.0 cm is recommended.\n 2. Moderate cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1244338, "text": " 5:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M with new onset seizures\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:58 AM\n 1. No evidence of acute intracranial injury. If clinical suspicion for an\n acute infarction is high, MRI is the recommended study of choice.\n 2. Mild age-inappropriate prominence of the sulci is stable.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New seizure.\n\n COMPARISON: CT head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared and\n reviewed.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, large vessel\n territorial infarction, shift of normally midline structures. The ventricles\n and sulci again appear prominent for the patient's age, but stable.\n -white matter differentiation appears well preserved. No acute fractures\n are identified. Mild mucosal thickening is noted in the ethmoidal and right\n maxillary sinuses.\n\n IMPRESSION:\n 1. Stable appearance in comparison to the prior study with no acute\n intracranial process identified. If clinical suspicion for an acute\n infarction is high, MR is the recommended study of choice.\n 2. Again identified is age-inappropriate prominence of sulci and ventricles.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1244374, "text": " 11:35 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Cirrhosis?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o EtOH abuse, admitted for withdrawal seizure, question\n whether has cirrhosis\n REASON FOR THIS EXAMINATION:\n Cirrhosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with history of ETOH abuse, withdrawal seizure,\n possible cirrhosis.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The liver is diffusely echogenic consistent with fatty\n infiltration. No focal liver lesion is identified. No biliary dilatation is\n seen and the common duct measures 0.2 cm. The portal vein is patent with\n hepatopetal flow. The gallbladder is normal. The pancreas is unremarkable,\n but is only minimally visualized due to overlying bowel gas. The aorta is of\n normal caliber but is only partially visualized. The intrahepatic portion of\n the IVC is unremarkable. No hydronephrosis is seen. The right kidney\n measures 12.5 cm and the left kidney measures 12.4 cm. The spleen is\n unremarkable measuring 10.2 cm. No ascites is seen in the abdomen.\n\n IMPRESSION: Echogenic liver consistent with fatty infiltration. Other forms\n of liver disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232693, "text": "Sinus rhythm. Compared to the previous tracing there is no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232694, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay and\nnon-diagnostic repolarization abnormalities. Compared to the previous tracing\nthere is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 232695, "text": "Sinus rhythm with non-diagnostic repolarization abnormalities. No previous\ntracing available for comparison.\nTRACING #1\n\n" } ]

89,992

185,262

85M with h/o CLL and many recent admissions to , recently for pneumonias (aspergillus and citrobacter) and recurrent UTIs (pseudomonas, VRE, E.coli), presenting from rehab facility with lethargy and fever, found to have pseudomonas bacteremia.

The rhythm is now sinus and lateralST-T wave changes not seen as prominantly.TRACING #1 Intraventricular conduction defect. Diffuse non-specificST segment abnormality consistent with left ventricular hypertrophy butnon-specific. Sinus rhythm with intraventricular conduction defect, likely due to leftanterior fascicular block. Left ventricular hypertrophy. Compared to the previoustracing atrial fibrillation is new. Poor R wave progression.Consider prior anteroseptal myocardial infarction. Non-specific lateral ST segment changes. Sinus tachycardia. Sinus rhythm. Atrial fibrillation with rapid ventricular response. Compared to the previoustracing of the rate has increased. Comparedto tracing #1 no diagnostic interim change.TRACING #2 Compared to the previous tracing of there has been amarked increase in sinus rate.

4

[ { "category": "ECG", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 298785, "text": "Sinus rhythm with intraventricular conduction defect, likely due to left\nanterior fascicular block. Non-specific lateral ST segment changes. Compared\nto tracing #1 no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 298786, "text": "Sinus rhythm. Intraventricular conduction defect. Poor R wave progression.\nConsider prior anteroseptal myocardial infarction. Compared to the previous\ntracing of the rate has increased. The rhythm is now sinus and lateral\nST-T wave changes not seen as prominantly.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 298787, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 298788, "text": "Sinus tachycardia. Left ventricular hypertrophy. Diffuse non-specific\nST segment abnormality consistent with left ventricular hypertrophy but\nnon-specific. Compared to the previous tracing of there has been a\nmarked increase in sinus rate. No other interval diagnostic change.\n\n" } ]

27,230

104,170

The patient tolerated the initial surgery (EBL 150cc) and was taken to the PACU. In the PACU, she became unresponsive and hypotensive. She was subsequently intubated without sedation and a code blue was called; a femoral a line and right subclavian triple lumen were placed (after failed attempt at left subclavian and right IJ complicated by arterial puncture). Per nursing there was a brief episode of ? PEA/Asystole, but once the MICU code team responded they noted a DP/femoral pulses. She was responsive and following commands (squeezed hand to command). There was attempted resuscitation in the PACU for one hour after which the patient was taken to the OR for exploration as her blood pressure remained labile despite tansfusion of 4 units. Of note, the patient was able to move all limbs during this time and the patient seemed to respond to her family prior to returning to the OR. In the OR, the patient was found to be bleeding from the the renal left renal artery into her RP. Her retroperitoneum was evacuated and the bleeding site was oversewn. Assistance was provided by Dr. of Transplant Surgery. The patient had strong pulses and stable vitals throughout the procedure. She was given 2gm cefazolin periop. In sum, the estimated blood loss was -2.5 L. She received 2.7L of PBRC (~ 18 U), many of which were not cross-matched ()-pt has autoantibodies: anti-, anti-JKa. She also received 8 and 3L of LR. Postoperatively she was transferred to the MICU for further management including central monitoring, delayed extubation, and transient requirement for neosynephrine. In the the patient was noted to have a left pneumothorax and required Gen to place a chest tube on POD #0. During the several days in the ICU, pt required fluid management with hydration and lasix, respiratory support with intubation until POD2 and O2 supplementation until leaving the ICU. Once transfered to Urology, the patient required a PT consult difficulty ambulating and a nutrition consult decreased po intake. Upon discharge, pt afebrile with vital signs stable. Pt going to rehab center for PT. Pt tolerating po feeds and requires supplements that she normally takes as an outpatient. Pt pain controlled with po pain meds.

for interval change FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. FINDINGS: There has been interval placement of a left chest tube with almost complete resolution of the previously noted significant left-sided pneumothorax. Cardiac: Hr intially 110-120's ST rare PVC, then with sleep pt hr down to 90's BP stable 110-130/70's GU: foley in place and draining well. Chest tube in situ on left side with almost complete resolution of previously noted left pneumothorax. SBP to 170's HR 120's.Propofol gtt d/c'd. A right subclavian central venous line is in situ. They were updated on pt's condition and POC by this RN.A/P:Coont PS o/n Eval in AM for extubation.Crit stable. Mouth care done Q4 hrs.Crit 29.6.Abd dsg D&I. FINDINGS: The left-sided chest tube has been removed. There is a new left-sided central venous catheter with the distal tip in the mid SVC slightly perpendicular to the SVC wall. An ET tube is in situ, tip of which is situated 4.5 cm proximal to the carina. There is a left-sided central venous catheter with the distal tip in the mid SVC. An ET tube is in situ,, the tip of which is 4.5 cm proximal to the carina. Post extubation vitals were HR 119, BP 172/89, RR 34 and non-labored, SpO2 100% on 0.5 FiO2 via OFM. Epidural catheter capped. Frequent alb/atr nebs given. Right subclavian central venous line. The right subclavian central venous line is identified with tip in the expected region of the right atrium. S/B & followed by Pain service.SBP & HR very variable level of sedation, stimulation. Lungs at start of the shift were very bronchiol ,dim LLL, coarse in upper lobes. Please evaluate endotracheal tube. Right subclavian central venous line with tip in the expected region of the right atrium. The tip of the chest tube appears to be rather medially placed. There is persistent elevation of the left hemidiaphragm. Nasogastric tube in situ. Tmax 99.6.CV: HR 81-1teen's. INDICATION: Acute blood loss, status post left nephrectomy with left pneumothorax. Being repleted with K.Resp: See carevue for ETT data. RESP CARE: Pt recieved alb/atr by MDI or neb Q3-4, Tol fair. Old blood under tegederm dsg. INDICATION: Acute blood loss status post nephrectomy with left pneumothorax. BP 145-180/80-95, 40mg lasix given, -1300.Resp: extuabted @ 1300, on humidified mask O2 sat 95-100%, RR 20-30. expiratory wheezes resolved with inhalers. While the patient is rotated there does appear to be rightward mediastinal shift and there is downward depression of the left hemidiaphragm very concerning features for tension. MICU Nursing Progress Note Respiratory: RR 22-30's BS crackles to diminished at the bases. INDICATION: Acute blood loss, status post left-sided nephrectomy with left-sided pneumothorax. A right subclavian central venous line is in situ, the tip of which is in the right atrium. Continues on q4hour HCT, which have been stable.Resp: LS's rhoncherous in upper airways, diminished at bases. +PP b/l. Short bursts of SVT to 170's noted x2, resolves on own. Recieving neb treatments q2-4hrs. CVP HAS BEEN .PT. Receiving albutrol, atrovert, Qvar. Resp Care,Pt. BP up to 180's..restarted on verapimil. HAS BEEN SUCTIONED FOR SCANT AMT'S OF CLEAR/TAN SECRETIONS. B/P HAS BEEN 99-214/58-120. ABG on PS 7, PEEP 5 83/50/7.38/31/2. DSG D&I. Hypoactive BS. ONCE PT. RSBI 118 this am. BS with scattered insp. NGT to LIS. fld volume status. RISBI. Remains vented on PS 10, PEEP 5. Maint IVF started. WAS STABLIZED B/P RANGED 110-140'S/58-80'S. After line placement changed to A/C. HAS NGT TO LEFT NARE. Rec'd Haldol .5mg IV x2 with mod effect. THIS PUTS PT. of RSBI attempts w/ 7 of PS (due to #7.0 ETT) and ? follw CVP trend. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. I&O's. IS TOLERATING THIS WELL. Elevated BP's with systolic to 170's. Respiratory therapy following.Chest tube in place..left ant. Eval readiness for extubation. Received PRBC's 13U & FFP 8U. HAS BEEN NSR/ST 90-110 WITH OCCASIONAL PVC'S NOTED UPON ARRIVAL FROM O.R. ABG. Returned to OR. DRAINAGE FROM CHEST TUBE REMAINS SEROUS SANG. Developed audible wheezes. REMAINS NPO AT THIS TIME, EXCEPT FOR MEDS. Suctioned for sm thk/thin tan secretions. Denies incisional pain.Crits 27.7 -> 30 -> 27.2 In AM maintaining UO approx 30-35 cc hr. Sinus tachycardiaRightward axis - is are nonspecific and may be within normal limitsSince previous tracing of , sinus tachycardia present and axis appearsmore rightward Once pt adequately sedated & settled CVP shortly after 13-14. ARRIVED TO UNIT FROM O.R. Cont. Has left chest tube in..pt lists to the right..splinting..per xray..lower lung volumes on right. This afteroon pt noted to have occas to frequent ABPC's. Short P-R interval. Cont A/C O/n. Positive air leak, crepitus. Sinus rhythm. Asses response to lasix. benefit, since Pt unable to use IS. 10mg Diltiazem IV x3 with good effect. CONTINUES TO MAE'S WITH IMPROVING STRENGTH.PT. VT 300's, RR high 20's. Last ABG showed resp acidosis with good oxygenation (on SBT). Last ABG showed a mixed resp acid/meta alk. On previcid.SBP 100-170's, HR 90's-130's depending on level of sedation, anxiety. Changed to IPS this am, awake. Placed to water seal this am..repeat CXR ok. ?DC in am..Draining serousanquincous liquid. wheezes. Not tolerating face tent well, trying NC at this time.GI: BS noted during 0400 assessment. Repleted with Mg sulfate x1, 40mEq KCl. IPS as tol. Respiratory CarePt remains intubated (#7.0 ETT 20@lip) and on vent support. Respiratory CarePt remains intubated (#7.0 ETT 20 @lip) and on vent support. RECEIVED 20MEQ OF KCL, AND 4GM OF MAG. Improved cough effort. Decision made to hold off on extubation, sedate pt & replace CVL. Abd soft, nt, mildly distended. MDI's given with good effect. MICU NPN 1900-0700Events: Pt initially tachycardic, rec'd total of 2L NS IV boluses with good effect on HR and u/o.Neuro: Pt remains sedated to on 100mcg fentanyl and 3mg versed.

29

[ { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967530, "text": " 3:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: coded - check intubation\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n\n REASON FOR THIS EXAMINATION:\n coded - check intubation\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 75-year-old woman with cardiac arrest, check intubation.\n\n FINDINGS: Comparison is made to the prior radiograph from .\n\n The tip of the endotracheal tube is 3 cm from the carina. There is a right-\n sided central venous catheter with distal tip at the proximal right atrium.\n There is no focal opacities. There are low lung volumes. There is a large\n amount of gas seen within the stomach.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967548, "text": " 8:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please reassess ETT/CVC position\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with bleeding\n\n REASON FOR THIS EXAMINATION:\n please reassess ETT/CVC position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 75-year-old female with acute blood loss status post left\n nephrectomy. Please evaluate endotracheal tube.\n\n COMPARISON: six hours previous.\n\n FINDINGS: There has been interval development of a large left-sided\n pneumothorax with complete collapse of the left upper lobe and near complete\n collapse of the left lower lobe. While the patient is rotated there does\n appear to be rightward mediastinal shift and there is downward depression of\n the left hemidiaphragm very concerning features for tension.\n\n The right subclavian central venous line is identified with tip in the\n expected region of the right atrium. Endotracheal tube is well positioned.\n The nasogastric tube is difficult to visualize as it courses towards the\n diaphragm but the tip appears to terminate in the region of the\n gastroesophageal junction.\n\n IMPRESSION:\n\n 1. Large left pneumothorax with complete collapse of the left upper lobe and\n near complete collapse of the left lower lobe. There are also findings\n consistent with a tension component.\n\n 2. Right subclavian central venous line with tip in the expected region of\n the right atrium. For optimal positioning the tip may be withdrawn\n approximately 3 cm.\n\n 3. Endotracheal tube is well positioned.\n\n 4. Nasogastric tube should be advanced approximately 5 cm for optimal\n positioning.\n\n Findings were immediately relayed to Dr. at the time of\n dictation.\n (Over)\n\n 8:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please reassess ETT/CVC position\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 967553, "text": " 11:51 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p chest tube replacement\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p chest tube replacement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n INDICATION: Acute blood loss status post nephrectomy with left pneumothorax.\n\n COMPARISON: Comparison was made with the previous chest x-ray from the same\n day from one and a half hours previously.\n\n There is a chest tube in the left upper hemithorax with subcutaneous emphysema\n noted superficial to the chest wall on the left side. The tip of the chest\n tube appears to be rather medially placed. An ET tube is in situ,, the tip of\n which is 4.5 cm proximal to the carina. A right subclavian central venous\n line is in situ. There has been good resolution of the previously noted\n pneumothorax. No focal lung lesion identified. Allowing for portable semi-\n erect rotated film, the heart size appears within normal limits.\n\n IMPRESSION:\n\n 1. Chest tube in situ on left side with almost complete resolution of\n previously noted left pneumothorax.\n\n 2. ET tube in good position.\n\n 3. Right subclavian central venous line in good position.\n\n 4. NG tube in situ.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 967551, "text": " 10:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p left chest tube\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p left chest tube\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n INDICATION: Acute blood loss, status post left nephrectomy with left\n pneumothorax.\n\n COMPARISON: Comparison was made with the previous chest x-ray from the same\n day from at one hour previously.\n\n FINDINGS: There has been interval placement of a left chest tube with almost\n complete resolution of the previously noted significant left-sided\n pneumothorax. Note is made of some surgical emphysema on the left side status\n post chest tube placement. A right subclavian central venous line is in situ,\n the tip of which is in the right atrium. An NG tube is in situ in the\n stomach. Some surgical clips are seen in the left paraspinal area. An ET\n tube is in situ, tip of which is situated 4.5 cm proximal to the carina.\n\n IMPRESSION:\n 1. Almost complete resolution of significant left pneumothorax when compared\n with the previous chest x-ray in patient status post chest tube placement on\n the left.\n 2. ET tube in good position.\n 3. Right subclavian central venous line.\n 4. Nasogastric tube in situ.\n\n" }, { "category": "Radiology", "chartdate": "2164-07-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 967710, "text": " 12:34 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check line placement\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with left\n pneumothorax from initial line placement; now s/p new line placement\n\n REASON FOR THIS EXAMINATION:\n please check line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 75-year-old woman with acute blood loss status post left nephrectomy\n with left pneumothorax. Please check line placement.\n\n FINDINGS: Comparison is made to the previous study performed six hours\n earlier.\n\n There is a left-sided chest tube. No pneumothoraces are seen. There is a\n large amount of subcutaneous emphysema in the left side. The tip of the\n endotracheal tube is again low lying, 2 cm above the carina and could be\n pulled back 2-3 cm for more optimal placement. There is a nasogastric tube\n whose side port is at the gastroesophageal junction and could be advanced\n slightly for more optimal placement. There is a new left-sided central venous\n catheter with the distal tip in the mid SVC slightly perpendicular to the SVC\n wall. There is persistent elevation of the left hemidiaphragm. No focal\n consolidation is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-18 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 968150, "text": " 2:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p CT removal\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with\n left pneumothorax, CT now to water seal.\n REASON FOR THIS EXAMINATION:\n s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, \n\n HISTORY: Status post chest tube removal.\n\n FINDINGS: The left-sided chest tube has been removed. No definite\n pneumothoraces are identified on either side. There is a left-sided central\n venous catheter with the distal tip in the mid SVC. Soft tissue emphysema is\n seen on the left side. There is a right-sided pleural effusion which is\n stable. There are lung volumes with crowding of the pulmonary vascular\n markings at the lung bases.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-07-17 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 968020, "text": " 2:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: FOR 2PM PLEASE. Eval. for interval change\n Admitting Diagnosis: KIDNEY TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with acute blood loss s/p left nephrectomy with\n left pneumothorax, CT now to water seal.\n REASON FOR THIS EXAMINATION:\n FOR 2PM PLEASE. Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Acute blood loss, status post left-sided nephrectomy with\n left-sided pneumothorax. Now chest tube in place on water seal. Evaluate for\n interval change. AP single view of the chest obtained with patient in _____\n supine position leaning towards the right is analyzed in direct comparison\n with a preceding similar study obtained nine hours earlier during the same\n date.\n\n The previously identified tiny left-sided apical pneumothorax cannot be seen\n anymore. The position of the chest tube is unaltered and the degree of\n left-sided subcutaneous chest wall emphysema has mildly decreased. No new\n pulmonary abnormalities are present.\n\n IMPRESSION: Disappearance of left-sided tiny pneumothorax on portable view.\n Unchanged chest tube position.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618327, "text": " 4 ICU NPN 0700-1900\nRemains on PS 10, PEEP 5, 50%. RR 15-23 minute. VT's ~450. ABG 108/51/7.43/35/7. Suctioned for small amts thick to thin tan secretions. L CT dsg became wet with serrosang fld at approx 1000. ICU resident aware. No increase in drainage rest of shift. Mouth care done Q4 hrs.\nCrit 29.6.\nAbd dsg D&I. Abd firm, distended with hypoactive BS\nPt initially very anxious,thrashing about in bed. Attempting to write. SBP to 170's HR 120's.Propofol gtt d/c'd. Cont on fent gtt. Presently on 100 mcgs hr. Versed gtt started. Now at 3mg hr. Additional fent 30-50 mcg boluses and versed 0.5-1mg boluses given with good effect. Epidural catheter capped. Old blood under tegederm dsg. S/B & followed by Pain service.\nSBP & HR very variable level of sedation, stimulation. Brief episode (few sedonds) of SVT to 200. BP stable. HR down to 90's low 100's without intervention. Second event to 150 which also broke on own with stable BP.\nUO down 25-30 cc's for several hrs this afternoon. Currently receving 250 cc fld bolus.\nNG asp- 50 ml coffee grounds. Of note pt had dry blood from around outside nares and when mouth care done. resident aware\nDtrs & as wel as several other family members in to visit. They were updated on pt's condition and POC by this RN.\nA/P:\nCoont PS o/n Eval in AM for extubation.\nCrit stable. Cont serial crits Q4.\nFent & versed gtts with additional boluses PRN.\nPain service will access epidural catheter if pain management becomes an issue once fent & versed gtt stopped.\n? if coffee grounds 2/2 blood tracking down back of throat from traumatic NGT placement. Assess for bleeding\nSupport to pt & family\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618333, "text": "NPN 1900-0700\nFull code multiple drug allergies Urology surgical pt\n\nNeuro: Pt slept off and on. Sedation off @ 0545. Pt had been very lightly sedated, easily arousable, mouthing words. Moves UE's on bed, able to lift and hold LE's b/l. Gag impaired, cough intact. Tmax 99.6.\n\nCV: HR 81-1teen's. Occasional-frequent premature atrial beats. PVC's occurred with increasing frequency early in shift, EKG to document. Ectopy greatly decreased overnight. AM labs: K=3.0, HCT=25.4 down from 26.9. Being repleted with K.\n\nResp: See carevue for ETT data. Put on pressure support @ 0600 10/5peep after RSBI of 84. Looks ready to wean. LS mostly clear, diminished in LLL. Chest tube intact, only drained 25cc overnoc; +air leak, +crepitus (team aware).\n\nGI: Mildly obese abd soft/distended with hypoactive sounds, no BM this shift. AM glucose 96. OGT patent,remains on LIS draining small amts brown contents with total output 100cc in canister.\n\nGU: Patent foley draining 30-100+ cc clear yellow urine. Rec'd Lasix 20mg IV x1 this shift as u/o dropped off. Urology in to see patient now, being kept informed of all MICU interventions.\n\nWound: Abd incision from nephrectomy has dressing CDI; Chest tube on L lateral chest @~5th intercostal with dressing CDI. Some pain at this site.\n\nLines: PIV in L hand, L SC TLC patent and dressing changed this am.\n\nSocial: daughter, telephoned earlier, spoke w/ this RN and Dr. . Will be in this am\n\nPlan: Monitor and support hemodynamics, replete w/K now\n Plan to extubate.\n Monitor/manage pain\n Monitor urine output, bowel activity\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618334, "text": "Resp Care: Pt continues intubated #7 oett secured @ 20 @ lip and on ventilatory support with a/c overnoc miantaining metabolic alkalosis with good oxygenation; BS rare wheeze, scattered crackles, sxn thick clear/white secretions, rx with mdi albuterol/atrovent/beclomethasone, rsbi 84,changed to 10/5 in an attempt to wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618335, "text": "Respiratory Care\nPt was extubated today at 1310. Post extubation vitals were HR 119, BP 172/89, RR 34 and non-labored, SpO2 100% on 0.5 FiO2 via OFM. Lung sounds were clear t/o (pt given Albuterol pre extubation) and no stridor was noted. Pt has a mild cough and a raspy soft voice. Care plan is to continue OFM w/cool-mist and to continue to wean as tol. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-16 00:00:00.000", "description": "Report", "row_id": 1618336, "text": "CV: ST with occasional runs of SVT 160-170s. BP 145-180/80-95, 40mg lasix given, -1300.\nResp: extuabted @ 1300, on humidified mask O2 sat 95-100%, RR 20-30. expiratory wheezes resolved with inhalers. LLL diminished, chest tube.\nNeuro: alert, ativan and morphine given regularly for complaints of anxiety and L side pain. follows commands, confused and anxious.\nGI/GU: foley putting out large amount of clear light yellow urine. no stool. L nares NGT tube to LIS, mod amount green/brown output.\nSkin: intact with multiple bruising. LUQ incision, stapled and open to air. L chest tube, dressing CDI.\nLines: L SC TL CVC, L hand PIV.\n\nFollowed by surgical urology.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618337, "text": "Respiratory Care: Pt became very wheezy and had episode of desaturation this shift. Frequent alb/atr nebs given. Placed on 60% hi flow aerosol mask. Weak cough. Will continue to follow with nebs at this time.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-18 00:00:00.000", "description": "Report", "row_id": 1618341, "text": "MICU Nursing Progress Note\n Respiratory: RR 22-30's BS crackles to diminished at the bases. right worse than left.CT to water seal on the left. draining serousangious fluid. output 140cc over 12hour period. incentive spirometry done with pt, poor complaince, only able to generate 200cc and mental status impeding improving that value. nemb treatments with mild CPT done q3-4 hour. congestive cough,O2 sat cont to be 96-98%.\n Neuro: pt very restless at the start of the night, unable to get comfortable in bed, trying to climb out of bed, pt able to tell you where she is but quickly will try to climb out of bed to go to the couch.. MAE, did recieve serax 10mg then morphine sulfate 0.5mg IV and able to fall asleep for 2hours, needs frequent repositioning to make her comfortable.\n Cardiac: Hr intially 110-120's ST rare PVC, then with sleep pt hr down to 90's BP stable 110-130/70's\n GU: foley in place and draining well. u/o 80-100cc/hr\n Skin: incision in the left chest wall, dry and intact,staples in place, +creptius posterior chest, edema noted over hip extending down to mid thiegh level,slighly pink, Dr. aware.\n Plan; cont to monitor BS, frequent nemb tx, plan is to D/C chest tube this morning. provide safety measures,all side rails up..reorient pt to her surrounding.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-18 00:00:00.000", "description": "Report", "row_id": 1618342, "text": "RESP CARE: Pt recieved alb/atr by MDI or neb Q3-4, Tol fair. 02 sats 97-99%.Insists she prefers the MDI over the neb Rxs. Lungs at start of the shift were very bronchiol ,dim LLL, coarse in upper lobes. Pt refused to cough stating \"it makes my asthma worse\" Gentle CPT to , pt constantly moving in the bed, insisting on leaning on R side. Pt also revieved Qvar x1 at 2200. Tol well. Will continue to follow as needed.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618323, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO ASA, ATENOLOL, BACTRIM, SULFA, SERVENT, AND ACE INHIBITORS.\n\nPT. AT PRESENT IS SEDATED ON FENTANYL GTT 25MCG/HR AND PROPOFOL GTT AT 10MCG/KG/MIN. PT. IS LIGHT ON THESE MEDICATIONS AND IS EASILY AROUSABLE. PT. NODS HEAD APPROPRIATELY TO QUESTIONS THROUGHOUT THIS SHIFT. PT. CONTINUES TO DENY ANY PAIN, OR DISCOMFORT. PT'S TEMP SPIKED TO 100.4, BUT PRESENTLY 99.8 ORALLY. PT'S PUPILS EXHIBIT A SURGICAL PUPIL ON THE RIGHT WHICH REMAINS UNREACTIVE, WHILE LEFT PUPIL IS 3MM AND BRISK. PT. REMAINS IN BILAT WRIST RESRAINTS FOR SAFETY, WITH PROTOCOL FOLLOWED AND PT. CONTINUES TO MAE'S WITH IMPROVING STRENGTH.\n\nPT. HAS BEEN NSR/ST 90-110 WITH OCCASIONAL PVC'S NOTED UPON ARRIVAL FROM O.R. BUT NO ECTOPTY NOTED OVER PAST 10HRS. RIGHT FEMORAL ALINE REMAINS INTACT, SECURED, AND FUNCTIONING WELL. THESE PRESSURES CORRELATE WITH CUFF PRESSURES. B/P HAS BEEN 99-214/58-120. MOST OF THIS SHIFT WHEN PT. WAS STABLIZED B/P RANGED 110-140'S/58-80'S. NO PRESSORS GIVEN DURING THIS SHIFT. SBP 214 DROPPED SIGNIFICANTLY ONCE PLACED ON PROPOFOL. CVP HAS BEEN .\nPT. RECEIVED 20MEQ OF KCL, AND 4GM OF MAG. PT. HCT HAS BEEN STABLE AT 29.5 WITH GOAL TO MAINTAIN HCT >28. NO BLOOD PRODUCTS WERE REQUIRED DURING THIS SHIFT. PT. RECEIVED 8UNITS OF PRBC'S AND 8UNITS OF FFP DURING INTRAOP, AND PACU STAY. FEW OF THESE UNITS WHERE NOT CROSS MATCH DUE TO PT. CODING. THIS PUTS PT. AT INCREASE RISK FOR HEMOLYSIS, AND PT. WILL PROBABLEY REMAIN INTUBATED FOR ANOTHER 24HRS, DUE TO INCREASE RISK OF FLASH PULMONARY EDEMA. AM LABS ARE PENDING AND LABS ARE TO BE CHECKED Q4HRS, NEST DUE AT 0900.\n\nPT. IS INTUBATED WITH A 7.0 AT 22CM LIP LINE. PT. HAS BEEN SUCCESSFULLY WEANED FROM AC TO PRESSURE SUPPORT SETTINGS OF AT 50% THIS AM AT 0530, PT. IS TOLERATING THIS WELL. PT. HAS BEEN SUCTIONED FOR SCANT AMT'S OF CLEAR/TAN SECRETIONS. O2 SATS REMAIN 100% WITH RESP RATE 14-24. ONCE PT. ARRIVED TO UNIT FROM O.R. PORTABLE CHEST XRAY PERFORMED, AND EXHIBITED MODERATE TO SEVERE LEFT PNEUMOTHORAX. CHEST TUBE PLACE AND THEN REPLACED FOR CORRECTED POSITIONING BY SURGERY. PT. TOLERATED THIS PROCEDURE WELL. #28 CHEST TUBE REMAINS INTACT, SECURED, WITH 20CM WALL SUCTION APPLIED. SMALL AIR LEAK NOTED WITH TEAM AWARE, AND VERY SMALL AREA OF CREPITIOUS NOTED AT INSERTION SITE. DRAINAGE FROM CHEST TUBE REMAINS SEROUS SANG. APPROX. 90-100CC SINCE INSERTION AT 2300.\n\nPT. REMAINS NPO AT THIS TIME, EXCEPT FOR MEDS. PT. HAS NGT TO LEFT NARE. ABD. IS LARGE ROUND AND FIRM . BOWEL SOUNDS ARE VERY HYPOACTIVE, BUT PRESENT X4 QUADRANTS. BLOOD SUGARS ARE ORDERED QID AND HAVE BEEN 120'S. FOLEY CATHETER REMAINS INPLACE, WITH URINE REMAINING CLEAR YELLOW, AND RANGING 38-160CC/HR. PT. HAS TRENDING DOWN OVER PAST TWO HRS FROM . TEAM IS AWARE.\n\nABD. TO LEFT FLANK EXHIBITS LARGE STERILE DRESSING WHICH REMAINS DRY AND INTACT. ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL.\n\nPT. REMAINS A FULL CODE. PT'S THREE DAUGHTER AND BROTHER WILL BE IN TODAY. THEY WIL\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618324, "text": "(Continued)\nL BE TAKING TURNS THROUGHTOUT THE DAY. PLAN IS TO KEEP PT. INTUBATED FOR ANOTHER 24HRS DUR TO INCREASE RISK OF FLASH PULMONARY EDEMA SECONDARY TO RECEIVING UNCROSSED BLOOD PRODUCTS DURING CODE SITUATION IN PACU YESTERDAY. PT. WILL NEED TO BE MONITORED FOR SIGNS OF HEMOLYSIS FOR UP TO 7DAYS. OTHERWISE PLAN ID FOR Q4HR BLOOD DRAWS AND REPLETION OF ELECTROLYTES, OR BLOOD PRODUCTS WHEN REQUIRED.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618325, "text": "Resp Care,\nPt. admitted from OR intubated #7ET taped at 20 lip. Ventilated on A/C overnoc, Fio2 weaned down to 50%. Changed to IPS this am, awake. VT 300's, RR high 20's. RSBI 118 this am. Cont. IPS as tol.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-14 00:00:00.000", "description": "Report", "row_id": 1618326, "text": "Respiratory Care\nPt remains intubated (#7.0 ETT 20 @lip) and on vent support. No vent changes were made t/o shift. Lung sounds were clear with periods of exp wheezes that responded to MDI's. Suctioned for sm thk/thin tan secretions. MDI's given with good results. Last ABG showed a mixed resp acid/meta alk. Care plan is to continue to wean as tol, ? of RSBI attempts w/ 7 of PS (due to #7.0 ETT) and ? of extubation in the next few days. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618328, "text": "MICU NPN 1900-0700\nEvents: Pt initially tachycardic, rec'd total of 2L NS IV boluses with good effect on HR and u/o.\n\nNeuro: Pt remains sedated to on 100mcg fentanyl and 3mg versed. Attempted to wean versed to 2mg/hour but pt was becoming more anxious, so rate returned to 3mg/hour. Pt has been sleeping, easily arousable, nodding head appropriately to yes/no questions, and is cooperative with care. Denies incisional pain, but does have throat discomfort related to ETT.\n\nCV: HR 110's-120's prior to IV bolus, down to 90's after 1500cc, NSR. Short bursts of SVT to 170's noted x2, resolves on own. Continues with low grade fevers 100-100.9. Continues on q4hour HCT, which have been stable.\n\nResp: LS's rhoncherous in upper airways, diminished at bases. Remains vented on PS 10, PEEP 5. RR 10's-20's, non-labored. O2 sat 95-98% on 50% FiO2. Suctioned initially for small amount thick tan secretions. Secretions are now minimal and clear. CT to left ant CW to 20cm suction with serosang drainage. +crepitus to left chest, small airleak noted.\n\nGI: Abd softly distended with +bs's. NGT in place, clamped without further coffee ground drainage noted.\n\nGU: Foley draining 20-45cc/hour clear amber urine. Low u/o responsive to fluid boluses.\n\nSkin: Left transverse abd incision with staples, no drainage noted, DSD changed. Left CT dressing changed, no further drainage noted from site. No breakdown noted to backside, turned and repositioned. Bilat wrist restraints in place.\n\nID: Pt is on cefazolin while CT is in place.\n\nSocial: Spoke with pt's daughter last eve and updated her on pt's current status.\n\nPlan: Cont to monitor VS's, I&O, labs, and resp status. Possible extubation this am if continues to do well.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618329, "text": "Resp Care: Pt cont intubated and on ventilatory support with psv, no vent changes overnoc maintaining spo2 95-98%; bs with episodic exp wheeze, rx with mdi albuterol/atrovent/beclomethasone, sxn thick clear secretions, rsbi 65, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618330, "text": "Nursing addendum 0630\nPt noted to have brown drainage from mouth and ETT. NGT hooked to suction and same drainage noted from stomach, drained for 100cc. Suctioned ETT for small amounts of gastric content.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618331, "text": "Respiratory Care\nPt remains intubated (#7.0 ETT 20@lip) and on vent support. Vent changes were a SBT at start of shift later placed back onto PSV. After line placement changed to A/C. Pt received a recruitment x1 for sats in the low 90's and PEEP increased to 10 (sats now 98-100%). Lung sounds were course exp wheezes that responded to MDI's. Suctioned for small amounts of thk yellow secretions. MDI's given with good effect. Last ABG showed resp acidosis with good oxygenation (on SBT). Care plan is to continue to wean as tol, return to PSV when tol and to follow ABG's (no A-line). Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-15 00:00:00.000", "description": "Report", "row_id": 1618332, "text": " 4 ICU NPN 0700-1900\n75 YO S/P L nephrectomy for renal mass complicated by episode of unresponsiveness & hypotension to 70's in PACU. ? brief episode of astole /PEA. Returned to OR. Bleeding was noted from renal artery which was corrected. Received PRBC's 13U & FFP 8U. Transferred to 4 postop for further management.\n\nThis morning RISBI 65, Fent & versed gtts d/c'd for SBT. AS pt became more awake she became more hypertensive & tachycardic. Developed audible wheezes. ABG on PS 7, PEEP 5 83/50/7.38/31/2. RR mid to high 20's, VT low to mid 300's. Decision made to hold off on extubation, sedate pt & replace CVL. Placed back on PS 10, PEEP 5, 50%. Sats at that X began dropping to low of 88%. Given recruitment breath & placed on A/C 450 X 16 X 50%, PEEP 10 with improvement in O2 sats. Sats now running 98-99%. BS with scattered insp. wheezes. Receiving albutrol, atrovert, Qvar. L chest tube to wall suction drained 150 cc's serosang fld this sgift. Positive air leak, crepitus. DSG D&I. CT sergery following\n\nL Nephrectomy DSG D&I. Denies incisional pain.Crits 27.7 -> 30 -> 27.2\n\n In AM maintaining UO approx 30-35 cc hr. Maint IVF started. CVL placed to monitor CVP's which was 19 on initial when pt hypertensive, tachycardic & agitated. Once pt adequately sedated & settled CVP shortly after 13-14. Urology MD aware of change in CVP value. The rest of the shift CVP ranging 13-15. UO dropping to 15-23 cc' hr. Lasix 20 mg IV X1 given at 1800.\n\nEpidural catheter removed by Pain service (anesthesia) in AM. Neuro checks done q2 hrs. FC, moving all extremities, positive sensation to extremities. On fentanly gtt 100 mcg hr, versed 2mg hr with additional versed 0.5mg & fentanyl 20-30 mcg boluses with good effect.\n Abd slightly less distended than previous 24hrs. NGT with mod amts coffee grounds 70-100 cc's. NGT to LIS. Hypoactive BS. No stool this admit. On previcid.\n\nSBP 100-170's, HR 90's-130's depending on level of sedation, anxiety. This afteroon pt noted to have occas to frequent ABPC's. No VEA or SVT noted.\n\nMany family members in to visit briefly with pt. Question answered. Dtr, HCP - stated Dr. (surgeon) phoned & updated her on pt's condition & POC.\n\nA/P: Developed exp wheezes with SBI & subsequent drop in sats in setting of marginal UO & ? fld volume status. ? wheezes cardiac VS pulmonary. Cont A/C O/n. In AM (0500). RISBI. ABG. wake up. Eval readiness for extubation. follw CVP trend. Asses response to lasix. I&O's.\n*** Per CT surgery Do not turn pt on L side while pt has CT in placed risk of kinking\n\nAssess pain & need for additional medications once gtts d/'d.\nNeuro checks Q2 hrs S/P removal of epidural catheter. PAIN service to follow.\n\nPage Urology for any interventions.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618338, "text": "NPN 1900-0700\nNeuro: Pt increasingly agitated overnoc, unfamiliar with surroundings. Rec'd Haldol .5mg IV x2 with mod effect. Frequent reorientation/repositioning. Denied pain but grimace with movement, given morphine 1mg x 2 w/moderate effect. Afebrile\n\nCV: ST with no ectopy noted this shift. Elevated BP's with systolic to 170's. 10mg Diltiazem IV x3 with good effect. +PP b/l. Chest tube intact draining small amts serosanginous fluid, dressing CDI. HCT stable @ 27-28 over past 48hrs. Began IVF at 300cc/hr x1 liter. Repleted with Mg sulfate x1, 40mEq KCl. K now 4.1\n\nResp: pt experienced acute asthma attack @, wheezing auscultated in all lobes, stridorous, highly anxious. Rec'd neb tx x2 immediately with very good effect and reg neb tx's now ordered. Pt now has scattered rales throughout, no sputum production. Improved cough effort. Not tolerating face tent well, trying NC at this time.\n\nGI: BS noted during 0400 assessment. Abd soft, nt, mildly distended. Pt has notmoved bowels since ICU admission.\n\nGU: Foley patent draining clear yellow urine @ ~100cc/hr.\n\nSkin: ecchymotic L anterior forearm, L thigh. Abd staples CDI\n\nLines: Patent PIV in L hand. TLC all ports flushing, only red port drawing.\n\nPlan: Monitor and support hemodynamic status\n Q4h nebs, monitor lung status\n Encourage turn/c/db\n CT may be d/c'd today\n Monitor u/o\n Reorient prn, anti-anxiety medications\n\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618339, "text": "Respiratory care: Pt seen for neb q2 hrs today. Pt c/o dyspnea, SpO2 95-98% on 6L NC, ? anxiety. At 1600 pt refused neb tx and requested MDI instead, ? benefit, since Pt unable to use IS. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2164-07-17 00:00:00.000", "description": "Report", "row_id": 1618340, "text": " 4 ICU nursing progress note:\n Respiratory: Placed on 4-6l nc..with sats 94-98%..rr 30's Has wet sounding cough. Non productive. Feels she is having asthma attack. Recieving neb treatments q2-4hrs. No wheezes heard..but pt feels she is wheezing. Respiratory therapy following.\nChest tube in place..left ant. Placed to water seal this am..repeat CXR ok. ?DC in am..Draining serousanquincous liquid.\n Cardiac: Continues to be tachycardic to 120's..attempted iv dilt this am without change. Given 20 lasix this afternoon..good diuresis..??needs more this evening. BP up to 180's..restarted on verapimil.\n GI: Per urology can take only sips of water. Faint BS..no stool..\nAbdomen soft,distended. DSD\n GU: Good u/o with lasix.\n Neuro: Pt agitated most of day..calling out..stating she cant breath, shes lonely, worst place shes ever been. At times refusing to take her inhalers and respiratory tx. OOB to chair..30min and up to 70min. Tolerated well. Assist of 2. Pt states she takes serax at home..and admits to a \"few\" during the day. ??possibiltiy of benzo withdrawl\" Serax ordered and given this afternoon.\n S/P L nephrectomy: post op day #4. C/O lower back ache..given morphine with minimal releif. Has left chest tube in..pt lists to the right..splinting..per xray..lower lung volumes on right.\n Social: Daughter in..updated..HO spoke with her also.\n" }, { "category": "ECG", "chartdate": "2164-07-13 00:00:00.000", "description": "Report", "row_id": 259670, "text": "Sinus tachycardia\nRightward axis - is are nonspecific and may be within normal limits\nSince previous tracing of , sinus tachycardia present and axis appears\nmore rightward\n\n" }, { "category": "ECG", "chartdate": "2164-07-19 00:00:00.000", "description": "Report", "row_id": 259669, "text": "Sinus rhythm. Short P-R interval. Poor R wave progression. Compared to\ntracing of poor R wave progression is new and could be positional and\ntachycardia has resolved.\n\n" } ]

41,067

194,692

23yo F with no significant PMH admitted for BRBPR of unclear etiology, likely lower GI bleed.

FINDINGS: CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized heart and pericardium are unremarkable. CTA: The intra-abdominal vasculature is unremarkable. No acute hemorrhage identified. FINDINGS: CHEST: The partially visualized heart and pericardium are again unremarkable. TECHNIQUE: MDCT axial imaging was obtained through the abdomen without the administration of intravenous contrast material. There is no intra- or extra-hepatic biliary dilatation. The gallbladder is unremarkable. The liver is otherwise again unremarkable. (Over) 1:43 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: eval for site of bleed Admitting Diagnosis: LOWER GI BLEED FINAL REPORT (Cont) IMPRESSION: No acute hemorrhage or source of bleeding identified. There is no pericardial effusion or pleural effusion. No ectopic tracer uptake is present in the right lower quadrant or elsewhere. No acute hemorrhage or active bleeding detected. The bladder, rectum, and sigmoid colon are unremarkable. There is no pericardial effusion. CT PELVIS: The bladder, rectum, and sigmoid colon are unremarkable. ABDOMEN AND PELVIS: The small hypodensity within the left lobe of the liver is again seen, unchanged, and too small to accurately characterize. No source of bleeding is identified within the bowel. There is no biliary dilatation. There is no free air or lymphadenopathy. OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. The visualized stomach, small and large bowel are unremarkable. There is no hydronephrosis. source of bleeding No contraindications for IV contrast WET READ: EHAb WED 7:28 PM 1. There is no free fluid, free air, or lymphadenopathy within the pelvis. There is no free fluid, free air, or lymphadenopathy within the abdomen. There is no source of bleeding identified within the loops of bowel. CTA: The intra-abdominal vasculature is normal. There is normal hepatic arterial anatomy. There is normal hepatic arterial anatomy. The stomach, small and large bowel are unremarkable. IMPRESSION: No evidence of Meckel's diverticulum. There are stable bilateral ovarian cysts, likely physiologic. No fractures or evidence of degenerative change. Flow images demonstrate no abnormal distribution of tracer. The gallbladder, pancreas, spleen, and adrenal glands are unremarkable. There is no evidence of contrast extravasation. There is no evidence of contrast extravasation. IMPRESSION: No evidence of GI bleed during the time of study. Delayed images show normal excretion of tracer in the stomach and bilateral renal uptake. Bilateral ovarian cysts, likely physiologic. The kidneys enhance and excrete contrast symmetrically without any focal lesions. Bilateral ovarian cysts, likely physiologic but incompletely evaluated on this study. The liver otherwise enhances homogenously without any focal lesions. COMPARISON: CT on . COMPARISONS: None. A small hypodensity within the left lobe of the liver (image 4B:180) is too small to characterize. Tiny hypodensity in the left lobe of the liver too small to characterize (4b:180). Cyst in the region of the cervix may represent Nabothian cyst, but incompletely evaluated on this study. The pancreas, spleen, kidneys, adrenals are normal. Dynamic blood pool images over 90 minutes show no evidence of bleeding. There is a small amount of free fluid within the pelvis, which is new since the previous examination, and likely physiologic. The dose length product was 1169.7 mGy-cm. The portal vein is patent. Blood flow images show normal flow of tracer through the vessels and organs. Coronal and sagittal reformats were provided. source of bleeding Admitting Diagnosis: LOWER GI BLEED Contrast: OMNIPAQUE Amt: 150 FINAL REPORT (Cont) 2.2 x 1.9 cm on the left (4:290) which are most likely physiologic. The portal veins are patent. Small hypodensity in the left lobe, too small to characterize. There are bilateral ovarian cysts measuring 2.3 x 1.8 cm on the right (4:285) and (Over) 6:06 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ? Coronal, sagittal, and maximum intensity projection imaging was obtained. The total DLP for the exam was 172.75 mGy/cm. , M.D. , M.D. , M.D. , M.D. IMPRESSION: 1. Approved: MON 3:02 PM RADLINE ; A radiology consult service. Approved: FRI 3:29 PM RADLINE ; A radiology consult service. The lung bases are clear. The lung bases are clear. MECKEL'S SCAN Clip # Reason: 22 Y/O W/ LARGE VOLUME GI BLEED X 1 DAY, COLONOSCOPY AND EGD NEGATIVE. 6:06 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: ?

4

[ { "category": "Radiology", "chartdate": "2143-01-09 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1217826, "text": " 6:06 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ? source of bleeding\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with large volume GI bleed, needing RBCs, symptomatic,\n negative EGD and colonoscopy\n REASON FOR THIS EXAMINATION:\n ? source of bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb WED 7:28 PM\n 1. No acute hemorrhage or active bleeding detected. 2. Bilateral ovarian\n cysts, likely physiologic but incompletely evaluated on this study. 3. Cyst in\n the region of the cervix may represent Nabothian cyst, but incompletely\n evaluated on this study. 4. Tiny hypodensity in the left lobe of the liver too\n small to characterize (4b:180).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old woman with large volume GI bleed, needing\n transfusion, symptomatic, negative EGD and colonoscopy, question source of\n bleeding.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial imaging was obtained through the abdomen without the\n administration of intravenous contrast material. Subsequently, MDCT axial\n imaging was obtained through the abdomen and pelvis following the mesenteric\n CTA protocol. Coronal, sagittal, and maximum intensity projection imaging was\n obtained. The total DLP for the exam was 172.75 mGy/cm.\n\n FINDINGS:\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized heart and pericardium\n are unremarkable. There is no pericardial effusion. The lung bases are\n clear. A small hypodensity within the left lobe of the liver (image 4B:180)\n is too small to characterize. The liver otherwise enhances homogenously\n without any focal lesions. The portal vein is patent. There is no intra- or\n extra-hepatic biliary dilatation. The gallbladder, pancreas, spleen, and\n adrenal glands are unremarkable. The kidneys enhance and excrete contrast\n symmetrically without any focal lesions. There is no hydronephrosis. The\n visualized stomach, small and large bowel are unremarkable. There is no\n source of bleeding identified within the loops of bowel. There is no free\n fluid, free air, or lymphadenopathy within the abdomen.\n\n CTA: The intra-abdominal vasculature is unremarkable. The major branches\n including the celiac, SMA, and are patent. There is normal hepatic\n arterial anatomy. There is no evidence of contrast extravasation.\n\n CT PELVIS: The bladder, rectum, and sigmoid colon are unremarkable. There\n are bilateral ovarian cysts measuring 2.3 x 1.8 cm on the right (4:285) and\n (Over)\n\n 6:06 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: ? source of bleeding\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2.2 x 1.9 cm on the left (4:290) which are most likely physiologic. There is\n no free fluid, free air, or lymphadenopathy within the pelvis.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. No acute hemorrhage identified.\n 2. Bilateral ovarian cysts, likely physiologic.\n 3. Small hypodensity in the left lobe, too small to characterize.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-01-09 00:00:00.000", "description": "MECKEL'S SCAN", "row_id": 1217828, "text": "MECKEL'S SCAN Clip # \n Reason: 22 Y/O W/ LARGE VOLUME GI BLEED X 1 DAY, COLONOSCOPY AND EGD NEGATIVE. ? AREA OF ECTOPIC GASTRIC MUCOSA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 10.5 mCi Tc-m Pertechnetate ();\n HISTORY: 22 yo with large volume GI bleed with blood at TI on otherwise normal\n colonoscopy.\n\n COMPARISON: Mesenteric CTA\n\n INTERPRETATION: Following the intravenous administration of Tc-m pertechnetate\n flow and 30 minute static images were obtained in the anterior and posterior\n projections. Flow images demonstrate no abnormal distribution of tracer.\n\n Delayed images show normal excretion of tracer in the stomach and bilateral\n renal uptake. Tracer flows out of the stomach and is seen looping through\n duodenum and proximal ileum on dynamic imaging.\n\n No ectopic tracer uptake is present in the right lower quadrant or elsewhere.\n\n IMPRESSION: No evidence of Meckel's diverticulum. Findings were discussed via\n phone with Dr via phone shortly after exam completion.\n\n\n\n\n , M.D.\n , M.D. Approved: FRI 3:29 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2143-01-11 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 1218113, "text": "GI BLEEDING STUDY Clip # \n Reason: BRBPR AND BLOOD IN COLON EVAL FOR GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 15.7 mCi Tc-m RBC ();\n HISTORY: Bright red blood per rectum and blood in the colon.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for minutes\n were obtained.\n\n Blood flow images show normal flow of tracer through the vessels and organs.\n\n Dynamic blood pool images over 90 minutes show no evidence of bleeding.\n\n IMPRESSION: No evidence of GI bleed during the time of study.\n\n\n , M.D.\n , M.D. Approved: MON 3:02 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2143-01-12 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1218250, "text": " 1:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for site of bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with BRBPR, likley lower GI bleed\n REASON FOR THIS EXAMINATION:\n eval for site of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAM OF THE ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: 23-year-old female with bright red blood per rectum, likely\n lower GI bleed. Evaluate for site of bleeding.\n\n COMPARISON: CT on .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis in a\n soft tissue algorithm before and after the administration of intravenous\n contrast material in the CTA protocol. Coronal and sagittal reformats were\n provided. The dose length product was 1169.7 mGy-cm.\n\n FINDINGS:\n\n CHEST: The partially visualized heart and pericardium are again unremarkable.\n There is no pericardial effusion or pleural effusion. The lung bases are\n clear.\n\n ABDOMEN AND PELVIS: The small hypodensity within the left lobe of the liver is\n again seen, unchanged, and too small to accurately characterize. The liver is\n otherwise again unremarkable. The portal veins are patent. There is no\n biliary dilatation. The gallbladder is unremarkable. The pancreas, spleen,\n kidneys, adrenals are normal.\n\n The stomach, small and large bowel are unremarkable. No source of bleeding is\n identified within the bowel.\n\n The bladder, rectum, and sigmoid colon are unremarkable. There are stable\n bilateral ovarian cysts, likely physiologic.\n\n There is a small amount of free fluid within the pelvis, which is new since\n the previous examination, and likely physiologic. There is no free air or\n lymphadenopathy.\n\n CTA: The intra-abdominal vasculature is normal. All the major branches\n including the celiac, SMA and are patent. There is normal hepatic\n arterial anatomy. There is no evidence of contrast extravasation.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. No\n fractures or evidence of degenerative change.\n\n (Over)\n\n 1:43 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for site of bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n No acute hemorrhage or source of bleeding identified.\n\n" } ]

12,183

145,571

MICU COURSE: On arrival to the MICU, the patient was found intubated and sedated. He was initially continued on broad spectrum antibiotics (cefepime, levofloxacin, vancomycin), vanc d/c'd on , cefepime d/c'd on as sputum culture came back pneumococcus sensitive to levofloxacin. DFA fr flu was negative. He was weaned off of a dopamine drip by . He received a steroid pulse and began a taper on . He was extubated on without complication. He had acute renal failure which resolved with fluids. Patient was transferred to the floor on in stable condition. . . . # PNA/COPD/Respiratory failure: Likely related to underlying poor pulmonary status (COPD) and pneumonia. Patient had a similar episode last year per his daughter when diagnosed with Strep pneumoniae. Sputum culture +S. pneumo. DFA for flu negative. S/p extubation , satting at 90% 3L. Patient was continued on Levofloxacin for which a 14 course will be completed. He will also remain on neb treatments and his home prednisone. All of his home medications were re-added back to his regimen prior to discharge. he idd have one episode of hypoxia that was thought to be due to mucus plugging and resolved quickly. . # Acute renal failure: Likely was volume depleted versus ATN in setting of sepsis. Resolved with aggessive fluid hydration. His urine output remained adequate while on the floor . # h/o NSTEMI: Patient was continued on statin, aspirin . . After discussion with the patient, the patient's daughter and the attending, all were in agreement that he was a suitable candidate for discharge. Medications on Admission: advair diskus 100/50 lasix 20 mg daily lipitor 10 mg daily lorazepam 0.5 mg prn prednisone 10 mg daily spiriva daily oxygen via NC 1 L/min Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 5 days. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation (2 times a day). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q2H PRN (). 16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB. Discharge Disposition: Expired Facility: & Rehab Center - Discharge Diagnosis: Primary Diagnosis: Streptococcus pneumonia pneumonia . Secondary Diagnoses: * H/o multilobar Strep pneumo pneumonia in requiring intubation at * HTN * hypercholesterolemia * Non-STEMI () * TIA/aphasia * s/p L CEA * COPD - PFTs FVC 2.95 (76%), FEV1 1.57 (62%), FEV1/FVC 53 (82%) * BPH s/p TURP * balanitis s/p circumcision * remote nephrolithiasis * former tobacco use (80 pack/year Hx) Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were initially admitted to the intensive care unit after requiring mechanical ventilation for what was found to be a serious pneumonia. You were extubated successfully and continue on antibiotics, for which you will continue for a total of 14 days. You also had an episode of hypoxiz while on the floor which was likely due to a mucus plug. . 1. Please take all medication as prescribed. 2. Please make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Dr. will contact you regarding a follow-up appointment.

A right central line ends in the upper SVC. A right subclavian PICC line terminates in the proximal one-third of the SVC. Bagged with ^ bp/hr. FINDINGS: In the interim, the upper mediastinal vessels including the azygos vein are less engorged on today's examination. Today's examination shows subtle interstitial markings that could be suggestive of slight interstitial edema. ID: Conts on antibx but is currently afebrile. Endotracheal tube and right subclavian CVL are in unchanged position. Bibasilar opacities have now resolved. Slight enlargement of the cardiac silhouette persists. O2 sats to be 88-92. lungs are clear/diminished. Otherwise, stable radiographic appearance of the chest with left lower lobe atelectasis. The "reverse-P" shaped opacity, projected over the lateral aspect of the right hemithorax, is no longer seen. While dtr driving him to noted him to be more cyanotic and pulseless> . Stable radiographic findings including interstitial opacities in both lungs, stable mild cardiomegaly, status post extubation. IMPRESSION: Endotracheal tube in satisfactory position as above. FINDINGS: This single bedside AP examination labeled "supine at 1710 H" is available for interpretation on . Sinus rhythmFirst degree A-V delayInferior infarct - age undetermined may be oldLow limb lead QRS voltagesDelayed R wave progression with late precordial QRS transition - is nonspecificST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -clinical correlation is suggestedSince previous tracing of , precordial lead T waves slight lessprominent Lungs with diminished aeration in bases otherwise clear. Sinus rhythmFirst degree AV delayInferior infarct, age indeterminate - may be oldLow limb lead QRS voltagesDelayed R wave progression with late precordial QRS transition - is nonspecificST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -clinical correlation is suggestedSince previous tracing of , no significant change CHEST AP: Cardiac, mediastinal, and hilar contours are unchanged. CV: Hr 60's 1st degree AVB, also noted AV disassociation with accelerated ventricular rhythm, team aware. CVP D/C. IMPRESSION: Interval placement of nasogastric tube with the proximal side hole near the GE junction. Lasix given x1 dose with good diauresis. The cardiac silhouette size is maintained slightly prominent. The proximal side hole is near the GE junction. Coccyx intact.A: rhythm disturbance ? FRONTAL CHEST RADIOGRAPH: The right-sided subclavian central venous line has been removed. Stable mild cardiomegaly. IMPRESSION: ET tube and right subclavian central venous catheter in satisfactory position, with persistent low lung volumes but no very short- interval change. weak peripheral pulses, A-line is very positional but matches cuff BP. cont to advise pt to cough up sx. Intubated and transferred here. Alb/atr mdi given as ordered.Strong cough reflex. NGT via R nare intact. The cardiac silhouette is within normal limits for size. Has multiple eccymotic areas and few skin tears. Lasix 40mg IV given with good diuresis.GI/GU: pt has NG tube, no residual. Minimal left basilar atelectasis is also evident. The lung volumes remain somewhat low with left more than right basilar atelectasis. pt cont on cefepime and levoflaxacin. pt sputum culture came back with strep. Pt bronchospastic with any movement and suctionning. Resp Care,Pt. drip up to 3mg back down to 2mg.CV: Nsr with occassional pvcs and pacs. see flow sheet for vent setting and ABGS,GI abd destended BS present. bronchospastic with turns and activity. Progress Note 0700-1900Pt admitted to MICU for PNA, pt has end stage COPD. PNA, vanco was D/C. ADM 83 yo reportly end stage COPD. started tf with little residual. Afternoon labs pndg.GI: Abd soft/obese with + BS. pt will at times drop SBP with suctioning.Cardio: NSR, HR 70-80, SBP 90-110. weak peripheral pulses, dopamine being weaned, goal CVP greater than 10, CVP is 8, goal map greater than 60.GI/GU: no bowel movement, pt is NPO, tube feeding consult is in, hypoactive bowel sounds, foley with good urine output. TF of Nutren Renal cont 2 goal 45ml/hr with scant residuals. no gtt needed at this time.SKIN: skin tears, bruising bil arms.ID: On levaqin, cefepime. Breath sounds still fairly tight, getting albuterol and atrovent inhalers. Hr and sbp improved post entubation. initally cvp 17 on arrival.Lungs: coarse throughout thick yellow to green sputum. Last ABG with adequate ventilation/oxygenation. pp intact Tmax 99.3 wbc elevating. RR 23-30. pt still haveing lots of inline secretions, whitie/yellow thick. sputum spect. positional, arm board onRESTRAINTS: dc'd. sputum sent for C+S. NKMA.Events: pt neg for Flu droplet prec. CVP 6-7. good peripheral pulses.A-line is very positional, having difficulty getting a good wave form.GI/GU: Tube feeds at goal of 35ml/hr no residuals noted, small smear brown bowel movement, foley 30-60 ml/hr. cvp 7-10. urine out minimal 30 cc hr. pt dopamine is being weaned, pt recieved 2 liters of NS bolus.Neuro: pt intubated, on versed at 2mg, pt is able to open eyes to voice, can follow commands, will mouth needs.Resp: AC 40%/500/26/10, goal O2 sat 88-92%. Respiratory CarePt remains on ventilator, Lung Sounds- Cl but diminished bilaterally. Resp CarePt remains intubated and currently vented on PSV 8/8 tol well with Vt around 500-600ml and MV 6-9L. placed on 2mg versed drip. ABG 7.33/54/106. given fluid for Low SBP then started on dopamine. D/C, also D/C tamiflu. Lung snds coarse->clear with freq suctionning of mod-copious amts thick white secretions. Sputum spec. Bronchodilators given with good effect noted. and pt turned.planmonitor sbp titrate dopamine as indicated.give fluid based on CVP , SBP and urine output. Clear dsg on RLA with scant amt serosang drainage.Social: Dgtr in to visit, updated by nurse.Plan: Cont to wean from vent as tol. pulm. toilet , vent and abgs as indicated Noted redness and skin breakdownon lt upper extrimity.Positioned and back care given as needed.Afebrile,on Levofloxacin/Cefipime.No contact from family at this shift.plan;? received order for prn fentanyl. palp DP/PT SBP 90-120's . awaiting coags.RESP: returned to AC ventation for hypovent with increase rr to 35 and diaphorectic and tachy. Pt transfered to . Extubate at AM.Haemodynamic monitoringUpdate with family.

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[ { "category": "Radiology", "chartdate": "2197-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005115, "text": " 3:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD. CAD, s/p resp arrest and PNA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and chest CT scan examination.\n\n HISTORY: 83-year-old man with COPD, coronary artery disease status post\n respiratory arrest and pneumonia, evaluate for interval change.\n\n FINDINGS: In the interim, the upper mediastinal vessels including the azygos\n vein are less engorged on today's examination. The pulmonary opacification\n seen in both lungs predominantly at the lung bases has decreased with better\n identification of the pulmonary vessels. Scarcity of the vessels in the upper\n lobes reflects underlying emphysematous lung changes. The pulmonary arteries\n are prominent in keeping with patient's pulmonary arterial hypertension. The\n heart is not enlarged. There is no pleural effusion.\n\n The endotracheal tube is approximately 4.2 cm above the carina. A right\n central line ends in the upper SVC. A feeding tube tip is out of view on this\n examination.\n\n IMPRESSION:\n 1. Gradual decrease of the volume overload. 2. Emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-16 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1004911, "text": " 5:01 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 1659 HOURS.\n\n HISTORY: Followup.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The patient has been intubated with the distal tip of the\n endotracheal tube approximately 5.4 cm from the carina. There is widening of\n the mediastinum, likely due to underlying body habitus and aortic tortuosity.\n However, in the setting of trauma, mediastinal vascular injury cannot be\n entirely excluded. The cardiac silhouette is within normal limits for size.\n No definite consolidation is noted, however, subtle increased density is seen\n along the lateral aspects of the right lung, likely due to overlying soft\n tissue. In the more superior aspect, there is an abnormal density resembling a\n reverse \"P\" which may be extrinsic to the patient. Minimal left basilar\n atelectasis is also evident. No definite effusion or pneumothorax is seen.\n\n IMPRESSION: Endotracheal tube in satisfactory position as above.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006060, "text": " 2:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with resolving pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with resolving pneumonia.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The right-sided subclavian central venous line has\n been removed. Slight enlargement of the cardiac silhouette persists. The\n main pulmonary arteries are prominent, which may reflect underlying pulmonary\n arterial hypertension. Bibasilar opacities have now resolved. There is no\n new focal consolidation.\n\n IMPRESSION:\n\n 1. Stable mild cardiomegaly.\n\n 2. No focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004912, "text": " 5:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED :\n\n HISTORY: Intubation.\n\n FINDINGS: This single bedside AP examination labeled \"supine at 1710 H\" is\n available for interpretation on . It is compared with a bedside study\n performed only eight minutes earlier and retrospectively compared with a\n series of studies through today. The tip of the ET tube lies 3.2 cm proximal\n to the carina and a newly-placed right subclavian central venous catheter\n reaches the distal SVC, with no supine evidence of pneumothorax. The lung\n volumes remain somewhat low with left more than right basilar atelectasis. The\n \"reverse-P\" shaped opacity, projected over the lateral aspect of the right\n hemithorax, is no longer seen. The cardiomediastinal contour is unchanged,\n with extensive atherosclerotic change involving the thoracic aorta, but no\n pulmonary vascular congestion, supine pleural effusion, or other evidence of\n CHF.\n\n IMPRESSION: ET tube and right subclavian central venous catheter in\n satisfactory position, with persistent low lung volumes but no very short-\n interval change.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005267, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with pneumococcal pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 83-year-old man with pneumococcal pneumonia, evaluate for interval\n change.\n\n FINDINGS: The endotracheal tube tip is 5.5 cm above the carinal bifurcation.\n A right subclavian PICC line terminates in the proximal one-third of the SVC.\n\n The lungs are emphysematous. The pulmonary arteries are prominent in keeping\n with patient's pulmonary arterial hypertension. The heart size is borderline.\n There is no pleural effusion.\n\n IMPRESSION:\n 1. Emphysema.\n 2. Negative examination for any acute or chronic acute cardiopulmonary\n process.\n\n" }, { "category": "Radiology", "chartdate": "2197-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004936, "text": " 12:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tubes/lines, infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD, prior MI, intubated with likely pneumonia.\n REASON FOR THIS EXAMINATION:\n eval tubes/lines, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with COPD, prior MI, intubated with likely\n pneumonia.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are unchanged. The aorta\n is calcified and tortuous. Pulmonary vasculature is unremarkable. There is\n left lower lobe atelectasis. No pleural effusion is identified, although the\n left costophrenic angle is not included on the exam. Endotracheal tube and\n right subclavian CVL are in unchanged position. There has been interval\n placement of a nasogastric tube with the tip in the stomach. The proximal\n side hole is near the GE junction.\n\n IMPRESSION: Interval placement of nasogastric tube with the proximal side\n hole near the GE junction. Otherwise, stable radiographic appearance of the\n chest with left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005577, "text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with COPD, PNA s/p extubation\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and .\n\n HISTORY: 83-year-old man with COPD, pneumonia, status post extubation,\n evaluate for interval change.\n\n FINDINGS: The patient has been extubated showing persistent interstitial\n opacities seen in both lungs. The cardiac silhouette size is maintained\n slightly prominent. No newly occurred parenchymal opacities suggestive of\n pneumonia. No pleural effusion or pneumothorax are noted.\n\n IMPRESSION:\n 1. Stable radiographic findings including interstitial opacities in both\n lungs, stable mild cardiomegaly, status post extubation.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005416, "text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with respiratory failure; PNA\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices are in unchanged position. Today's examination shows subtle\n interstitial markings that could be suggestive of slight interstitial edema.\n The size of the cardiac silhouette is minimally increased. No newly occurred\n parenchymal opacities suggestive of pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 155271, "text": "Sinus rhythm\nFirst degree AV delay\nInferior infarct, age indeterminate - may be old\nLow limb lead QRS voltages\nDelayed R wave progression with late precordial QRS transition - is nonspecific\nST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -\nclinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-04-16 00:00:00.000", "description": "Report", "row_id": 155272, "text": "Sinus rhythm\nFirst degree A-V delay\nInferior infarct - age undetermined may be old\nLow limb lead QRS voltages\nDelayed R wave progression with late precordial QRS transition - is nonspecific\nST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -\nclinical correlation is suggested\nSince previous tracing of , precordial lead T waves slight less\nprominent\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422313, "text": "resp care\nPt remained on psv8/peep8 and 40% with sats 96%. Vt ranged from 400-1000cc and rr 8-20.BS coarse bil. Suct for copious amts of creammy thick sput. Alb/atr mdi given as ordered.Strong cough reflex. RSBI done =42.ABG revealed a resp acidosis.Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422314, "text": "MICU Progress Note 0700-1900\npt is 83 yr old adm. for PNA, pt has end stage COPD, Full code, NKMA\n\nEvents: pt was extubated in AM, tolerating it well. Pt still has NG tube and is NPO at this time. pt is able to cough up and sx lots of secretions. CVP D/C. Lasix given x1 dose with good diauresis. pt sat in chair for 1 hr today.\n\nNeuro: pt is alert x3, able to verbalize needs, follows commands, no pain.\n\nResp: pt on 35% FiO2 face tent. O2 sats to be 88-92. lungs are clear/diminished. pt is coughing up a lot of sx that he is able to sx out white/thick sx. pt does ask for mouth swabs.\n\nCardio: HR 50-70, 1st degree AV block, team knows about HR dropping into the 50's. In AM pt SBP was 170-180's 10mg of hydralizine given with good response, since extubation pt SBP 120-140's. weak peripheral pulses, A-line is very positional but matches cuff BP. Lasix 40mg IV given with good diuresis.\n\nGI/GU: pt has NG tube, no residual. NPO at this time. good bowel sounds. pt getting Q 4 hr fluid boluses for high sodium, sodium is decreasing. No bowel movement this shift. D5W at 125/hr.\n\nSocial: pt daughter is (HCP) numbers on the board, she also works at and has been in and out today and is updated with pt status.\n\nPlan: cont. antibiotics, monitor labs replete electrolyes as needed. cont to advise pt to cough up sx. monitor O2 sats. ? advancing diet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-21 00:00:00.000", "description": "Report", "row_id": 1422315, "text": "MICU NPN\n83 yo with pmhx of COPD (on home o2), NSTEMI and HTN. Was not doing well at home. While dtr driving him to noted him to be more cyanotic and pulseless> . Bagged with ^ bp/hr. Intubated and transferred here. DX with pna.\n ID: Conts on antibx but is currently afebrile.\n CV: Hr 60's 1st degree AVB, also noted AV disassociation with accelerated ventricular rhythm, team aware. Also has occ blocked pac's. BP 130-150's.\n Resp: O2 at 35% face tent with sats rnaging 90-96%, decrease sats to 86-88% on room air. Lungs with diminished aeration in bases otherwise clear. At beginning of shift productive cough of thick white sputum.\n GI/GU: Abd soft with (+) bowel sounds. No bm. NGT via R nare intact. Was given water but appeared to cough a few seconds after drinking. His NA is 141 today, no further free water boluses given. Foley drng clear yellow urine was -700cc yesterday and approx 300 for today. Is (+) approx 4500cc for LOS.\n MS: Alert and oriented. Able to follow all commands. Initially unsure of year, but otherwise intact.\n Skin: Weeping from R arm noted. Has multiple eccymotic areas and few skin tears. Coccyx intact.\nA: rhythm disturbance\n ? swallowing difficulty\nP: cont to follow rhythm closely, avoid nodal blockers, ? EP study\n cont to monitor closely swallowing ? swallowing study\n enc oob\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422309, "text": "Resp Care\nRemains intubated and ventilated overnight on a/c. Rate decreased from 26 to 22 but pt still taking one or two breaths above. Breath sounds still fairly tight, getting albuterol and atrovent inhalers. Suctioned for thick tan/yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422310, "text": "Nursing Progress Note 0700-1900\nReview of systems:\n\nNeuro: Pt remains very lightly sedated on Versed qtt @ 2mg/hr. Opens eyes to voice and responds approp with head nods and mouthing words. Follows commands consistantly and assists turning STS in bed. OOB to chair via 1200-1700, tolerated well. Consistantly denies pain.\n\nResp: pt on vent settings AC 40%/500 X 22/+10, with pt overbreathing rate ~ 2X/min. O2sat 95-97%. ABG 7.33/54/106. At 1600 vent changed to PS 8/+8/40%, RR low 20's. O2 sat unchanged and ABG 7.35/52/100. Lung snds coarse->clear with freq suctionning of mod-copious amts thick white secretions. Pt bronchospastic with any movement and suctionning. Very strong cough.\n\nCV: HR 65-76 1st degree AV block with escape beats->SR. BP 128/54-164/69. FWB increased to 150ml Q4hrs for am Na 149. Afternoon labs pndg.\n\nGI: Abd soft/obese with + BS. TF of Nutren Renal cont 2 goal 45ml/hr with scant residuals. Pt had med soft brown stool X 1.\n\nGU: Urine yellow/clear, draining via foley @ 40-90ml/hr. 24hr fluid balance +576ml @ 1700, LOS balance +5.6liters.\n\nSkin: Skin tears and bruising on both arms unchanged. Clear dsg on RLA with scant amt serosang drainage.\n\nSocial: Dgtr in to visit, updated by nurse.\n\nPlan: Cont to wean from vent as tol. NPO after MN for ? extubation tomorrow. Monitor Na level. Eggcrate pad to chair. Cont emotional support to pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422311, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 8/8 tol well with Vt around 500-600ml and MV 6-9L. BS course sxing for large to copious amts of secretions. Pt does have a good strong cough. Bronchodilators given with good effect noted. ETT rotated and retaped at 23cm at the lip. Last ABG with adequate ventilation/oxygenation. Will cont with vent support and reassess for further weaning with possible extubation tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-20 00:00:00.000", "description": "Report", "row_id": 1422312, "text": "83 y/o male admitted with PNA,has PMH of COPD,intubated OSH since pt was unresponsive on the way to ,remains full code.NKDA.\n\nSedated with Versed 2 mg/hr pt alert and able to follow commands,coperative with care,moves all extrimities.\n\nLS are coarse/dim at bases,on CPAP 40/8/8 suctioned sevaral times for copiuos amts of thick yellow colored secretion.No vent changes overnight has good cough reflex.\n\nHR 60-80's occasional PVC's,ABP high to 170's when awake.For access one multilumen CVL,A-Line remains patent.Positive pedal pulses.+peripheral edema.D5W 100 ml/hr onflow for 1000ml-for NA 149,Getting Q4hr water bolus too.\n\nAbdomen obese positive bowel sounds,TF stopped since MN for possibe extubation,had bowel movement last night.\n\nFoley catheter draining adequte output.\n\nSkin has redness at sacrum,remains intact except both upper extrimities. Noted redness and skin breakdownon lt upper extrimity.Positioned and back care given as needed.\n\nAfebrile,on Levofloxacin/Cefipime.\n\nNo contact from family at this shift.\n\nplan;\n? Extubate at AM.\nHaemodynamic monitoring\nUpdate with family.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422306, "text": "Respiratory Care\nPatient remains intubated, on mechanical ventilation, breath sounds bilaterally diminished, suctioned intermittently for small to moderate amounts of thick yellow to white secretions, treated with Albuterol and atrovent inhalers, no ABGs drawn nor vent changes made, patient is alert, responsive, will continue to be followed.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422307, "text": "Progress Note 0700-1900\nPt admitted to MICU for PNA, pt has end stage COPD. Full code. NKMA.\n\nEvents: pt neg for Flu droplet prec. D/C, also D/C tamiflu. insulin sliding scale started. pt sputum culture came back with strep. PNA, vanco was D/C. pt cont on cefepime and levoflaxacin. Pt also started on prednisone taper dose. pt up to the chair for 1.5 hrs.\n\nNeuro: pt alert, versed at 3mg/hr. pt can follow commands, mouths needs, denies pain.\n\nResp: no changes to vent settings: AC 40%/500/26/10. RR 23-30. pt still haveing lots of inline secretions, whitie/yellow thick. also pt needs good oral care. pt has been asking for oral swobs for dry mouth and have been using vasoline for lips. lung sounds are clear/course.\n\nCardio: 1st degree AV block, HR 70-80, SBP 110-120. no additional boluses given during this shift. CVP 6-7. good peripheral pulses.\nA-line is very positional, having difficulty getting a good wave form.\n\nGI/GU: Tube feeds at goal of 35ml/hr no residuals noted, small smear brown bowel movement, foley 30-60 ml/hr. + bowel sounds.\n\nSocial: daughter is HCP, she works at visited pt twice today. pt ring was sent home with her today.\n\nPlan: cont antibiotics, try to wean from vent, cont good suctioning and oral care. cont monitoring urine output and CVP. Update family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-19 00:00:00.000", "description": "Report", "row_id": 1422308, "text": "1900-0700 NPN\nNEURO: pt spont opens eyes, confused as to place, knows name, knows yr. mae, currently on versed 2 mgm hr decreased from 3 mgm overnight.\nPERL, follows commands\n\nCV: 1st degree avb with reg. dropped beats not wenkebach, not wandering atrial. denies chest pain. serial enzymes on admit neg. cms intact. Tmax 99.8 oral, urine out average 40cc hr this night. cvp 2-4\n\nRESP: diminished lower right lobe, BUL clear, left clear, no wheeze, AC 40%, TV 500cc rate decreased to 23 from 26 peep 10. suctioned for copious amts thick light yellow secretions, copious oral secretions. bronchospastic with turns and activity. good cough effort.\n\nGU/GI: foley with average out 40 cc. clear, abd rounded BT active. given senna. large soft brwn hem neg stool incont.\n\nENDO: bs elevated to 200's, sliding scale in place. pt on steroids and tube feeds nutren pulm at goal rate 45 cc hr with min. to no residuals\n\nPAIN: c/o pain general and ETT related. received order for prn fentanyl. gave 2 doses 50 mcq through night prn. no gtt needed at this time.\n\nSKIN: skin tears, bruising bil arms.\n\nID: On levaqin, cefepime. pending sputum cultures\n\nSOCIAL: family to visit. pt. appears well supported by family.\n\nPLAN: cont. pulm toilet, antibiotics, daily trials, wean from vent when appropriate, mobilize, replete elect. as needed. monitor card rhythm closely to see if further elongation or pr or other block developes.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422302, "text": "MICU Progress Note: 0700-1900\nPt is 83 yr old in for PNA and end stage COPD, pt is full code, NKMA.\n\nEvents: pt 2 decreased from 50% to 40%, goal O2 sat is 88-92%. pt dopamine is being weaned, pt recieved 2 liters of NS bolus.\n\nNeuro: pt intubated, on versed at 2mg, pt is able to open eyes to voice, can follow commands, will mouth needs.\n\nResp: AC 40%/500/26/10, goal O2 sat 88-92%. lungs are course, and pt has tons of copious yellow secretions both in-line and in mouth. pt will at times drop SBP with suctioning.\n\nCardio: NSR, HR 70-80, SBP 90-110. weak peripheral pulses, dopamine being weaned, goal CVP greater than 10, CVP is 8, goal map greater than 60.\n\nGI/GU: no bowel movement, pt is NPO, tube feeding consult is in, hypoactive bowel sounds, foley with good urine output. total of 2 liters of fluid boluses given.\n\nPlan: cont antibiotics, cont to wean dopamine off, may need to give additional fluid boluses, monitor blood pressure. lots of suctioning for thick secreations.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422303, "text": "Respiratory Care\nPt remains on ventilator, Lung Sounds- Cl but diminished bilaterally. FiO2 was lowered to 40%, where the target oxygen saturations are to be in the range of 88-92%. MDIs given at the appropriate times. Whiel ETT was being retaped, Copious amounts of secretions were suctioned out of both the tube and the mouth. Pt remains , con't to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422304, "text": "1900-0700 NPN\nNEURO: intact, mae, perl, follows commands. Increase versed to 4mgm hr for agitation and increase rr, decreased to 3 mgm hr this am and doing well.\n\nCV: pr .24 1st degree avb with occ. PVC. sys 127-140 off dopamine gtt. cvp 7-10. urine out minimal 30 cc hr. pp intact Tmax 99.3 wbc elevating. awaiting coags.\n\nRESP: returned to AC ventation for hypovent with increase rr to 35 and diaphorectic and tachy. suctioned for copious amt yellow secretions, mod oral clear secretions. lung sounds coarse and diminished bibasilar. sputum spect. sent.\n\nGU/GI: foley with 30 cc hr output average, abd with active BT. started tf with little residual. bun falling slightly creat stable. phos low.\n\nENDO: bs 150-200 . tube feedings advancing toward goal. pt pn steroids\n\nPAIN: denies\n\nSKIN: small skin tear left forearm drsd for prevent of further shearing.\n\nACCESS: mulitlumen right all ports avail., 1 , . line within 20 mmhg of cuff bp. positional, arm board on\n\nRESTRAINTS: dc'd. pt able to understand and not pull on tubes. follow commands.\n\nID: on levafloxin and cefapime and vanco, cultures pending\n\nSOCIAL: no visit or calls this night\n\nPLAN: pulm toilet, cont. antibiotics, cvp goal , replete electolytes prn, mobilize asap\n" }, { "category": "Nursing/other", "chartdate": "2197-04-18 00:00:00.000", "description": "Report", "row_id": 1422305, "text": "Resp Care\nRemains intubated and ventilated on a/c with no remarkable changes overnight. Breath sounds with tight sounding expir wheezes. Suctioned for small to moderate amounts of thick tan sputum. Awaiting results of nasal aspirate for flu later today.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422300, "text": "Resp Care,\nPt. admitted from ED intubated #8ET taped at 23@lip. Placed on A/C, peep at 10 cm due to auto-peep. Suctioned copious amount very thick yellow sputum. Sputum spec. sent. MDI's as ordered. ABG acceptable, maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2197-04-17 00:00:00.000", "description": "Report", "row_id": 1422301, "text": "ADM 83 yo reportly end stage COPD. on home O2. pt with hx URI for several days report by daughter who is a RN that he was cyanotic am. While daughter was transporting Pt to pt became unresponsive. Daughter took Pt to hospital. pt was reported pulselesss and unresponsive. pt at osh. copious amt of thick green sputum suctioned . antibiotics given. Hr and sbp improved post entubation. Pt transfered to . given fluid for Low SBP then started on dopamine. on arrival to floor pt had recieved 4L fluid, uo was 1000cc; Dopamine was at5mcg/kg.\n\nNuero: pt restless fighting vent . placed on 2mg versed drip. noted to MAE on bed. not opening eyes. drip up to 3mg back down to 2mg.\nCV: Nsr with occassional pvcs and pacs. palp DP/PT SBP 90-120's . sbp dropped when suctioned. dopamine initially 5mcg/kg down to 3mcg most of shift currently 2mcg. NS bolus 500cc given for CVP of 6 . initally cvp 17 on arrival.\nLungs: coarse throughout thick yellow to green sputum. sputum sent for C+S. see flow sheet for vent setting and ABGS,\nGI abd destended BS present. NG LWS initially coffee ground cleared with 50cc flush bilious drainage about 150cc.\nGu foley to gravity on arrival pt had scab on penis and pus draining around foley area cleaned and gauze applied.\nskin : very dry . purple spot and fragile skin noted on arms. rt leg with some scratches, coccyx red no breaks in skin lotion applied. and pt turned.\nplan\nmonitor sbp titrate dopamine as indicated.\ngive fluid based on CVP , SBP and urine output.\n pulm. toilet , vent and abgs as indicated\n" } ]

29,773

149,695

Patient admitted on with abdominal pain. CT scan confirmed appendicitis. On patient went to the operating room for a laparoscopic appendectomy without complications. He tolerated the procedure well. He was progressing well postoperatively until when he was noted to be in a rapid afib. He was given two additional doses of beta blocker with resulting hypotension. Patient was transferred to the intensive care unit. He was monitored and enzymes checked times 3. They were all negative. Cardiology was consulted. Cardiology recommends beta blocker, full dose asa, 1/2 dose of valsartan. Patient is now in normal sinus rhythm. completed, Showing little change from previous.

The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm.Conclusions:The left atrium is normal in size. There is no pericardialeffusion.IMPRESSION: Normal global and regional biventricular systolic function. IMPRESSION: No acute cardiopulmonary process - stable. Mildmitral annular calcification. Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. Sinus rhythmBorderline first degree A-V delayLeft atrial abnormalityEarly precordial QRS transition - is nonspecificSince previous tracing of the same date, atrial fibrillation absent VOIDING ADEQUATE AMOUNTS. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Normal aortic valve leaflets (3). The estimatedpulmonary artery systolic pressure is normal. Spontaneously voiding adequate amounts cyu. ABDOMEN SOFTLY DISTENDED, LAP SITES WITH STERI-STRIPS INTACT WITH NO REDNESS OR DRAINAGE. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Stable radiograph. Abd soft/approp tender to palpation. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. IMPRESSION: No acute pulmonary process. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.Height: (in) 69Weight (lb): 260BSA (m2): 2.31 m2BP (mm Hg): 120/55HR (bpm): 75Status: InpatientDate/Time: at 11:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). BP stable. FINAL REPORT CT ABDOMEN AND PELVIS WITH CONTRAST. Sinus rhythm with borderline P-R interval prolongation. The small bowel loops are normal in caliber and without focal wall thickening. The cardiac silhouette is within normal limits for size. +pp/csm. Compared to theprevious tracing of there is no significant change. Abdomenal lap sites intact. LE edema noted. Atrial fibrillation with rapid ventricular responseEarly precordial QRS transition - is nonspecificSince previous tracing of , atrial fibrillation now present The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. APPY/DIVERTIC. APPY/DIVERTIC. HISTORY: Bibasilar rales with intermittent shortness of breath. IV contrast was administered. denies n/v. 10mg IV Lasix x1 with + effect. +bs. Coronal and sagittal reformats were performed. Tolerating clears without incident. FINDINGS: Accounting for the more lordotic projection, there is no significant interval change with no evidence of new infiltrate, effusion, or worsening of fluid status. Nodiastolic dysfunction, pulmonary hypertension or significant valvular diseaseseen.Compared with the report of the prior study (images unavailable for review) of, the degree of LVH and aortic dilatation may be slightly reduced onthe current study. There is no mitral valve prolapse. No AS. No effusion or pneumothorax is noted. Coarse calcifications within the prostate are noted. ADAT. The rectum, sigmoid colon and bladder are unremarkable. AFEBRILE. Reporting minimal abdomenal pain with repositioning and palpation, but declining pain medications. There is a tortuous aorta with atheromatous disease. There is no intrahepatic or extrahepatic biliary dilatation. Nsg.progress notes;See flow sheet for specific:PAtient is alert and oriented, very pleasant and co op with care, able to get OOB by himself,denies pain, NSR, HR:60-80, with rare PVC'S,pottasium 20mmol replaced today morning for K 3.9, SBP 120-135, cardiac echo done at bed side, cardiology referred and seeen by them no new recomendation,denies CP or discomfort.afebriele, on anbx.ON RA, LS clear, O2 sat 95-97%, no cough. FINDINGS: The lung bases are clear. BREATHING UNLABORED @ REST, SP02 91-95% WITHOUT SUPPLEMENTAL O2. (Over) 7:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. COMPARISON: None. There is no pericardial or pleural effusion identified. Calm and cooperative with nursing care. There is no mesenteric or retroperitoneal lymphadenopathy. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). NURSING NOTEASSESSMENT: PATIENT ORIENTED AND APPROPRIATE. 7:59 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. There is no pelvic or inguinal lymphadenopathy. Pulmonary hygiene. Field of view: 45 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) Able to independently reposition self in bed.Plan: Monitor cardiac status closely. LSCTA - diminished at bases - using IS with good technique - O2 sats >95% on RA. Degenerative changes of the spine are noted. IMPRESSION: Fluid filled and dilated appendix measuring up to 1.3 cm with adjacent fat stranding consistent with uncomplicated appendicitis. HEART RATE MOSTLY 60'S NORMAL SINUS, SBP 130-140'S. TAKING LIQUIDS OVERNIGHT.PLAN: TRANSFER TO FLOOR IN AM. PHYSICAL THERAPY CONSULT. ? ? ? ? TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were obtained. COMPARISON: at 17:58. COMPARISON: Multiple priors, the most recent dated . The gallbladder is distended and contains multiple gallstones. COMPLAINING OF ABDOMINAL PAIN @ BEGINNING OF THE SHIFT, RELIEVED BY PERCOCET. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. There is no evidence of adjacent fluid collection or free air. Nursing NotePlease see carevue for detailsPt A&O x3. The liver, spleen, pancreas, adrenal glands and kidneys are unremarkable. There is no free fluid or free air. Bridging osteophytes are noted throughout the thoracic spine with degenerative changes also noted in the right acromioclavicular joint. PROVIDE SUPPORT. FINDINGS: The lungs are well expanded and clear. Field of view: 45 Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 71 year old man with epigastric pain this am and RLQ tenderness on exam REASON FOR THIS EXAMINATION: ?APPY, diverticulitis No contraindications for IV contrast WET READ: 8:27 PM Appendicitis.

10

[ { "category": "Echo", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 65242, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 69\nWeight (lb): 260\nBSA (m2): 2.31 m2\nBP (mm Hg): 120/55\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\ndiastolic dysfunction, pulmonary hypertension or significant valvular disease\nseen.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the degree of LVH and aortic dilatation may be slightly reduced on\nthe current study.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1015754, "text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: AFIB on floor\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p lap appy for rupt appendicitis\n REASON FOR THIS EXAMINATION:\n AFIB on floor\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 04:09\n\n INDICATION: New onset of atrial fibrillation.\n\n COMPARISON: at 17:58.\n\n FINDINGS:\n\n Accounting for the more lordotic projection, there is no significant interval\n change with no evidence of new infiltrate, effusion, or worsening of fluid\n status.\n\n IMPRESSION: No acute cardiopulmonary process - stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 1647237, "text": "Nursing Note\nPlease see carevue for details\n\nPt A&O x3. Calm and cooperative with nursing care. Pt in Afib with frequent PVCs and PACs at start of shift - over course of shift pt converted to NSR with occasional PVCs. 10mg IV Lasix x1 with + effect. BP stable. +pp/csm. LE edema noted. LSCTA - diminished at bases - using IS with good technique - O2 sats >95% on RA. Abd soft/approp tender to palpation. +bs. denies n/v. Tolerating clears without incident. Spontaneously voiding adequate amounts cyu. Abdomenal lap sites intact. Reporting minimal abdomenal pain with repositioning and palpation, but declining pain medications. Standing at bedside to urinate with steady gait. Able to independently reposition self in bed.\n\nPlan: Monitor cardiac status closely. Pulmonary hygiene. ADAT. ? transfer to floor/home in am.\n" }, { "category": "Nursing/other", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 1647238, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED AND APPROPRIATE. COMPLAINING OF ABDOMINAL PAIN @ BEGINNING OF THE SHIFT, RELIEVED BY PERCOCET. PATIENT SLEEPING ON/OFF OVERNIGHT. HEART RATE MOSTLY 60'S NORMAL SINUS, SBP 130-140'S. AFEBRILE. BREATHING UNLABORED @ REST, SP02 91-95% WITHOUT SUPPLEMENTAL O2. ABDOMEN SOFTLY DISTENDED, LAP SITES WITH STERI-STRIPS INTACT WITH NO REDNESS OR DRAINAGE. VOIDING ADEQUATE AMOUNTS. TAKING LIQUIDS OVERNIGHT.\nPLAN:\n TRANSFER TO FLOOR IN AM. ? PHYSICAL THERAPY CONSULT. PROVIDE SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2155-06-09 00:00:00.000", "description": "Report", "row_id": 1647239, "text": "Nsg.progress notes;\nSee flow sheet for specific:\n\nPAtient is alert and oriented, very pleasant and co op with care, able to get OOB by himself,denies pain, NSR, HR:60-80, with rare PVC'S,pottasium 20mmol replaced today morning for K 3.9, SBP 120-135, cardiac echo done at bed side, cardiology referred and seeen by them no new recomendation,denies CP or discomfort.afebriele, on anbx.ON RA, LS clear, O2 sat 95-97%, no cough. Abd soft, +BS, BM x 2, using commode at bed side.voiding adq yellow clear urine in the urinal, Bld sug checked q6h , treated with Regular insulin per sliding scale,seen by Dr. this am, can discharge to home after echo and cardiology consult, all discharge paper work done by NP suregry, waiting for wife to come to take him home.\n\nPlan: monitor, discharge to home.\n" }, { "category": "Radiology", "chartdate": "2155-06-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1015478, "text": " 5:56 PM\n CHEST (PA & LAT) Clip # \n Reason: ?Effusion, pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with b/l basalar rales, intermittant sob\n REASON FOR THIS EXAMINATION:\n ?Effusion, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST AT 1758 HOURS.\n\n HISTORY: Bibasilar rales with intermittent shortness of breath.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The lungs are well expanded and clear. There is a tortuous aorta\n with atheromatous disease. The cardiac silhouette is within normal limits for\n size. No effusion or pneumothorax is noted. Bridging osteophytes are noted\n throughout the thoracic spine with degenerative changes also noted in the\n right acromioclavicular joint.\n\n IMPRESSION: No acute pulmonary process. Stable radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-06-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1015494, "text": " 7:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. ? APPY/DIVERTIC.\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with epigastric pain this am and RLQ tenderness on exam\n REASON FOR THIS EXAMINATION:\n ?APPY, diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:27 PM\n Appendicitis.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH CONTRAST.\n\n COMPARISON: None.\n\n HISTORY: 71-year-old male with epigastric pain this morning and right lower\n quadrant tenderness.\n\n TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed.\n\n FINDINGS: The lung bases are clear. There is no pericardial or pleural\n effusion identified. The liver, spleen, pancreas, adrenal glands and kidneys\n are unremarkable. The gallbladder is distended and contains multiple\n gallstones. There is no intrahepatic or extrahepatic biliary dilatation.\n There is no mesenteric or retroperitoneal lymphadenopathy. The small bowel\n loops are normal in caliber and without focal wall thickening. There is no\n free fluid or free air.\n\n CT OF THE PELVIS: The appendix is fluid filled and dilated up to 1.3 cm with\n associated fat stranding. There is no evidence of adjacent fluid collection\n or free air. There is no pelvic or inguinal lymphadenopathy. The rectum,\n sigmoid colon and bladder are unremarkable. Coarse calcifications within the\n prostate are noted.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n Degenerative changes of the spine are noted.\n\n IMPRESSION: Fluid filled and dilated appendix measuring up to 1.3 cm with\n adjacent fat stranding consistent with uncomplicated appendicitis.\n\n These findings were posted to the ED dashboard.\n\n\n\n (Over)\n\n 7:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: EPIGASTRIC PAIN AND RLQ TENDERNES. ? APPY/DIVERTIC.\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 130074, "text": "Sinus rhythm\nBorderline first degree A-V delay\nLeft atrial abnormality\nEarly precordial QRS transition - is nonspecific\nSince previous tracing of the same date, atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2155-06-08 00:00:00.000", "description": "Report", "row_id": 130075, "text": "Atrial fibrillation with rapid ventricular response\nEarly precordial QRS transition - is nonspecific\nSince previous tracing of , atrial fibrillation now present\n\n" }, { "category": "ECG", "chartdate": "2155-06-05 00:00:00.000", "description": "Report", "row_id": 130076, "text": "Sinus rhythm with borderline P-R interval prolongation. Compared to the\nprevious tracing of there is no significant change.\n\n" } ]

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76 yo male with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia Pan-Sensitive Enterococcus who was admitted from rehab for fevers and lethargy. . 1. Fevers: Patient was changed from Ampicillin/CTX to Vanc and Aztreonam secondary to drug rash. Infectious disease was consulted. Neurosurgery was consulted, and MRI of L spine was negative for epidural abscess. MRI showed ongoing discitis and osteo. Per ID recommendation, discitis/osteomyelitis is presumed to be Enterococcus at this time and patient is to complete 6 week course of Daptomycin for Enterococcus bactermia and osteomyelitis. Echo was negative for valvular vegetations concerning for endocarditis. Main concern is for recurrence of epidural abscess. CXR done on arrival to ICU showed increasing RLL infiltrate concerning for PNA vs Aspiration Pneumonitis. Patient was initially treated with Vancomycin and Aztreonam for a 2 week course given recent history of enterococcal bacteremia. C diff was negative. Blood cultures, UA and urine cultures were negative. CT torso was performed on which was only remarkable for pneumonia, not underlying abscess. -Pati ID recommended Daptomycin for an additional 2 weeks for enterococcal bacteremia/osteomyelitis (last day being ). -Please check weekly CKs, CBC, LFTs, BUN, Cr while on Daptomycin -Patient has follow up in Infectious disease clinic on with Dr. . . 2. Hypoxemic respiratory failure: During admission, patient decompensated from a respiratory standpoint becoming tachycardic with increased work of breathing. Right lower lobe opacification seemed to have worsened. The patient was emergently intubated on after aspirating his medications. He was continued on Vancomycin and Aztreonam for a 2 week course. Clindamycin was added for 8 days to cover for anaerobes that may have been associated with an aspiration event. However patient developed a maculopapular rash on . On Vanc and Aztreonam were stopped, and patient was started on Daptomycin (as above). Patient was successfully extubated on . . 3. Altered Mental status: Likely secondary to fevers and likely infection. CT Head done in ED showed no signs of acute hemorrhage or infarction. Patient was given Morphine 4mg IV x 3 in ED which may have contributed to AMS. Sedating meds were held. Mental status improved without other interventions. 4. Hypotension: Patient was briefly on neosynephrine for hypotension likely associated with pneumonia and afib with RVR. Patient was weaned off of vasopressors for several days prior to being discharged. 5. Acute renal failure: Patient had muddy brown casts in urine, consistent with ATN. Likely secondary to hypotension. Cr 2.3 on admission, peaked at 3.2. Trending down to 1.8 on discharge. 6. Atrial fibrillation: Patient was loaded with Amiodarone for 2 weeks. 7. Hypertension: Patient was persistently hypertensive. He was started on Hydralazine 30mg po q6h, Metoprolol 37.5mg po tid, and Amlodipine 10mg po daily. 8. Right atrial appendage thrombus: Patient was on coumadin as an outpatient. This was held as an inpatient because his INR was supratherapeutic. No thrombus seen on repeat ECHO, last ECHO also reviewed by cardiology, no thrombus seen. Thus anticoagulation was stopped. 9. Aspiration events: Patient was evaluated by speech and swallow and continued to aspirate. He was kept NPO, and was fed via NG tube with tube feeds. 10. Hypernatremia: Na 150 on discharge. Patient was given free water IV and in tube feeds. Also given 500cc of D5w today. Please follow up electrolytes and adjust free water appropriately. If increasing then may need diuresis and patient is total body fluid overloaded.

Pt appearing in distress post-intubation, Fentanyl gtt and versed gtt initiated. Plan for Echo today to R/O abscess. -- follow PT/INR - restart coumadin . Action: Received vancomycin, aztreonam, clindamycin. # FEN: IVFs / replete lytes prn / NPO for now # PPX: PPI, anticoagulated, bowel regimen # ACCESS: PIV # CODE: Full Code # DISPO: ICU ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 02:05 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. Pt with episodes of rapid afib and hypotension leading to IV amiodarone with bridge to PO amiodarone (converted to sinus rythym), and brief period of pressor requirement (neosynephrine). Response: Stable Plan: Sepsis, Severe (with organ dysfunction) Assessment: T-max 99.6 WBC Action: Response: Plan: Likely to demand ischemia in the setting of hypotenstion, renal failure and afib with RVR. Likely to demand ischemia in the setting of hypotenstion, renal failure and afib with RVR. - Cont vanc / aztreonam / clinda (check vanc level) - F/U cultures - F/U glucan / galactomannan - F/U ID and NSG recs # Anemia: Hct from 24 to 22 today. - Cont vanc / aztreonam / clinda (check vanc level) - F/U cultures - F/U glucan / galactomannan - F/U ID and NSG recs # Anemia: Hct from 24 to 22 today. Respiratory failure, acute (not ARDS/) Assessment: Started shift w/ pt on A/C. #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65 --Consider switch to PCV in AM #HypoTN resolved, now off neo. Respiratory failure, acute (not ARDS/) Assessment: Started shift w/ pt on A/C. Yesterday, he developed afib and shock,- on amiodarone/neo infusion. Switch to flagyl with concerns regarding C Diff - Appreciate ID input # Anemia: Hct stable. Pt with episodes of rapid afib and hypotension leading to IV amiodarone with bridge to PO amiodarone (converted to sinus rythym), and brief period of pressor requirement (neosynephrine). #Hypoxemic respiratory failure on vent (APRV) --Cont APRV, wean FiO2 to PaO2 > 65 #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. Plan for Echo today to R/O abscess. From rehab: - C. Diff neg, stool cx negative , , - Blood cultures NGTD. From rehab: - C. Diff neg, stool cx negative , , - Blood cultures NGTD. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. # HTN: Likely to weaning sedation - Continue to uptitrate hydralazine # Emesis: NPO. Hypertension, benign Assessment: Sbp in 180s in the begning of shift Action: Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and Lopressor Response: Sbp in the 140s. Hypertension, benign Assessment: Sbp in 180s in the begning of shift Action: Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and Lopressor Response: Sbp in the 140s. HPI: 24 Hour Events: PICC placed yest, RUE US yest with superficial cephalic v clot. Plan: Monitor temps, continue IV antibxs, check results of q day BCs. # HTN: Likely to weaning sedation - Continue to uptitrate hydralazine # Emesis: NPO. Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Afebrile today. Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats 93-97%. - rate control, restarted ASA, statin, restart home beta-blocker and uptitirate as tolerated # AMS: Initially had AMS likely fevers and infection. - rate control, restarted ASA, statin, restart home beta-blocker and uptitirate as tolerated # AMS: Initially had AMS likely fevers and infection. Will cont to monitor - f/u rheum recs - f/u nsgy recs # Hypertension: .On po hydral. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. Will cont to monitor - f/u rheum recs - f/u nsgy recs # Hypertension: .On po hydral. Action: Pt given standing PO hydral and Strted on amlodepine and mtoprolol Response: Normotensive most of the shift. - Consider pain consult in a few days when mental status fully cleared #Afib RVR: Initially on amio gtt, now transitioned to PO. - Consider pain consult in a few days when mental status fully cleared #Afib RVR: Initially on amio gtt, now transitioned to PO. Action: Pt turned gently, Lidocaine patch per order, restarted on his PO/NG neurontin. - Cont vanc / aztreonam, dosing vanco by level, due today - C-diff negative. Right-sided central venous line ends low in the SVC. Since the previous tracing of sinus tachycardiais now present. IMPRESSION: There is a small posterior paraspinal fluid collection surrounding postoperative changes at L5-S1. There is soft tissue with heterogeneous enhencement posterior to the sacrum (9:12) , differential diagnosis is phlegmon, granulation tissue, or venous congestion. Unchanged extent and density of the pre-existing right lung opacities. Unchanged extent of the pre-existing small left-sided pleural effusion. Unchanged suspicion of mild left pleural effusion. COMPARISON: Non-contrast head CT, . Unchanged size of the cardiac silhouette, unchanged retrocardiac atelectasis. There is minimal right upper lobe bronchiectasis. UPRIGHT AP PORTABLE VIEW OF THE CHEST: Right PICC tip terminates in the mid SVC. Interstitial edema has almost resolved. There is persistent left retrocardiac opacity. A right IJ catheter terminates in the upper SVC. Diffuse hyperintensities are identified involving the musculature posteriorly. The previously noted fluid at the superior margin of the laminectomy has decreased. Bilateral subcutaneous edema is noted. A small fluid (Over) 12:03 AM MR L SPINE W/O CONTRAST Clip # Reason: cord compression?

310

[ { "category": "Nutrition", "chartdate": "2146-10-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706125, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 27\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 115%\n 10/09) 71.67 kg\n 112 %\n Diagnosis: fever\n PMHx:\n - Epidural abscess\n - Possible septic emboli versus infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Food allergies and intolerances: none noted\n Pertinent medications: fentanyl drip, versed drip, Lasix, ABX, Colace\n *held*, Pantoprazole, Coumadin, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:33 AM\n BUN\n 33 mg/dL\n 03:33 AM\n Creatinine\n 2.6 mg/dL\n 03:33 AM\n Sodium\n 139 mEq/L\n 03:33 AM\n Potassium\n 3.7 mEq/L\n 03:33 AM\n Chloride\n 108 mEq/L\n 03:33 AM\n TCO2\n 22 mEq/L\n 03:33 AM\n PO2 (arterial)\n 68 mm Hg\n 11:38 AM\n PCO2 (arterial)\n 41 mm Hg\n 11:38 AM\n pH (arterial)\n 7.36 units\n 11:38 AM\n pH (urine)\n 5.0 units\n 09:14 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:38 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:33 AM\n Phosphorus\n 3.5 mg/dL\n 03:33 AM\n Ionized Calcium\n 1.05 mmol/L\n 02:32 AM\n Magnesium\n 1.8 mg/dL\n 03:33 AM\n ALT\n 19 IU/L\n 03:33 AM\n Alkaline Phosphate\n 119 IU/L\n 03:33 AM\n AST\n 26 IU/L\n 03:33 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:33 AM\n WBC\n 6.1 K/uL\n 03:33 AM\n Hgb\n 7.6 g/dL\n 03:33 AM\n Hematocrit\n 23.4 %\n 03:33 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft/distended, (+) bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: -2256 (25-28 cal/kg)\n Protein: 80-105 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n76 YO male admitted from rehab with drug rash, altered mental status, fever and\ntachypnea. Concern for sepsis. MRI head/spine showed L5-S1 discitis/osteomylit\nis. Also likely RLL PNA. Deferred s+s evaluation . Noted last s+s evaluat\nion , SLP recommended soft solids and thin liquids. Emergently intubated 1\n after witnessed aspiration after patient had taken pills. Consulted for tub\ne feed recommendations. Patient with OGT. Agree with tube feed for nutrition s\nupport. Per rehab note, patient on no added salt diet with Healthshakes TID and\n 10 oz Prostat (protein supplement) twice a day.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Begin Fibersource HN @\n 20ml/hr, advance as tolerated to goal of 70ml/hr = calories and\n 89g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n" }, { "category": "Nutrition", "chartdate": "2146-10-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706126, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 27\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 115%\n 10/09) 71.67 kg\n 112 %\n Diagnosis: fever\n PMHx:\n - Epidural abscess\n - Possible septic emboli versus infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Food allergies and intolerances: none noted\n Pertinent medications: fentanyl drip, versed drip, Lasix, ABX, Colace\n *held*, Pantoprazole, Coumadin, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:33 AM\n BUN\n 33 mg/dL\n 03:33 AM\n Creatinine\n 2.6 mg/dL\n 03:33 AM\n Sodium\n 139 mEq/L\n 03:33 AM\n Potassium\n 3.7 mEq/L\n 03:33 AM\n Chloride\n 108 mEq/L\n 03:33 AM\n TCO2\n 22 mEq/L\n 03:33 AM\n PO2 (arterial)\n 68 mm Hg\n 11:38 AM\n PCO2 (arterial)\n 41 mm Hg\n 11:38 AM\n pH (arterial)\n 7.36 units\n 11:38 AM\n pH (urine)\n 5.0 units\n 09:14 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:38 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:33 AM\n Phosphorus\n 3.5 mg/dL\n 03:33 AM\n Ionized Calcium\n 1.05 mmol/L\n 02:32 AM\n Magnesium\n 1.8 mg/dL\n 03:33 AM\n ALT\n 19 IU/L\n 03:33 AM\n Alkaline Phosphate\n 119 IU/L\n 03:33 AM\n AST\n 26 IU/L\n 03:33 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:33 AM\n WBC\n 6.1 K/uL\n 03:33 AM\n Hgb\n 7.6 g/dL\n 03:33 AM\n Hematocrit\n 23.4 %\n 03:33 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft/distended, (+) bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: -2256 (25-28 cal/kg)\n Protein: 80-105 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n76 YO male admitted from rehab with drug rash, altered mental status, fever and\ntachypnea. (+) fever likely due to right-sided pneumonia. Also osteomyelitis a\nnd discitis (per MRI head/spine) may be contributing. Deferred s+s evaluation 1\n. Noted last s+s evaluation , SLP recommended soft solids and thin liqu\nids. Emergently intubated after witnessed aspiration following patient \ning juice after pills. Consulted for tube feed recommendations. Patient with O\nGT. Agree with tube feed for nutrition support. Per rehab note, patient on no\nadded salt diet with Healthshakes TID and 10 oz Prostat (protein supplement) twi\nce a day. BS well controlled. Renal following, no need for HD at this time.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Begin Fibersource HN @\n 20ml/hr, advance as tolerated to goal of 70ml/hr = calories and\n 89g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n BS management\n Will follow, page if questions *\n" }, { "category": "Respiratory ", "chartdate": "2146-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706043, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Active exhalations, High flow demand; Comments:\n SEttle on PCV to match high flow demand.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: REq heavy sedation.\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Frequent alarms (High min. ventilation)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated;\n Comments: No RSBi for High PEEP & Fio2.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705882, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 101.4 ax/ HR 90s-160\ns with bursts of raf. NBP ranging 1-teens\n to 130s/50-60s. Pt with 2 episode of rapid afib to 170s, ist episode\n self limiting. Dr. . aware. generalized pitting edema +4. PP\n dopplerable. Lungs diminished bilaterally. CXR with worsening RLL\n infiltrate, Rec\nd on 4L nc. Pt had mri of head and spine done without\n incident. Incission at back from recent surgery for Epidural abscess\n on - approximated, open to air. Sm. Abrasion at perineal\n area. UOP at 40-60 ml/hr. Contact precautions for MRSA. Repeat Bld\n cx\ns done this am. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n MRI brain, and MRI L-spine done, receive GAT contrast dye for exam.\n Phone consent done in mri suite. - Pt and family aware of risks r/t\n kidneys, On vanco and aztreonam for coverage. Pt received lopressor 5mg\n ivp for 2^nd episode of raf with fair response. Cxr done and showed\n worsenin of rll infiltrate. Pt very wheezy and wob increased with resp\n rate as high as the 40\ns. nt sx\nd , med with morphine for pain. O2\n increased to high flow neb with 4 liter nc.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. o2 sat\ns in\n the mid 90s.\n Plan:\n Pt now cont taking off o2, need to check pt freq otherwise o2 sat\n down in the low 80\ns. keep right side down. Pulm toileting as\n tolerated. Morphine for pain.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. LE. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch removed. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n AM\n" }, { "category": "Respiratory ", "chartdate": "2146-10-20 00:00:00.000", "description": "Generic Note", "row_id": 705884, "text": "TITLE:\n Resp Care\n Pt. had increased resp distress with tight-audible expir wheezes. Given\n albuterol/atrovent nebs with some improvement. Desaturated down to 88on\n nasal prongs and changed to 95% hi flow neb. He appears more\n comfortable now, still with some tight sounding wheezes and maintaining\n sats in 95-97% range. NT suctioned x 1 for small amount of thick tan\n sputum. Will continue with albuterol/atrovent nebs q6, suction as\n needed.\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 705670, "text": "Chief Complaint:\n HPI:\n This is a 76 yom with history of Asthma, Gouth, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .\n Currently, Patient denies any pain or shortness of breath.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Daptomycin 300mg IV Daily\n Senna 2 tabs PO qHS\n Colace 100mg PO BID\n MVI daily\n Lidocaine 5% patch to low back\n Gabapentin 100mg PO BID\n Metoprolol 100mg PO BID\n Amlodipine 10mg daily\n Oxycodone 10mg PO QID\n Oxycontin 10mg PO BID\n Prostat?\n Prevacid 30mg daily\n Coumadin?\n Past medical history:\n Family history:\n Social History:\n Asthma\n Cataracts\n Gout\n Benign prostate hypertrophy\n (Prostate biopsy , TURP , cystoscopy/transrectal US\n )\n Chronic kidney disease (baseline 1.5-2.0)\n Epidural Abscess s/p L5-S1 Laminectomy\n Aortic Endocarditis\n Bactermia Enterococcus\n Non-contributory\n Born in . Lives with his wife, has 3 children and many\n grandchildren. Retired but frequently helps out at family restaurant.\n Denies any IVDU or alcohol use. Quit smoking 25 years ago.\n Review of systems:\n Flowsheet Data as of 04:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 106 (106 - 121) bpm\n BP: 107/48(64) {107/48(64) - 148/78(95)} mmHg\n RR: 13 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,037 mL\n PO:\n TF:\n IVF:\n 37 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,707 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76.//-2\n Physical Examination\n Vitals - T: 99.8 BP: 141/78 HR: 121 RR: 21 02 sat: 95%\n GENERAL: Elderly male in mild respiratory distress\n HEENT: ACAT,\n CARDIAC: +S1/S2, no M/R/G, +tachycardia\n LUNG: +Expiratory ronchi, no wheezes or crackles\n ABDOMEN: +BS, NT/ND\n EXT: +2 pitting anasarca, dopplerable pedal pulses\n NEURO: AAO x 1 to person, date and year is , does not recall\n place. Opens eyes on commands but not conversant, answers questions\n preferentially, moving all extremities.\n DERM: mild macular blanching rash of torso\n Labs / Radiology\n 286\n 112\n 2.3\n 27\n 23\n 102 mEq/L\n 4.3 mEq/L\n 137 mEq/L\n 25.5\n 13\n [image002.jpg]\n \n 2:33 A11/4/ 01:00 AM\n \n 10:20 P11/4/ 02:32 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n Other labs: CK / CKMB / Troponin-T:213/3/0.07, Lactic Acid:1.6 mmol/L\n ABG: pH 7.38, pCo2 37, pO2 76\n MICROBIOLOGY:\n UA: WBC, mod bacteria, many yeast\n At :\n C.diff toxin : negative\n Fecal Leukocytes : negative\n Blood cultures : NGTD\n LABS ():\n : WBC 10.5, HCT 23.7, PLT 216\n Na 138, K 3.8, Cl 104, Bicarb 24, BUN 16, Creat 2, Ca 7.7, Mg 1.9\n STUDIES:\n CXR :\n IMPRESSION: Retrocardiac opacity which is non-specific and may\n represent atelectasis, but an area of infection is not excluded.\n .\n CT Head :\n Suboptimal due to motion in the scanner.\n No acute hemmorhage. Evolving deep white matter infarcts, as seen on\n recent MR. If concern for acute ischemia MRI is more sensitive.\n Assessment and Plan\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ASSESSMENT & PLAN:\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n .\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n .\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705779, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 100.4. HR 90s-110s SR with no ectopy noted. NBP ranging 1-teens\n to 130s/50-60s. Pt with 1 episode of rapid afib to 170s, self\n limiting, EKG obtained, Dr. . aware. generalized pitting\n edema +4. PP dopplerable. Lungs clear to diminished bilaterally. CXR\n with RLL infiltrate, ? pna. Rec\nd on 4L nc. PICC removed and tip sent\n for culture on arrival. CT head negative. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Bld cx + for gram positive cocci in clusters.\n Pt with history of aortic vegetation seen on TEE last admission.\n Action:\n MRI brain, and MRI L-spine ordered, pt must receive GAT contrast dye\n for exam. Per history, pt has rec\nd HD post-MRI. Renal consult, their\n rec\ns are for pt to get a temporary HD line, then dialysis after\n rec\ning contrast dye. Pt and family aware of risks r/t kidneys, plan\n is for MRI with contrast, and no HD after (of note, pt with INR 2.2).\n Neurosurgery following. Bedside Echo this afternoon, awaiting\n results. On vanco and aztreonam for coverage.\n Response:\n Tcurrent 97.8. Afebrile this shift. Awaiting time for MRI. Pt\n family to sign a waiver form for contrast dye.\n Plan:\n Plan for MRI head & Spine. Follow fever curve. Closely monitor Heart\n rate & resp status. Cont monitoring Mental status closely. Wean off O2\n as tolerated. F/u with lab results./all culture data. F/U with ID for\n coverage.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, only c/o pain 1x despite grimacing with any\n manipulation of LE. Pupils are unequal .Rt >left & rt pupil\n non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch applied to back. Reoriented as needed.\n Family at bedside. Diet advanced to regular, only taking in 10% with\n assistance fm family. Frequent neuro checks.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706054, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705661, "text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with recent admission for epidural abscess with enterococcal\n bacteremia with aortic valve vegitation seen and sent out on Amp/CTX.\n At rehab patient with change to Daptomycin due to rash and now admitted\n to for recurrent fevers in that setting.\n Here--patient with altered mental status but found to have fever to 102\n and tachypnea.\n Vanco/Aztreonam started for broadened antibiotic coverage after\n discussion with ID and neurosurgery consultation.\n MRI desired and not able to be completed in the setting of patient\n non-compliance and LP deferred without MRI evaluation based upon\n neurosurgery input.\n MSO4 given for pain in ED (12mg total) and sent to ICU for further\n care.\n Upon arrival here patient able to be weaned to 4 liters NC for support\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Asthma\n Gout\n BPH\n Chronic Renal Failure\n Non-contributory\n Occupation: None\n Drugs: None\n Tobacco: None--quit 25 years ago\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:45 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 109 (109 - 121) bpm\n BP: 112/50(65) {112/50(65) - 148/78(95)} mmHg\n RR: 13 (13 - 21) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,019 mL\n PO:\n TF:\n IVF:\n 19 mL\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,689 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.38/37/76.//-2\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, Rash: improved areas of blanching with previous\n drug reaction\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, not appropriate, surgical pupil noted\n Labs / Radiology\n 286\n 25.5\n 108 mg/dL\n 2.3\n 27\n 106 mEq/L\n 3.8 mEq/L\n 132 mEq/L\n 13\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n Other labs: CK / CKMB / Troponin-T:213/3/0.07, Lactic Acid:1.6 mmol/L\n Fluid analysis / Other labs: 7.38/37/76\n U/A-moderate bacteria, WBC \n Imaging: CXR--Patient with right lower lobe opacity seen and\n persistence of left sided retrocardiac opacity.\n CT Head-no lesions or hemorrhage seen\n ECG: ST, normal intervals seen\n Assessment and Plan\n 76 yo male with recent epidural abscess and now with recurrence of\n significant fever in the setting of ongoing antibiotics with recent\n change to daptomycin. He has possible pulmonary source for sepsis but\n of more significant concern is possible evolution of endocarditis and\n epidural abscess is of concern.\n 1)SEPSIS WITHOUT ORGAN DYSFUNCTION-Possible sources as above\n -Will continue with Vanco/Aztreonam\n -Sputum culture when obtained\n -Will follow up with MRI for possible recurrence of epidural abscess\n when patient able to tolerate\n -Neurosurgery following\n -Will have to consider repeat ECHO to evaluate for persistent\n vegitation but reasonable to consider ID consultation\n -IVF as needed and will look to see trend down in heart rate as volume\n replaced\n -Consider CTX for CNS penetration if Aztreonam not adequate\n -Cultures pending\n ICU Care\n Nutrition: NPO pending improvement in mental status\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705773, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Received patient from ED on NRM. Patient is lethargic, opens eyes to\n verbal stimuli & follows simple commands. He denies pain but patient\n grimaces whenever touched him for movement / turning. From the\n grimace scale it is obvious that he has intense pain at the bilat\n lower extremities. Pupils are unequal .Rt >left & rt pupil\n non-reactiove ( S/P cataract sx) . Significant generalized pitting\n edema +4. Pedal pulses dopplerable. Moves extremities on the bed.\n Received 3 L IVF at Ed for Sinus tachy episode ( HR at 130\ns). Upon\n arrival to ICU he has been Sinus tachy mostly., satting at high 90\n nasal cannula. Febrile : T max : 102.2 ( Oral) . Lungs rhonchous &\n insp/exp wheezing bilat. Drug Rash present all over the body from\n Ceft & ampi at rehab, switched to Daptomycin as recommended by ID.\n Monitor shows Sinus tachy with no ectopics. HR went upto 150\ns for a\n brief period with movement/turning. Foleys cath in place , placed at\n ED today Patient has had PICC at rt AC , Non-functioning. Received 3 L\n NS at ED. Received Morphine sulfate 4 mg X3 at ED. Received Vancomycin\n 1 gm & Aztreonam 1 gm IV & 650 mg Tylenol Supp at ED. CT head done for\n ? mental status changes. Incission at back from recent surgery for\n Epidural abscess on /09l close approximated, opens to\n air.Abrasion at perineal area. UOP at 10-30 ml/hr. Contact precautions\n for VRE Pos.\n Action:\n CXR done upon arrival to MICU 07, Atrovent nebs given. IV nurse pulled\n out PICC line & tip sent for culture. Blood culture & Urine culture\n send. Tylenol Sup given. Weaned O2 to 4 L from NRM. Ct head done.\n Neurosurgery consulted. ABG done upon arrival. Pain meds held off at\n this time for ? mental status. restart pain meds once mental\n status improves. .\n Response:\n CXR showing RLL infiltration. Ct head Negative. Na : 132, HCT :\n 25.8, WBC : 12.9. Trop : 0.07 & CK : 213. Last ABG : 7.38/37/76. T :\n 98.4 after Tylenol sups.\n Plan:\n Plan for MRI head & Spine. Plan for Echo today to R/O abscess.\n Follow fever curve. Closely monitor Heart rate & resp status. Cont\n monitoring Mental status closely. Need good pain control regimen.\n Wean off O2 as tolerated. need Nasotracheal suctioning if\n needed. F/u with lab results. F/U with ID for coverage.\n" }, { "category": "General", "chartdate": "2146-10-20 00:00:00.000", "description": "ICU Event Note", "row_id": 705993, "text": "TITLE: ICU Event Note\n Clinician: Attending\n Around 5pm, the pt was witnessed by the nurse , after which\n he abruptly became tachypneic and tachycardic with dropping sats on\n 95-100% NRB- intubated for acute respiratory failure due to\n PNA/aspiration. Remained persistently hypoxic after intubation with\n oxygen sats 82-87% with bagging followed by AC ventilation (PEEP 10,\n FiO2 1.0). However, there was significant improvt once re-positioned\n for left side down.\n with PNA/aspiration would normally consider ARDSnet Tidal volumes-\n however his CXR this morning and positional influence on oxygenation\n suggests unilateral process. As PEEP may be worsening respiratory\n status, would favor decreasing. Post-intubation film pending.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705983, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At 1800, attempted to give pt PO Tylenol, pt with witnessed aspiration\n on juice following Tylenol. Pt coughing, desating to 84%, HR up to\n 140s ST.\n Action:\n Anesthesia paged stat, pt emergently intubated uneventfully.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706059, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706060, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706063, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - restart coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706064, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - continue coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706065, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po, heart rate in the 150\ns, wbc down to 6.1 this am.\n u/o initially very good from Lasix given in prior shift.\n Action:\n Pt given Tylenol, and cooling blanket placed on top of pt.\n Response:\n Temp came down only to 102.8 after a few hours with cooling blanket on\n top of pt. pt given a cool bath, more Tylenol and cooling blanket\n placed underneath pt. temp has come down quickly to 99.5 orally. Pt\n remains tachycardic with hr in the low 100\n Plan:\n Follow temp, remove cooling blanket as soon as able.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705989, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n Addendum:\n ****Respiratory failure, acute (not ARDS/)\n Assessment:\n Given 40mg ivp Lasix at 1700. At 1800, attempted to give pt PO\n Tylenol, pt with witnessed aspiration on juice following Tylenol. Pt\n coughing, desating to 84%, HR up to 140s ST.\n Action:\n Anesthesia paged stat, pt emergently intubated uneventfully. Pt\n appearing in distress post-intubation, Fentanyl gtt and versed gtt\n initiated. CXR taken post-intubation. Sxned for copious pink-tinged\n frothy sputum. ABG 7.41/30/48 prior to intubation\n Response:\n Pt currently sating 98% on AC 100% 500/14/10 PEEP, pt dysynchronous\n with vent, titrating sedation to comfort. Currently on 75 mcg/hr\n Fentanyl gtt, 2mg/hr versed gtt. UO 380cc to Lasix.\n Plan:\n Pulm. Toilet, ? more Lasix. f/u with post-intubation ABG.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706369, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706562, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG. Possible\n Bronchoscopy of R lung.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706563, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG. Possible\n Bronchoscopy of R lung.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706552, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue ventilating as ordered; wean settings as\n tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706547, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n He is tolerating APRV better with improved ventilation and oxygenation.\n Secretions are minimal. He continues to have good UO for now despite\n elevated creatinine. We will attempt slowly diurese if BP and HR\n allow. Broad antibiotics to continue for now until culture data back.\n He may need therapeutic bronchoscopy if there is evidence for mucous\n plugging as pneumonia begins to resolve. His wife has been updated\n regarding his progress.\n Patient is critically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 15:51 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706653, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706610, "text": "Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given ,\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706618, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706619, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n TF off at 2am\n Response:\n No NGT asp noted, still no stool + bowel sounds, increasing LFT\n Plan:\n Restart TF after procedure, cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. His u/o is about the same despite gently\n diuresis\n Action:\n Pt cont on IVAB, Lasix given , Vanco dose given (level 5.4)\n Response:\n Hemodynamically stable but min rsp to lasix so far\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n Social; family phoned in for update.\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706774, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 40cc/hr. Goal 80cc/hr.\n Action:\n Checked residuals q4h, advanced TF as tolerated.\n Response:\n still no stool, + bowel sounds, increasing LFT\ns, TF at 70cc/hr.\n Plan:\n cont with bowel meds, cont. to advance TF as tolerated.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr.\n Plan:\n Next PTT @ 0600AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706450, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and BO back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good. No changes needed in sedation meds\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%, Pt still very rigid and grimacing with any\n touching or moving especially when moving left leg\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down. Cont\n sedation/pain meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n Alteration in Nutrition\n Assessment:\n Pts ABD still distended and hypoactive bowel sounds, no stool as yet,\n no NGT asp noted\n Action:\n Senecot and colace given\n Response:\n No rsp as yet\n Plan:\n Nutrition consult for TF\n Social; family in to visit and updated by NSG\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706751, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706755, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Cont abx, vanco trough prior to giving tonight\ns dose, monitor temp,\n f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 40mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H.\n Increased fentanyl gtt to 100mcg for better pain control.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 40mg\n IV lasix, LS remain clear RUL and diminished in all other fields. CXR\n from AM shows improvement MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO\n Action:\n Started heparin gtt @ 1300units/hr after 3000unit bolus.\n Response:\n HR regular with stable BP. Hep gtt running @ 1300units/hr.\n Plan:\n Next PTT @ 2200pm.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706831, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. Currently off pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred two nights ago and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current\n ECHO,last ECHO also reviewed and per Dr. , no thrombus seen\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706833, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706835, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to have slightly improved since yesterday on CXR. Patient on APRV,\n will cont to wean as tolerated. On Vanc/Aztreonam/Clinda\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. Currently off pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred two nights ago and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current\n ECHO,last ECHO also reviewed and per Dr. , no thrombus seen\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706997, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Since admissions patient\ns course has been c/b high oxygen\n requirements, with witnessed asp. Event leading to intubation. Febrile\n daily, with neg. cultures to date. Pt with episodes of rapid afib and\n hypotension leading to IV amiodarone with bridge to PO amiodarone\n (converted to sinus rythym), and brief period of pressor requirement\n (neosynephrine). Pt remains intubated, sedated, and off pressors.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Tmax 100.7.\n Action:\n Pt cont on IVAB, lasix started , Vanco held tonight again for level\n 23.3, c.diff cx sent, would reorder Tylenol if temp over 101 persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50%. ETT advanced on day shift.\n Action:\n No vent changes made o/n. Sxned for copious pink tinged thin\n secretions. Rec\nd standing dose lasix.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4\n generalized edema. UO > 180 cc/hr fm diureses.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn. Wean vent. As tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Prior Echo with ? of clot in right\n atrium. Repeat Echo and review of prior echo revealing no clot.\n Heparin gtt dc\nd yesterday 11/10 days.\n Action:\n On SQ hep TID, Pboots, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >170s with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707176, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707189, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CT torso - multifocal PNA, bilateral effusions, biliary sludge,\n diverticulosis\n - C. diff negative\n - Tm 100.9\n - Possible aspiration this am after CXR when OG tube came out while TF\n were running - now with increased secretions and rhoncorous breath\n sounds\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.4\nC (99.4\n HR: 79 (71 - 88) bpm\n BP: 128/44(69) {110/38(60) - 150/56(84)} mmHg\n RR: 12 (10 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 3,202 mL\n 919 mL\n PO:\n TF:\n 1,011 mL\n 432 mL\n IVF:\n 1,201 mL\n 427 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,330 mL\n Urine:\n 3,720 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -518 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 636 (465 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 8.3 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.4 g/dL\n 268 K/uL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Imaging: CT torso - multifocal PNA, bilateral effusions, biliary\n sludge, diverticulosis\n Microbiology: C. diff negative.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - Recheck CXR given possible aspiration this am\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam / clinda\n - F/U cultures, fever curve\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 25 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707092, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen. Electrolyte repletion.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP.\n Action:\n Attempted to place pt on 50%- however, due to patients worsening\n chest xray- PEEP was increased to 10. Now is on CPAP/PS, 50%.\n Obtained Chest and abdominal CT today. ET pulled out by 2cm.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707172, "text": "Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours:\n \\\\\\\\\\\\\\\\ support:\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg on this patient. RSBI deferred due\n to high PEEP requirements.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706817, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: Pt demonstrates periods of vent dysynchrony, but able to tol\n APRV well.\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707152, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP. CXR worsening.\n Abd/Chest CT, awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707164, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707165, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707086, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1400\n uneventful\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear and diminished, suctioned intermittently for small to\n moderate amounts of thick blood-tinged to tan secretions, PEEP\n increased from 5 to 10, traveled to CT around 1400 for chest and\n abdominal CT, uneventful trip, SPO2 remained upper 90s, no distress\n occurred, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707235, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n CT torso:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n HCT down to 22.4\n C diff negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:29 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37\nC (98.6\n HR: 77 (71 - 88) bpm\n BP: 129/41(66) {110/39(60) - 150/56(84)} mmHg\n RR: 12 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 9)mmHg\n Total In:\n 3,201 mL\n 547 mL\n PO:\n TF:\n 1,011 mL\n 274 mL\n IVF:\n 1,200 mL\n 243 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,010 mL\n Urine:\n 3,720 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -519 mL\n -463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (375 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 7.1 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 268 K/uL\n 7.4 g/dL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 8 of 14) /Aztreonam (day 8 of 14)/ Clinda (day 7 of 10)\n -keep PEEP at 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with lasix drip for goal negative 2L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso did not reveal obvious source of infxn\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707237, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Plan to transfuse 1U PRBC\ns. Pt is a difficult cross match- awaiting\n blood from blood bank. Resident aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Initiated Lasix gtt after administering\n 60 mg IVP bolus.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706147, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706286, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt has remained nicely in SR rate in70\n Action:\n Pt cont on Amiodarone drip, now at .5mg until 5pm this evening\n Response:\n SR cont , BP inching up\n Plan:\n Will cont with load and? starting po vs IV dosing\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated , no changes made, Good O2 sats , min secretions,\n Remains sedated but not comfortable\n Action:\n Freq SX, cont in IVAB , Not placed with RT side lung down(desats),\n Cont onfentanyland versed drips\n Response:\n New aspiration PNA, more comfortable in APRV mode, Still very\n uncomfortable with any turning or moving\n Plan:\n Aggressive pulm toilet,\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP was slowly increasing once in SR but then when he was given\n PRBC, BP increased nicely\n Action:\n Given 1unit of blood and even Lasix to push those kidneys (no u/o after\n the IVF bolus) CVP up to 16\n Response:\n Min u/o rsp but by 5am, pt able to be weaned off NEO( also coincided\n with CXR so ? pain response)\n Plan:\n Check hct, keep BP up to perfuse kidneys, note lytes and follow renal\n function\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706294, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n APRV\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706296, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n APRV\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation. C diff negative. Urine legionella Ag\n negative.\n -- cont Vanco/Aztreonam/Clinda\n --f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- change foley\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 4.3 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706140, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706141, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707071, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Guiac negative\n - PS decreased from to \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.2\n HR: 87 (81 - 106) bpm\n BP: 136/49(74) {120/41(64) - 195/59(99)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 14)mmHg\n Total In:\n 2,565 mL\n 1,009 mL\n PO:\n TF:\n 1,424 mL\n 449 mL\n IVF:\n 900 mL\n 501 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,600 mL\n Urine:\n 3,815 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,250 mL\n -591 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (160 - 741) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.38/41/86/25/0\n Ve: 5.6 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Crackles : R,\n Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.6 g/dL\n 247 K/uL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: Glucan negative.\n Imaging: CXR- Worsening R-sided infiltrate/effusion.\n Microbiology: C. diff negative. sputum culture + MRSA,\n yeast\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Bronchodilators\n - Pull back ET tube 2 cm\n No attempt to wean on PSV until secretions/ fevers and clinical wheeze\n improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Would consider effusion/empymea\n given CXR appearance. Drug fever would be dx of exclusion.\n - CT scan to evaluate for possible R sided effusion\n if effusion\n ,would have concern for empyema as source of fevers\n - Will scan abd/pelvis while at CT scanner\n - Cont vanc / aztreonam / clinda\n - F/U cultures\n - F/U galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >21\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706113, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Intbuated, sedated, using some abdominal muscles to breathe\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles on R side, on anterior exam\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation. C diff negative. Urine legionella Ag\n negative.\n -- cont Vanco/Aztreonam/Clinda\n --f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- change foley\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 4.3 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706096, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation,\n possible aspiration event in setting of worsening R-sided infiltrate on\n CXR\n - Placed on PCV for comfort\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706097, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706099, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2146-10-21 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 706100, "text": "TITLE:\n DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on \n from rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have\n pan-sensitive enteroccus fecalis AV endocarditis, bacteremia,\n spinal epidural abscess s/p L5 & S1 laminectomy and abscess\n decompression on , as well as neurologic microabscesses. He\n was readmitted with rash, persistent fevers. Portable CXR with\n possible retrocardiac infiltrate so started empirically on\n antibiotics for possible pneumonia. Then repeat CXR with RLL\n opacity. We were consulted to evaluate oral and pharyngeal\n swallow function to determine if aspiration/dysphagia could be\n contributing to current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the\n previous admission. Was initially recommended for soft solids\n and nectar thick liquids on with aspiration of thin liquids.\n Etiology of dysphagia was suggested to be either related to\n medications or neuro issues. On , re-evaluated and cleared\n for diet upgrade to soft solids and thin liquids, as dysphagia\n was resolving. Records from Hospital state pt on house\n diet with supplements TID. Consult was received on , however, it\n was deferred on RN request.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n Returned today for swallowing evaluation. Upon arrival to unit, pt was\n intubated with ET tube and OG tube. Please reconsult when pt is stable\n post extubation.\n __________________________________\n , B.A., SLP/s\n Pager #\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n" }, { "category": "Rehab Services", "chartdate": "2146-10-21 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 706103, "text": "TITLE:\n DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on \n from rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have\n pan-sensitive enteroccus fecalis AV endocarditis, bacteremia,\n spinal epidural abscess s/p L5 & S1 laminectomy and abscess\n decompression on , as well as neurologic microabscesses. He\n was readmitted with rash, persistent fevers. Portable CXR with\n possible retrocardiac infiltrate so started empirically on\n antibiotics for possible pneumonia. Then repeat CXR with RLL\n opacity. We were consulted to evaluate oral and pharyngeal\n swallow function to determine if aspiration/dysphagia could be\n contributing to current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the\n previous admission. Was initially recommended for soft solids\n and nectar thick liquids on with aspiration of thin liquids.\n Etiology of dysphagia was suggested to be either related to\n medications or neuro issues. On , re-evaluated and cleared\n for diet upgrade to soft solids and thin liquids, as dysphagia\n was resolving. Records from Hospital state pt on house\n diet with supplements TID. Consult was received on , however, it\n was deferred on RN request.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n Returned today for swallowing evaluation. Upon arrival to unit, pt was\n intubated with ET tube and OG tube. Please reconsult when pt is stable\n post extubation.\n __________________________________\n , B.A., SLP/s\n Pager #\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: Whitmill, SLP\n on: 10:32 AM ------\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706364, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95%\n Plan:\n Wean vent as tol. Follow seriel ABG\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Amiodarone infusion conversion to Amiodarone PO.\n Response:\n Stable\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706311, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:35 PM\n MULTI LUMEN - START 03:07 PM\n Went into atrial fib with RVR, became hypotensive, CVL placed, started\n on Neo and Amiodarone\n Converted to NSR in the early evening, Blood pressures improved, Neo\n weaned, currently at 0.5 mcg/kg\n TEE planned for monday\n Final MRI read shows continued discitis which has not progressed since\n last MRI, there is a small fluid collection not in epidural space,\n ?abscess.\n +hypoxemia during hypotension yesterday, required changed from AC to\n \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 01:35 PM\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 80 (65 - 154) bpm\n BP: 106/44(63) {83/37(52) - 180/62(92)} mmHg\n RR: 17 (13 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 13 (13 - 17)mmHg\n Total In:\n 4,893 mL\n 915 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 480 mL\n Blood products:\n 594 mL\n 375 mL\n Total out:\n 625 mL\n 115 mL\n Urine:\n 625 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 800 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n RR (Set): 18\n RR (Spontaneous): 19\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.39/34/95./19/-3\n Ve: 11.2 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.6 g/dL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 03:33 AM\n 04:48 AM\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n WBC\n 6.1\n 8.3\n Hct\n 23.4\n 21.4\n 25.7\n Plt\n 318\n 301\n Cr\n 2.6\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n TCO2\n 23\n 24\n 23\n 20\n 21\n Glucose\n 89\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.54, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient with worsening\n Right Lung Pneumonia which seems to involve the entire lung field on\n CXR. Patient on , cont to wean as tolerated. On\n Vanc/Aztreonam/Clina, with minimal improvement. Will speak with ID\n regarding Abx coverage\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. Patient was started on amiodarone and now converted\n to NSR.\n - monitor on tele\n - cont Amio, transition to PO\n - wean Neo as tolerated\n .\n # Hypotension: Likely Pneumonia as well as Afib yesterday. BP\n improved with return to NSR. Still requiring low dose Neo today.\n - 1L IVF bolus with goal of weaning Neo off.\n - abx as above\n # Troponin leak: Patient with troponin leak after episode of afib\n yesterday. CK elevated slightly but MB flat. Likely to \n ischemia in the setting of hypotenstion, renal failure and afib with\n RVR. Troponin continues to rise this morning\n - recheck Cardiac Enzymes this afternoon\n - if continues to rise, consider cards consult\n # Fevers: Presented for continued fevers, which have now resolved.\n Improvement suggests that antibiotic coverage is working but Right lung\n worsening is concerning. Will cont the course for now and speak with\n ID as above\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 5.9 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706631, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706632, "text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 09:00 AM\n FEVER - 102.8\nF - 08:00 AM\n -diuresed well overnight\n HCT 26.2--> 24.4\n Fibrinogen not low\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 12:00 AM\n Aztreonam - 12:30 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.9\nC (100.2\n HR: 82 (77 - 94) bpm\n BP: 133/51(75) {104/46(64) - 160/57(85)} mmHg\n RR: 24 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 367 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 257 mL\n Blood products:\n Total out:\n 1,925 mL\n 260 mL\n Urine:\n 1,925 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n 107 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 3\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94.//-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 257 K/uL\n 7.9 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to involve the entire lung field on CXR; it seems to have slightly\n improved since yesterday on CXR. Patient on , cont to wean as\n tolerated. On Vanc/Aztreonam/Clinda, but persistently febrile.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706713, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.8\n - Neurosurgery came by - nothing to add at this time.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, PPI, Gabapentin, Lido TD, Vanco, Versed, Clinda, Aztreonam,\n Fentanyl gtt, Atrovent, Amio, Aspirin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.1\nC (100.5\n HR: 89 (77 - 94) bpm\n BP: 150/50(79) {104/46(64) - 153/57(81)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 601 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 431 mL\n Blood products:\n Total out:\n 1,925 mL\n 675 mL\n Urine:\n 1,925 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 10\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94./21/-2\n Ve: 10.8 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: R, L\n base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 257 K/uL\n 123 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 107 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n 3.1\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n 123\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR\n Improved R sided infiltrate.\n Microbiology: Sputum + MRSA; No other new cultures.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n #HypoTN: Afib. Now resolved and off neo. Continue to follow. This\n is likely etiology of renal failure too.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706891, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n still no stool, + bowel sounds, TF\ns @ goal.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr, repeat PTT\n at 0400 > 150, heparin gtt held, will resume at 0500.\n Plan:\n Will resume heparin gtt at 0500, at a rate of 700units/hr, plan to\n recheck PTT at 1200 PM.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706894, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 1-2 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:40 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706448, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and BO back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706380, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706382, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Follow cultures and ID recommendations.\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone 6g Afib load. After amio gtt completed (24hr) start\n amio 400mg PO tid\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n Goal MAP>60\n Fluid Bolus for low u/o\n Real following refer to recommendations.\n resume TF pending U/S results.\n Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706383, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down. Requires Resp\n recruitment Per RT. Pt having pain with any movement/repositioning\n extreme rigidity, facial grimace pain management Fentanyl bolus 50mcg\n x2 with each turn.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%. Desats 80\ns slow to\n recover requiring resp recruitment per RT. Reposition supine to L\n side. Sx thick tan blood tinge Sputum sent for C&S. CXR worsening\n consoilidation R lung field. ABX vanco/ clindamycin/Azetrenam\n Response:\n Pain control with Fentanyl bolus, FI02 70% maintain sats 90-95% ABG\n 7.36-35-81-21\n Plan:\n Wean vent as tol. Follow seriel ABG\n Follow cultures and ID recommendations.\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/min EKG St changes Ant lat\n Demand Ischemia. CE trending ^Troponin 0.54/ Pending, CK445/pending .\n BNP 10,0000\n Action:\n Amiodarone 0.5mg !V completed @ 1800 Plan conversion to Amiodarone PO.\n Response:\n Stable NSR rare PAC\n Plan:\n Seriel cardiac enzymes\n Follow daily EKG\n Start PO Amiodarone 6g Afib load. After amio gtt completed (24hr) start\n amio 400mg PO tid\n Plan TEE \n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC 8.4. Receive pt off pressor as of 0600 L radial Aline\n BP trended down to 80\ns Resumed Neo 0.5mcg/kg/min BP labile\n 85-126/40-50 MAPS>60 transient hypotension SBP<90 MAPS<60 Neo titrated\n to 1mcg/kg/min. RIJ TLC CVP 13-19. Fluid Bolus 1L x2 for low u/o and\n hypotension. @ 1400 Neo wean off @ 1630. Foley u/o 20-80cc/hr Creat\n ^3.0 Hct 25.7 received 2U PRBC. S/p Hct 25.4. Abd firm distended\n hypoactive BS OGT clamped. No stool this shift. Lactate trending down\n 1.6/1.7 Anasarca. ^ LFT Abd U/S result pending.\n Action:\n BP labile Neo on off titrated Off As 0f 1630, Oliguric, low grade temp\n 100.6. ABX Vanco/azetrenam/clindamycin. Fluid Bolus 1L x2. Transfused\n 2UPRBC . D/c Lipitor. Abd U/S\n Response:\n Minimal u/o response to Fluid bolus.\n Plan:\n Goal MAP>60\n Fluid Bolus for low u/o\n Real following refer to recommendations.\n resume TF pending U/S results.\n Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706471, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Atrial fibrillation (Afib)\n Assessment:\n Pt again flipped into AF rate of 160\ns at 12mn, he would have\n intermittent breaks of SR but by 12:45 am his BP was dropping to 80\n He was started on po amiodarone\n Action:\n Pt given an IV bolus of Amiodarone and started on po loading dose of\n Amio at this time . He was also started on NEO again to get BP up after\n RVR\n Response:\n Pt broke the RVR about 30 min into the infusion of IV amiodarone and\n now cont with HR in 80\ns and Bp back up to 110/ so quickly weaned off\n NEO again\n Plan:\n Monitor GI absorption of po meds and watch for return of AF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on APVR mode of ventilation, RT with some flow changes but\n ABG and O2 sats remain good. No changes needed in sedation meds\n Action:\n Cont with freq SX , checking ABG\n Response:\n O2 sats cont to be >96%, Pt still very rigid and grimacing with any\n touching or moving especially when moving left leg\n Plan:\n Cont to evaluate improvement in PNA, avoid keeping rt side down. Cont\n sedation/pain meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt again spiking but cx are NTD, u/o remains marginal but dependent on\n a higher BP\n Action:\n Pt on NEO for short time with RVR but improved once back in SR\n Response:\n Temp still up but nothing showing, u/o still not improved\n Plan:\n Cont to follow renal function, await cx results cont IVAB\n Alteration in Nutrition\n Assessment:\n Pts ABD still distended and hypoactive bowel sounds, no stool as yet,\n no NGT asp noted\n Action:\n Senecot and colace given\n Response:\n No rsp as yet\n Plan:\n Nutrition consult for TF\n Social; family in to visit and updated by NSG\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706633, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n CXR may be beginning to improve. Pt scheduled for TEE today. Remains\n ventilated on , ABG WNL on those settings. See flow sheet\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706880, "text": "Chief Complaint:\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 10:40 AM\n BLOOD CULTURED - At 11:30 AM\n fungal cx.\n FEVER - 101.2\nF - 12:00 PM\n TEE done yesterday shows smal Vegetation on Aortic Valve, no Atrial\n appendage thrombus seen\n Lasix 40mg IV x 1 and then 20mg IV x 1 given with good response, -500cc\n at midnight\n Weaned down to AC around 8am\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Clindamycin - 11:16 PM\n Aztreonam - 12:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 89) bpm\n BP: 126/45(69) {106/40(60) - 150/61(87)} mmHg\n RR: 16 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (8 - 12)mmHg\n Total In:\n 1,873 mL\n 698 mL\n PO:\n TF:\n 660 mL\n 442 mL\n IVF:\n 983 mL\n 257 mL\n Blood products:\n Total out:\n 2,340 mL\n 550 mL\n Urine:\n 2,340 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 8 L/min\n Physical Examination\n Gen: Intubated, Sedated\n Lungs Rhochi bilaterally on anterior exam\n CV: RRR. No murmurs\n Abdomen: Distended. NT. +BS. Soft. No rebound or guarding\n Extremities: WWP. 2+ LE edema bilaterally\n Labs / Radiology\n 221 K/uL\n 7.5 g/dL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n Blood culture pending\n Sputum: S. aureus\n Sputum: S. aureus\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS this morning. On Vanc (day 6\n of 14) /Aztreonam (day 6 of 14)/ Clinda (day 5 of 10)\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -advance ET tube this morning\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Resolved. Likely Pneumonia. Currently off\n pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- cont Vanco (day 6 of 14) /Aztreonam (day 6 of 14) /Clinda (day 5 of\n 10)\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/d heparin gtt\n .\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -d/c heparin gtt\n -active T&S\n -check HCT\n -guaiac stools\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706268, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706473, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Oxygenation has remained good t/o night, last ABG WNL on APRV 20/3\n pressures. 3/.6 sec\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706571, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706882, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 1-2 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:30 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706210, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Rec\nd on PCV 60% 18/12 PEEP. Lung sounds very rhonchorus, sx\ning very\n small amt\ns of thin tan secretions. Rec\nd pt sedated on fent 125mcg/hr\n /versed 1 mg/hr, but initially was very dysynchronous with the vent.\n Action:\n Titrating fentanyl and versed gtt to comfort. Pt appearing more\n comfortable on higher sedation ( 200mcg/hr fentanyl gtt, and 3 mg/hr\n versed gtt) but became hypotensive and gtt paused, then restarted at 50\n mcg/hr fentanyl gtt and 1 mg/hr versed gtt. Multiple vent chg\ns made\n according to abg\ns/sats that had been drawn. Attempted to wean peep\n to 10, pt desating to 87%, so peep increased to 12. ABG obtained.\n Response:\n Pt appearing to be comfortable on current sedation, no longer\n dysynchronous with vent. Sating 98%. Last ABG 7.35/40/61.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as needed.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n statin. SBP currently 95.\n Plan:\n ? cards. Consult. Cont. amio gtt per protocol.\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on 3mcg/kg/min neo gtt. SBP 95. CVP 13. UO poor\n (15-30cc/hr)\n Plan:\n Dr. . aware of low uo, plan is to cont. to monitor. Cont. to\n wean neo as tolerated.\n ------ Protected Section ------\n HR converted to SR 60s-70s. Able to wean neo gtt slightly, currently\n on 2.5 mcg/kg/min. Amio gtt infusing per protocol. UO o for past\n three hours, 1 unit PRBCs ordered. Awaiting product fm blood bank,\n currently rec\ning a 250cc NS bolus. Family in to see patient, updated\n by this RN and MD about pt\ns tenuous status/current POC. Support\n offered.\n ------ Protected Section Addendum Entered By: , RN\n on: 22:32 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706794, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 40cc/hr. Goal 80cc/hr.\n Action:\n Checked residuals q4h, advanced TF as tolerated.\n Response:\n still no stool, + bowel sounds, increasing LFT\ns, TF at 80cc/hr.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given (20mg ivp x1), Vanco held trough of\n 31, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed sm vegetation and no\n clots. Remain with low grade temp w/ tmax 99.7.\n Plan:\n Cont abx, monitor temp, f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 20mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H. Cont\n with fentanyl gtt 100mcg and rec\ning 50mcg Fentanyl bolus with turns\n for better pain control. On 2mg/hr midaz. Gtt. Sxned for small-mod.\n amounts of blood-tinged thin secretions.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 20mg\n IV lasix, LS remain rhonchorous t/o. CXR from AM shows improvement \n MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 1300\n units/hr.\n Action:\n 2200 PTT > 150, heparin gtt held, and reduced to 1000 units/hr per\n protocol.\n Response:\n HR regular with stable BP. Hep gtt running @ 1000units/hr, repeat PTT\n at 0400 > 150, heparin gtt held, will resume at 0500.\n Plan:\n Will resume heparin gtt at 0500, at a rate of 700units/hr, plan to\n recheck PTT at 1200 PM.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706080, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:00 PM --difficulty\n oxygenating, dyssynchronous with the vent\n ARTERIAL LINE - START 09:11 PM\n BLOOD CULTURED - At 10:09 PM\n URINE CULTURE - At 10:09 PM\n FEVER - 103.6\nF - 11:00 PM -started Clinda for aspiration\n pna\n CXR: pulm edema -got 40 IV lasix x2\n -HCT 23.4 this AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Aztreonam - 12:18 AM\n Clindamycin - 12:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.5\nC (99.5\n HR: 110 (93 - 147) bpm\n BP: 153/106(123) {84/35(51) - 198/106(123)} mmHg\n RR: 30 (15 - 30) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 501 mL\n 279 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 219 mL\n Blood products:\n Total out:\n 2,380 mL\n 250 mL\n Urine:\n 2,380 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 24 cmH2O\n SpO2: 92%\n ABG: 7.43/34/71/22/0\n Ve: 12.2 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: Intbuated, sedated, using some abdominal muscles to breathe\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles on R side, on anterior exam\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 318 K/uL\n 7.6 g/dL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient seemed to\n aspiration yesterday, requiring intubation for hypoxemia and increased\n work of breathing. However, he has been difficult to oxygenate\n overnight. Likely all due to aspiration pneumonia\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztrenam/Clinda for aspiration pneumonia\n -diurese with lasix as BP tolerates\n -daily chest x-rays\n .\n # Fevers: Several sources possible. MRI of Lspine done shows L5-S1\n discitis/osteo which could be the reason for his continued fevers.\n Blood cultures from yesterday also growing Gram +cocci in clusters\n which may be a contaminant as it seems to be from one bottle. We will\n have to await speciation. CXR also showing RLL consolidation which may\n be to aspiration which occurred in ED here. If blood cultures are\n + for Enterococcus then will need to perform TEE to evaluate for\n worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n -- f/u urine legionella Ag\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - continue coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706688, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.8\n - Neurosurgery came by - nothing to add at this time.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, PPI, Gabapentin, Lido TD, Vanco, Versed, Clinda, Aztreonam,\n Fentanyl gtt, Atrovent, Amio, Aspirin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.1\nC (100.5\n HR: 89 (77 - 94) bpm\n BP: 150/50(79) {104/46(64) - 153/57(81)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (10 - 15)mmHg\n Total In:\n 1,763 mL\n 601 mL\n PO:\n TF:\n 390 mL\n 60 mL\n IVF:\n 1,133 mL\n 431 mL\n Blood products:\n Total out:\n 1,925 mL\n 675 mL\n Urine:\n 1,925 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n -162 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 537 (537 - 650) mL\n RR (Spontaneous): 10\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.36/40/94./21/-2\n Ve: 10.8 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: R, L\n base)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 257 K/uL\n 123 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 107 mEq/L\n 138 mEq/L\n 24.2 %\n 7.4 K/uL\n [image002.jpg]\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n WBC\n 8.4\n 9.4\n 8.2\n 7.4\n Hct\n 25.4\n 26.2\n 24.4\n 24.2\n Plt\n 57\n Cr\n 3.1\n 3.5\n 3.1\n TropT\n 0.70\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 107\n 95\n 123\n Other labs: PT / PTT / INR:15.7/38.8/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, LDH:678\n IU/L, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR\n Improved R sided infiltrate.\n Microbiology: Sputum + MRSA; No other new cultures.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n #HypoTN: Afib. Now resolved and off neo. Continue to follow.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706870, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV): Likely to\n HAP/aspiration PNA + pulmonary edema.\n - Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam/clinda) for aspiration/HAP\n - Continue diuresis\n - Advance ET tube 3 cm\n #HypoTN: Afib. Now resolved and off neo. Continue to follow. This\n is likely etiology of renal failure too.\n #Continued fevers. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - Pan culture: sputum / blood/ urine\n - Send glucan / galactomannan\n - Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n - TEE today\n - F/U ID and NSG recs\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n - Defer RUQ U/S for now since unlikely to change management.\n - Statin d/c'ed.\n - Trend LFTs\n #Elevated cardiac biomarkers: Most likely demand in setting of RVR\n / hypoTN.\n - Cont ASA\n - Defer BB in setting of intermittent hypoTN\n #Atrial thrombus: Elevated INR 5.9 to 9. Coumadin held x3d, now 1.4\n - Start heparin gtt\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706872, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - TEE - small vegetation on aortic valve. No atrial trombus.\n - Tm 101.2\n - Diuresed\n - Changed from APVR to AC\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 700 units/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium - 03:30 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38\nC (100.4\n HR: 83 (74 - 86) bpm\n BP: 135/47(72) {106/40(60) - 148/61(87)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 14 (8 - 14)mmHg\n Total In:\n 1,873 mL\n 1,321 mL\n PO:\n TF:\n 660 mL\n 827 mL\n IVF:\n 983 mL\n 464 mL\n Blood products:\n Total out:\n 2,340 mL\n 855 mL\n Urine:\n 2,340 mL\n 855 mL\n NG:\n Stool:\n Drains:\n Balance:\n -467 mL\n 466 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R, Diminished: L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 221 K/uL\n 142 mg/dL\n 3.2 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 51 mg/dL\n 107 mEq/L\n 139 mEq/L\n 22.8 %\n 7.6 K/uL\n [image002.jpg]\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n WBC\n 9.4\n 8.2\n 7.4\n 7.6\n Hct\n 26.2\n 24.4\n 24.2\n 22.8\n Plt\n 297\n 277\n 257\n 221\n Cr\n 3.5\n 3.1\n 3.2\n TCO2\n 20\n 20\n 21\n 21\n 21\n 24\n Glucose\n 95\n 123\n 142\n Other labs: PT / PTT / INR:17.1/150.0/1.5, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:122/107, Alk Phos / T Bili:217/0.9,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:678 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR -\n Microbiology: Sputum cultures with staph aureus\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS this am\n wean as tolerated\n - Consider switching to PCV\n - Continue abx (vanc/aztreonam Day / and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Nebs\n - Advance ET tube 3 cm\n #Continued fevers. PNA: CXR--bilateral infiltrates. Enterococcus aortic\n valve endocarditis and discitis. Vanc level therapeutic.\n - Cont vanc / aztreonam / clinda (check vanc level)\n - F/U cultures\n - F/U glucan / galactomannan\n - TEE today\n - F/U ID and NSG recs\n # Anemia: Hct from 24 to 22 today. No obvious source of bleeding.\n - Occult stools\n - Hct goal >21\n - Hcts\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time.\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation. Statin d/c\ned. Deferred RUQ U/S for now since\n unlikely to change management.\n - Trend LFTs\n #Atrial thrombus: Now thought not to have an atrial thrombus on\n original TEE, but rather that it was heterogeneity of an atrial\n appendage. Repeat TEE confirmed that there is no thrombus.\n - D/c heparin gtt\n - Start SQ heparin\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:02 AM 80 mL/hour\n Talk to\n nutrition about more concentrated TF.\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:30 minutes\n" }, { "category": "Nutrition", "chartdate": "2146-10-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706875, "text": "Objective\n Pertinent medications: Fentanyl drip, Versed drip, Heparin drip, Normal\n saline @ 10ml/hr, Colace, ABX, Lasix, Pantoprazole\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 03:41 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 51 mg/dL\n 03:41 AM\n Creatinine\n 3.2 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.0 mEq/L\n 03:41 AM\n Chloride\n 107 mEq/L\n 03:41 AM\n TCO2\n 22 mEq/L\n 03:41 AM\n PO2 (arterial)\n 94. mm Hg\n 05:41 AM\n PCO2 (arterial)\n 40 mm Hg\n 05:41 AM\n pH (arterial)\n 7.36 units\n 05:41 AM\n pH (urine)\n 5.0 units\n 08:35 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 05:41 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.2 mg/dL\n 03:41 AM\n Phosphorus\n 4.1 mg/dL\n 03:41 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.0 mg/dL\n 03:41 AM\n ALT\n 122 IU/L\n 03:41 AM\n Alkaline Phosphate\n 217 IU/L\n 03:41 AM\n AST\n 107 IU/L\n 03:41 AM\n Total Bilirubin\n 0.9 mg/dL\n 03:41 AM\n WBC\n 7.6 K/uL\n 03:41 AM\n Hgb\n 7.5 g/dL\n 03:41 AM\n Hematocrit\n 22.8 %\n 03:41 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Fibersource HN @ 70ml/hr\n GI: soft, (+) bowel sounds\n Assessment of Nutritional Status\n Estimation of current intake: Excessive\n Specifics:\n Patient admitted with aspiration PNA with dense, large R-sided\n infiltrate. Remains intubated/sedated, pressor off. Tube feed running\n at 80ml/hr, goal changed to 70ml/hr after discussion with MD . \n RN, patient tolerating tube feed, but team would like more concentrated\n tube feed formula to minimize fluid. Also, goal for patient to have bm\n today. Agree with plan, can change to 2 calorie per ml formula to\n decrease free water to 700ml (currently getting 1.5 L).\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Change to Nutren 2.0 with goal\n of 42ml/hr = calories and 81g protein\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel\n BS management\n Bowel regimen PRN\n Will follow, page if questions *\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707049, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Guiac negative\n - PS decreased from to \n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.2\n HR: 87 (81 - 106) bpm\n BP: 136/49(74) {120/41(64) - 195/59(99)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (3 - 14)mmHg\n Total In:\n 2,565 mL\n 1,009 mL\n PO:\n TF:\n 1,424 mL\n 449 mL\n IVF:\n 900 mL\n 501 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,600 mL\n Urine:\n 3,815 mL\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,250 mL\n -591 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (160 - 741) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.38/41/86/25/0\n Ve: 5.6 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Crackles : R,\n Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.6 g/dL\n 247 K/uL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: Glucan negative.\n Imaging: CXR- Worsening R-sided infiltrate/effusion.\n Microbiology: C. diff negative. sputum culture + MRSA,\n yeast\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis\n - Bronchodilators\n - Pull back ET tube 2 cm\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Would consider effusion/empymea\n given CXR appearance. Drug fever would be dx of exclusion.\n - CT scan to evaluate for possible R sided effusion\n if effusion\n ,would have concern for empyema as source of fevers\n - Will scan abd/pelvis while at CT scanner\n - Cont vanc / aztreonam / clinda\n - F/U cultures\n - F/U galactomannan\n - F/U ID and NSG recs\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >21\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 22 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707060, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/Dl\n Beta glucan negative\n Galactomannam\n All bcx negative or pending\n MRSA in sputum from \n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 7 of 14) /Aztreonam (day 7 of 14)/ Clinda (day 6 of 10)\n -increase PEEP to 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -pull back ET tube this morning 1-2cm\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, consider restart ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso to eval for empyema and/or abdominal process\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n - consider starting asa 325\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706355, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706523, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts\n ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Lung Pneumonia which seems\n to involve the entire lung field on CXR; it seems to have slightly\n improved since yesterday on CXR. Patient on , cont to wean as\n tolerated. On Vanc/Aztreonam/Clinda, but persistently febrile.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Likely Pneumonia. UOP and BP were fluid\n responsive yesterday and neo was weaned. Currently off pressors.\n - now off pressors and fluid overloaded, will begin diuresis\n - abx as above\n - albumin\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred last night and resolved with\n second IV load, now on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week, then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. Need TEE to rule out progession of\n endocarditis.\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- lipase\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 9 today (likely combo of amio,\n shock liver, Abx). Given 5mg IV Vit K.\n -- follow PT/INR, goal \n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706190, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Rec\nd on PCV 60% 18/12 PEEP. Lung sounds very rhonchorus, sx\ning very\n small amt\ns of thin tan secretions. Rec\nd pt sedated on fent 125mcg/hr\n /versed 1 mg/hr, but initially was very dysynchronous with the vent.\n Action:\n Titrating fentanyl and versed gtt to comfort. Pt appearing more\n comfortable on higher sedation ( 200mcg/hr fentanyl gtt, and 3 mg/hr\n versed gtt) but became hypotensive and gtt paused, then restarted at 50\n mcg/hr fentanyl gtt and 1 mg/hr versed gtt. Multiple vent chg\ns made\n according to abg\ns/sats that had been drawn. Attempted to wean peep\n to 10, pt desating to 87%, so peep increased to 12. ABG obtained.\n Response:\n Pt appearing to be comfortable on current sedation, no longer\n dysynchronous with vent. Sating 98%. Last ABG 7.35/40/61.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as needed.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n statin. SBP currently 95.\n Plan:\n ? cards. Consult. Cont. amio gtt per protocol.\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on 3mcg/kg/min neo gtt. SBP 95. CVP 13. UO poor\n (15-30cc/hr)\n Plan:\n Dr. . aware of low uo, plan is to cont. to monitor. Cont. to\n wean neo as tolerated.\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706527, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #PNA: Continued fever. CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] send sputum cx\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n #Fevers:\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] send lipase\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706529, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706531, "text": "Chief Complaint: respiratory failure, fevers, intermittent hypoTN, AMS\n HPI: 76M (h/o asthma, gout and recent complicated hospital course\n including epidural abscess requring surgery, enterococcus bactermia,\n aortic endocarditis, septic emboli to brain, atrial thrombus, NSTEMI)\n p/w aspiration PNA with dense, large R-sided infiltrate.\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 09:15 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Pantoprazole (Protonix) - 10:00 AM\n Furosemide (Lasix) - 10:30 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:39 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.7\nC (101.6\n HR: 92 (73 - 157) bpm\n BP: 148/50(76) {91/38(55) - 160/57(85)} mmHg\n RR: 18 (12 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 755 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 605 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 865 mL\n Urine:\n 800 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 650 (498 - 650) mL\n RR (Spontaneous): 5\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.39/33/135/24/-3\n Ve: 9.1 L/min\n PaO2 / FiO2: 270\n Physical Examination\n GEN: sedated\n Heent: intubated\n Cor: RRR no m/r/g\n Lung: bilateral rhonchi\n Abd: soft NT/nd +BS\n Ext: +LE edema, no c/c\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n 12:18 PM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to 0.5 and further PaO2 > 65\n --Consider switch to PCV in AM\n #HypoTN resolved, now off neo. Monitor\n #Continued fever. PNA: CXR--bilateral infiltrates improved. Vanc level\n therapeutic.\n [] cont vanc / aztreonam / clinda\n [] send sputum cx.\n [] f/u blood, urine cx.\n [] send lipase\n --Discussed broadening abx with ID since continued fevers. ID\n recommended staying with vanc (rather than lineazolid). If hypoTN or\n other clinical deterioration will re-discuss broadening with ID\n [] TEE on Mon\n [] f/u ID recs, NSY recs\n [] if fevers persist, consider glucan / galactomannan\n #Afib RVR: amio gtt started Friday. rebolused o/n.\n [] amio 400mg PO tid x1 week, start today\n #Acute transaminitis. Fri PM increase from ALT 19 -> 326; AST 26 ->\n 1177. Now trended down. Most likely due to shock liver in setting of\n hypoTN during Afib RVR. Hepatic vein thrombosis unlikely in setting of\n anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n --Statin d/c'ed.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat at 9.\n Most likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of intermittent hypoTN\n #Elevated INR 5.9 to 9. Coumadin held x2d\n --Vit K 5 x1 today. need more vit K tomorrow.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706604, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706346, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV TV> 500 RR 20-24\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706347, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV 20/12peep 80% TV> 500 RR 20-24, 7.39-34-95-21,\n wean to 60% desat 80\ns 7.37-36-55-22, FIO2^70% 7.38-35-81-21 no\n further vent changes. Lungs Dim RLL diffuse rhonchi, Suctioned via ETT\n for sm-mod thick tan blood tinge. Resp status labile desats with\n positioning 80\ns. desats when pos R side down.\n Action:\n Slow wean desats with positioning. Wean FIO2 70%.\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max 99.6 WBC\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706939, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n Now stooling; /loose, guiac negative, sent for c.diff sample, +\n bowel sounds, TF\ns @ goal, residuals down.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, lasix started , Vanco to be held tonight again for\n level 23.3, c.diff cx sent, would reorder Tylenol if temp over 101\n persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt on A/C.\n Action:\n Changed to psup , 50%, advanced ETT 3cm, CXR confirmed placement.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4 generalized\n edema.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 700\n units/hr.\n Action:\n Dc\nd hep gtt and started SQ hep TID, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >200 with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707018, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: __________\n : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707019, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 04:15 PM\n FEVER - 101.9\nF - 04:00 PM\n - heparin drip stopped, SQH started\n - renal fxn improving, diuresis continued\n - guiaic negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.7\n HR: 89 (79 - 106) bpm\n BP: 131/50(74) {115/41(64) - 195/59(99)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (4 - 14)mmHg\n Total In:\n 2,526 mL\n 554 mL\n PO:\n TF:\n 1,424 mL\n 278 mL\n IVF:\n 862 mL\n 246 mL\n Blood products:\n Total out:\n 3,815 mL\n 1,160 mL\n Urine:\n 3,815 mL\n 1,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,289 mL\n -606 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 653 (160 - 741) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.38/41/86/25/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: __________\n : )\n Abdominal: Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 7.6 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 108 mEq/L\n 141 mEq/L\n 24.2 %\n 9.3 K/uL\n [image002.jpg]\n 05:31 AM\n 12:18 PM\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n Plt\n 277\n 257\n 221\n 247\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n TCO2\n 21\n 21\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n Other labs: PT / PTT / INR:17.7/38.2/1.6, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:85/66, Alk Phos / T Bili:267/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.0 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS this morning. On Vanc (day 6\n of 14) /Aztreonam (day 6 of 14)/ Clinda (day 5 of 10)\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with 40 IV lasix for goal negative 1-2L\n -MDIs PRN\n -f/u ABG\n -advance ET tube this morning\n -daily chest x-rays\n .\n # Hypotension/Sepsis: Resolved. Likely Pneumonia. Currently off\n pressors.\n - now off pressors and fluid overloaded, will cont diuresis\n - abx as above\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, ASA, statin on hold given tranaminitis\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- cont Vanco (day 6 of 14) /Aztreonam (day 6 of 14) /Clinda (day 5 of\n 10)\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/d heparin gtt\n .\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -d/c heparin gtt\n -active T&S\n -check HCT\n -guaiac stools\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:47 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706179, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po, heart rate in the 150\ns, wbc down to 6.1 this am.\n u/o initially very good from Lasix given in prior shift.\n Action:\n Pt given Tylenol, and cooling blanket placed on top of pt.\n Response:\n Temp came down only to 102.8 after a few hours with cooling blanket on\n top of pt. pt given a cool bath, more Tylenol and cooling blanket\n placed underneath pt. temp has come down quickly to 99.5 orally. Pt\n remains tachycardic with hr in the low 100\n Plan:\n Follow temp, remove cooling blanket as soon as able.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n pla\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706339, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706342, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706345, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Receive pt intubated lightly sedated Fentanyl 50mcg/hr and versed\n 1mg/hr Vent Mode APRV TV> 500 RR 20-24\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n MP NSR rare PAC 75-90 Amiodarone 0.5mg/hr\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706493, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts! ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 706494, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n - muddy brown casts! ATN, likely from hypotension. FENA pending\n - reloaded IV as went into AFIB/RVR last night with good effect,\n ordered for 400mg tid for one week.\n - per ID, checked hapto, lactate, retiuc ct, TEE ordered, Abd US\n ordered\n - UOP increased to 1L NS x2 and 1uPRBC, neo weaned off\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 454 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 354 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: \n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n R>L)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Microbiology: YEAST IN SPUTUM, ALL OTHER BCX NEGATIVE\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Persistent hypoxemic respiratory failure: Patient with worsening\n Right Lung Pneumonia which seems to involve the entire lung field on\n CXR. Patient on , cont to wean as tolerated. On\n Vanc/Aztreonam/Clina, with minimal improvement. Will speak with ID\n regarding Abx coverage\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. Patient was started on amiodarone and now converted\n to NSR.\n - monitor on tele\n - cont Amio, transition to PO\n - wean Neo as tolerated\n .\n # Hypotension: Likely Pneumonia as well as Afib yesterday. BP\n improved with return to NSR. Still requiring low dose Neo today.\n - 1L IVF bolus with goal of weaning Neo off.\n - abx as above\n # Troponin leak: Patient with troponin leak after episode of afib\n yesterday. CK elevated slightly but MB flat. Likely to \n ischemia in the setting of hypotenstion, renal failure and afib with\n RVR. Troponin continues to rise this morning\n - recheck Cardiac Enzymes this afternoon\n - if continues to rise, consider cards consult\n # Fevers: Presented for continued fevers, which have now resolved.\n Improvement suggests that antibiotic coverage is working but Right lung\n worsening is concerning. Will cont the course for now and speak with\n ID as above\n -- cont Vanco/Aztreonam/Clinda\n -- f/u ID recs\n -- f/u Neurosurgery recs\n -- f/u blood cultures, Ucx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently unable to assess mental status given large amount of\n sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 5.9 today. Hold coumadin\n today.\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam/Clinda as above\n -- f/u ID recs\n -- obtain TEE per ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706496, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 457 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 357 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706738, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Cont abx, vanco trough prior to giving tonight\ns dose, monitor temp,\n f/u on cx data.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down. Sedated on fent/versed gtts.\n Action:\n Diuresed w/ 40mg IV lasix for goal 1 to 1.5L neg @ MN. Turn Q2H.\n Increased fentanyl gtt to 100mcg for better pain control.\n Response:\n Pt cont with good O2 sats >97%, min secretions, good response to 40mg\n IV lasix, LS remain clear RUL and diminished in all other fields. CXR\n from AM shows improvement MD\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO\n Action:\n Started heparin gtt @ 1300units/hr after 3000unit bolus.\n Response:\n HR regular with stable BP. Hep gtt running @ 1300units/hr.\n Plan:\n Next PTT @ 2200pm.\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706983, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Since admissions patient\ns course has been c/b high oxygen\n requirements, with witnessed asp. Event leading to intubation. Febrile\n daily, with neg. cultures to date. Pt with episodes of rapid afib and\n hypotension leading to IV amiodarone with bridge to PO amiodarone\n (converted to sinus rythym), and brief period of pressor requirement\n (neosynephrine). Pt remains intubated, sedated, and off pressors.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Tmax 100.7.\n Action:\n Pt cont on IVAB, lasix started , Vanco held tonight again for level\n 23.3, c.diff cx sent, would reorder Tylenol if temp over 101 persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50%. ETT advanced on day shift.\n Action:\n No vent changes made o/n. Sxned for copious pink tinged thin\n secretions. Rec\nd standing dose lasix.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4\n generalized edema. UO > 180 cc/hr fm diureses.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn. Wean vent. As tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Prior Echo with ? of clot in right\n atrium. Repeat Echo and review of prior echo revealing no clot.\n Heparin gtt dc\nd yesterday 11/10 days.\n Action:\n On SQ hep TID, Pboots, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >170s with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707008, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg re4sults at this time. RSBI = 37 on\n 0-PEEP and 5 cm PSV.\n" }, { "category": "Physician ", "chartdate": "2146-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707208, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CT torso - multifocal PNA, bilateral effusions, biliary sludge,\n diverticulosis\n - C. diff negative\n - Tm 100.9\n - Possible aspiration this am after CXR when OG tube came out while TF\n were running - now with increased secretions and rhoncorous breath\n sounds\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Aztreonam - 08:00 AM\n Clindamycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.4\nC (99.4\n HR: 79 (71 - 88) bpm\n BP: 128/44(69) {110/38(60) - 150/56(84)} mmHg\n RR: 12 (10 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 3,202 mL\n 919 mL\n PO:\n TF:\n 1,011 mL\n 432 mL\n IVF:\n 1,201 mL\n 427 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,330 mL\n Urine:\n 3,720 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -518 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 636 (465 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 8.3 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ,\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.4 g/dL\n 268 K/uL\n 116 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 107 mEq/L\n 138 mEq/L\n 22.4 %\n 12.2 K/uL\n [image002.jpg]\n 03:56 PM\n 04:18 PM\n 05:01 AM\n 05:41 AM\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n WBC\n 8.2\n 7.4\n 7.6\n 9.3\n 12.2\n Hct\n 24.4\n 24.2\n 22.8\n 24.2\n 24.2\n 22.4\n Plt\n 277\n 257\n 221\n 247\n 268\n Cr\n 3.1\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n TCO2\n 21\n 24\n 25\n Glucose\n 123\n 142\n 141\n 126\n 118\n 116\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.4 mg/dL\n Imaging: CT torso - multifocal PNA, bilateral effusions, biliary\n sludge, diverticulosis\n Microbiology: C. diff negative.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema.\n - On PS with worsening CXR, likely lower PEEP. Will increase and\n repeat CXR in am. Consider bronch if no improvement tomorrow.\n - Continue abx (vanc/aztreonam Day and clinda Day ) for\n aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - Recheck CXR given possible aspiration this am\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam / clinda\n - F/U cultures, fever curve? Switch to flagyl with concerns regarding C\n Diff\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:24 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706185, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with witnessed asp. Event yesterday evening resulting in intubation.\n Pt had been intubated at change of shift last eve, pt placed with left\n side down with o2 sat\ns in the high 90\ns on 100%. Lung sounds very\n rhonchorus, sx\ning very small amt\ns of thin tan secretions. heart rate\n high 140\ns. pt sedated on fent/versed, but initially was very\n dysynchronous with the vent.\n Action:\n Multiple vent chg\ns made according to abg\ns that had been drawn. Left\n rad aline was placed. Currently pt is on 60% pcv/as x 18 with 12 peep,\n Response:\n After many vent chg\ns pt became more in synch with the vent, pt\n sedation had been increased initially to 300mcq of fent because pt\n appeared to be in a lot of pain. Once pt completely sedated and\n appeared to be pain free, fent was decreased back to 100mcq\n currently pt\ns po2 only in the 70\ns on 60%, no chgs made at this time.\n Plan:\n Cont to monitor o2 sat\ns and abg\ns. Make ch\ng as neede.\n .H/O sepsis without organ dysfunction\n Assessment:\n Temp max 103.6 po o/n- rec\nd pt on cooling blanket. Tmax today 98.5,\n cooling blanket removed. wbc down to 6.1 this am. U/O poor, 15-30cc/hr\n MD aware. CXR with large right side pna.\n Action:\n On standing Tylenol. On aztreonam/vanco/clindamycin for coverage.\n Turning pt on left side for optimal ventilation. Given 40mg ivp lasix\n with no response.\n Response:\n Currently afebrile, off cooling blanket. HR 120s-140s afib.\n Plan:\n Follow temp, f/u cultures. Cont. antibx.\n Atrial fibrillation (Afib)\n Assessment:\n At 1330, pt with rapid afib to 170s, hypotensive to 80s. Dr. .\n at bedside\n Action:\n EKG obtained, 5mg ivp lopressor given with little effect. IVF given\n for hypotension. A RIJ was placed, and pt was loaded with 150mg\n amiodarone, followed by an amiodarone gtt.\n Response:\n HR currently 120s-140s afib, HR fluctuating frequently even on gtt- as\n high as 150s. Troponin 0.46. CKs 272. Pt was started on aspirin and\n pla\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt becoming hypotensive this afternoon at 1200. SBP 80s. HR 90s-100s\n SR.\n Action:\n Given 1L ns bolus with little effect, SBP 90s. Then HR went into rapid\n afib (as stated above), given an additional 1L of LR before started a\n phenylephrine gtt. RIJ placed, CVP 13.\n Response:\n Currently on\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2146-10-23 00:00:00.000", "description": "Generic Note", "row_id": 706502, "text": "Nutrition:\n Received consult for tube feeding recommendations. Consulted for tube\n feeding recommendations on see full nutrition assessment on \n for further details, tube feeding not started yet. Recommend goal of\n Fibersource HN @ 70 ml/hr to provide 2106 kcals and 89 g protein. Will\n follow. Page with questions\n" }, { "category": "Physician ", "chartdate": "2146-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706504, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 11:28 AM\n ULTRASOUND - At 03:30 PM\n abd\n FEVER - 101.3\nF - 08:00 PM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Aztreonam - 12:00 AM\n Clindamycin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 02:55 PM\n Amiodarone - 01:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 86 (73 - 157) bpm\n BP: 136/48(73) {91/38(55) - 156/55(84)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 16 (12 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,046 mL\n 457 mL\n PO:\n TF:\n IVF:\n 3,141 mL\n 357 mL\n Blood products:\n 725 mL\n Total out:\n 800 mL\n 215 mL\n Urine:\n 800 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,246 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n Vt (Spontaneous): 498 (498 - 580) mL\n RR (Spontaneous): 4\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/36/87./24/-4\n Ve: 9.7 L/min\n PaO2 / FiO2: 147\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 297 K/uL\n 95 mg/dL\n 3.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n 04:43 PM\n 04:57 PM\n 01:29 AM\n 05:24 AM\n 05:31 AM\n WBC\n 8.3\n 8.4\n 9.4\n Hct\n 25.7\n 25.4\n 26.2\n Plt\n \n Cr\n 3.0\n 3.1\n 3.5\n TropT\n 0.54\n 0.71\n 0.70\n TCO2\n 21\n 22\n 21\n 20\n 20\n 21\n Glucose\n 99\n 107\n 95\n Other labs: PT / PTT / INR:76.1/62.5/9.0, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:215/481, Alk Phos / T Bili:183/1.2,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.2 mmol/L, LDH:678 IU/L, Ca++:7.3 mg/dL, Mg++:2.4 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV) likely PNA\n [] Cont APRV, wean FiO2 to PaO2 > 65\n #PNA (with persistent hypotension): Continued fever, CXR improved R\n dense opacity. Sputum c MRSA. Vanc level 19.\n [] vanc / aztreonam / clinda\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n [] f/u repeat blood cx and sputum sent this morning.\n [] send lipase\n #hct 26 (no increase after 1u pRBC yesterday)\n [] hct , goal hct > 25\n #CV/R: Afib RVR: amio gtt started 2d ago, rebolused with amio yesterday\n now back in NSR\n [] 6g Afib load. Amio 400mg PO tid x 1week\n #CV/I: Elevated cardiac biomarkers: TnI was elevated at 0.5, CKMB flat\n at 9. Most likely demand in setting of RVR / hypoTN.\n [] cont ASA, defer BB in setting of hypoTN/vasopressor\n #Acute transaminitis. Fri night increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n Now LFTs trended down to 215 / 481.\n --Defer RUQ U/S for now since unlikely to change management and LFTs\n improving.\n --statin has been d/c\n [] trend LFTs\n #Elevated INR 5.9\n 9.1 (coumadin started at 1mg 2 days ago).\n --vit K 5 given this AM, monitor\n #HypoTN: briefly on neo o/n, now back off. UOP 30mL/hr. CVP = 13. fluid\n response in past.\n [] check albumin (may need alb/lasix for diuresis if low)\n [] for total body volume up, attempt gentle diuresis net 0.5L out.\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Elevated Cr: muddy brown casts in urine sed\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition: tube feed, off at MN for TEE\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2146-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706725, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Alteration in Nutrition\n Assessment:\n Pt NPO after mn for TEE\n Action:\n Restarted TF (fibersource HN) @ 40cc/hr w/ goal 80cc/hr.\n Response:\n still no stool, + bowel sounds, increasing LFT\n Plan:\n cont with bowel meds\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, Lasix given, Vanco trough drawn this evening, TEE done\n Response:\n Hemodynamically stable, some response to lasix (BUN/Creat improving), +\n MRSA in sputum, vanco trough pending, TEE showed no vegetation and no\n clots. Remains febrile w/ tmax 101.2.\n Plan:\n Will recheck vanco level in am and pm , follow cx results, TEE in am to\n eval Endocarditis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in APVR mode of ventilation, Cont to tolerate RT side lung\n down . No changes in sedation needed but pt cont to look very\n uncomfortable whenever he is turned or moved\n Action:\n Aggressive pulm toilet and sx, gentle diuresis for now\n Response:\n Pt cont with good O2 sats >97%, min secretions, mild rsp to lasix-only\n 300cc u/o rsp\n Plan:\n Will cont to follow CXR for improvement\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in SR all shift\n Action:\n Cont on po amiodarone\n Response:\n HR regular with stable BP\n Plan:\n Cont to follow for changes , Check am labls\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707081, "text": "This is a 76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen. Electrolyte repletion.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on psup 50% and in no apparent distress. Continues to be\n diuresed with aztreonam and Lasix IVP.\n Action:\n Attempted to place pt on 50%- however, due to patients worsening\n chest xray- PEEP was increased to 10. Now is on CPAP/PS, 50%.\n Obtained Chest and abdominal CT today. ET pulled out by 2cm.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Plan:\n Daiily CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and\n LS\ns. sxn prn. CT results pending.\n" }, { "category": "Nursing", "chartdate": "2146-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707200, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Initiated Lasix gtt after administering\n 60 mg IVP bolus.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Nursing", "chartdate": "2146-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706586, "text": "This is a 76 male with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on APVR mode of vent. Fi02 60% RR & O2 sat WNL. LS rhonchi\n with diminished bases. Previous Chest Xray showed great improvement on\n R lung.\n Action:\n Suctioned tan/blood tinged sputum. ABG on FiO2 60%- PCO2 33. PO2 135.\n Changed FiO2 50%. Turn patient on R side.\n Response:\n ABG on FiO2 50% PCO2 33. PO2 106. LS clear with scattered rhonchi and\n diminished bases. RR & O2 sat continue to be WNL. Pt tolerated R side\n well.\n Plan:\n Continue to wean FiO2. Suction q4 & PRN. Monitor ABG.\n Atrial fibrillation (Afib)\n Assessment:\n Received patient off pressors since 0400. Pt maintained stable BP. HR\n 80s, sinus rhythm. CVP-12. Weak PPP. Hct 24.4. Output about 40-50mL/h.\n Action:\n Received PO amiodarone. Received Lasix.\n Response:\n Pt output increased 100-150 mL/h. HR & BP remained stable, sinus\n rhythm. BP increase with stimulation.\n Plan:\n Continue monitoring for AF. Monitor absorption of PO aminodrone.\n Monitor BP off pressors. Hct goal 25. Output goal -500mL. TEE tomorrow.\n NPO after midnight.\n Alteration in Nutrition\n Assessment:\n Pt abd soft & distended, hypoactive BS. Pt skin intact & edematous.\n Gluteus skin tear and incisional scar from recent surgery on back.\n Action:\n Tube feedings resumed @ 30ml/hr with 100mL flush h20 q4. Received Senna\n and Colace. Gluteus tear open to air, barrier cream applied.\n Response:\n Pt has not had a BM. Pt tolerated tube feedings well, no residuals.\n Plan:\n Continue bowel regime. Continue tube feedings. Stop tube feedings @\n midnight.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt sleepy and sedated on Fetanyl and Versed. PERRLA. Pt continues to\n have temp. Tmax 102.6. Pt skin is warm. BP stable.\n Action:\n Received vancomycin, aztreonam, clindamycin. Pt received 20mg lasix @\n 1030 & 1450. Acetaminophen d/c. Blood, sputum, urine cultures sent.\n Labs drawn at 1600.\n Response:\n Temp continues to be high, 101.7. Output 100-150mL/h. Pt continues to\n be sleepy and sedated. Creatine 3.5\n Plan:\n Continue to monitor temp and renal function. Goal -500mL output.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706732, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear over the right upper lobe, diminished every where\n else, suctioned intermittently for small amounts of thick to thin tan\n secretions, treated with Albuterol and Atrovent inhalers, SPO2 remained\n upper 90s, no distress occurred, will continues to be followed.\n" }, { "category": "Nursing", "chartdate": "2146-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706981, "text": "Alteration in Nutrition\n Assessment:\n Rec\nd on TF at 80cc/hr (fibersource HN). No stool, +BS.\n Action:\n Changed to Nutren 2.0 @ 42cc/hr to decrease pt\ns fluid intake. Given\n x1 Lactulose via OGT and QD Miralaxx via OGT.\n Response:\n Now stooling; /loose, guiac negative, sent for c.diff sample, +\n bowel sounds, TF\ns @ goal, residuals down.\n Plan:\n cont with bowel meds, cont. to check TF residuals q4h.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile but with neg cx to date, He has been\n hemodynamically stable. had spinal abscess drained/washed.\n Action:\n Pt cont on IVAB, lasix started , Vanco to be held tonight again for\n level 23.3, c.diff cx sent, would reorder Tylenol if temp over 101\n persists.\n Response:\n Hemodynamically stable, good response to 40mg IV lasix, + MRSA in\n sputum, sputum increasing tan/bloody/thick.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt on A/C.\n Action:\n Changed to psup , 50%, advanced ETT 3cm, CXR confirmed placement.\n Response:\n O2sat remains >96%, ABG good on psup, increased cough and sputum\n production since ETT advanced, CXR still wet and pt w/ +4 generalized\n edema.\n Plan:\n AM CXR\ns, diurese for goal 1-1.5L neg by MN, monitor o2sat and LS\n sxn prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, getting amiodarone PO. Rec\nd on heparin gtt at 700\n units/hr.\n Action:\n Dc\nd hep gtt and started SQ hep TID, cont amio PO\n Response:\n HR remains NSR <100, SBP increased since placed on Psup. BP >200 with\n stimulation/care.\n Plan:\n Cont amio, monitor tele for rhythm changes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707247, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilationPMHX: epidural abcess. Now\n with fever aortic endocarditis.suctioned for thick tan looking\n sputum,remains on PSV\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706392, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined the pt, and was physically present with the ICU team\n for the key portions of services provided. I agree with Dr. \n note,including assessment and plan. I would add: 76 yo male with gout,\n asthma, recent complicated hospitalization for enterococcal aortic\n valve endocarditis, epidural abscess, atrial thrombus on coumadin,\n admitted with recurrent fevers. In the ICU he developed worsening\n respiratory distress with witnessed aspiration resulting in\n intubation/mechanical ventilation. Yesterday, he developed afib and\n shock,- on amiodarone/neo infusion. Converted to NSR overnight.\n Plans:\n 1. Acute respiratory failure- has Aspiration/PNA with MRSA\n recovered from sputums ((+) cultures last hospitalization, then felt to\n be a contaminant)- on Vanco. Ventilator requirements have been\n difficult given process almost exlucisvely involves the right side.\n Previously dyssynchronous on AC, transiently on PC ventilation.\n Attempts to decrease PEEP (due to concern of overdistending normal\n lung) resulted in hypoxia, desaturations do respond to recruitment\n maneuvers. Now on APRV and tolerating reasonably. Keep left side down.\n 2. elevated transaminases: shock liver most likely in his\n scenario, will follow LFT\ns and consider abd US if it does not improve\n 3. Fevers: Blood culture previously reported as GPC returned\n NEGative as final result, LS MRI negative for progression and only\n positive culture S.aureus from sputum\nmostly pointing toward lung as\n primary source. Abx are Vanc/aztreonam to cover PNA/enterococcal\n endocaridtis- will touch base with ID re abx\n Pt is critically ill. Total time spent: 45 minutes.\n ------ Protected Section Addendum Entered By: , Fellow\n on: 19:00 ------\n" }, { "category": "Respiratory ", "chartdate": "2146-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706910, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear and diminished, suctioned intermittently for small\n to moderate amounts of thick tan to old blood-tinged secretions,\n treated with Atrovent inhaler, switched from APRV to AC, well tolerated\n then, weaned to PSV so far well tolerated, SPO2 remained upper 90s,\n will continues with Diuretics, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2146-10-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706170, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Worsening respiratory failure yesterday pm requiring intubation.\n Witnessed aspiration while taking pills. Worsening R-sided infiltrate\n on CXR\n - Placed on PCV for comfort, but still with forced exhalation\n - A line placed\n - Tm 103.6 -> clinda started for anaerobic coverage\n - Afib with RVR requiring IV lopressor and amio gtt\n - CL placed\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 03:37 PM\n Clindamycin - 08:25 AM\n Aztreonam - 08:25 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:23 PM\n Labetalol - 06:00 PM\n Midazolam (Versed) - 06:20 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Colace, Lido TD, PPI, Neurontin, Tylenol, Coumadin, Atrovent MDI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 36.9\nC (98.5\n HR: 116 (93 - 147) bpm\n BP: 146/62(88) {84/35(51) - 198/106(123)} mmHg\n RR: 24 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 501 mL\n 521 mL\n PO:\n 20 mL\n TF:\n IVF:\n 481 mL\n 431 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,380 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,879 mL\n 131 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 900 (900 - 900) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 18 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.43/34/71/22/0\n Ve: 14.8 L/min\n PaO2 / FiO2: 118\n Physical Examination\n General Appearance: Thin, Uncomfortable on vent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: ), R>L\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 318 K/uL\n 89 mg/dL\n 2.6 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:34 AM\n 03:30 AM\n 12:11 PM\n 12:33 PM\n 05:41 PM\n 07:03 PM\n 09:30 PM\n 09:43 PM\n 03:33 AM\n 04:48 AM\n WBC\n 12.9\n 8.7\n 8.3\n 6.1\n Hct\n 25.8\n 24.1\n 24.3\n 23.4\n Plt\n 18\n Cr\n 2.3\n 2.5\n 2.4\n 2.6\n TCO2\n 23\n 23\n 20\n 22\n 23\n 23\n Glucose\n 95\n 129\n 120\n 89\n Other labs: PT / PTT / INR:41.2/48.4/4.3, CK / CKMB /\n Troponin-T:213/3/0.07, ALT / AST:19/26, Alk Phos / T Bili:119/0.7,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.6 mmol/L, LDH:272 IU/L, Ca++:7.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.5\n mg/dL\n Imaging: CXR - Worsening R-sided infiltrate\n Microbiology: No new culture data.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and witnessed aspiration event requiring mechanical\n ventilation.\n #Acute respiratory distress: Likely PNA and aspiration with h/o\n asthma. Intubated for worsening respiratory distress in setting\n of witnessed aspiration. Also with some volume overload.\n - On antibiotics to cover HAP and aspiration\n - Uncomfortable on vent\n will try increasing sedation and possibly\n swtiching to propofol or paralysis if not settling out\n - Borderline oxygenation, but does not meed ARDS criteia (L lung\n relatively spared).\n - Diuresis\n - Wean PEEP as tolerated given lack of ARDS physiology and concerns\n that high PEEP will overdistend good lung. Can consider double lumen\n tube if necessary.\n # Fevers: Likely due to R-sided pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID, added clinda for anaerobic\n coverage\n - F/U urine legionella\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n - F/U neurosurgery recs\n - F/U ID recs\n - TEE requested by consult service\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Holding coumadin given supratherapeutic INR\n # Afib with RVR:\n - Amio gtt\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined this pt, and was present with the ICU team for the\n relevant portions of services provided. I agree with Dr. \ns note,\n and would add: 76 yo male with asthma, with recent complicated hospital\n course from Enterococcal aoV endocarditis, left atrial clot, epidural\n abscess, readmitted with fevers and respiratory distress from\n aspiration vs. PNA. Intubated yesterday for acutely worsening distress\n developing immediately after witnessed aspiration. This afternoon, he\n developed rapid afib with hypotension, now on neo and amio infusion.\n Microbiology still shows just the one +bd culture for GPC (since\n amended to NEGATIVE blood culture), no speciation back yet and\n surveillance cx\ns NGTD.\n CXR shows progressing of infiltrates- very impressive unilateral\n process.\n Imp: 76 yo male with fevers, acute respiratory failure from aspiration,\n afib, shock. With blood cultures so far negative and Lspine MRI\n negative for recurrent abscess, lung appears to be the only\n identifiable source so far.\n On abx for HAP, PC ventilation, amiodarone, neo infusion. Given\n strongly unilateral process, would position pt left side down to\n increase blood flow to more functional lung. Some concern in this\n context that PEEP could be over-distending his normal lung- did not\n tolerate attempt to drop earlier this afternoon, but several vent\n changes made and pt then in rapid afib. Will continue amio for rate\n control, neo infusion to maintain MAP>60.\n Pt is critically ill. Total time spent: 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:22 ------\n" }, { "category": "Respiratory ", "chartdate": "2146-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 706176, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Frequent desaturation episodes\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2146-10-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 706397, "text": "Chief Complaint: hypoxemic respiratory failure, PNA\n HPI:\n 76M (h/o asthma, gout and recent complicated hospitalcourse including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI and\n temporary HD for gadolinium exposure) was d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Pt developed rash attributed to medication and\n switched to daptomycin. Pt developed fevers, lethargy and AMS. Pt\n intubated after witnessed aspiration event. Pt now has dense\n R-sided infiltrate.\n 24 Hour Events:\n Developed afib with RVR requiring lopressor then vasopressor (neo)\n and amio gtt. Trop 0.43. Pt converted to NSR yesterday evening with\n improvement in MAPs (although still requiring lower levels of neo).\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:35 PM\n Clindamycin - 08:30 AM\n Aztreonam - 03:30 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Phenylephrine - 0.3 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Fentanyl - 02:55 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: Tube feeds\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.6\n HR: 80 (65 - 130) bpm\n BP: 112/45(66) {91/37(53) - 180/58(92)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 15 (13 - 17)mmHg\n Mixed Venous O2% Sat: 92 - 92\n Total In:\n 4,893 mL\n 3,851 mL\n PO:\n TF:\n IVF:\n 4,119 mL\n 3,006 mL\n Blood products:\n 594 mL\n 725 mL\n Total out:\n 625 mL\n 505 mL\n Urine:\n 625 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 3,346 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: APRV\n RR (Spontaneous): 9\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.36/35/81./19/-4\n Ve: 12 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: R--diminished, rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 301 K/uL\n 99 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 43 mg/dL\n 106 mEq/L\n 138 mEq/L\n 25.7 %\n 8.3 K/uL\n [image002.jpg]\n 11:38 AM\n 01:57 PM\n 02:01 PM\n 04:53 PM\n 08:31 PM\n 09:51 PM\n 06:16 AM\n 07:59 AM\n 09:56 AM\n 12:45 PM\n WBC\n 8.3\n Hct\n 21.4\n 25.7\n Plt\n 301\n Cr\n 2.5\n 3.0\n TropT\n 0.46\n 0.54\n 0.71\n TCO2\n 24\n 23\n 20\n 21\n 22\n 21\n Glucose\n 100\n 99\n Other labs: PT / PTT / INR:53.1/58.1/5.9, CK / CKMB /\n Troponin-T:421/9/0.71, ALT / AST:, Alk Phos / T Bili:157/1.4,\n Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, LDH:1269 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.4\n mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n #Hypoxemic respiratory failure on vent (APRV)\n --Cont APRV, wean FiO2 to PaO2 > 65\n #HypoTN on vasopressor (neo): Etiology includes early sepsis (e.g. \n PNA) versus heart failure (BNP 10,000)\n [] IVF challenge (1L bolus) + 1u pRBC. Further fluid challenge or\n diuresis pending the response to this challenge.\n #PNA (with persistent hypotension): Pt appears to be clinically worse\n despite >2d on vanc / aztreonam (hypoTN, worsening CXR).\n [] send sputum cx\n [] send vanc level\n [] Discuss broadening abx coverage with ID (including consideration of\n fluoroquinolone v. aminoglycoside)\n #Afib RVR: amio gtt started yesterday.\n [] 6g Afib load. After amio gtt completed (24hr) start amio 400mg PO\n tid\n #Acute transaminitis. Overnight increase from ALT 19 -> 326; AST 26 ->\n 1177. Most likely due to shock liver in setting of hypoTN during Afib\n RVR. Hepatic vein thrombosis unlikely in setting of anti-coagulation.\n --Defer RUQ U/S for now since unlikely to change management.\n [] trend LFTs\n [] d/c statin\n #Elevated cardiac biomarkers: TnI elevated at 0.5, CKMB flat at 9. Most\n likely demand in setting of RVR / hypoTN.\n [] cont ASA\n -- defer BB in setting of hypoTN/vasopressor\n [] trend biomarkers to peak\n #Elevated INR 5.9 (coumadin started at 1mg 2 days ago).\n [] hold coumadin\n -- defer vit K (no evidence of active bleeding)\n #s/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n [] Discuss fluid collection with NSY c/s who is following.\n #Fevers: afebrile O/N\n [] Cardiology plans TEE on Mon\n [] f/u ID recs, NSY recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined the pt, and was physically present with the ICU team\n for the key portions of services provided. I agree with Dr. \n note,including assessment and plan. I would add: 76 yo male with gout,\n asthma, recent complicated hospitalization for enterococcal aortic\n valve endocarditis, epidural abscess, atrial thrombus on coumadin,\n admitted with recurrent fevers. In the ICU he developed worsening\n respiratory distress with witnessed aspiration resulting in\n intubation/mechanical ventilation. Yesterday, he developed afib and\n shock,- on amiodarone/neo infusion. Converted to NSR overnight.\n Plans:\n 1. Acute respiratory failure- has Aspiration/PNA with MRSA\n recovered from sputums ((+) cultures last hospitalization, then felt to\n be a contaminant)- on Vanco. Ventilator requirements have been\n difficult given process almost exlucisvely involves the right side.\n Previously dyssynchronous on AC, transiently on PC ventilation.\n Attempts to decrease PEEP (due to concern of overdistending normal\n lung) resulted in hypoxia, desaturations do respond to recruitment\n maneuvers. Now on APRV and tolerating reasonably. Keep left side down.\n 2. elevated transaminases: shock liver most likely in his\n scenario, will follow LFT\ns and consider abd US if it does not improve\n 3. Fevers: Blood culture previously reported as GPC returned\n NEGative as final result, LS MRI negative for progression and only\n positive culture S.aureus from sputum\nmostly pointing toward lung as\n primary source. Abx are Vanc/aztreonam to cover PNA/enterococcal\n endocaridtis- will touch base with ID re abx\n Pt is critically ill. Total time spent: 45 minutes.\n ------ Protected Section Addendum Entered By: , Fellow\n on: 19:00 ------\n Please note that the above addendum was actually written by me but\n signed under the wrong account.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:51 ------\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705725, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain noted to touch, but denied it\n when asked.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Home meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Athma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n - Epidural abscess\n - Aortic veg\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in \n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): Person, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n # Asthma:\n -- Ipratropium nebs PRN\n # Gout: no acute issues\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705729, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain to touch. Picc line pulled and\n tip sent for culture.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Rehab meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Epidural abscess\n - Possible septic emboli vs infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Athma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in , English speaking\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to):\n Person/Place/Year, Movement: Wiggles b/l toes, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705695, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Received patient from ED on NRM. Patient is lethargic, opens eyes to\n verbal stimuli & follows simple commands. He denies pain but patient\n grimaces whenever touched him for movement / turning. From the\n grimace scale it is obvious that he has intense pain at the bilat\n lower extremities. Pupils are unequal .Rt >left & rt pupil\n non-reactiove ( S/P cataract sx) . Significant generalized pitting\n edema +4. Pedal pulses dopplerable. Moves extremities on the bed.\n Received 3 L IVF at Ed for Sinus tachy episode ( HR at 130\ns). Upon\n arrival to ICU he has been Sinus tachy mostly., satting at high 90\n nasal cannula. Febrile : T max : 102.2 ( Oral) . Lungs rhonchous &\n insp/exp wheezing bilat. Drug Rash present all over the body from\n Ceft & ampi at rehab, switched to Daptomycin as recommended by ID.\n Monitor shows Sinus tachy with no ectopics. HR went upto 150\ns for a\n brief period with movement/turning. Foleys cath in place , placed at\n ED today Patient has had PICC at rt AC , Non-functioning. Received 3 L\n NS at ED. Received Morphine sulfate 4 mg X3 at ED. Received Vancomycin\n 1 gm & Aztreonam 1 gm IV & 650 mg Tylenol Supp at ED. CT head done for\n ? mental status changes. Incission at back from recent surgery for\n Epidural abscess on /09l close approximated, opens to\n air.Abrasion at perineal area. UOP at 10-30 ml/hr. Contact precautions\n for VRE Pos.\n Action:\n CXR done upon arrival to MICU 07, Atrovent nebs given. IV nurse pulled\n out PICC line & tip sent for culture. Blood culture & Urine culture\n send. Tylenol Sup given. Weaned O2 to 4 L from NRM. Ct head done.\n Neurosurgery consulted. ABG done upon arrival. Pain meds held off at\n this time for ? mental status. restart pain meds once mental\n status improves. .\n Response:\n CXR showing RLL infiltration. Ct head Negative. Na : 132, HCT :\n 25.8, WBC : 12.9. Trop : 0.07 & CK : 213. Last ABG : 7.38/37/76. T :\n 98.4 after Tylenol sups.\n Plan:\n Plan for MRI head & Spine. Plan for Echo today to R/O abscess.\n Follow fever curve. Closely monitor Heart rate & resp status. Cont\n monitoring Mental status closely. Need good pain control regimen.\n Wean off O2 as tolerated. need Nasotracheal suctioning if needed.\n F/u with lab results. F/U with ID for coverage.\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705940, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing discitis and\n osteomyelitis of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - On antibiotics to cover HCAp\n -supportive care with supplemental oxygen and nebs\n - Check ABG given high oxygen requirement, slightly somnolent state\n this morning\n - Keep NPO until trajectory of pt\ns respiratory status becomes clearer-\n may need intubation if worsens\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n ICU Care\n Nutrition: NPO, SLP consult\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 44 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705955, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n GEN: Elderly male lying bed with face mask in place, answering\n questions with yes no, opens eyes on command\n CVS: +S1/S2, no m/r/g, rrr\n LUNGS: +crackles in right lower base, no wheezing or ronchi\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of b/l lower extremities\n SKIN: no rashes\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Several sources possible. MRI of Lspine done yesterday\n shows L5-S1 discitis/osteo which could be the reason for his continued\n fevers. Blood cultures from yesterday also growing Gram +cocci in\n clusters which may be a contaminant as it seems to be from one bottle.\n We will have to await speciation. CXR also showing RLL consolidation\n which may be to aspiration which occurred in ED here. If blood\n cultures are + for Enterococcus then will need to perform TEE to\n evaluate for worsening aortic vegetation.\n -- cont Vanco/Aztreonam\n -- f/u final MR \n -- f/u c.diff\n -- f/u Neurosurgery recs\n -- f/u blood cultures, UCx\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Patient\n was given Morphine 4mg IV x 3 in ED which may have contributed to AMS.\n Currently with improved MS.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: INR 2.8 today. Will restart\n coumadin at 1mg per day.\n -- follow PT/INR\n - restart coumadin\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n Per NSurg no invtervention needed at this time.\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now on Vanco\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n -- f/u ID recs\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Rehab Services", "chartdate": "2146-10-20 00:00:00.000", "description": "Deferred Bedside Swallowing Evaluation", "row_id": 705956, "text": "TITLE: DEFERRED BEDSIDE SWALLOWING EVALUATION\n HISTORY:\n Thank you for referring this 76 yo man re-admitted on from\n rehab. Pt originally admitted approximately one month ago\n ()with fevers and back pain, found to have pan-sensitive\n enteroccus fecalis AV endocarditis, bacteremia, spinal epidural abscess\n s/p L5 & S1 laminectomy and abscess decompression on , as well as\n neurologic microabscesses. He was readmitted with rash, persistent\n fevers. Portable CXR with possible retrocardiac infiltrate so started\n empirically on antibiotics for possible pneumonia. Then repeat CXR with\n RLL opacity. We were consulted to evaluate oral and pharyngeal swallow\n function to determine if aspiration/dysphagia could be contributing to\n current fever and opacity on CXR.\n Pt is known to our department by four evaluations during the previous\n admission. Was initially recommended for soft solids and nectar thick\n liquids on with aspiration of thin liquids. Etiology of dysphagia\n was suggested to be either related to medications or neuro issues. On\n , re-evaluated and cleared for diet upgrade to soft solids and\n thin liquids, as dysphagia was resolving. Records from \n Hospital state pt on house diet with supplements TID.\n PAST MEDICAL HISTORY:\n 1. Osteoporosis\n 2. Gout\n 3. Cataracts\n PAST SURGICAL HISTORY:\n s/p cataract repair\n DEFERRED EVALUATION\n RN, pt's daughter fed him on without overt difficulties (on\n regular diet/thin liquids). On evening , pt had episode of desat\n to high 80s, required NRB. MD notes from AM suggest need to remain NPO\n pending possible intubation, though consult placed mid-day. Currently\n sating in mid-90s on 100% O2 via face mask. RN feels not appropriate\n for PO today. We will return tomorrow morning to attempt the\n evaluation, if stable. Pending our evaluation, encourage maintaining\n NPO except essential meds and ice chips for comfort, both with strict\n 1:1 supervision by RN for aspiration precautions.\n _________________________________\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705957, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of head and spine\n showing ? L1 osteomylitis. Incission at back from recent surgery for\n Epidural abscess on - approximated, open to air. Sm. Abrasion\n at perineal area. UOP at 40-60 ml/hr. Contact precautions for MRSA.\n Repeat Bld cx\ns done this am. Pt with history of aortic vegetation\n seen on TEE last admission.\n Action:\n MRI brain, and MRI L-spine done, receive GAT contrast dye for exam.\n Phone consent done in mri suite. - Pt and family aware of risks r/t\n kidneys, On vanco and aztreonam for coverage. Pt received lopressor 5mg\n ivp for 2^nd episode of raf with fair response. Cxr done and showed\n worsenin of rll infiltrate. Pt very wheezy and wob increased with resp\n rate as high as the 40\ns. nt sx\nd , med with morphine for pain. O2\n increased to high flow neb with 4 liter nc.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. o2 sat\ns in\n the mid 90s.\n Plan:\n Pt now cont taking off o2, need to check pt freq otherwise o2 sat\n down in the low 80\ns. keep right side down. Pulm toileting as\n tolerated. Morphine for pain.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. LE. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. PRN morphine, rec\nd 2mg ivp x1\n this shift. Lidocaine patch removed. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n ? pain service consult. Cont. PRN morphine and standing Tylenol.\n Cont. to reorient as needed.\n" }, { "category": "Nursing", "chartdate": "2146-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705958, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia\n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy. Patient is currently unable to provide history altered\n mental status. Per ED report, patient as on Amp/Ceftriax at when he developed ?drug rash. Antibiotics were then switched to\n Daptomycin. He then began having persistent fevers and was transferred\n to for further care\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to broad\n spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol\n 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L.\n .H/O sepsis without organ dysfunction\n Assessment:\n Tmax 98 ax/ HR 90s-100\ns SR/ST with no ectopy. NBP ranging 1-teens to\n 130s/50-60s. generalized pitting edema +4. PP dopplerable. Lungs\n diminished on left, rhoncorous on right. CXR with worsening RLL\n infiltrate, Rec\nd on 95% high flow neb. Pt had mri of spine showing\n L5-S1 discitis/osteo, awaiting final read. Incission at back from\n recent surgery for Epidural abscess on - approximated, open to\n air. Sm. Abrasion at perineal area. UOP at 40-60 ml/hr. Contact\n precautions for MRSA. Pt with history of aortic vegetation seen on TEE\n last admission.\n Action:\n On vanco and aztreonam for coverage. On standing dose nebs. Unable to\n wean O2 today, pt desating to mid-80s with turning, especially while on\n left side. ABG obtained. Bilateral chest PT/NTS for scant-small\n amounts of thick tan secretions. 2^nd set of bld cultures sent.\n Ampicillin and ceftriaxone now listed as drug allergy in POE.\n Response:\n Pt now breathing in the teens. Hr now in 90\ns to low 100\ns. On 95%\n high flow neb, sating 97%. ABG 7.42/34/102 on high flow neb.\n Plan:\n Wean O2 as tolerated. f/u culture data. Cont. antibx. Cont. chest\n PT/ NTS as tolerated. keep right side down.\n Altered mental status (not Delirium)/Pain\n Assessment:\n Patient is lethargic, opens eyes to verbal stimuli & follows simple\n commands, oriented x2, unsure of date. Patient grimaces with\n movement/turning, does not c/o pain despite grimacing. Pupils are\n unequal .Rt >left & rt pupil non-reactive ( S/P cataract sx).\n Action:\n On standing Tylenol for pain control. Morphine ivp dc\nd AMS,\n started on PRN tramadol- rec\nd 1 dose this shift. Lidocaine patch\n applied. Reoriented as needed.\n Response:\n Pt seeming more interactive as shift progressed. Oriented x2, able to\n make needs known. Pain control remains an issue, per non-verbal\n ques/grimace scale pt does not seem adequately controlled.\n Plan:\n Team aware of ongoing pain issue, plan is to involve pain service once\n resp. status improved/pt is less acutely ill. Cont. PRN tramadol and\n standing Tylenol. Cont. to reorient as needed.\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705901, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705902, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 08:29 PM\n FEVER - 101.4\nF - 01:00 AM\n - ID agrees with current abx covg, rec checking random vanoc level\n tomorrow; serial BCX, rpt sputum.\n - ECHO showing worsened MR, Ao valve poorly visualized\n - MR read showing possbie ongoing discitis/osteo\n - Pt decompensated from respiratory point of view: tachycardic over the\n course of the day with HR in 110-120, but btw 1 and 2am, became tachy\n to 150s sinus with increased WOB. Sats down and had to be switched to\n NRB. Neither wheezy nor particualry wet on exam. Nebs somewhat helpful.\n Also got lopressor IV 5mg x 1. CXR showing significant interval\n progression of RLL opacification. Subequntly breathing comfortably on\n NRB with rr~18-20.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 03:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.4\nC (99.3\n HR: 100 (89 - 168) bpm\n BP: 118/51(67) {99/42(59) - 143/74(91)} mmHg\n RR: 15 (15 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n PO:\n TF:\n IVF:\n 650 mL\n Blood products:\n Total out:\n 1,215 mL\n 320 mL\n Urine:\n 915 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 7.7 g/dL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n .\n # Fevers: Patient was changed from Ampicillin/CTX to Daptomycin \n rash. patient then began to have worsening fevers and lethary at\n rehab. Main concern is for recurrence of epidural abscess.\n Neurosurgery has been consulted and recommend MR . Patient also\n has Aortic Vegetation seen on TEE during last admission, which may have\n progressed to an abscess. will order repeat ECHO for evaluation.\n Other possibilities include meningitis given AMS as well as abcess\n formation in brain from previously known septic emboli. CXR done on\n arrival to ICU showed increasing RLL infiltrate concerning for PNA vs\n Aspiration Pneumonitis. Will need to follow imaging to confirm whether\n PNA vs Pneumonitis. UA with no pyuria but +bacteria, many yeast,\n catheter changed in ED.\n -- cont Vanco/Aztreonam\n -- MR \n -- MR \n -- ECHO in AM\n -- send c.diff\n -- f/u Neurosurgery recs\n -- repeat CXR tomorrow in AM\n -- send blood cultures/UA/UCx\n .\n # AMS: Likely fevers and likely infection. CT Head done in ED\n shows no signs of acute hemorrhage or infarction. Patient was given\n Morphine 4mg IV x 3 in ED which may have contributed to AMS\n -- cont to monitor\n -- hold Morphine\n .\n # Right Atrial Appendage Thrombus: INR 2, OSH records do not report\n Coumadin on med list in morning, will confirm in AM.\n -- confirm anticoagulation meds in AM\n -- follow PT/INR\n .\n # Epidural Abscess s/p L5-S1 laminectomy: Nsurg consulted as above.\n will need to perform MR for evalution to determine if there is\n recurrence of abscesses\n -- MR in AM\n -- f/u Nsurg recs\n .\n # Enterococcal Bacteremia: Developed rash to Amp/CTX changed to dapto,\n now spiking fevers.\n -- f/u blood cultures\n -- cont Vanco/Aztreonam as above\n .\n # Asthma:\n -- Ipratropium nebs PRN\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n # PPX: PPI, anticoagulated, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705920, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing osteo of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n #Acute respiratory distress: initially tachypneic and on NRB- improved\n after a nebulizer with oxygen weaned to 4 liters n.c. This likely\n represents PNA vs aspiration with underlying asthma\n - Wean oxygen as tolerated\n - nebulizers prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705923, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Acutely hypoxemia and tachycardia overnight with worsening CXR.\n Placed on NRB. Somewhat improved with lopressor and nebs.\n - ID consult recommended continuing Vanc and aztreonam\n - TTE: Worsening MR, poorly visualized aortic valve\n - L-spine MRI: Prelim read with possible ongoing discitis and\n osteomyelitis of L5-S1\n - Tm 101.4\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:58 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:13 AM\n Metoprolol - 12:30 AM\n Other medications:\n colace, Lidocaine TD, PPI, Vanc, gabapentin, Aztreonam, tylenol,\n albuterol/atrovent neb,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 100 (89 - 168) bpm\n BP: 111/46(61) {99/42(59) - 143/74(91)} mmHg\n RR: 17 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,650 mL\n 100 mL\n PO:\n TF:\n IVF:\n 650 mL\n 100 mL\n Blood products:\n Total out:\n 1,215 mL\n 480 mL\n Urine:\n 915 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,435 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 264 K/uL\n 129 mg/dL\n 2.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 109 mEq/L\n 140 mEq/L\n 24.1 %\n 8.7 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n 03:30 AM\n WBC\n 12.9\n 8.7\n Hct\n 25.8\n 24.1\n Plt\n 264\n 264\n Cr\n 2.3\n 2.5\n TropT\n 0.07\n TCO2\n 23\n Glucose\n 108\n 95\n 129\n Other labs: PT / PTT / INR:28.8/49.6/2.8, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Imaging: CXR - Worsening RLL infiltrate\n Microbiology: Blood 11/4: GPCC in anerobic bottle. Other cultures\n negative. Urine cx pending. Sputum: >20pmn, <10 epis, oropharyngeal\n flora. C. diff negative.\n Assessment and Plan\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic emboli to brain, NSTEMI, RA\n thrombus, and temporary HD for gadolinium exposure -- d/c'ed to rehab\n on ampicillin and CTX x 6 weeks. Developed drug rash at rehab and\n switched to daptomycin and then started developing fevers, lethargy and\n AMS. Trasferred here for further management. Noted to have worsening\n RLL infiltrate and GPCC bacteremia.\n # Fevers: Likely due to RLL pneumonia. Also osteomyelitis and\n discitis may be contributing. Positive blood culture may be a\n contaminant.\n - Copntinue vanc and aztreonam per ID\n - F/U final read of L-spine MR\n - F/U cultures and GPCC speciation (if enterococcus, would treat for\n another 6 weeks for endocarditis)\n - Continue vanc for enterococcus endocarditis\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Restart coumadin\n #Acute respiratory distress: Likely PNA with h/o asthma.\n - Wean oxygen as tolerated\n - Nebulizers prn\n - Continue antibiotics\n ICU Care\n Nutrition: NPO, SLP consult\n Glycemic Control:\n Lines:\n 18 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Echo", "chartdate": "2146-10-24 00:00:00.000", "description": "Report", "row_id": 84461, "text": "PATIENT/TEST INFORMATION:\nIndication: Prior aortic vegetation. Recurrent enterococcus bacteremia. Rule out recurrent endocarditis.\nHeight: (in) 55\nWeight (lb): 140\nBSA (m2): 1.51 m2\nBP (mm Hg): 140/75\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:35\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of\nthe RA. Good RAA ejection velocity (>20cm/s). No thrombus in the RAA.\nLipomatous hypertrophy of the interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTA: Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Small vegetation on\naortic valve. Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nLeft pleural effusion.\n\nConclusions:\nNo spontaneous echo contrast or mass/thrombus is seen in the left atrium/left\natrial appendage. Mild spontaneous echo contrast is seen in the body of the\nright atrium. No thrombus or spontaneous echo contrast is seen in the body of\nthe right atrium or right atrial appendage (heavily trabeculated). Right\natrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect\nis seen by 2D or color Doppler. Overall left ventricular systolic function is\nnormal (LVEF>55%). There are complex (>4mm, non-mobile) atheroma in the\ndescending thoracic aorta and aortic arch. The aortic valve leaflets (3) are\nmildly thickened. A small vegetation (4mm) is seen in the LVOT side of the\naortic valve. There is no associated abscess. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is\nseen. There is a trivial/physiologic circumferential pericardial effusion.\n\nIMPRESSION: Mild-moderate aortic regurgitation with small vegetation. Mild\nmiltral regurgitation. No intra-atrial thrombi identified.\nCompared with the prior TEE study (images reviewed) of , severity of\naortic regurgitation is greater and the aortic valve vegetation is smaller.\nThe previously noted right atrial appendage thrombus appears to be\ntrabeculations in the RAA.\n\n\n" }, { "category": "Echo", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 84462, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 122/51\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 12:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. A vegetation or abscess cannot be adequately excluded. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is a small\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , mitral\nregurgitation is now more prominent.\nUnable to adequately compare presence/absence or size of aortic valve\nvegetation identified in the transesophageal echocardiogram. The\nsmall pericardial effusion appears similar.\n\n\n" }, { "category": "Physician ", "chartdate": "2146-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 705770, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 76 y/o male with h/o asthma, gout and recent complicated hospital\n course including epidural abscess requring surgery, enterococcus\n bactermia, aortic endocarditis, septic embolit to brain, NSTEMI, and\n temporary HD for gadolinium exposure -- d/c'ed to rehab on ampicillin\n and CTX x 6 weeks. Developed drug rash at rehab and switched to\n daptomycin and then started developing fevers, lethargy and AMS.\n Trasferred here for further management.\n In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR\n was done which showed no acute process. Neurosurgery was consulted and\n recommended repeat MRI, however, patient was rigoring so decision was\n made to hold on MRI. ID called and recommended change to Vanco and\n Aztreonam. LP deferred given recent surgery and concerns over\n recurrent epidural abscess per neurosurgery. Also received morphine\n 12mg for pain.\n In ICU, on NRB and tachypneic. Weaned to 4 L once less agitated. Only\n oriented to person. Diffuse body pain to touch. Picc line pulled and\n tip sent for culture.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Altered mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Aztreonam - 07:21 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:20 AM\n Other medications:\n Rehab meds: Dapto, senna/colase, gabapentin, metoprolol, amlodipine,\n coumadin, prevacid, pain meds\n Past medical history:\n Family history:\n Social History:\n - Epidural abscess\n - Possible septic emboli vs infarcts to brain\n - Aortic endocarditis\n - RA thrombus\n - Asthma\n - Gout\n - BPH\n - CKD\n - Cataract surgery\n Non-contributory\n Occupation:\n Drugs: Denies\n Tobacco: Quit 25 years ago\n Alcohol: Denies\n Other: Born in , English speaking\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38\nC (100.4\n HR: 97 (97 - 121) bpm\n BP: 118/50(67) {107/48(64) - 148/78(95)} mmHg\n RR: 15 (13 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,234 mL\n PO:\n TF:\n IVF:\n 234 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,679 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/37/76 on 4L NC\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Surgical pupil on R\n Head, Ears, Nose, Throat: Normocephalic, Dried blood in mouth, ulcers\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Anasarca\n Skin: normal turgor, warm, no rashes\n Neurologic: Responds to: verbal commands, Oriented (to):\n Person/Place/Year, Movement: Wiggles b/l toes, Tone: Not assessed\n Labs / Radiology\n 264 K/uL\n 25.8 %\n 8.0 g/dL\n 95 mg/dL\n 2.3 mg/dL\n 25 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.0 mEq/L\n 140 mEq/L\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:32 AM\n 03:34 AM\n WBC\n 12.9\n Hct\n 25.8\n Plt\n 264\n Cr\n 2.3\n TropT\n 0.07\n TC02\n 23\n Glucose\n 108\n 95\n Other labs: PT / PTT / INR:23.4/40.8/2.2, CK / CKMB /\n Troponin-T:213/3/0.07, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Lactic Acid:1.6 mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR - Initially clear, but then developed RLL infiltrate on\n repeat after IVF.\n Head CT - Motion artifact, but nothing acute.\n Microbiology: None. U/A mod bacteria and many yeast, no WBC.\n From rehab:\n - C. Diff neg, stool cx negative\n , , - Blood cultures NGTD.\n Assessment and Plan\n 76 yom with history of Asthma, Gouth, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abcess and bactremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy.\n # Fevers: Multiple sources -- Possible conversion of septic emboli in\n brain to abscess. Also with aortic endocarditis. Infiltrate on CXR\n and oxygen requirement concerning for PNA or aspiration. Menigitis is\n less concerning given improvement of mental status now that morphine\n has worn off. Foley changed in ED.\n - TTE to evaluate for abscess or progression of endocarditis\n - Blood / urine cultures, repeat U/A, c. diff\n - Repeat MR head and spine (will be coordinated with renal given\n decreased GFR and need for gadolinium)\n - Copntinue vanc and aztreonam per ID\n - ID consult\n - Repeat CXR in am\n # AMS: Likely fevers and morphine. CT Head done in ED shows no\n signs of acute hemorrhage or infarction. Improved this am.\n -- Cont to monitor\n -- Hold Morphine\n # CRI: At baseline, but low GFR concerning for gadolinium\n administration.\n - Discuss contrast with renal\n # Pain: Altered on morphine. Has been poorly controlled at baseline.\n - Try non-narcotic regimen.\n - Consider pain consult if not controlled with abovel.\n # Right Atrial Appendage Thrombus: Started on coumadin during last\n hospitalization.\n - Hold coumadin given possible procedures today\n - Start heparin if INR < 2\n #Acute respiratory distress: initially tachypneic and on NRB- improved\n after a nebulizer with oxygen weaned to 4 liters n.c. This likely\n represents PNA vs aspiration with underlying asthma\n - Wean oxygen as tolerated\n - nebulizers prn\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:05 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707838, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n This pm started having muscle twitching of right\n shoulder. Awake at the time and able to nod to questions. Dr\n made aware. Will see if she can find a muscle relaxant that\n will not effect his level of awakeness.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile. Temp max 98.2.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400. resp around 9 with tv around 700cc. sats 98%.\n Abg 7.44/44/103/31/ . Rested on 5 and 5.\n Plan:\n ? extubate in am.\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Cont to sleep when not stimulation. When stimulated awakens and obeys\n commands. Nods to questions.\n Plan:\n Wean Fentanyl drip further tomorrow.\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc. Wife in later in\n day and updated on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707942, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707944, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Extubate today\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever. Now\n afebrile x 24 hours.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responsive today. Head CT unremarkable.\n - Off sedation\n - Will assess pain once extubated and consider pain consult\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO. Will need formal assessment for aspiration before\n starting any POs.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707946, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Will need formal speech and swallow consult prior to starting po\n Without ngt at present.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Rehab Services", "chartdate": "2146-11-02 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 707948, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: respiratory failure / 088.81\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 76 yo M with recent\n admission enterococcal aortic valve endocarditis, NSTEMI, ARF,\n and L5 epidural abscess s/p laminectomy. He is now admitted from rehab\n on with fevers and lethargy c/w aspiration pneumonia and was\n subsequently intubated for dense large R-sided infiltrate. Extubated\n .\n Past Medical / Surgical History: BPH, gout, CKD\n Medications: aspirin, heparin, tylenol, amiodarone, gabapentin,\n fentanyl, lactulose, hydralazine, daptomycin\n Radiology: CXR - Increasing opacification at the left base in the\n retrocardiac region is consistent with substantial left lower lung\n atelectasis\n Labs:\n 23.0\n 7.1\n 380\n 9.1\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest, ok for EOB activity\n Social / Occupational History: retired, lives with wife and family.\n more recently at rehab.\n Living Environment: multi-level home with flight of stairs to enter\n Prior Functional Status / Activity Level: Ind prior to initial\n admission, more recently at rehab however per daughter has not been\n mobilizing there.\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic but easily\n arousable, follows all simple commands, oriented to self and place,\n . Hypophonic, minimally verbal.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 90\n 162/50\n 97% on FT\n Activity\n 92\n 185/62\n 96% on FT\n Recovery\n 90\n 152/52\n 96% on FT\n Total distance walked:\n Minutes:\n Pulmonary Status: coarse upper BS R>L, strong congested cough, did not\n expectorate. Tolerated gentle percussion to B lung fields in sitting.\n On 40% FiO2 via face tent.\n Integumentary / Vascular: L radial a-line, RIJ multilumen, foley,\n rectal tube, R PIV, tele\n Sensory Integrity: B LE's intact to light touch, denies parasthesias\n Pain / Limiting Symptoms: denies pain however grimaces with LLE ROM and\n mobility, hypersensitive\n Posture: mild kyphosis\n Range of Motion\n Muscle Performance\n B LE's grossly WNL, B gastroc tightness\n moves BLE extremities against gravity, not tolerating resistance.\n B UE's grossly t/o\n Motor Function: rapid flexion reaction to ROM LLE.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: not assessed\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: able to maintain static sitting at edge of bed with min-mod A.\n Tolerated sitting at edge of bed for several minutes, limited by\n increased BP requiring return to supine.\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n 5.\n Impaired pulmonary hygiene\n 6.\n Increased pain\n Clinical impression / Prognosis: 76 yo M with respiratory failure p/w\n above impairments a/w ventilatory pump dysfunction. He is most limited\n by general weakness and deconditioning a/w prolonged icu\n hospitalization and bedrest, as well as Le hip and knee pain. He is\n significantly below his baseline level and would recommend rehab upon\n d/c. Prognosis remains guarded given his age and prolonged and\n complicated medical course, however would anticipate fair to good rehab\n potential given his prior level of function and his home support. PT\n to continue to follow and progress as able at acute level.\n Goals\n Time frame: 1 week\n 1.\n Mod A bed mobility, assess transfers\n 2.\n CG static/dynamic sitting, assess standing balance\n 3.\n Tolerate OOB >/= 2 hours/day\n 4.\n Tolerates daily strengthening\n 5.\n Able to clear secretions independently\n 6.\n Tolerates PT/OOB mobility despite pain\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, ambulation, balance, strengthening, chest PT,\n endurance, education, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707951, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707952, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events- Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds will be held tonight including neurotin and amiodarone.\n Dr aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Extubated at 1115. pos cuff leak prior to\n extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Weaned to 2l nc with sats in mid 90\ns. Could not get the grasp of how\n to use is. Encouraged to take deep breaths and cough which he does\n well. Coughing and raising thick yellow sputum.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708045, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708046, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics, on Dapto for treatment of Enterococcus.\n SBT went well this morning, not extubated and doing well on face tent.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS done yesterday negative for clot. Left knee not tender to\n palpation today, less concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/rising leukocytosis: Improved today, afebrile overnight,\n likely drug fever/rash, now improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708218, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n ( drug fever and rashes from other antibiotics)\n # Pain:\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708223, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708228, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708232, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n - Auto\ndiuresed overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: voice\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg] ALT 43, AST 32, Alk phos 165, LDH 262\n Sputum: S aureus\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - continue 2 week course of Dapto\nfinal day \n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: resolved.\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - Increase metoprolol to 37.5 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , d/c amiodarone today\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ, PICC line placement today\n # CODE: Full Code\n # DISPO: case management re: d/c to LTAC tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708348, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n ULTRASOUND - At 01:00 PM\n of right arm\n PICC LINE - START 02:53 PM\n RUE US: + for superficial cephalic vein clot\n PICC line placed\n Has a bed for rehab\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 85 (80 - 96) bpm\n BP: 130/58(75) {128/57(75) - 175/88(100)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 937 mL\n PO:\n TF:\n 836 mL\n 244 mL\n IVF:\n 455 mL\n 393 mL\n Blood products:\n Total out:\n 2,415 mL\n 370 mL\n Urine:\n 1,915 mL\n 370 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 765 K/uL\n 7.8 g/dL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presented from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - continue 2 week course of Dapto\nfinal day \n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: resolved.\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - Increase metoprolol to 37.5 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , d/c amiodarone today\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ, PICC line placement today\n # CODE: Full Code\n # DISPO: case management re: d/c to LTAC tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708355, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in 180\ns in the begning of shift\n Action:\n Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and\n Lopressor\n Response:\n Sbp in the 140\ns. Of not his cuff for bp is on his leg as he has a picc\n on the left arm and a clot is his right arm.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707386, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Suctioning yellow secreations via ett lung sound diminished in bases\n pt remains on a lasix drip at 2 mg /hr.\n Response:\n pending\n Plan:\n Wean vent\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n Cont on neurontin, Grimacing for any simple touch on him, Bolused w/\n Fentanyl and versed before doing any care on him. MRI done result\n pending.\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Follow MRI result and neuro team, ? pain consult.\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707390, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: )\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP\n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707543, "text": "Chief Complaint: AMS, aspiration\n HPI:\n I saw and examined the patient, and was physically present with Dr.\n for key portions of the services provided. I agree with the\n medicine resident note and would add / emphasize and add the following\n points:\n 24 Hour Events:\n Fever to 102, PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n - MRI per ID and NeuroSurg not concerning for new infectious process\n - Taper MRI\n - Versed gtt d/c\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Lidoderm patch, ASA, Lipitor. Fentanyl patch, Neurontin, Amiodarone\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), RRR\n Peripheral Vascular: (Right radial pulse: palpable), (Left radial\n pulse: palpable), (Right DP pulse: palpable), (Left DP pulse: palpable)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilaterally )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: No rash\n Ext: Bilat LE edema to mid shin, warm L knee, L ankle, no effusion\n Neurologic: Responds to: painful stimuli, moves extremities to stimuli;\n no spont movement\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Sputum\n MRSA\n Urine legionella Negative\n C Diff negative\n Blood Cx NGTD\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, mental status is main barrier\n currently to extubation.\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout,\n Rheum eval for ?tap ?gout\n if ID w/u is otherwise negative, would\n consider pred for gout flare.\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition: On TFs\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: PPI\n VAP: HOB at 30 degrees, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Pt is critically ill.\n Total time spent: 35 min\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707619, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707620, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -stop Lasix gtt as UOP decreased on 12mg/hr\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today and SBT\n - ET tube at 8cm yesterday will f/u today and advance ET as needed\n # L leg contracture: Given tenderness of Left knee on exam, likely \n gouty arthritis\n -patient given prednisone this morning but will hold off on more\n prednisone for now, will consult Rheum for definitive diagnosis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest today to look for intraabdominal source, pulmonary\n source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2146-10-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 707314, "text": "Objective\n Pertinent medications: Fentanyl drip, versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole\n Labs:\n Value\n Date\n Glucose\n 108 mg/dL\n 05:41 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 46 mg/dL\n 05:41 AM\n Creatinine\n 2.5 mg/dL\n 05:41 AM\n Sodium\n 141 mEq/L\n 05:41 AM\n Potassium\n 4.1 mEq/L\n 05:41 AM\n Chloride\n 106 mEq/L\n 05:41 AM\n TCO2\n 28 mEq/L\n 05:41 AM\n PO2 (arterial)\n 251 mm Hg\n 06:01 AM\n PCO2 (arterial)\n 43 mm Hg\n 06:01 AM\n pH (arterial)\n 7.44 units\n 06:01 AM\n pH (urine)\n 5.0 units\n 08:35 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 06:01 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.2 mg/dL\n 05:41 AM\n Phosphorus\n 3.7 mg/dL\n 05:41 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.0 mg/dL\n 05:41 AM\n ALT\n 58 IU/L\n 04:15 AM\n Alkaline Phosphate\n 203 IU/L\n 04:15 AM\n AST\n 36 IU/L\n 04:15 AM\n Total Bilirubin\n 0.6 mg/dL\n 04:15 AM\n WBC\n 12.9 K/uL\n 05:41 AM\n Hgb\n 8.0 g/dL\n 05:41 AM\n Hematocrit\n 25.2 %\n 05:41 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren 2.0 @ 42ml/hr\n GI: soft/distended, (+) bowel sounds; loose-liquid stool\n Assessment of Nutritional Status\n Specifics:\n Patient with aspiration PNA with dense, large R-sided infiltrate, now\n improving, (+) persistent fevers. Tube feed changed to very\n concentrated formula as team trying to diuresis patient.\n Currently, tube feed running at 40ml/hr. Liquid/loose bm after 3 days\n of polyethylene glycol. Possible extubation over the weekend. Noted\n lytes/ FSBG WNL.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Increase tube feed to goal of\n 42ml/hr = calories and 81g protein\n o Check residuals, hold tube feed if greater than 200ml\n Bowel regimen PRN\n Check chemistry 10 panel\n If extubated, recommend NPO until seen by SLP for bedside\n evaluation\n SLP deferred evaluation due to intubation\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707612, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Cont on fentanyl GTT still grimacing w/ activity but relatively less.,\n Fent weaned to 50mics/kg/min.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% CMV/10/5/5\n Action:\n No vent changes overnight. Suctioned for moderate amount blood tinged\n secretion\n Response:\n Pending\n Plan:\n Continue to attempt to wean sedation and ?\ning extubation in the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 40-60cc u/o.\n Action:\n monitiring\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708402, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC placed yest, RUE US yest with superficial cephalic v clot.\n History obtained from Medical records\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Lidocaine patch, ASA, Heparin SC, Lipitor, Neurontin, fentanyl patch,\n hydralazine, amlodipine, metoprolol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 78 (78 - 90) bpm\n BP: 142/71(89) {128/54(72) - 175/88(100)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 1,443 mL\n PO:\n TF:\n 836 mL\n 468 mL\n IVF:\n 455 mL\n 425 mL\n Blood products:\n Total out:\n 2,415 mL\n 630 mL\n Urine:\n 1,915 mL\n 630 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, 2+ UE edema bilaterally\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.8 g/dL\n 765 K/uL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Imaging: RUE US- superficial cephalic v clot.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA now\n improving and extubated .\n HAP/aspiration PNA + pulmonary edema- Extubated and resolved\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n - repeat echo without abscess or vegetations\n L5-S1 discitis/ osteomyelitis: stable from to MRI\n -will touch base re: f/u and tx for this as separate from endocarditis\n Hypernatremia: stabilized and not improved with increased free H2O\n flushes yest\n - cont enteric free H20, will give 500cc D5W today as well and monitor\n RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n Afib RVR: resolved\n - now off amio and in sinus\n - no anticoag at this time, will f/u with Cards as an outpt\n HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n Aspiration risk: Failed swallow study with tachypnea, desaturation and\n evidence of applesauce in pharynx.\n - Dobhoff placed and will cont tube feeds\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Comments: 250 q4 free H2O\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 45 minutes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707277, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains minimally vent supported on PSV/CPAP. No changes made\n overnight. Administering Albuterol and Atrovent MDI\ns as ordered.\n Legionella cx sent. See flowsheet for further pt data. Will follow,\n wean as tolerable.\n 06:15\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707280, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt has remained febrile and with neg cultures to date. Hemodynamically\n stable.\n Action:\n Clindamycin d/c\nd and stool for Cdiff sent. Results are pending at this\n time. Otherwise continues on antibiotic regimen.\n Response:\n Hemodynamically stable, + MRSA in sputum- amounts continue to increase.\n Plan:\n Cont abx, monitor temp, f/u on cx data, sxn prn. Replete lytes PRN\n Transfused 1U PRBC\ns last evening. Pt is a difficult cross match-\n blood from blood bank. Resident aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on CPAP/PS 50% and in no apparent distress. Abd/Chest CT,\n awaiting official read.\n Action:\n Sxned q2-4h mod. to copious amounts of pink tinged frothy/thick\n sputum. No vent changes o/n. Lasix gtt infusing at 3mg/hr. Plan to\n run pt. -2 liters.\n Response:\n O2sat remains >96%. Pt does not appear to be in any distress.\n Tolerating Lasix gtt well- hemodynamically stable. Pt. met goal of -2.5\n liters at midnight.\n Plan:\n Daiily CXR\ns, diurese for goal 2L q 24 hours. Titrate Lasix gtt for\n UOP > or = to 100cc/hr. Monitor o2sat and LS\ns. sxn prn. CT results\n pending. Team is hoping to extubate pt during the weekend. Will also\n need to touch base with family regarding goals and plan of care.\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707290, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707374, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation \n RSBI 18\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 2330\n MRI L-spine without incident\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707499, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707456, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contracted. MRI of spine\n showed no changes from previous one, no abscess or cord compression\n noted. When not stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl and Versed with any activity. PO Neurontin\n increased to 300mg PO bid and increased Fentanyl patch from 100mcq to\n 200mcq.\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently..\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results. IV antibx\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707526, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707721, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500. NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708365, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in 180\ns in the begning of shift\n Action:\n Received hydralazine 10mg IVP and Cont on hydralazine, amlodipine, and\n Lopressor\n Response:\n Sbp in the 140\ns. Of not his cuff for bp is on his leg as he has a picc\n on the left arm and a clot is his right arm.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n ------ Protected Section ------\n Screening for rehab, Follow up w/ case manager in am.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:47 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707369, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Suctioning this yellow secreations out or mouth and yellow secreation\n via ett lung sound diminished in bases pt remains on a lasix drip at 2\n mg /hr\n Response:\n pending\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707502, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -daily chest x-rays\n # L leg contracture: Concerning for central process vs. gouty\n arthiritis of knee given history of gout.\n -f/u MRI read\n -speak with neurosurgery regarding read\n -would not treat with gout medications right now given renal function.\n If above are negative, consider prednisone for gouty arthritis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -increase gabapentin to 300 po tid\n -increase Fentanyl patch to 200mcg/72 hours\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n -repeat C diff\n -consider CT abdomen to look for intraabdominal source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n - change to Amio 200 tid starting \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: continue to follow\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707503, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contracted. When not\n stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl with any activity. Versed GTT turned off @\n 0500\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently Lasix GTT 12mg /hr urine\n output 110-160ml/hr.\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 102 PO 0400\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results. IV antibx\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707516, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 min\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708035, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc12.2 down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707600, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Cont on fentanyl GTT still grimacing w/ activity but relatively less.,\n Fent weaned to 50mics/kg/min.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% CMV/10/5/5\n Action:\n No vent changes overnight. Suctioned for moderate amount blood tinged\n secretion\n Response:\n Pending\n Plan:\n Continue to attempt to wean sedation and ?\ning extubation in the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 40-60cc u/o.\n Action:\n monitiring\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Respiratory ", "chartdate": "2146-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707603, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Comments: ETT advanced ~ 3 cm.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments: Low resp drine. Placed on MMV. Will atemp to place back on\n PSV.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~26.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707715, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli , obey simple commands at times. Was seen by pain mx\n yesterday . Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt\n stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head .\n Plan:\n Wean Fentanyl Gtt as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500. NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707588, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was Remains on Fentanyl Gtt.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd on Lasix Gtt @ 12mg/hr with only 40-60cc u/o. BUN/Cre elevated to\n 49/2.5 from 46/2.2. K+4.5.\n Action:\n Lasix Gtt was d/c\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707705, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.5\nF - 08:00 AM\n CT Head done yesterday was negaive for stroke or bleed.\n CT Chest/ABD/Pelvis:\n IMPRESSION:\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n 2. Stable moderate bilateral pleural effusions.\n 3. No source of infection identified within the abdomen or pelvis.\n Vanco level 11.7, was redosed to 750mg qdaily\n Lasix gtt stopped as he was not responding to 12mg/hr, 2L UOP by\n midnight without lasix\n Left leg continues to be contracted, Rheum consulted out of concern for\n Gout, but do not believe this represents Gout. Prednisone started\n initially but then stopped. Allopurinol also started and stopped as it\n is contraindicated to start during an acute flare. Rheum recommended\n speaking to radiology regarding left hip. Rads called, left hip on CT\n scan shows no abnormalities.\n Nurse overnight noted blanching macular/papular over body. Vanco held\n this morning. ID notified\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 12:11 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 36.9\nC (98.4\n HR: 87 (66 - 97) bpm\n BP: 133/48(74) {109/40(62) - 158/54(87)} mmHg\n RR: 9 (7 - 15) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 542 mL\n PO:\n TF:\n 886 mL\n 317 mL\n IVF:\n 1,179 mL\n 225 mL\n Blood products:\n Total out:\n 1,895 mL\n 310 mL\n Urine:\n 1,895 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 232 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 993 (434 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 3.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 575 K/uL\n 8.1 g/dL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n Glucose\n 121\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS now MMV apnea . CXR\n subsequently worsesend with reduced PEEP likely increased\n atelectasis. On Vanc (day 11 of 14) /Aztreonam (day 11 of 14)/ Clinda\n stopped on day 7 of 10\n -MMV\nPSV, wean sedation to decrease apnea\n -stop Vanc/Aztreonam for PNA per ID given course to date and rash\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today; c/s pain service for assistance\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:19 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Respiratory ", "chartdate": "2146-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707822, "text": "Demographics\n Day of mechanical ventilation: 13\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n ETT:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n :\n Comments: passed sbt. Good abg. Plan extubation tomorrow.\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707923, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707924, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - BLENIS negative\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.8\n HR: 80 (74 - 97) bpm\n BP: 123/39(64) {108/38(60) - 168/55(94)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 414 mL\n PO:\n TF:\n IVF:\n 419 mL\n 204 mL\n Blood products:\n Total out:\n 2,650 mL\n 595 mL\n Urine:\n 1,450 mL\n 595 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 715 (521 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: 7.42/48/155/29/6 on SBT\n Ve: 5.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 690 K/uL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n WBC\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 524\n 575\n 626\n 690\n Cr\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n 32\n Glucose\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Microbiology: Sputum - GPC, yeast. Urine - yeast.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Extubate today\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever. Now\n afebrile x 24 hours.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responsive today. Head CT unremarkable.\n - Off sedation\n - Will assess pain once extubated and consider pain consult\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO. Will need formal assessment for aspiration before\n starting any POs.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707928, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707929, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday. Drug rash all\n over body slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Exttubated at 1115. pos cough leak prior\n to extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707931, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n GEN: Intubated, awake, responding to commands appropriately\n CVS: +S1/S2, no M/R/G, RRR\n LUNGS: CTAB in anterior lung fields\n ABD: +BS, soft, NT/ND\n EXT: +b/l upper extremity and lower extremity peripheral edema, +2\n pulses, no rashes, no TTP of left knee\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics, on Dapto for treatment of Enterococcus.\n SBT went well this morning, not extubated and doing well on face tent.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS done yesterday negative for clot. Left knee not tender to\n palpation today, less concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n # Fevers/rising leukocytosis: Improved today, afebrile overnight,\n likely drug fever/rash, now improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707343, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Pt been on since around 12 noon, suctioning this yellow secreations\n out or mouth and yellow secreation via ett lung sound diminished in\n bases pt remains on a lasix drip at 2 mg /hr\n Response:\n Abg on above settings 7.42/45/116\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707423, "text": "Chief Complaint: Aspiration, Atrial Fibrillation\n HPI:\n 24 Hour Events:\n -- Found to have contracted LLE contracture, concern for cord\n compression, obtained MRI after discussion with Neurosurgery\n -- Marked pain, P-boots d/c\nd, neurontin increased\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Other medications:\n ASA, Amiodarone, Hep sc, Lipitor, atrovent, neurontin, lidoderm patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: bounding), (Left radial\n pulse: bounding), (Right DP pulse: dopplerable), (Left DP pulse:\n Dopplerable)\n Respiratory / Chest: (Breath Sounds: Crackles and Diminished at bases:\n )\n Skin: Not assessed\n Ext: L knee flexed, slightly warm, anasarcic\n Neurologic: Grimaces in pain\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Urine Culture\n Pending\n C. Diff\n Negative x2\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: Protonix\n VAP: Chlorhexidine, Elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2146-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707347, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt changed to CPAP/PS today.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707350, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on vent now on / 450/ 40%\n Action:\n Pt been on since around 12 noon, suctioning this yellow secreations\n out or mouth and yellow secreation via ett lung sound diminished in\n bases pt remains on a lasix drip at 2 mg /hr\n Response:\n Abg on above settings 7.42/45/116\n Plan:\n Plans are to decrease sedation tonight and try to extubate tomorrow\n Chronic Pain\n Assessment:\n Pt remains on 100 mcgs of Fentanyl and versed 2 mg/hr having pain with\n turning, noted this afternoon pt would no straighten L leg seems more\n contracted, and is in pain when we move that leg\n Action:\n We added fent patch this afternoon, and Increased neuronton today\n Response:\n Pt still requiring fent boluses with turning\n Plan:\n Plan to call neuro service about left hip.\n ------ Protected Section ------\n Consult came by neurosurg tonight because of contracture of left hip,\n will be put in for an mri tonight, for rule out cord compression.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:52 ------\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707433, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving\n slowly, but now with increased pain.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch. Responds to painful stimuli,\n but can not obey commands. L leg remains contact. MRI of spine showed\n no changes from previous one, no abscess or cord compression noted.\n When not stimulated appears comfortable.\n Action:\n Rec\ning boluses of Fentanyl and Versed with any activity. PO Neurontin\n increased to 300mg PO bid and increased Fentanyl patch from 100mcq to\n 200mcq.\n Response:\n Remains in a great deal of pain with any movement or touch.\n Plan:\n Continue with Fentanyl Gtt, and administer PO Neurontin and Fentanyl\n patch. Consult Pain Service.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n No vent changes made, suctioning frequently..\n Response:\n Remains vented.\n Plan:\n Continue with pulmonary toilet, monitor O2 sats and ABG\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remains on Aztreonam IV.\n Response:\n ?\ning source of fevers,\n Plan:\n Monitor temps, check culture results.\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707358, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n RRR, no mr/r/g, lungs clear on anterior exam, 2+ pitting edema in lower\n ext., hyperesthesia over lower exts. Abd mildly TTP diffusely, no\n guarding or rebund, warm ext\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 9 of 14) /Aztreonam (day 9 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707811, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400. resp around 9 with tv around 700cc. sats 98%.\n Abg 7.44/44/103/31/ . Rested on 5 and 5.\n Plan:\n ? extubate in am.\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Cont to sleep when not stimulation. When stimulated awakens and obeys\n commands. Nods to questions.\n Plan:\n Wean Fentanyl drip further tomorrow.\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708032, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc12.2 down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707410, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Chronic Pain\n Assessment:\n On Fentanyl Gtt @ 100mcq, Versed @ 2mg, appears to be in great deal of\n pain with any activity or just to touch.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS-5 Peep-5 FIO2-40% with O2 sats\n 93-97%. Suctioning frequ for mod amts thick tan secretions.\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp spike to 101.4 PO this AM with elevated WBC- 14.5.\n Action:\n Was fully cultured, remain on Aztreonam IV.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707413, "text": "Chief Complaint: Aspiration, Atrial Fibrillation\n HPI:\n 24 Hour Events:\n -- Found to have contracted LLE contracture, concern for cord\n compression, obtained MRI after discussion with Neurosurgery\n -- Marked pain, P-boots d/c\nd, neurontin increased\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Other medications:\n ASA, Amiodarone, Hep sc, Lipitor, atrovent, neurontin, lidoderm patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.8\n HR: 90 (79 - 92) bpm\n BP: 165/49(80) {84/41(62) - 182/89(104)} mmHg\n RR: 17 (12 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 591 mL\n PO:\n TF:\n 1,172 mL\n 313 mL\n IVF:\n 678 mL\n 278 mL\n Blood products:\n Total out:\n 2,825 mL\n 310 mL\n Urine:\n 2,825 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 677 (416 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.42/45/116/29/4\n Ve: 12.1 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: bounding), (Left radial\n pulse: bounding), (Right DP pulse: dopplerable), (Left DP pulse:\n Dopplerable)\n Respiratory / Chest: (Breath Sounds: Crackles and Diminished at bases:\n )\n Skin: Not assessed\n Ext: L knee flexed, slightly warm, anasarcic\n Neurologic: Grimaces in pain\n Labs / Radiology\n 8.1 g/dL\n 427 K/uL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Urine Culture\n Pending\n C. Diff\n Negative x2\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP, goal -1L/24hrs\n - Bronchodilators\n - Weaned PS to now, CXR improved, but still poor mental status\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday , tapering. Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: Protonix\n VAP: Chlorhexidine, Elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent: 25\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707417, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Gen: Intubated, sedated. Grimaces with pain\n CV: RRR. No murmurs.\n Lungs: CTAB on anterior exam. No wheezes or crackles.\n Abdomen: Soft, NT, ND. No masses\n Extremities: L leg contracted. Pain with movement. L knee may be warm,\n though no effusion or erythema.\n R leg without contracture. 1+ DP and PT pulses bilaterally.\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg] UA +, UCx pending\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -daily chest x-rays\n # L leg contracture: Concerning for central process vs. gouty\n arthiritis of knee given history of gout.\n -f/u MRI read\n -speak with neurosurgery regarding read\n -would not treat with gout medications right now given renal function.\n If above are negative, consider prednisone for gouty arthritis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -increase gabapentin to 300 po tid\n -increase Fentanyl patch to 200mcg/72 hours\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n -repeat C diff\n -consider CT abdomen to look for intraabdominal source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n - change to Amio 200 tid starting \n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: continue to follow\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707692, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.3 in this shift,am labs with wbc 17,pt had evolved new drug\n rash in the abdomen,thigh and left arm predominantly\n Action:\n d/ced vanco and aztrenem,changed to daptomycin ,received 1^st dose\n today,also given Tylenol 650mg x1 ,pt had undergone usg of the rt knee\n to r/out any effusion\n Response:\n Pt had undergone ct of abd pelvis,chest head yesterday,no souce of\n infection ct chest shows improving pnuemonia\n Plan:\n Monitor temps, continue IV antibx\ns, follow final cx and senitivities\n Chronic Pain\n Assessment:\n Pt extremely grimaces with pain,especially with left knee,left knee is\n contracted,even with slight slight pt grimaces,poorly tolerates\n turns,received the pt on fent patch 50mcg and fent patch 200mcg.\n Action:\n Pt had pain consult today,fent drip incrased to 75 but patch decreased\n to 100mcg/hr,contd gabapentin and Lidocaine patch\n Response:\n Pt was better until around 4pm,becomes more awake even though doesn\n follow commands,but become grimacing very bad and becomes more\n tachycardic and hypertensive,pain team wants to cut it down fent and\n lean forward for extubation\n Plan:\n Continue with Fentanyl gtt,will titrate up if needed,monitor bowel\n function with fent use\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on MMV 40%,10,,sats 96-100%,ronchorous breath\n sounds,\n Action:\n Vent settings changed to cpap/spsv 5/.5,sedation weaned\n slightly,suctioned as needed\n Response:\n Pt MS this am,arousable with stimulation,pt was getting\n apnic spells,pt was more asouable this afternoon,apparently it was\n noted pt was more hypertensive tachycardic around 5pm with increased\n secretions,suctioned for large amount of secretions ,and pt did vomit\n small amount of tube feed,pt didn\nt drop sats during this time,tube\n feed turned off and started NG to suction.mental status has been a\n limiting factor for extubation,abg was 7.41,44,116\n Plan:\n Will cont vent support,manage pain adequately,suction as needed,\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707804, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n - Rheum consult\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday. B/L LENIS negative per report.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707806, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin. Holding off on mri of left knee and hip per\n rheumatology recommendations.\n Response:\n Remains afebrile.\n Plan:\n Meropenum to be added if becomes unstable.\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched. At times though\n does not even open his eyes when his name is called. \n obeys commands.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Wean Fentanyl drip to off tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc. sats in the upper 90\n placed on sbt at 1400.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands inconsistently.\n Action:\n Weaning fentanyl drip.\n Response:\n Plan:\n Social- patient\ns daughter called and was updated by this nurse.\n Another daughter in later in day and updaterd on poc.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707887, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Events: leni\ns done on bilat lower ext to r/o dvt. Per tech no clots\n seen. Awaiting official read.\n Tf on hold per micu team s/p vomiting with ? aspiration\n yesterday. Ogt to liws with minimal bilious drainage.\n This pm started having muscle twitching of right\n shoulder. Awake at the time and able to nod to questions. Dr\n made aware. Will see if she can find a muscle relaxant that\n will not effect his level of awakeness.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600,\n Remains afebrile on IVAB\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707912, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am. Wbc down to 14.2 from 19.2 yesterday.\n Action:\n Cont on daptomycin.\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n mucha reaction from him.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708136, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708137, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:12 AM\n Extubated successfully.\n No overnight events\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:57 PM\n Heparin Sodium (Prophylaxis) - 11:47 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98.1\n HR: 97 (80 - 100) bpm\n BP: 154/47(81) {123/39(64) - 169/59(98)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 171 mL\n PO:\n TF:\n IVF:\n 435 mL\n 171 mL\n Blood products:\n Total out:\n 2,115 mL\n 695 mL\n Urine:\n 2,065 mL\n 695 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 715 (715 - 715) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n Ve: 5.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 720 K/uL\n 7.9 g/dL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Auto-diuresing, will dose lasix if not 1L neagtive at 8pm\n Picc line to be placed as needs dapto for VRE until \n ------ Protected Section Addendum Entered By: , MD\n on: 20:49 ------\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707401, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707403, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:14 AM\n -Patient weaned to \n -weaned sedation overnight\n -late in evening found to have contracted lower extremities\n -Neurosurg called for concern for cord compression\n -MRI with gad ordered -radiology had concerns over renal function\n -got MRI without gad\n -read pending\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:14 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.6\nC (101.5\n HR: 90 (79 - 92) bpm\n BP: 136/48(73) {84/41(62) - 182/89(104)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n CVP: 4 (2 - 42)mmHg\n Total In:\n 1,970 mL\n 634 mL\n PO:\n TF:\n 1,172 mL\n 340 mL\n IVF:\n 678 mL\n 294 mL\n Blood products:\n Total out:\n 2,825 mL\n 530 mL\n Urine:\n 2,825 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -855 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 963 (416 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/45/116/29/4\n Ve: 6.2 L/min\n PaO2 / FiO2: 290\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 427 K/uL\n 8.1 g/dL\n 113 mg/dL\n 2.3 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 46 mg/dL\n 104 mEq/L\n 140 mEq/L\n 25.3 %\n 14.7 K/uL\n [image002.jpg]\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n WBC\n 9.3\n 12.2\n 12.9\n 14.7\n Hct\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n Plt\n 247\n 268\n 316\n 427\n Cr\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n TCO2\n 30\n 30\n Glucose\n 126\n 118\n 116\n 121\n 108\n 136\n 113\n Other labs: PT / PTT / INR:15.4/32.9/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n No other new culture data\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 9 of 14) /Aztreonam (day 9 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -diurese with lasix drip for goal negative 1L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum pending, urine negative. Will\n Rpt UA/UCX\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:51 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707479, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: remain on min PSV.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~84.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707563, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 27.2 ,\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707564, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 27.2 ,\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707565, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nursing", "chartdate": "2146-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707566, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp elevation to 102.6 PO with WBC to 17.0 from 14.7.\n Action:\n was placed on cooling blanket, with cool bath and 1GM of Tylenol and\n was fully cultured again.\n remains on Aztreonam q8hr and started back on IV Vanco 750mg q24h. Was\n also taken down for CT scan of Head,Chest and .\n Response:\n Temps down to 96.0 PO.\n Plan:\n Monitor temps, continue IV antibx\ns, check results of q day BC\ns. Check\n results of CT scan.\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg still contracted up. Does open eyes to\n stimuli but unable to obey any commands. Was seen by Rheum Team for a\n question of gout. Remains on Fentanyl Gtt, Versed Gtt was stopped over\n night.\n Action:\n Was started on Allopurinol 100mg PO qd and rec\nd Prednisone 20mg PO\n times one dose then was d/c\nd. Fentanyl Gtt was decreased to 75mcq IV,\n was on 50mcq did not tolerate lower doses. Did rec several IV boluses\n for comfort when taken down for CT scan and with turning.\n Response:\n Remains in moderate pain.\n Plan:\n Continue with Fentanyl Gtt, and PO meds, adjust as needed for pt\n comfort, and as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on 40% Peep-5\nPS-5, did need to be on CMV rate when\n taken down to CT scan when needed several IV boluses of Fentanyl.\n RR-. L/S clear to diminished.\n Action:\n On CVM and PS when required due to sedation.\n Response:\n Not able to extubate.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd on Lasix Gtt @ 12mg/hr with only 40-60cc u/o. BUN/Cre elevated to\n 49/2.5 from 46/2.2. K+4.5.\n Action:\n Lasix Gtt was d/c\n Response:\n U/O 30-60cc/hr off of Lasix.\n Plan:\n Continue to monitor u/o, and lytes.\n" }, { "category": "Nursing", "chartdate": "2146-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707689, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.3 in this shift,am labs with wbc 17,pt had evolved new drur\n rash in the abdomen,thigh and left arm predominantly\n Action:\n d/ced vanco and aztrenem,changed to daptomycin ,received 1^st dose\n today,also given Tylenol 650mg x1 ,pt had undergone usg of the rt knee\n to r/out any effusion\n Response:\n Pt had undergone ct of abd pelvis,chest head yesterday,no souce of\n infection ct chest shows improving pnuemonia\n Plan:\n Monitor temps, continue IV antibx\ns, follow final cx and senitivities\n Chronic Pain\n Assessment:\n Pt extremely grimace with pain,especially with left knee,left knee is\n contracted,even with slight slight pt grimaces,poorly tolerates\n turns,received the pt on fent patch 50mcg and fent pacth 200mcg.\n Action:\n Pt had pain consult today,fent drip incrased to 75 but patch decresed\n to 100mcg/hr\n Response:\n Pt was better until around 4pm,becomes more awake even thogh doesn\n follow commands,but become grimacing very bad and becomes more\n tachycardic and hypertensive,pain team wants to cut it the down fent\n and lean forward for extubation\n Plan:\n Continue with Fentanyl gtt,will titrate up if needed,monitor bowel\n function with fent use\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on MMV 40%,10,,sats 96-100%,ronchorous breath\n sounds,\n Action:\n Vent settings changed to cpap/spsv 5/.5,sedation weaned\n slightly,suctioned as needed\n Response:\n Pt MS this am,arousable with stimulation,pt was getting\n apnic spells,pt was more asouable this afternoon\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM.\n" }, { "category": "Nutrition", "chartdate": "2146-11-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 707792, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 77.6 kg ( 08:00 AM)\n 27\n Pertinent medications: Fentanyl drip, Normal saline @ 10ml/hr,\n Pantoprazole, Heparin\n Labs:\n Value\n Date\n Glucose\n 125 mg/dL\n 04:40 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 57 mg/dL\n 04:40 AM\n Creatinine\n 2.3 mg/dL\n 04:40 AM\n Sodium\n 139 mEq/L\n 04:40 AM\n Potassium\n 4.4 mEq/L\n 04:40 AM\n Chloride\n 103 mEq/L\n 04:40 AM\n TCO2\n 28 mEq/L\n 04:40 AM\n PO2 (arterial)\n 222 mm Hg\n 05:05 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:05 AM\n pH (arterial)\n 7.46 units\n 05:05 AM\n pH (urine)\n 5.0 units\n 08:23 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 05:05 AM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 7.3 mg/dL\n 04:40 AM\n Phosphorus\n 3.2 mg/dL\n 04:40 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.1 mg/dL\n 04:40 AM\n ALT\n 44 IU/L\n 05:01 AM\n Alkaline Phosphate\n 183 IU/L\n 05:01 AM\n AST\n 40 IU/L\n 05:01 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:01 AM\n WBC\n 19.2 K/uL\n 04:40 AM\n Hgb\n 8.3 g/dL\n 04:40 AM\n Hematocrit\n 26.3 %\n 04:40 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: OFF (Nutren 2.0 @ 42ml/hr = calories and 81g protein)\n GI: soft, (+) bowel sounds; guiac negative loose stool\n Assessment of Nutritional Status\n Specifics:\n Patient presents with aspiration PNA with dense, large R-sided\n infiltrate, now improving. Remains intubated/sedated. Patient was\n tolerating tube feed at goal until episode of emesis pm. Tube\n feed on hold since with NGT to intermittent suction. Possible\n extubation today, if not then plan to discuss tracheostomy with\n family. (+) stooling after Lactulose last night.\n Medical Nutrition Therapy Plan - Recommend the Following\n If unable to extubate, recommend restart tube feeds\n o Check residuals, hold tube feeds if greater than 200ml\n o Monitor for N/V\n o Consider starting Reglan\n If extubated, recommend restart tube feeds for now\n o Consult SLP for swallowing evaluation before beginning po\n diet\n SLP was following before intubation\n o Patient may need tube feeds for full or supplemental\n nutrition support even if po diet started\n Check chemistry 10 panel daily\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707885, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707886, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has rested overnight on PSV of , Pt with lots of secretions at\n beginning of shift and especially with RT side up draining sputum\n Action:\n Have cont with freq SX and pulmonary toilet\n Response:\n O2 sats have been consistently >98%, With RR of and TV of 600\n Plan:\n Aggressive pulm toilet and eval for weaning this am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt cont to show improvement with increased u/o and improved CR\n Action:\n Have cont to follow u/o and labs\n Response:\n CR down to 2\n Plan:\n Will cont to follow\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to look more engaged with the speaker and he will follow\n simple commands\n Action:\n No Increase in meds needed\n Response:\n He still looks uncomfortable with any turning but not as bad as\n previous i\n Plan:\n Will cont to wean Fentanyl and asses for mental status improvement\n" }, { "category": "Respiratory ", "chartdate": "2146-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707892, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707893, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation\n . VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708128, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing IV hydral per order, pt started on PO hydral, \n taken to check correlation. Pain treated.\n Response:\n Pt\ns ABP with no significant change after IV hydral, PO hydral with\n mild improvement. Pt\ns systolic 20 points lower than ABP.\n Pt denies pain when at rest.\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO.\n Action:\n Speech and swallow eval done at bedside with pt upright in chair, pt\n grossly failed and had post pyloric dobhoff placed in IR today.\n Response:\n Pt now receiving PO meds through the dobhoff.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, he did get up to the stretcher chair x3hours. A new\n Fentanyl patch was placed, Lidocaine patch per order, restarted on his\n PO/NG neurontin.\n Response:\n Although pt with deny pain when he is laying down he does still grimace\n with movement, however, nurses more familiar with the patient have\n stated his pain appears to be more under control than in previous\n shift.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC, LSCTA bilaterally.\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions and provide frequently mouth\n care.\n" }, { "category": "Nursing", "chartdate": "2146-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707408, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2146-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707562, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707639, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, mental status is main barrier\n currently to extubation.\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout,\n Rheum eval for ?tap ?gout\n if ID w/u is otherwise negative, would\n consider pred for gout flare.\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707783, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C. diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Wean sedation\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707784, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 103.8\n - Pain consult - weaning pain meds\n - Uptitrated anti-HTN\n - Emesis yesterday - TF held\n - Switched between MMV and PS\n - Rheum consult\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 83 (77 - 118) bpm\n BP: 141/50(81) {114/41(63) - 218/63(104)} mmHg\n RR: 14 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,946 mL\n 358 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 118 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,405 mL\n Urine:\n 1,550 mL\n 605 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -1,046 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 643 (568 - 1,030) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 626 K/uL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR - Stable since yesterday. B/L LENIS negative per report.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - I/Os even\n - Day 12 of ET tube\n if not extubated tomorrow, then will d/w family\n possible trach Thurs/Fri\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. No DVT. Effusions on CT do\n not appear to be empyemas. Glucan/Galactomannan negative. C. diff\n negative. Rash and eosinophilia points to possible drug fever\n - Change abx to daptomycin for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation\n - consider fungal coverage if does not defervesce given yeast in\n sputum/urine.\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Minimally more responsive today. Head CT unremarkable.\n - Wean sedation\n - Pain consult to come by formally when patient extubated and\n interactive\n # L knee/great toe pain: Concerning for gout. Low suspicion for septic\n joints. No fluid on knee U/S.\n - Discuss possible septic joint with ID, but will hold on MRI for now\n - Start steroids\n - Send uric acid level\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n # HTN: Likely to weaning sedation\n - Continue to uptitrate hydralazine\n # Emesis: NPO with OG tube to suction to prevent further aspiration\n events.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707787, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile today. Wbc 19.2 from 17 today. Cont to have pain in left leg\n when it is touched. Especially left knee.\n Action:\n Cont on daptomycin.\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Patient nods to questions. Nods no to are you in pain right now. Nods\n yes to do you have pain when your left leg is touched.\n Action:\n Cont on fentanyl 100mcg/hr patch. Fentanyl drip weaned to 25mcgs/hr\n from 50mcgs/hr and cont on neurotin 300mg .\n Response:\n Comfortable at rest.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n This am on 40% fio2 peep of 5 and ps of 10. resp with tv of 800 or\n so with periods of apnea lasting 20-30sec. bs with rhonchi of rul and\n clear lul and bilat lower lobes. Suctioned for thick yellow sputum.\n Action:\n Resp in and changed ps to 5.\n Response:\n On ps of 5 resp with tv around 800cc.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient does arouse when legs touched especially left leg. Does nod his\n head to questions in what appears to be an appropriate manner . mae\n slightly on bed. Obeys commands.\n Action:\n Weaning fentanyl drip.\n Response:\n Plan:\n Social- patient\ns daughter called and was updated by this nurse.\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707788, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n - rheum c/s concerned for septic joint and dvt\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation .\n VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition: tube feeds on hold in anticipation of SBT this pm\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer: ppi\n VAP: routine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707874, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707875, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n ULTRASOUND - At 09:20 AM\n leni's -Negative for DVT\n LFTs slightly more elevated\n Tolerated SBT well\n ID felt that septic joint was a real possibility. Recommended against\n prednisone for gout. Didn't think this was gout.\n Uric acid level high\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37\nC (98.6\n HR: 85 (74 - 97) bpm\n BP: 134/45(74) {108/38(60) - 183/62(100)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.6 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 909 mL\n 266 mL\n PO:\n TF:\n IVF:\n 419 mL\n 136 mL\n Blood products:\n Total out:\n 2,650 mL\n 400 mL\n Urine:\n 1,450 mL\n 400 mL\n NG:\n Stool:\n 1,200 mL\n Drains:\n Balance:\n -1,741 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 521 (521 - 662) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.44/44/103/29/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 690 K/uL\n 7.6 g/dL\n 103 mg/dL\n 2.1 mg/dL\n 29 mEq/L\n 4.3 mEq/L\n 53 mg/dL\n 105 mEq/L\n 140 mEq/L\n 24.1 %\n 14.2 K/uL\n [image002.jpg]\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n 14.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n 24.1\n Plt\n 427\n 524\n 575\n 626\n 690\n Cr\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n 2.1\n TCO2\n 28\n 29\n 30\n 31\n Glucose\n 113\n 158\n 130\n 148\n 125\n 103\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:119/192, Alk Phos / T Bili:292/0.4,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient doing well on PSV, apnea has improved with decreased sedation\n . VANCO/AZTREONAM stopped on d12 (), CLINDA stopped on d7 ()\n - PSV, continue to wean sedation to decrease apnea gently given pain\n considerations below\n - continue , if doing well this pm, then SBT, possible extubation\n -MDIs PRN\n - daily chest x-rays\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n - LENIS ordered per rheum recommendation\n - will discuss MRI of HIP/KNEE with ID\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation. Pain consulted, per their initial assessment, there is no\n good way to control his pain during wean of sedation; addition of other\n agents could further cloud his mental status and thus further\n complicate mental status.\n -cont gabapentin AT CURRENT DOSE, would increase and possibly add other\n agents after extubation per pain c/s recs\n -cont Fentanyl patch at 100, wean drip\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n - f/u ID recs: seems that all possible sourses have been evaluated and\n should have been covered by HAP course\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- Rheum dose not think so\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708003, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down to 14.2 Drug rash all over body slowly\n improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and neurotin cont as ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on 40% fio2 peep of 5 and 5 ps this am. On this resp rate 9-12\n with tv around 700cc. Bs rhonchorous. Diminished at the bases.\n Suctioned for nothing this am and then for thick yellow secretions that\n were blood tinged.\n Action:\n Fentanyl drip shut off as has been weaned over the last few days.\n Placed on sbt. Rsbi done.\n Response:\n Rsbi 20. abg 7.42/48/155/32. Extubated at 1115. pos cuff leak prior to\n extubation. Placed on 40% cool neb shovel mask. Resp 12 to low teens\n with sats mid to upper 90\ns. Post extubation abg 7.43/44/98/30.\n Weaned to 2l nc with sats in mid 90\ns. Could not get the grasp of how\n to use is. Encouraged to take deep breaths and cough which he does\n well. Coughing and raising thick yellow sputum.\n Plan:\n Cont pulmonary toilet\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708005, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 140-160. Was getting hyralazine 30mg po qid via ogt while\n intubated. Extubated sbp > 160. Patient without ngt.\n Action:\n Dr informed 10mg iv hydralazine 1 x dose ordered and given.,\n Response:\n Sbp down into the 140\ns. Dr wrote for 10mg iv hyralazine q6\n hours while without ngt.\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Nursing", "chartdate": "2146-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708006, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n - Extubated.\n Put in for speech and swollow consult in am as patient\n with episodes of aspiration in the past. Ogt removed with extubation.\n No ngt placed today as wants to see how speech and swollow is without\n tube. Po meds held tonight including neurotin and amiodarone. Dr\n aware of this.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile overnight. Wbc down from 14.2 Drug rash all over body\n slowly improving.\n Action:\n Cont on daptomycin.\n Response:\n Remains afebrile. Id cont to follow.\n Plan:\n Cont daptomycin as ordered.\n Chronic Pain\n Assessment:\n Does nod that he is not in pain when he is resting in bed when asked.\n When leg is touched appears to have less pain than yesterday as not as\n much reaction from him.\n Action:\n Fentanyl patch 100mcgs/hr and Lidocain patch and neurotin cont as\n ordered.\n Response:\n Pain much improved today.\n Plan:\n Cont to monitor pain.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on NC 2L, sat 98%, LS diminished with insp wheezing .pt\n alert oriented x2 in himself and place, pt follows simple commands.\n Able to take deep breath and cough yellow thick secretion\n Action:\n Cont nebs\n Response:\n Does wel with cough and raising section up.\n Plan:\n Cont pulmonary toilet Encouraged to take deep breaths and cough\n Hypertension, benign\n Assessment:\n Sbp 150-160, pt does not have NGT unable to give Hydralazin PO, given\n Hydralazin IV. During turning BP up to 170\n Action:\n Dr informed 10mg iv hydralazine 1omg x2 x dose\n Response:\n Sbp down into the 140\ns. cont Hydralazin IVq6hr\n Plan:\n Hydralazine 10mg iv q 6 hours.\n Social- daughter in when patient Extubated. She is aware of poc. When\n daughter in concerned about twitching patient is having in right\n shoulder. He has been having this at rehab. Dr. aware and saw\n this. It comes and goes. Seems to be more pronounced right after\n turning him.\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708190, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708191, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:56 AM\n - ID signing off, they should be notififed re: placement prior to\n transfer vs discharge\n - Post pyloric dobhoff placed and TFs resstarted, PICC int he AM\n - Auto -diuresisng\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.4\n HR: 94 (85 - 102) bpm\n BP: 149/57(80) {140/50(73) - 157/73(92)} mmHg\n RR: 11 (8 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 204 mL\n PO:\n TF:\n 131 mL\n IVF:\n 330 mL\n 73 mL\n Blood products:\n Total out:\n 1,830 mL\n 540 mL\n Urine:\n 1,830 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 853 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia, now\n improved, off of antibiotics (s/p course vanco, aztreonam), still on\n Dapto for treatment of Enterococcus.\n - albuterol nebs PRN\n - cont fact tent, wean O2 as tolerated\n # L leg contracture: Improved now s/p extubation and no sedation.\n LENIS negative. Left knee not tender to palpation today, less\n concerning for gout. Will cont to monitor\n - f/u rheum recs\n - f/u nsgy recs\n # Hypertension: .On po hydral. Will transition to home meds: amlodipine\n 10 and metoprolol. Wean hydral as these take effect.\n - start amlodipine 10\n - metoprolol 25 tid (home dose is 100 )\n # VRE endocardtis: daptomycin course finishes on \n # Recurrent Aspiration: Failed S&S\n - Post-pyloric dobhoff\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation, however, now that sedation has been completely weaned\n -cont gabapentin\n -cont Fentanyl patch\n - defer pain c/s until MS improved\n # Fevers/ leukocytosis: Both Improved likely drug fever/rash, now\n improved after stopping Vanco/Aztreonam\n - f/u Blood cx/urine cx\n - f/u ID recs\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week, day , then wean; unclear if he\n needs to be on amio long term\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin, restart home beta-blocker and\n uptitirate as tolerated\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Repeat CT\n scan done a few days ago also was negative, currently extubated and\n responding to commands and questions, seems improved\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source, HCT stable\n -check HCT daily\n .\n # Gout: no acute issues\n .\n # FEN: replete lytes prn / hold TF s/p extubation, may need NG tube\n tomorrow\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707645, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - Pain consult\n - I/Os even\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Pain consult.\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707652, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 102.5\n - CT head unremarkable\n - CT Chest/Abd/Pelvis - Improving chest, no sources of infection in\n abd/pelvis\n - Rheum c/s for L knee pain and warmth - unlikely to be gout\n - Evolving rash with eosinophilia - switch from vanc to dapto, d/c\n aztreonam\n - Changed to MMV for apnea\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:34 PM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (66 - 94) bpm\n BP: 118/42(66) {109/40(62) - 158/54(87)} mmHg\n RR: 8 (7 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,985 mL\n 883 mL\n PO:\n TF:\n 886 mL\n 453 mL\n IVF:\n 1,179 mL\n 370 mL\n Blood products:\n Total out:\n 1,895 mL\n 530 mL\n Urine:\n 1,895 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,090 mL\n 353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 128 (128 - 1,134) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 26\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: 7.37/47/162/28/1\n Ve: 6.9 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 575 K/uL\n 148 mg/dL\n 2.6 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 100 mEq/L\n 136 mEq/L\n 25.5 %\n 17.0 K/uL\n [image002.jpg]\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n WBC\n 12.9\n 14.7\n 17.0\n 17.0\n Hct\n 25.0\n 25.2\n 25.3\n 24.5\n 25.5\n Plt\n 75\n Cr\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n TCO2\n 30\n 30\n 28\n Glucose\n 108\n 136\n 113\n 158\n 130\n 148\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: Chest CT - improvement in R sided infiltrates/effusions. CXR\n - Stable with tubes/lines in place.\n Microbiology: No new culture data.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Wean to PS; mental status currently main barrier to extubation given\n pain/sedation\n - Pain consult\n - I/Os even\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff negative. Rash\n and eosinophilia points to possible drug fever\n - Change abx to daptomycin\n - Appreciate ID input\n Meropenem for any decompensation\n # Altered Mental Status: Likely from oversedation due to pain regimen.\n Responds only to pain. Head CT unremarkable.\n - Pain consult.\n # L knee/great toe pain: Concerning for gout.\n - Rediscuss with rheum regarding possible tap\n - L knee ultrasound\n - Send uric acid level\n - Consider pred for gout flare\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:54 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2146-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707674, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ? extubation in the am.\n Reason for continuing current ventilatory support: Cannot protect\n airway\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707741, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\ns. WBC uo to 19.2 from\n 17.0\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Et # 7.5 , 26 cm at teeth. Bilat breathing sounds auscultated.\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, , 40% at 0515 am. Patient seems more awake at this time,\n following simple commands at times. . NG tube connected to LIS. Tube\n feeding has been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm. Last ABG ( AC/40%/X16/500) :\n 7.46/41/222/5/30\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-180\ns. Minimal response to PO hydralazine. MD made aware.\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n [image002.jpg]\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707761, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707763, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 08:00 PM\n - Max fentanyl drip had been 125/hr and over the wkend, pt was switched\n to 200mcg/hr patch + 25mcg/hr drip. Apneic in the am but still in pain.\n Pain c/s requested to determine if there was a way to wean but still\n provide adequate pain control with another .\n - Per them, there is no good way to do this as all ohter agents would\n further cloud mental status and complicate extubation.\n - Fentanyl patch decreased 200mcg/hr to 100mcg/hr and drip increased to\n provide transition, but total dose = 200+25-->100+50.\n - hypertensive with systolics over 200: hydral started and upttitrated\n overnight to 30 q6h. HTN improved with hydral, but mainly responsive to\n fentanyl.\n - vomitted yesterday, tube feeds stopped and ng placed to suction\n overnight\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 02:56 PM\n Aztreonam - 08:00 AM\n Daptomycin - 02:32 PM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:11 PM\n Hydralazine - 05:58 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (82 - 118) bpm\n BP: 169/49(84) {116/42(65) - 218/63(104)} mmHg\n RR: 11 (8 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,946 mL\n 262 mL\n PO:\n TF:\n 790 mL\n IVF:\n 566 mL\n 82 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,215 mL\n Urine:\n 1,550 mL\n 415 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n 396 mL\n -953 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 568 (128 - 1,030) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n Compliance: 87.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/41/222/28/5\n Ve: 7.5 L/min\n PaO2 / FiO2: 555\n Physical Examination\n General Appearance: Well nourished, wincing to minimal stimuli\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, no rebound or guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 626 K/uL\n 8.3 g/dL\n 125 mg/dL\n 2.3 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n WBC\n 14.7\n 17.0\n 17.0\n 19.2\n Hct\n 25.3\n 24.5\n 25.5\n 26.3\n Plt\n 427\n 524\n 575\n 626\n Cr\n 2.2\n 2.3\n 2.2\n 2.5\n 2.6\n 2.3\n TCO2\n 30\n 28\n 29\n 30\n Glucose\n 136\n 113\n 158\n 130\n 148\n 125\n Other labs: PT / PTT / INR:15.1/33.6/1.3, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:44/40, Alk Phos / T Bili:183/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:284 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yo m with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS now MMV apnea . CXR\n subsequently worsesend with reduced PEEP likely increased\n atelectasis. On Vanc (day 11 of 14) /Aztreonam (day 11 of 14)/ Clinda\n stopped on day 7 of 10\n -MMV\nPSV, wean sedation to decrease apnea\n -stop Vanc/Aztreonam for PNA per ID given course to date and rash\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today; c/s pain service for assistance\n # L leg contracture: Unclear if true contracture vs joint process vs\n muscle spasm\n - f/u rheum recs\n - f/u nsgy recs\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest without source\n - trend off curent Abx, given rash this could have been drug fever\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708180, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive most of the shift.\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert and oriented 1 to 2, occasionally he is able to say that he\n is in the hospital. Has short term memory loss, Put legs through side\n rails and try to come out of bed, Denies pain.\n Action:\n Reoriented frequently, Bed alarm on,\n Response:\n Cont to be confused\n Plan:\n Monitoring and frequent reorientation\n" }, { "category": "Physician ", "chartdate": "2146-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 708346, "text": "Chief Complaint: Altered mental status\n 24 Hour Events:\n ULTRASOUND - At 01:00 PM\n of right arm\n PICC LINE - START 02:53 PM\n RUE US: + for superficial cephalic vein clot\n PICC line placed\n Has a bed for rehab\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Daptomycin - 03:59 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.2\nC (97.2\n HR: 85 (80 - 96) bpm\n BP: 130/58(75) {128/57(75) - 175/88(100)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 1,861 mL\n 937 mL\n PO:\n TF:\n 836 mL\n 244 mL\n IVF:\n 455 mL\n 393 mL\n Blood products:\n Total out:\n 2,415 mL\n 370 mL\n Urine:\n 1,915 mL\n 370 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n -554 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 765 K/uL\n 7.8 g/dL\n 173 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 35 mg/dL\n 115 mEq/L\n 150 mEq/L\n 24.7 %\n 14.2 K/uL\n [image002.jpg]\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n 05:29 PM\n 04:29 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n 14.2\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n 24.7\n Plt\n 53\n 765\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n 1.7\n 1.6\n TCO2\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n 162\n 173\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:42/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHRONIC PAIN\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:08 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n PICC Line - 02:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707728, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, at 0515 am. Patient seems more awake at this time, following\n simple commands at times. . NG tube connected to LIS. Tube feeding has\n been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-170\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707729, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Hypoxemic respiratory failure on vent: Likely to HAP/aspiration PNA\n + pulmonary edema. CXR improving\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 103.8. No shivering noted. Hr upto 110\ns. drug rash all over\n the body ? from vancomycin.\n Action:\n Placed on cooling blanket. Cool bath given. Tylenol PO given. Blood\n culture X2 sent.\n Started on Daptomycin IV. Received 1 dose 11/16.\n Response:\n Temps down to 96.7 . HR down to 90\ns from 110\n Plan:\n Monitor fever curve , continue IVdaptomycin, check results of q day\n BC\n Chronic Pain\n Assessment:\n Still appears to be in acute pain with any touch or activity, grimances\n and withdrawls to pain, L leg contracted up. Does open eyes to stimuli\n , obey simple commands at times. Was seen by pain mx yesterday .\n Remains on Fentanyl Gtt @ 75 mcg/kg/hr Versed Gtt stopped.\n Action:\n Fentanyl Gtt was decreased to 50 mcq IV. Required fent bolus 25 mcg\n X2 for comfort when turning. Lidocaine patch @ back. Fentanyl patch\n dosage reduced to 100 mcg/hr as per pain management team as patient\n had freq apnic episode yesterday.\n Response:\n Remains in moderate pain as evidenced by grimaces & at times patient\n nods his head . No apnic episode noted overnight.\n Plan:\n Wean Fentanyl Gtt as tolerated. Plan for BLE US to R/O DVT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on vent CPAP , . Patient looked exhausted. ? aspiration .\n Action:\n Et # 7.5 , 26 cm at teeth. Bilat breathing sounds auscultated.\n Switched to AC/40%, sx16/ 10/500 till 0500 am this am. Put him on\n CPAP, at 0515 am. Patient seems more awake at this time, following\n simple commands at times. . NG tube connected to LIS. Tube feeding has\n been off since yesterday afternoon for ? aspiration\n Response:\n Satting at high 90\ns. RR : 22bpm.\n Plan:\n Continue to attempt to attempt to wean sedation and ?\ning extubation in\n the AM. resume tube feeding if does not extubate today.\n Hypertension\n Assessment:\n SBP at 200\ns at the beginning of the shift. Map 90\n Action:\n Started on Hydralazine Po 20 mg TID. Received 10 mg IV yesterday.\n Increased hydralazine Po to 30 mg from 20 mg as SBP been on higher\n side (170-180\n Response:\n SBP at 160-180\ns. Minimal response to PO hydralazine. MD made aware.\n Plan:\n Cont monitoring for pain. Cont with hydralazine 30 mg Po tid. Cont\n monitoring SBP.\n" }, { "category": "Respiratory ", "chartdate": "2146-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 707732, "text": "Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2146-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707746, "text": "76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708178, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive,\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708283, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray done. Awaiting confirmation by xray. Wire\n remains in picc.\n Hypertension, benign\n Assessment:\n Sbp in the 160\ns this am.\n Action:\n Cont on hydralazine and amlodipine. Lopressor increased to 37.5mg tid\n today from 25mg.\n Response:\n Sbp in the 140\ns. after picc line repositioned his sbp up to170\ns. he\n was due for his hydralazine which he just received. Of not his cuff for\n bp is on his leg as he has a picc on the left arm and a clot is his\n right.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Cont to reorient patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bs clear upper. Diminished at the bases. Takes good deep breaths on\n command. Does not hold tight seal around is when using it. Better\n having him take deep breaths and cough.\n Action:\n Cont pulm toilet.\n Response:\n Sats mid 90\ns on 2l nc.\n Plan:\n Cont pulm toilt. .\n son and daughter in at different times today. Updated on poc.\n Plan is for ? rehab tomorrow. He has a bed most likely at .\n Case management will check on sat to see if he is ready and bed is\n available.\n" }, { "category": "General", "chartdate": "2146-10-31 00:00:00.000", "description": "Generic Note", "row_id": 707631, "text": "TITLE:\n Rehab Services Physical Therapy: Events noted. Will f/u once sedation\n weaned to initiate PT eval. X32507\n" }, { "category": "Rehab Services", "chartdate": "2146-11-03 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 708087, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for referring this 76 yo man re-admitted on \nfrom rehab. Pt originally admitted approximately one month ago\n()with fevers and back pain, found to have\npan-sensitive enterococcus fecalis AV endocarditis, bacteremia,\nspinal epidural abscess s/p L5 and S1 laminectomy and abscess\ndecompression on , as well as neurologic microabscesses. He\nwas readmitted with rash, persistent fevers. Portable CXR with\npossible retrocardiac infiltrate so started empirically on\nantibiotics for possible pneumonia. Then repeat CXR with RLL\nopacity. We were consulted to evaluate oral and pharyngeal\nswallow function to determine if aspiration/dysphagia could be\ncontributing to current fever and opacity on CXR.\nPt is known to our department by four evaluations during the\nprevious admission. Was initially recommended for soft solids\nand nectar thick liquids on with aspiration of thin liquids.\nEtiology of dysphagia was suggested to be either related to\nmedications or neuro issues. On , re-evaluated and cleared\nfor diet upgrade to soft solids and thin liquids, as dysphagia\nwas resolving. Records from Hospital state pt on house\ndiet with supplements TID.\nWe attempted to see him this admission on but evaluation was\ndeferred possible intubation which occurred later on .\nChart documents witnessed aspiration with pills with worsened\nright sided infiltrate on CXR. Pt with MRSA in sputum. TEE showed\nsm vegetation and no clots. Pt had difficulty weaning from the\nvent but was extubated . Of note, pt had question of\naspiration of tube feeds with aspiration event, and tube feeds\nwere held the 2 days prior to extubation. Pt continues to be NPO\nand RN has held meds.\nPAST MEDICAL HISTORY:\n1. Osteoporosis\n2. Gout\n3. Cataracts\nPAST SURGICAL HISTORY:\ns/p cataract repair\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair in the MICU.\nCognition, language, speech, voice:\nPt was awake, but uncomfortable with reduced interaction. His\nvoice was initially aphonic, improved with ice chips and oral\nswabs. Pt was oriented and followed basic one step commands.\nTeeth: full set in average condition\nSecretions: dry oral mucosa with mild coating of dried secretions\n- wet cough before POs that was intermittently productive\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nPalatal elevation was symmetrical. Gag present with Yankauer\nsuctioning.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp), nectar thick\nliquids (tsp) and tsp of puree. Oral transit was timely and\nwithout oral cavity residue, but laryngeal elevation was mild to\nmoderately reduced to palpation.He had overt coughing after ice\nchips and water with desat to 95% and increase in RR to low 30s.\nPt had delayed cough after nectar liquids and reported puree was\nstuck in his throat. He was suctioned with return of apple sauce\nfrom the pharynx. He took swallows for all bites and sips. He\nhad increased SOB as the exam continued.\nSUMMARY / IMPRESSION:\nMr. is having mild difficulty tolerating secretions and had\novert signs of aspiration and pharyngeal residue with all boluses\ngiven. He had multiple episodes of desaturation and increase in\nRR and had observable SOB as the exam continued. He is not safe\nfor anything PO at this time, including meds which were not\ngiven. He will likely need to have the Dobbhoff replaced for\nalternate means of nutrition, hydration and medication.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 1.\nRECOMMENDATIONS:\n1. Suggest pt remain NPO, including ice chips and meds.\n2. Consider humidified shovel mask to assist with keeping oral\nmucosa moist.\n3. Pt will likely need to have Dobbhoff replaced.\n4. Q4 oral care.\n5. We will f/u early next week to repeat the evaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 9:30-9:45\nTotal time: 50 minutes\n [BUTTON Input] (not implemented)_____\n 01:10 PM\n" }, { "category": "Nutrition", "chartdate": "2146-11-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 708091, "text": "Subjective\n Patient off floor getting feeding tube placed\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 80.6 kg\n 76.7 kg ( 07:00 AM)\n 27\n Pertinent medications: normal saline @ 10ml/hr, Pantoprazole, Heparin\n Labs:\n Value\n Date\n Glucose\n 92 mg/dL\n 03:36 AM\n Glucose Finger Stick\n 112\n 06:00 PM\n BUN\n 49 mg/dL\n 03:36 AM\n Creatinine\n 2.0 mg/dL\n 03:36 AM\n Sodium\n 145 mEq/L\n 03:36 AM\n Potassium\n 4.0 mEq/L\n 03:36 AM\n Chloride\n 109 mEq/L\n 03:36 AM\n TCO2\n 25 mEq/L\n 03:36 AM\n PO2 (arterial)\n 98. mm Hg\n 12:10 PM\n PCO2 (arterial)\n 44 mm Hg\n 12:10 PM\n pH (arterial)\n 7.43 units\n 12:10 PM\n pH (urine)\n 5.0 units\n 08:23 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 12:10 PM\n Albumin\n 2.1 g/dL\n 03:41 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:36 AM\n Phosphorus\n 4.0 mg/dL\n 03:36 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 PM\n Magnesium\n 2.3 mg/dL\n 03:36 AM\n ALT\n 52 IU/L\n 03:36 AM\n Alkaline Phosphate\n 182 IU/L\n 03:36 AM\n AST\n 41 IU/L\n 03:36 AM\n Total Bilirubin\n 0.5 mg/dL\n 03:36 AM\n WBC\n 12.2 K/uL\n 03:36 AM\n Hgb\n 7.9 g/dL\n 03:36 AM\n Hematocrit\n 24.6 %\n 03:36 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: OFF - Nutren 2.0 @ 42ml/hr\n GI: soft, (+) bowel sounds; liquid stool\n Assessment of Nutritional Status\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n Patient with HAP/aspiration PNA + pulmonary edema. Extubated .\n Has been NPO and without enteral nutrition since after emesis.\n Seen by SLP today, who recommended NPO as patient having difficulty\n with secretions. MD, patient getting PPFT now. Patient also\n getting double lumen PICC with one port available for TPN if patient\n does not tolerate enteral nutrition. Agree with enteral nutrition for\n nutrition support while NPO. TPN may not decrease aspiration risk as\n patient can aspirate on own secretions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: NPO\n o After feeding tube placed and checked, resume tube feed\n o Nutren 2.0 @ 20ml/hr, advanced as tolerated to goal of\n 42ml/hr = calories and 81g protein\n Multivitamin / Mineral supplement: in tube feed\n No residual checks with PPFT, monitor abdominal exam; N/V\n Monitor hydration, Na; may need to change tube feed formula\n Check chemistry 10 panel daily\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708278, "text": "This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline\n Cr 1.5-2 with recent hospitalization for epidural abscess and\n bacteremia Pan-Sensitive Enterococcus who presented from rehab for\n fevers and lethargy subsequently intubated for PNA of entire right\n lung. Sucessfully extubated on .\n Events: right ue with edema- u/s done showing clot in superficial\n cephalic vein.\n Picc placed on left arm. Not in far enough. Picc replced\n over wire by iv nurse. Xray needs to be done to confirm placement.\n Hypertension, benign\n Assessment:\n Sbp in the 160\ns this am.\n Action:\n Cont on hydralazine and amlodipine. Lopressor increased to 37.5mg tid\n today from 25mg.\n Response:\n Sbp in the 140\ns. after picc line repositioned his sbp up to170\ns. he\n was due for his hydralazine which he just received. Of not his cuff for\n bp is on his leg as he has a picc on the left arm and a clot is his\n right.\n Plan:\n Cont to monitor bp.\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2 this am. Does not know year or month.\n Action:\n Cont to reorient patient.\n Response:\n Remains oriented x2.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 707329, "text": "76 male with recent hospitalization for epidural abscess and\n bacteremia. Pt now presents from rehab for fevers and lethargy.\n Hospital course c/b high oxygen requirements, with witnessed aspiration\n event leading to intubation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708069, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated yesterday\n - Failed SLP eval\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Hydralazine - 09:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 100 (80 - 102) bpm\n BP: 163/54(89) {123/39(64) - 169/59(98)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 208 mL\n PO:\n TF:\n IVF:\n 435 mL\n 208 mL\n Blood products:\n Total out:\n 2,115 mL\n 945 mL\n Urine:\n 2,065 mL\n 945 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -737 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 720 K/uL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Diuresis\n # Persistent fevers: Now afebrile - presumed drug fever.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation. Will discuss\n how to list drug allergies given numerous reactions to abx\n # Pain: Knee concerning for gout. Low suspicion for septic joints. No\n fluid on knee U/S.\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placement today\n - NPO\n - Will get double lumen picc for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition: Dobhoff as above.\n Glycemic Control:\n Lines: Order PICC today (double lumen)\n Arterial Line - 09:11 PM\n d/c today\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor after Dobhoff\n Total time spent: 25 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708079, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated yesterday\n - Failed SLP eval\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Daptomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:14 AM\n Heparin Sodium (Prophylaxis) - 08:14 AM\n Hydralazine - 09:40 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 100 (80 - 102) bpm\n BP: 163/54(89) {123/39(64) - 169/59(98)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.7 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 705 mL\n 208 mL\n PO:\n TF:\n IVF:\n 435 mL\n 208 mL\n Blood products:\n Total out:\n 2,115 mL\n 945 mL\n Urine:\n 2,065 mL\n 945 mL\n NG:\n Stool:\n 50 mL\n Drains:\n Balance:\n -1,410 mL\n -737 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 20\n SpO2: 97%\n ABG: 7.43/44/98./25/3\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 720 K/uL\n 92 mg/dL\n 2.0 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 49 mg/dL\n 109 mEq/L\n 145 mEq/L\n 24.6 %\n 12.2 K/uL\n [image002.jpg]\n 05:01 AM\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n WBC\n 17.0\n 19.2\n 14.2\n 12.2\n Hct\n 25.5\n 26.3\n 24.1\n 24.6\n Plt\n 575\n 626\n 690\n 720\n Cr\n 2.6\n 2.3\n 2.1\n 2.0\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 148\n 125\n 103\n 92\n Other labs: PT / PTT / INR:15.7/55.1/1.4, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:52/41, Alk Phos / T Bili:182/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:297 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Diuresis\n # Persistent fevers: Now afebrile - presumed drug fever.\n - On daptomycin x 6 weeks from for enterococcus endocarditis\n - Appreciate ID input\n Meropenem for any decompensation. Will discuss\n how to list drug allergies given numerous reactions to abx\n # Pain: Knee concerning for gout. Low suspicion for septic joints. No\n fluid on knee U/S.\n - Observation for now as improved.\n - Consider pain consult in a few days when mental status fully cleared\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid ; 200mg daily\n .\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation and amio plan deferred for closer to\n discharge.\n # HTN:\n - Continue to uptitrate hydralazine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placement today\n - NPO\n - Will get double lumen picc for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition: Dobhoff as above.\n Glycemic Control:\n Lines: Order PICC today (double lumen)\n Arterial Line - 09:11 PM\n d/c today\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor after Dobhoff if stable\n Total time spent: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2146-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708155, "text": "Hypertension, benign\n Assessment:\n Pt with systolic ABPS 160s-200s. ? if BP is also pain related.\n Action:\n Pt given standing PO hydral and Strted on amlodepine and mtoprolol\n Response:\n Normotensive,\n Plan:\n Continue to monitor BP, ?d/c aline, medicate for pain.\n Alteration in Nutrition\n Assessment:\n Pt extubated on and had NGT removed at that time. ? if pt is\n aspirating and kept NPO. Dobhoff placed on , failed speech and\n swallow\n Action:\n Tube feed started nutrine full strength @ 40ml/hr.\n Response:\n Tolerating the feed well.\n Plan:\n Restart pt\ns tube feeds, continue with PO/NG meds.\n Chronic Pain\n Assessment:\n Pt with pain per grimace in BLE. Pt denies pain when at rest but\n grimaces with movement.\n Action:\n Pt turned gently, Lidocaine patch per order, restarted on his PO/NG\n neurontin.\n Response:\n pain.\n Plan:\n Continue to assess for pain and treat per order.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2L O2 NC,\n Action:\n Pt given incentive Spirometer and done x4 today. Pt also encourage to\n deep breath and cough, mouth care provided frequently.\n Response:\n LS remain clear, pt did cough up small amounts of thick yellow\n secretion with he is unable to clear from the back of his throat.\n Plan:\n Continue to assess resp status and lung exam, IS and cough and deep\n breath, assist pt to clear secretions\n" }, { "category": "Nursing", "chartdate": "2146-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708424, "text": "Discharge to rehab: pt was d/ced to at at\n 1600 hrs today,all d/c meds and x ray report faxed to rehab,vs were at\n the time of transfer were 99.2,80,157/70,98% 2l nc,the Rt IJ CVl was\n removed prior to d/c.,Dtr was called and informed about the d/c\n plan.pt was up in the chair .all dc paper works sent with the pt,all\n meds due at 1600 hrs were also given .pt updated about the plan.\n" }, { "category": "Physician ", "chartdate": "2146-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 708259, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - A. line pulled\n - ID signed off - want to be notified prior to d/c to arrange\n outpatient follow-up\n - Post-pyloric dobhoff placed, TF started\n - Autodiuresing\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Vancomycin\n Rash; Fever/\n Aztreonam\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Heparin Sodium (Prophylaxis) - 10:05 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.9\nC (96.7\n HR: 90 (85 - 100) bpm\n BP: 157/63(86) {140/50(73) - 157/73(92)} mmHg\n RR: 10 (8 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 80.6 kg\n Height: 68 Inch\n Total In:\n 590 mL\n 513 mL\n PO:\n TF:\n 251 mL\n IVF:\n 330 mL\n 102 mL\n Blood products:\n Total out:\n 1,830 mL\n 830 mL\n Urine:\n 1,830 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,240 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, RUE edema more prominent than left\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 853 K/uL\n 124 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 42 mg/dL\n 113 mEq/L\n 150 mEq/L\n 27.0 %\n 12.1 K/uL\n [image002.jpg]\n 07:51 AM\n 04:28 PM\n 04:40 AM\n 05:05 AM\n 02:39 PM\n 05:10 AM\n 10:41 AM\n 12:10 PM\n 03:36 AM\n 04:07 AM\n WBC\n 19.2\n 14.2\n 12.2\n 12.1\n Hct\n 26.3\n 24.1\n 24.6\n 27.0\n Plt\n 53\n Cr\n 2.3\n 2.1\n 2.0\n 1.8\n TCO2\n 28\n 29\n 30\n 31\n 32\n 30\n Glucose\n 125\n 103\n 92\n 124\n Other labs: PT / PTT / INR:16.7/84.3/1.5, CK / CKMB /\n Troponin-T:33/7/0.70, ALT / AST:43/32, Alk Phos / T Bili:165/0.5,\n Amylase / Lipase:/52, Differential-Neuts:75.6 %, Lymph:10.2 %, Mono:7.4\n %, Eos:6.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: No new imaging.\n Microbiology: No new micro.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, NSTEMI) p/w aspiration PNA with\n dense, large R-sided infiltrate, now improving and extubated .\n # Hypoxemic respiratory failure: Likely to HAP/aspiration PNA +\n pulmonary edema. Extubated .\n - Finished 14 days of vanc/aztreonam for aspiration/HAP\n - Bronchodilators\n - Autodiuresis\n # Hypernatremia:\n - FWF\n # RUE swelling: Likely positioning and diuresis\n - U/S to r/o DVT\n # Enterococcus endocarditis:\n - On daptomycin x 6 weeks from (end date ) for\n enterococcus endocarditis ( drug fever and rashes from other\n antibiotics)\n # Pain:\n - Observation for now as improved.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid \n d/c amio as\n afib likely critical illness associated. Will readdress long-term amio\n if reoccurs.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n # HTN:\n - Continue to up titrate hydralazine, metoprolol, and amlodipine\n # Aspiration risk: Failed swallow study with tachypnea, desaturation\n and evidence of applesauce in pharynx.\n - Dobhoff placed\n - Will get double lumen picc today for possible TPN depending on how he\n tolerates TF\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:00 AM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor vs rehab\n will discuss with case\n management\n Total time spent: 20 minutes\n" }, { "category": "Case Management ", "chartdate": "2146-11-04 00:00:00.000", "description": "Discharge Plan", "row_id": 708262, "text": "Case Management Discharge Planning Note\n The patient is 76M a (h/o asthma, gout and recent complicated hospital\n course including epidural abscess requiring surgery, enterococcus\n bacteremia, aortic endocarditis, septic emboli to brain, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving and\n extubated . Per the MICU team, he should be ready for LTACH\n transfer on Saturday, .\n This Nurse case manager spoke with the patient\ns daughter \n ( regarding post-acute care options. expressed some\n concern about the patient going to in where he has\n been in the past, and asked for a referral to . This NCM\n did make that referral and was informed that has no male\n beds available and none expected through the weekend. This NCM also\n informed and she indicated that she will talk to her mother and\n get back to case management on whether the family will agree to\n . did call back to say that she and her family agree to\n the patient\ns transfer to \n The patient does have a bed on Saturday at . The weekend case\n manager will call central intake at ( on Saturday\n to set up a time for transfer and will f/u with the MICU team to\n facilitate the discharge.\n Please page anytime for case management assistance.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Page: \n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707291, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.9\nF - 08:00 PM\n Repeat CXR stable\n PRBC not given until PM as patient has antibodies and blood needed to\n be screened. HCT 25 at midnight s/p transfusion.\n UOP responding well to lasix. 4L of UOP by midnight, -2.3L net at MN\n ID recs: recommended sending Urine Legionella and Sputum for Legionella\n Clindamycin d/ced yesterday continued fevers and concern for\n c.diff. Stool for c.diff also sent.\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.5\nC (99.5\n HR: 88 (76 - 104) bpm\n BP: 138/54(81) {116/38(60) - 170/62(98)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 524 mL\n PO:\n TF:\n 1,014 mL\n 298 mL\n IVF:\n 770 mL\n 225 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,250 mL\n Urine:\n 4,570 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 438 (438 - 636) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n SpO2: 100%\n ABG: 7.44/43/251/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 502\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ATRIAL FIBRILLATION (AFIB)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O SEPSIS WITHOUT ORGAN DYSFUNCTION\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right aspiration Pneumonia.\n Patient on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 8 of 14) /Aztreonam (day 8 of 14)/ Clinda (day 7 of 10)\n -keep PEEP at 10, maintain PS at 5.\n -keep patient on left side to get better blood flow to L lung\n -continue Vanc/Aztreonam/Clinda for PNA, consider broadening if\n decompensates\n -diurese with lasix drip for goal negative 2L\n -MDIs PRN\n -f/u ABG\n -daily chest x-rays\n .\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont Amio 400 tid x 1 week (day 1 = ), then taper\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # Fevers: Persistent fevers. Does not necessarily represent failure of\n current Abx. BCx negative to date. TEE negative for new endovascular\n infection. Sputum cultures growing S. aureus Has known enterococcal\n bacteremia. Developed rash to ampicillin and ceftriaxone. Now on\n Vancomycin.\n -- f/u ID recs\n -- f/u Neurosurgery recs (no plans for surgery currently)\n -- f/u blood cultures, Ucx\n -- CT torso did not reveal obvious source of infxn\n .\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- cont to monitor\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO,\n last ECHO also reviewed and per Dr. , no thrombus seen\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: no acute issues\n .\n # FEN: IVFs / replete lytes prn / nutrition consult for tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full Code\n # DISPO: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707302, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow , need albumin\n - Bronchodilators\n - No attempt to wean on PSV until secretions/ fevers improve\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. C .diff a posibility given increased diarrhea and clinda\n use. Drug fever would be dx of exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - F/U cultures, sputum legionella culture, fever curve\n - Appreciate ID input\n # Anemia: Hct stable. No obvious source of bleeding. Stool occult\n negative.\n - Hct goal >25\n Transfuse 1 unit PRBC today.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday \n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n #Acute transaminitis: Most likely due to shock liver in setting of\n hypoTN during Afib RVR.\n - Trend LFTs\n - Restart lipitor\n #S/p epidural abscess, aortic endocarditis. Repeat spine MRI showed\n discitis L5-S1 that shows no progression compared with MR 3-4wks ago.\n New small fluid collection of uncertain significance.\n - NSY\n no intervention for now\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707303, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow \n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707319, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Tm 101.9\n - Clinda d/c'ed out of concern for c. diff\n - 1 unit PRBC - Hct stable after transfusion\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:05 PM\n Clindamycin - 08:00 AM\n Aztreonam - 09:09 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.4\nC (99.3\n HR: 83 (79 - 104) bpm\n BP: 89/47(62) {89/44(62) - 170/62(98)} mmHg\n RR: 18 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (5 - 16)mmHg\n Total In:\n 2,225 mL\n 874 mL\n PO:\n TF:\n 1,014 mL\n 412 mL\n IVF:\n 771 mL\n 342 mL\n Blood products:\n 350 mL\n Total out:\n 4,570 mL\n 1,700 mL\n Urine:\n 4,570 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,345 mL\n -826 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 531 (438 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.44/43/251/28/5\n Ve: 9.6 L/min\n PaO2 / FiO2: 628\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 108 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 106 mEq/L\n 141 mEq/L\n 25.2 %\n 12.9 K/uL\n [image002.jpg]\n 03:41 AM\n 11:19 AM\n 04:45 PM\n 04:03 AM\n 05:15 PM\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n WBC\n 7.6\n 9.3\n 12.2\n 12.9\n Hct\n 22.8\n 24.2\n 24.2\n 22.4\n 23.4\n 25.0\n 25.2\n Plt\n 221\n 247\n 268\n 316\n Cr\n 3.2\n 3.0\n 2.9\n 2.7\n 2.7\n 2.5\n 2.5\n TCO2\n 25\n 30\n Glucose\n 142\n 141\n 126\n 118\n 116\n 121\n 108\n Other labs: PT / PTT / INR:16.3/38.4/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:58/36, Alk Phos / T Bili:203/0.6,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:356 IU/L, Ca++:7.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - Stable.\n Microbiology: Sputum legionella culture pending. C.diff ordered.\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Continue diuresis with lasix gtt, follow UOP\n - Bronchodilators\n - Wean PS to now, ABG in pm, CXR in am\n consider extubation\n tomorrow am if clinically doing well\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam\n - Clinda d/c'ed and c. diff ordered.\n - Send urinalysis and culture, F/U sputum legionella culture\n - Appreciate ID input\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio 400mg PO tid x1 week, started Sunday . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 707530, "text": "Chief Complaint: AMS, aspiration\n HPI:\n 24 Hour Events:\n Fever to 102, PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n - MRI per ID and NSG not concerning for new infectious process\n - Taper MRI\n - Versed gtt d/c\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Lidoderm patch, ASA, Lipitor. Fentanyl patch, Neurontin, Amiodarone\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 634 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 360 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -446 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), RRR\n Peripheral Vascular: (Right radial pulse: palpable), (Left radial\n pulse: palpable), (Right DP pulse: palpable), (Left DP pulse: palpable)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilaterally )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: No rash\n Ext: Bilat LE edema to mid shin, warm L knee, L ankle, no effusion\n Neurologic: Responds to: painful stimuli, moves extremities to stimuli\n Labs / Radiology\n 7.9 g/dL\n 524 K/uL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Sputum\n MRSA\n Urine legionella Negative\n C Diff negative\n Blood Cx NGTD\n Assessment and Plan\n 76M (h/o asthma, gout and recent complicated hospital course including\n epidural abscess requring surgery, enterococcus bactermia, aortic\n endocarditis, septic emboli to brain, atrial thrombus, NSTEMI) p/w\n aspiration PNA with dense, large R-sided infiltrate, now improving.\n # Hypoxemic respiratory failure on vent: Likely to HAP/aspiration\n PNA + pulmonary edema. CXR improving.\n - Continue abx (vanc/aztreonam Day ) for aspiration/HAP\n - Bronchodilators\n - Weaned PS to now, SBT today, consider extubation in next \n hrs pending MS\n - Stop diuresis, follow I/Os\n # Persistent fevers: Known PNA\n but would expect him to be afebrile at\n this time from PNA. Enterococcus aortic valve endocarditis and\n discitis stable. No new source identified. DVT unlikely given recent\n anticoagulation and now SQ heparin. Effusions on CT do not appear to\n be empyemas. Glucan/Galactomannan negative. C .diff a posibility\n given increased diarrhea and clinda use. Drug fever would be dx of\n exclusion.\n - Cont vanc / aztreonam, dosing vanco by level, due today\n - C-diff negative.\n - All cultures NGTD\n - CT-Chest/Abd per ID\n - Check diff on CBC\n - Appreciate ID input\n # Altered Mental Status: Responds only to pain.\n - Head CT given poor MS\n # L Leg Contracture: Consider central process, vs inflammatory or\n infectious arthropathy\n - Await MRI read, d/w neurosurgery\n - Monitor L knee, hip, if tappable effusion tap given history of\n hematogenous infection, leaning towards gout, will try Prednisone 20mg\n daily\n # Diffuse Body Pain: Still in marked discomfort despite fentanyl drip,\n neurontin.\n - Increase fentanyl patch, neurontin, wean fentanyl\n # Anemia: Hct stable s/p 1 unit PRBC yesterday. No obvious source of\n bleeding. Stool occult negative.\n - Hct goal >25.\n #Afib RVR: Initially on amio gtt, now transitioned to PO.\n - Amio started Sunday , tapered to 200mg tid . Check EKG.\n - In sinus rhythm, so no anticoagulation at this time. On aspirin.\n Long term anticoagulation plan deferred for closer to discharge.\n ICU Care\n Nutrition: On TFs\n Glycemic Control:\n Lines:\n Arterial Line - 09:11 PM\n Multi Lumen - 03:07 PM\n Prophylaxis:\n DVT: Hep sc\n Stress ulcer: PPI\n VAP: HOB at 30 degrees, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 min\n" }, { "category": "Physician ", "chartdate": "2146-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 707538, "text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n PAN CULTURE - At 09:02 AM\n urine. sputum,BC's one from A-line and one from Central line sent\n FEVER - 102.0\nF - 04:00 AM\n MRI read:\n Previously noted fluid collection at the laminectomy site at the\n superior margin of the laminectomy has decreased with a small 2 cm\n fluid collection adjacent to the right facet joint between L4 and L5 is\n identified. This area demonstrates restricted diffusion. Given the\n history of recent surgery, this could be secondary to blood products,\n but associated infection cannot be excluded given the restricted\n diffusion.\n -neurosurg aware, no acute issues\n -changed amio dose to 200 tid\n -ID recommended CT abd: held off...just had one 5 days ago that was\n negative\n -increased lasix gtt to 12\n -rising white count\n Allergies:\n Ampicillin\n Rash;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Clindamycin - 08:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:04 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 96 (77 - 98) bpm\n BP: 108/41(60) {103/35(54) - 167/65(93)} mmHg\n RR: 11 (9 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 2,505 mL\n 591 mL\n PO:\n TF:\n 1,014 mL\n 274 mL\n IVF:\n 971 mL\n 317 mL\n Blood products:\n Total out:\n 1,725 mL\n 1,080 mL\n Urine:\n 1,675 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 615 (560 - 963) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 8.5 L/min\n Physical Examination\n GEN: Intubated, sedated, +grimacing when palpating left knee\n CVS: +S1/S2, no M/R/G, RRR\n LUNGS: CTAB anterior lung fields\n ABD: +BS, NT/ND\n EXT: +2 pitting edema of bilateral LE\n Labs / Radiology\n 524 K/uL\n 7.9 g/dL\n 130 mg/dL\n 2.5 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 49 mg/dL\n 103 mEq/L\n 139 mEq/L\n 24.5 %\n 17.0 K/uL\n [image002.jpg]\n 04:15 AM\n 07:52 PM\n 12:01 AM\n 05:41 AM\n 06:01 AM\n 05:03 PM\n 05:18 PM\n 03:03 AM\n 05:03 PM\n 04:27 AM\n WBC\n 12.2\n 12.9\n 14.7\n 17.0\n Hct\n 22.4\n 23.4\n 25.0\n 25.2\n 25.3\n 24.5\n Plt\n 24\n Cr\n 2.7\n 2.5\n 2.5\n 2.2\n 2.3\n 2.2\n 2.5\n TCO2\n 30\n 30\n Glucose\n 116\n 121\n 108\n 136\n 113\n 158\n 130\n Other labs: PT / PTT / INR:15.7/35.1/1.4, CK / CKMB /\n Troponin-T:434/7/0.70, ALT / AST:52/59, Alk Phos / T Bili:217/0.7,\n Amylase / Lipase:/52, Differential-Neuts:88.0 %, Lymph:7.5 %, Mono:2.6\n %, Eos:1.6 %, Fibrinogen:473 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.1\n g/dL, LDH:309 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Microbiology: C diff negative\n Sputum culture pending\n Blood cultures pending\n Urine culture pending\n Assessment and Plan\n 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2\n with recent hospitalization for epidural abscess and bacteremia \n Pan-Sensitive Enterococcus who presents from rehab for fevers and\n lethargy subsequently intubated for PNA of entire right lung.\n # Respiratory failure: Patient with Right Aspiration Pneumonia.\n Patient was on APRV, weaned to AC, then PS yesterday. CXR subsequently\n worsesend with reduced PEEP likely increased atelectasis. On Vanc\n (day 10 of 14) /Aztreonam (day 10 of 14)/ Clinda stopped on day 7 of 10\n -decrease PEEP to 5, maintain PS at 5, wean sedation, rpt gas in pm\n -continue Vanc/Aztreonam for PNA, consider broadening if decompensates\n -stop Lasix gtt as UOP decreased on 12mg/hr\n -MDIs PRN\n -daily chest x-rays\n - attempt to wean sedation today and SBT\n - ET tube at 8cm yesterday will f/u today and advance ET as needed\n # L leg contracture: Given tenderness of Left knee on exam, likely \n gouty arthritis\n -patient given prednisone this morning but will hold off on more\n prednisone for now, will consult Rheum for definitive diagnosis\n .\n # Pain control: Patient with chronic pain, exacerbated by weaning\n sedation.\n -cont gabapentin\n -cont Fentanyl patch\n .\n # Fevers/rising leukocytosis: Pt with improving resp status. Abd exam\n unchanged since last imaging of abd on . Fungal markers negative.\n Fungal Cxs pending. Legionalla sputum negattive, urine negative. UA\n done yesterday negative. Cdiff yesterday negative\n -f/u Blood cx/urine cx\n - CT abdomen/chest today to look for intraabdominal source, pulmonary\n source\n # Atrial Fibrillation with RVR: patient had an episode of afib with\n RVR c/b hypotension which required CVL placement and Neo for blood\n pressure support. AFIB/RVR recurred resolved with second IV load, now\n on po load.\n - monitor on tele\n - cont amio to 200mg TID for 1 week\n # Troponin leak: Patient with troponin leak after episode of afib\n earlier in the week. CK elevated slightly but MB flat. Likely to\n demand ischemia in the setting of hypotenstion, renal failure and afib\n with RVR.\n - rate control, restarted ASA, statin\n # AMS: Initially had AMS likely fevers and infection. CT Head\n done in ED shows no signs of acute hemorrhage or infarction. Currently\n unable to assess mental status given large amount of sedation.\n -- will obtain CT Head today for revaluation\n # Right Atrial Appendage Thrombus: No thrombus seen on current ECHO\n -d/c\ned heparin gtt\n .\n # Anemia: no clear source of blood loss, hapto wnl. Will follow \n Hct, goal 25\n -active T&S\n -check HCT daily\n -guaiac negative, hapto levels nml\n .\n # Gout: ?Gout of left knee.\n -- consult Rheum\n .\n # FEN: replete lytes prn / cont tube feeds\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: R IJ\n # CODE: Full Code\n # DISPO: ICU\n" }, { "category": "ECG", "chartdate": "2146-10-21 00:00:00.000", "description": "Report", "row_id": 227665, "text": "Atrial fibrillation with rapid ventricular response. Non-specific\nintraventricular conduction delay. Poor R wave progression. Non-specific\ninferolateral T wave flattening. Low QRS voltage in the limb leads. Compared to\nthe previous tracing of the seven beat run of wide complex tachycardia\nis absent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 227666, "text": "Atrial fibrillation with rapid ventricular response. After a pause, an early\nbeat is followed by seven beats of wide complex tachycardia -aberration versus\nventricular tachycardia. Since the previous tracing of atrial\nfibrillation is new and wide complex tachycardia is new. Clinical correlation\nis suggested.\n\n" }, { "category": "ECG", "chartdate": "2146-10-19 00:00:00.000", "description": "Report", "row_id": 227667, "text": "Sinus tachycardia. Low limb lead QRS voltage. Delayed R wave progression.\nST-T wave abnormalities. Findings are non-specific and unstable baseline makes\nassessment difficult. Since the previous tracing of sinus tachycardia\nis now present. Delayed R wave progression is more prominent and further\nST-T wave changes are seen.\n\n" }, { "category": "ECG", "chartdate": "2146-10-28 00:00:00.000", "description": "Report", "row_id": 227661, "text": "Sinus rhythm. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2146-10-23 00:00:00.000", "description": "Report", "row_id": 227662, "text": "Sinus rhythm. Baseline artifact. Poor R wave progression. Possible septal\nmyocardial infarction of indeterminate age. Non-specific inferolateral T wave\nflattening. Low QRS voltages in limb leads. Compared to the previous tracing\nof the wide complex tachycardia, left bundle-branch block and\nST segment depression are now absent.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2146-10-22 00:00:00.000", "description": "Report", "row_id": 227663, "text": "Wide complex tachycardia, probably supraventricular. Left bundle-branch block\npattern. Lateral ST segment depression with possible retrograde P waves.\nCompared to tracing #2 earlier the same day wide complex tachycardia, left\nbundle-branch block and ST segment depression are all new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2146-10-22 00:00:00.000", "description": "Report", "row_id": 227664, "text": "Sinus rhythm. Short P-R interval without other signs of pre-excitation.\nNon-specific inferolateral T wave flattening. Low QRS voltage in the limb\nleads. Compared to tracing #1 on rapid atrial fibrillation is absent.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2146-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106658, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with HAP, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased. This could be a consequence of mechanical ventilation. Diffuse\n but mainly perihilar extensive opacity in the right lung has minimally\n decreased in size. Unchanged is the retrocardiac atelectasis. The size of\n the cardiac silhouette is unchanged. The appearance of the left lung\n parenchyma is constant.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1106460, "text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for right CVL placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RLL PNA, now hypotensive with afib, intubated, newly\n placed central line\n REASON FOR THIS EXAMINATION:\n eval for right CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: Evaluate right central venous line placement.\n\n FINDINGS: The new right CVL line tip is in the upper SVC in satisfactory\n position with no evidence of a pneumothorax.\n\n Increased diffuse consolidation throughout the right lung with mild\n superimposed pulmonary edema is noted with mild cardiomegaly. Left lower lobe\n atelectasis is unchanged.\n\n The NG tube passes into the stomach and out of view. ET tube is satisfactory\n at the thoracic inlet and 47 mm above the carina.\n\n IMPRESSION:\n\n Increased right-sided diffuse infectious consolidation and mild pulmonary\n edema. Satisfactory placement of right central venous line.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1105950, "text": " 12:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed? septic emboli?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with AMS, fevers, h/o endocarditis\n REASON FOR THIS EXAMINATION:\n bleed? septic emboli?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 1:53 AM\n Suboptimal due to motion in the scanner.\n No acute hemmorhage. Evolving deep white matter infarcts, as seen on recent\n MR.\n If concern for acute ischemia MRI is more sensitive.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with altered mental status, fevers and history of\n endocarditis. Evaluate for bleed or septic emboli.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: Compared to MR and NECT head .\n\n FINDINGS: This is a suboptimal evaluation, particularly of the posterior\n fossa, due to excessive patient motion-artifact (despite four attempts).\n\n There is no evidence of acute hemorrhage, large acute vascular territorial\n infarction, mass or cerebral edema. There are scattered subcortical\n paraventricular hypodensities likely reflecting chronic microvascular ischemic\n changes. There is a hypodense focus within the right centrum semiovale\n (2:24-25), new from the prior CT, likely representing the evolving small\n subcortical white matter infarct, as seen on recent MR/DWI. There is no shift\n of midline structures. There is no evidence of hydrocephalus. There is\n mucosal thickening in the right maxillary sinus. No fracture is seen.\n\n IMPRESSION: No acute hemorrhage. Evolving small infarct in the subcortical\n white matter of the right centrum semiovale, as seen on the recent MR.\n If concern for furtheracute ischemia, MRI is more sensitive.\n\n Findings posted to the ED dashboard.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105954, "text": " 2:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with sepsis, now s/p 4L IVF with oxygen desaturation\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with sepsis. Hypoxia following fluid resuscitation.\n\n IMPRESSION: AP chest compared to at 7:36 p.m.:\n\n New opacification in both lower lobes, much greater on the right, could be\n considered pneumonia until proved otherwise. Small bilateral pleural\n effusions and mild perihilar haze on the left suggests a component of cardiac\n decompensation. Heart size is normal and mediastinal vasculature is not\n particularly engorged. Right-sided central venous line ends low in the SVC.\n No pneumothorax. Findings were discussed by telephone with Dr. at\n the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107125, "text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure.\n\n Comparison is made with prior study performed a day earlier.\n\n Extensive opacities in the right lung have increased in the base this could be\n due to increased atelectasis and increased in the pleural effusion and\n unchanged in position of the patient. A small left pleural effusion with\n adjacent atelectasis is stable. ET tube, NG tube and right IJ catheter remain\n in place. Right perihilar consolidation is unchanged. Mild interstitial\n edema is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-19 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 1106116, "text": " 8:03 PM\n MR W & W/O CONTRAST Clip # \n Reason: eval for epidural abscess. Please use contrast\n Admitting Diagnosis: FEVER\n Contrast: PROHANCE Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with history of epidural abscess s/p L5-S1 laminectomy who\n returns with fevers/lethary, concern for recurrent epidural abscess\n REASON FOR THIS EXAMINATION:\n eval for epidural abscess. Please use contrast\n CONTRAINDICATIONS for IV CONTRAST:\n Chronic Renal Failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: IPf 3:16 AM\n Post-surgical changes seen in the lower lumbar spine. There is soft tissue\n with heterogeneous enhencement posterior to the sacrum (9:12) , differential\n diagnosis is phlegmon, granulation tissue, or venous congestion. No definite\n fluid collection seen. There is increased signal in STIR at the disk at L5-S1\n and endplates at this level, concerning for ongoing discitis-osteomyelitis.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Lumbar spine MRI with and without contrast.\n\n HISTORY: 76-year-old male who presents with a history of epidural abscess,\n status post L5-S1 laminectomy who returns with fevers and lethargy and\n clinical concern for recurrent abscess.\n\n COMPARISON: Multiple prior lumbar spine MRIs and .\n\n TECHNIQUE: Sagittal pre- and post-gadolinium T1, T2 FSE, STIR, axial pre- and\n post-gadolinium T1- and T2-weighted sequences of the lumbar spine were\n obtained. Note, the clinical team received a nephrology consultation allowed\n for dialysis given the patient's EGFR of 28.\n\n FINDINGS: The patient is status post L5-S1 laminectomy. There is extensive\n enhancement within the posterior paraspinal soft tissues with an ovoid 4.0 x\n 0.6 cm fluid collection superficial to the laminectomy at L5 which\n demonstrates peripheral enhancement. No significant extension into the\n epidural space. There is circumferential epidural enhancement which is\n predominantly present at and below the L5-S1 intervertebral disc space. This\n surrounds the bilateral S1 roots.\n\n There is a linear intrathecal enhancement which is likely venous without\n additional abnormal intrathecal enhancement.\n\n Irregularity, increased T2 signal and enhancement surrounding the L5-S1 disc\n space is diminished when compared to the prior study, particularly the\n anterior paraspinal fluid collection and enhancement. No progressive endplate\n irregularity is identified to suggest progressive discitis.\n\n (Over)\n\n 8:03 PM\n MR W & W/O CONTRAST Clip # \n Reason: eval for epidural abscess. Please use contrast\n Admitting Diagnosis: FEVER\n Contrast: PROHANCE Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The appearance of the remainder of the spine, including T2 hyperintense signal\n within the intervertebral discs at multiple levels is unchanged. No new\n epidural or bone marrow signal abnormality is present.\n\n IMPRESSION: There is a small posterior paraspinal fluid collection\n surrounding postoperative changes at L5-S1. Represent infected material or\n simply reflect postoperative change, and this does not continue into the\n epidural space. There is circumferential thick epidural enhancement\n surrounding the caudal thecal sac which likely reflects phlegmonous change\n with no new compressive lesions. There is nonprogressive\n discitis/osteomyelitis at L5-S1 with no new areas of involvement.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1108570, "text": ", MED MICU-7 12:52 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RUE swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n Thrombus in the right cephalic vein, which is a superficial vein. No right\n upper\n extremity deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1108331, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with R-sided PNA, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Followup pneumonia.\n\n Comparison is made with prior study performed a day earlier.\n\n Lower lobe consolidation/pneumonia is unchanged. Left lower lobe retrocardiac\n opacity is a combination of pleural effusion and atelectasis. Of note a right\n lateral CP angle was not included on the film, there appears to be a small\n pleural effusion on the right. Right IJ catheter tip is in the mid SVC.\n Cardiac size is normal.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-03 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1108440, "text": " 2:38 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric dobhoff\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recurrent aspiration PNA\n REASON FOR THIS EXAMINATION:\n please place post-pyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with recurrent aspiration pneumonia. Please\n place post-pyloric Dobbhoff tube.\n\n TECHNIQUE: Fluoroscopy guided post-pyloric Dobbhoff tube (nasointestinal\n tube) placement.\n\n PROCEDURE/FINDINGS:\n After local anesthesia of the right nostril and the nasopharynx with lidocaine\n gel and spray, a Dobbhoff tube was advanced through the right nostril into the\n esophagus. Tube was advanced beyond the GE junction and location of the in\n the stomach was confirmed under fluoroscopy. Subsequently, the tube was\n advanced beyond the pylorus into the descending duodenum. Subsequently,\n post-pyloric placement of the tube was confirmed by contrast. The tip of the\n tube projects over the proximal transverse portion of the duodenum.\n\n IMPRESSION:\n Successful placement of a post-pyloric nasointestinal tube.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1108592, "text": " 3:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 47 cm Picc placed in left brachial vein, need Picc tip place\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc placed in left brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: New PICC line.\n\n FINDINGS: The new left-sided PICC line tip is in the distal brachiocephalic\n vein, right central venous line is unchanged. An NG tube passes into the\n stomach and out of view. A small left pleural effusion is stable,\n consolidation in the right lower lobe is unchanged. Heart size is top normal.\n\n IMPRESSION:\n New left PICC line tip is in the brachiocephalic vein, IV nurse informed.\n Bilateral pleural effusions with unchanged right lower lobe consolidation,\n most likely pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1108569, "text": " 12:52 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with RUE swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf FRI 2:21 PM\n Thrombus in the right cephalic vein, which is a superficial vein. No right\n upper\n extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER EXTREMITY VENOUS SON\n\n INDICATION: 76-year-old man with right upper extremity edema.\n\n COMPARISON: Not available at the .\n\n FINDINGS: Grayscale and color Doppler images of the right internal jugular,\n subclavian, axillary, brachial, basilic, and cephalic veins were obtained.\n There is lack of color flow, non-compressibility and lack of pulse Doppler\n waveforms in the right cephalic vein, consistent with thrombus. The remainder\n of the venous structures demonstrate normal color flow and compressibility and\n pulse Doppler waveforms.\n\n IMPRESSION: Thrombosed right cephalic vein, which is a superficial vein. No\n deep venous thrombosis in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1108613, "text": " 5:40 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 51cm SL L PICC exchanged - 47cm PICC at bracheocephalic\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 51cm SL L PICC exchanged - 47cm PICC at bracheocephalic\n ______________________________________________________________________________\n WET READ: IPf FRI 6:38 PM\n PICC line at mid SVC. Othervise no significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess left PICC.\n\n Comparison is made to prior study performed three hours earlier.\n\n PICC tip is in the mid-to-lower SVC. Otherwise no interval change from prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107612, "text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 76-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The tip of the endotracheal tube is 8 cm above the carina and has migrated\n more proximally since the previous study. The feeding tube is unchanged and\n distal tip is below the field of view of the study. There is a unchanged\n right IJ central venous catheter with the distal lead tip in proximal SVC.\n\n There is a unchanged left retrocardiac opacity.\n\n Remains some mild interstitial edema. There is faint areas of consolidation\n within the right lower lobe, stable.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106766, "text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices are in unchanged position. The pre-existing right-sided parenchymal\n opacity, predominantly in perihilar distribution, has further decreased in\n extent. Unchanged size of the cardiac silhouette, on today's radiograph,\n there is new blunting of the left costophrenic sinus, potentially caused by a\n small pleural effusion. No other changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107301, "text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung pna, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a slight decrease\n in severity of the pre-existing right parenchymal opacities. The right lung\n base is slightly improved in transparency as compared to the previous\n examination. The left lung base is also slightly more transparent, suggesting\n improved ventilation. Unchanged extent of the pre-existing small left-sided\n pleural effusion. The size of the cardiac silhouette is unchanged. The\n nasogastric tube has been removed in the interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106546, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: , 3:45 p.m.\n\n FINDINGS: The monitoring and support devices are in unchanged position.\n Unchanged size of the cardiac silhouette, unchanged retrocardiac atelectasis.\n The extensive right-sided parenchymal opacity is better delineated than on the\n previous examination, the right costophrenic sinus is no longer blunted.\n Unchanged aspect of the left lung, no evidence of newly appeared left lung\n opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105919, "text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia? CHF?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with fever, pain, early SIRS picture\n REASON FOR THIS EXAMINATION:\n pneumonia? CHF?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, pain, early SIRS picture.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP PORTABLE VIEW OF THE CHEST: Right PICC tip terminates in the mid\n SVC. The cardiac, mediastinal and hilar contours are unremarkable and\n unchanged without evidence of cardiomegaly. Aortic knob calcifications are\n again noted. The pulmonary vascularity is normal. Retrocardiac opacity is\n non-specific, and may represent an area of atelectasis but infection is not\n excluded. No large pleural effusion or pneumothorax is visualized. Mild\n degenerative changes are noted in the thoracic spine.\n\n IMPRESSION: Retrocardiac opacity which is non-specific and may represent\n atelectasis, but an area of infection is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1107761, "text": " 12:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SUN 1:49 PM\n No hemorrhage, edema, or significant change since days prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with altered mental status. Evaluate for interval\n change.\n\n COMPARISON: Non-contrast head CT, .\n\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\n vertex without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass effect,\n shift of midline structures, or evidence of major vascular territory\n infarction. Bilateral punctate basal ganglia calcifications are again seen. A\n focal hypodensity in the right centrum semiovale (2:23) is somewhat more\n prominent than the prior study, but apparently represents sequela of apparent\n prior infarction (MRI, ), with no current evidence of ischemia,\n allowing for limitations of non-contrast CT. There is no hemorrhage. The\n periventricular white matter demonstrates diffuse hypodensity consistent with\n chronic small vessel ischemic change (as on the MR). The left maxillary sinus\n demonstrates air-fluid level and a mucus- retention cyst (2:4). There is mild\n ethmoid mucosal thickening (2:8). The globes and remainder of soft tissues\n appear unremarkable.\n\n IMPRESSION: No hemorrhage, edema, or significant change since the NECT of 11\n days before; MRI with DWI would be more sensitive for an acute ischemic\n event.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1107762, "text": ", MED MICU-7 12:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No hemorrhage, edema, or significant change since days prior\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107763, "text": " 12:29 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with fevers\n REASON FOR THIS EXAMINATION:\n eval for infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp SUN 4:48 PM\n Findings c/w multifocal pna persist decreased, perisistent mod b/l simple\n effusions, vic contrast Vs sludge in GB, nrml appendix, diverticulosis w/o\n diverticulitis, L inguinal bowel containing hernia wo/obstruction, sigmoidal\n wall thickness underdistension, bladder appararent wall thickening prob\n underdistension ( w./UA) GWlms\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of endocarditis and pneumonia with fevers.\n\n TECHNIQUE: MDCT of the chest, abdomen, and pelvis was performed following\n administration of oral contrast only.\n\n Comparison exam is dated .\n\n CHEST: Again noted are moderate bilateral pleural effusions, stable from the\n prior exam. There are prominent mediastinal lymph nodes, which may be\n reactive. An endotracheal tube in satisfactory position. A right-sided\n central venous line terminates in the superior vena cava. A nasogastric tube\n is identified, and oral contrast is seen within the esophagus. There are\n aortic and coronary artery calcifications.\n\n Lung windows demonstrate patchy multifocal areas of consolidation consistent\n with infection, which are decreased from the prior exam. No new areas of\n consolidation are identified. The central airways are patent. There is\n minimal right upper lobe bronchiectasis.\n\n ABDOMEN: Layering density is noted within the gallbladder, consistent with\n sludge. The gallbladder is otherwise grossly unremarkable. Allowing for lack\n of IV contrast, the liver, spleen, right kidney, adrenal glands, and pancreas\n are grossly normal. Again noted is a hypodensity projecting from the\n posterior left renal mid pole, likely a cyst. There are no pathologically\n enlarged lymph nodes. A nasogastric tube terminates in the distal stomach.\n\n There is diverticulosis, without evidence of acute inflammation. The small\n bowel loops are non-dilated. There is no free fluid or focal fluid\n collection. Diffuse mild-to-moderate anasarca is noted. There are moderate\n atherosclerotic calcifications of the aorta and iliac arteries.\n\n PELVIS: There is moderate sigmoid diverticulosis, without evidence of acute\n inflammation. Again noted is a left inguinal hernia, which now contains a\n (Over)\n\n 12:29 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious source\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portion of sigmoid colon. There is no evidence of bowel obstruction. There\n is no free fluid, and there are no pathologically enlarged lymph nodes. The\n bladder contains a Foley catheter and gas.\n\n Bone windows demonstrate degenerative changes of the spine and lumbar\n laminectomy.\n\n IMPRESSION:\n\n 1. Interval improvement in appearance of bilateral multifocal pulmonary\n infiltrates.\n\n 2. Stable moderate bilateral pleural effusions.\n\n 3. No source of infection identified within the abdomen or pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107827, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure.\n\n Portable AP chest radiograph was compared to obtained at\n 04:51 a.m.\n\n The ET tube tip is 3.5 cm above the carina. The NG tube tip passes below the\n diaphragm, most likely terminating at the stomach. The right internal jugular\n line tip is at the level of mid SVC. The cardiomediastinal silhouette is\n unchanged. There is slight improvement in the left retrocardiac aeration.\n The patient continues to be in mild volume overload with most likely present\n bilateral pleural effusion. No overt pneumothorax is noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1107346, "text": " 10:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recurrent aspiration event\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recurrent aspiration. Evaluation for interval change.\n\n COMPARISON: , 4:21 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged extent and density of the pre-existing right lung\n opacities. Unchanged suspicion of mild left pleural effusion. In the\n interval, a nasogastric tube has been placed. The tip of the tube is not\n included in the image, the side port is located 3 cm below the\n gastroesophageal junction. No evidence of complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107205, "text": " 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung Pneumonia, continues with fevers\n REASON FOR THIS EXAMINATION:\n eval for effusion, PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh WED 4:59 PM\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with right lung pneumonia and continued fever.\n\n STUDY: CT of the torso without contrast; MDCT images were generated through\n the chest, abdomen, and pelvis without intravenous contrast and with oral\n contrast. Coronal and sagittal reformatted images were also generated.\n\n COMPARISON: .\n\n FINDINGS:\n\n CHEST: The thyroid is normal appearing without evidence of masses. The\n patient is intubated with the endotracheal tube approximately 2.5 cm above the\n carina. Moderate-sized bilateral pleural effusions are noted and the patchy\n densities are seen in the right upper and right lower lung lobes as well as in\n the left upper lung lobe. Air bronchograms are seen through these opacities.\n This appearance is consistent with multifocal pneumonia. Calcified\n atherosclerotic disease is seen along the aortic arch and descending aorta. A\n central line tip is seen in the lower SVC. A very small pericardial effusion\n is seen (2; 45).\n\n ABDOMEN: The liver shows no evidence of focal lesions or biliary dilatation.\n The spleen is normal in size and appearance. Gallbladder shows high-density\n blurring consistent with biliary sludge. The pancreas is normal appearing\n without evidence of masses, cysts, or calcifications. The adrenal glands are\n normal appearing bilaterally without evidence of masses. In the left kidney,\n there is a well-circumscribed area of low density that measures 33 x 25 mm and\n likely represents a simple cyst. The large and small intestines show no signs\n of obstruction, wall thickening, or masses. Diverticulosis without evidence\n for diverticulitis is seen in the sigmoid colon. On this limited non-contrast\n study, the aorta, IVC, portal vein and their major branches all appear patent.\n No lymphadenopathy is seen. No free air or fluid is noted in the abdomen.\n Diffuse anasarca is noted within the abdominal wall.\n\n PELVIS: Foley catheter is noted within the bladder. The prostate and rectum\n (Over)\n\n 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appear normal. No lymphadenopathy is seen. No free air or fluid is noted in\n the pelvis. In the left inguinal canal, there is a fat- and fluid-filled\n hernia that does not appear to contain a loop of bowel.\n\n BONES: Mild levoscoliosis is noted in the lumbar spine with moderate\n degenerative changes noted at nearly all levels of the thoracolumbar spine.\n Vacuum phenomenon seen at the L4-L5 intervertebral disc with a likely\n Schmorl's node at the inferior endplate of L4. No focal lytic or sclerotic\n lesions are seen.\n\n IMPRESSION:\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-31 00:00:00.000", "description": "US EXTREMITY NONVASCULAR", "row_id": 1107879, "text": " 11:27 AM\n US EXTREMITY NONVASCULAR Clip # \n Reason: LT KNEE PAIN. EVL FOR EFFUSION\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with history of gout, intubated for PNA, now with pain in left\n knee. please eval left knee for effusion\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 76-year-old man with pain in the left knee. Evaluate for\n effusion.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Transverse and sagittal images of the joint space at the left knee\n were obtained. No joint effusion could be identified on this exam. Note is\n made of some soft tissue edema in the subcutaneous tissues.\n\n IMPRESSION: No fluid collection identified in the left knee space although\n some soft tissue edema is seen in the subcutaneous tissues.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107206, "text": ", MED MICU-7 1:59 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung Pneumonia, continues with fevers\n REASON FOR THIS EXAMINATION:\n eval for effusion, PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Multifocal pneumonia with bilateral pleural effusions.\n 2. Diffuse anasarca.\n 3. Biliary sludge.\n 4. Diverticulosis without evidence of diverticulitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106312, "text": " 5:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET tube placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for ET tube placement\n ______________________________________________________________________________\n WET READ: 6:46 PM\n ETT 6.8cm above carina. New extensive RUL opacification from 00:34 hrs ,\n progressive left retrocardiac opacity. Persistent central, perihilar\n bilateral opacities, right much greater than left, Kerley B lines suggestive\n of pulmonary edema. Layering left effusion. Cardiac silhouette similar to\n most recent study.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 18:18\n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Endotracheal tube assessment.\n\n FINDINGS: Endotracheal tube terminates approximately 6.5 cm above the carina.\n Cardiac silhouette is upper limits of normal in size. Pulmonary vascularity\n is engorged and indistinct, and bilateral septal lines are present.\n Additionally, there is a worsening right-sided central alveolar process, which\n has now extended superiorly to also involve the right upper lobe.\n Additionally, there is worsening dense left retrocardiac opacification as well\n as an increasing small left pleural effusion and persistent small right\n effusion.\n\n IMPRESSION:\n 1. Endotracheal tube terminates 6.5 cm above carina.\n 2. Worsening multifocal pneumonia superimposed upon interstitial pulmonary\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1106610, "text": " 2:53 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFTS ACUTE PROCESS\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man intubated, aspiration PNA, LFT elevation likely secondary to\n shock liver, but please eval liver w/ dopplers\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 4:51 PM\n PFI:\n\n 1. Main portal venous flow hepatopetal.\n\n 2. No intra or extrahepatic bile duct dilatation with a CBD measuring 5 mm.\n\n 3. Hepatic veins patent.\n\n 4. No ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, aspiration pneumonia, LFT elevation likely secondary\n to shock liver but please evaluate the liver.\n\n COMPARISON: .\n\n PORTABLE SON STUDY OF THE LIVER: Grayscale and color son\n images were obtained. The liver appears homogeneous in echotexture. There is\n no ascites. There is no intra- or extra-hepatic bile duct dilatation with the\n CBD measuring to 5 mm. Main portal venous flow is patent with wall-to-wall\n hepatopedal flow. The gallbladder appears normal with no evidence of\n cholelithiasis. The hepatic veins are patent and normal in terms of direction\n and flow demonstrating wall-to-wall flow. There is a small right pleural\n effusion.\n\n IMPRESSION:\n 1. Patent portal vein and hepatic venous system.\n 2. No cholelithiasis.\n 3. No ascites.\n 4. Small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-22 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1106611, "text": ", C. MED MICU-7 2:53 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFTS ACUTE PROCESS\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man intubated, aspiration PNA, LFT elevation likely secondary to\n shock liver, but please eval liver w/ dopplers\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Main portal venous flow hepatopetal.\n\n 2. No intra or extrahepatic bile duct dilatation with a CBD measuring 5 mm.\n\n 3. Hepatic veins patent.\n\n 4. No ascites.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107982, "text": " 3:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with multilobar PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multilobar pneumonia.\n\n FINDINGS: In comparison with study of , allowing for some obliquity of\n the patient, there is no change in the appearance of the monitoring and\n support devices. Increasing opacification at the left base in the\n retrocardiac region is consistent with substantial left lower lung\n atelectasis. Poor definition of the hemidiaphragms persists, consistent with\n layering effusions. Prominence of interstitial markings is consistent with\n some volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106357, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with study , there is worsening opacification\n with air bronchograms that now involve almost the entire right lung. The\n pulmonary vascular congestion is slowly improving. Opacification at the left\n base is consistent with some atelectasis or consolidation with pleural fluid.\n\n Endotracheal tube tip lies approximately 6.5 cm above the carina and\n nasogastric tube extends well into the stomach.\n\n IMPRESSION: Worsening right lung pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1107998, "text": " 7:37 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: LE EDEMA, PLEASE ASSESS FOR DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LE edema, left sided contracture and intractable LE pain\n REASON FOR THIS EXAMINATION:\n please assess for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 11:39 AM\n PFI: No lower extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VEIN SON\n\n INDICATION: A 76-year-old man with lower extremity edema, left-sided\n contracture and intractable lower extremity pain.\n\n COMPARISON: Left lower extremity son dated .\n\n FINDINGS: Grayscale and color Doppler images of the left and right common\n femoral, superficial femoral and popliteal veins were obtained. These\n demonstrate normal flow, compressibility and augmentation.\n\n Bilateral subcutaneous edema is noted.\n\n IMPRESSION: No evidence of deep venous thrombosis in the lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1107999, "text": ", MED MICU-7 7:37 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: LE EDEMA, PLEASE ASSESS FOR DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LE edema, left sided contracture and intractable LE pain\n REASON FOR THIS EXAMINATION:\n please assess for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No lower extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107715, "text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 76-year-old man with respiratory failure.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is persistent left retrocardiac opacity. There is again seen some\n prominence of pulmonary interstitial markings consistent with fluid overload.\n Lines and tubes are unchanged. There is a left-sided pleural effusion which is\n slightly increased.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1107593, "text": " 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL ADDENDUM\n This is a correction regarding the communication between Dr. and Dr.\n described in the impression . Dr. did not directly speak to Dr. \n but left a message for him.\n\n\n 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with l-spine abcesses s/p laminectomy. Intubated for PNA. Now\n with contracture of left leg. Pt's Cr=2.2. Family has waived HD for gado--NSGY\n wants contrast.\n REASON FOR THIS EXAMINATION:\n cord compression? porgression of fluid collections? abcess?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 11:05 AM\n PFI:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the lumbar spine.\n\n CLINICAL INFORMATION: Patient with lumbar spine abscess status post\n laminectomy and intubation with high creatinine, for further evaluation.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were acquired. Diffusion sagittal images were also obtained.\n Given patient's renal failure and prior discussion with the referring\n physician, . , gadolinium enhancement was not performed. Comparison was\n made with the previous MRI examination of .\n\n FINDINGS: From T11-12 to L4-5, no change in appearance of the lumbar spine\n seen with degenerative change and disc bulging as described previously with\n signal changes within the discs. At L5-S1 level, increased signal is\n identified within the disc, predominantly on the left side. Mild thickening\n of the epidural soft tissues is seen immediately posterior to the L5-S1 disc.\n This finding is essentially unchanged compared to the prior study. No\n intraspinal fluid collection is identified. No paraspinal fluid collection is\n seen, although evaluation is slightly limited without contrast administration.\n\n Extensive soft tissue changes are seen posteriorly within the soft tissues,\n particularly at the level of laminectomy at L5-S1 level. The previously noted\n fluid at the superior margin of the laminectomy has decreased. A small fluid\n (Over)\n\n 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collection is now seen measuring 2 cm adjacent to the right facet joint at\n L4-5 level. This fluid collection demonstrates restricted diffusion on the\n diffusion-weighted images. There is no new fluid collection seen in the\n posterior soft tissues. Diffuse hyperintensities are identified involving the\n musculature posteriorly.\n\n The distal spinal cord shows normal signal intensities.\n\n IMPRESSION:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-29 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1107594, "text": ", MED MICU-7 12:03 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: cord compression? porgression of fluid collections? abcess?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with l-spine abcesses s/p laminectomy. Intubated for PNA. Now\n with contracture of left leg. Pt's Cr=2.2. Family has waived HD for gado--NSGY\n wants contrast.\n REASON FOR THIS EXAMINATION:\n cord compression? porgression of fluid collections? abcess?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. The signal changes at L5-S1 level as well as the epidural soft tissue\n thickening have not significantly changed. No intraspinal or paraspinal fluid\n collection identified. No new abnormalities seen in this region.\n 2. Previously noted fluid collection at the laminectomy site at the superior\n margin of the laminectomy has decreased with a small 2 cm fluid collection\n adjacent to the right facet joint between L4 and L5 is identified. This area\n demonstrates restricted diffusion. Given the history of recent surgery, this\n could be secondary to blood products, but associated infection cannot be\n excluded given the restricted diffusion.\n 3. Multilevel degenerative changes and other findings described previously\n are again identified.\n 4. The findings were discussed with Dr. by Dr. of\n radiology on at about 10 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107044, "text": " 1:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Respiratory failure.\n\n FINDINGS: Since the chest radiograph earlier of the same date, the position\n of the ET tube is lower in the trachea and 2 cm above the carina. NG tube\n passes into the stomach and out of view.\n\n Right peri- and infrahilar consolidation is unchanged; however, there has been\n some improvement in the asymmetrical superimposed pulmonary edema, layering\n right pleural effusion is unchanged, and mild cardiomegaly stable with no\n pneumothorax.\n\n IMPRESSION:\n\n Interval improvement in superimposed pulmonary edema with stable right lung\n consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106136, "text": " 12:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inteerval change, flash pulm edema?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with acute resp distress\n REASON FOR THIS EXAMINATION:\n inteerval change, flash pulm edema?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Acute respiratory distress, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing bilateral\n opacities, much more evident on the right than on the left, show a clear\n tendency to concentrate in the central and perihilar areas of the lung. The\n dynamic of the changes as compared to the previous examination as well as the\n development of a subtle interstitial component (Kerley B lines) strongly\n suggests pulmonary edema.\n\n The size of the cardiac silhouette has minimally increased. The lowest part\n of the left and the complete right costophrenic sinus are not included in the\n image. The right-sided PICC line is not visible on today's examination.\n\n IMPRESSION: Increasing centralization of pre-existing pulmonary edema,\n development of a subtle interstitial component.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106956, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INTERVAL CHANGE\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with unilateral PNA.\n REASON FOR THIS EXAMINATION:\n INTERVAL CHANGE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Interval change in unilateral pneumonia.\n\n COMPARISON: Chest radiograph from and .\n\n SINGLE AP SEMI UPRIGHT BEDSIDE CHEST RADIOGRAPH: In comparison with the prior\n radiograph, there has been no significant change in the multifocal airspace\n opacities within the entire right lung, allowing for differences in technique\n and lung volumes. The left lung appears clear. The left costophrenic angle is\n not well visualized and a small left pleural effusion cannot be excluded.\n There is mild pulmonary vascular congestion better seen on the left lung, may\n suggest underlying volume overload.\n\n The endotracheal tube is in stable position with the tip 7 cm from the carina.\n A right IJ catheter terminates in the upper SVC.\n\n IMPRESSION: Findings suggestive of mild volume overload with no significant\n interval change in the right lung pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107453, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure.\n\n Comparison is made with prior study .\n\n Cardiomediastinal contours are normal. Almost complete collapse of the left\n lower lobe has improved. Small left and moderate right pleural effusions are\n unchanged. Right perihilar consolidation has slightly improved. Interstitial\n edema has almost resolved. ET tube tip is 5.7 cm above the carina. NG tube\n tip is out of view below the diaphragm. Right IJ catheter remains in place.\n There is no pneumothorax.\n\n" } ]

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43F with no prior cardiac history presenting with vague esophageal symptoms and a slightly positive troponins.

In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute EKG changes. Nopathologic valvular abnormality seen. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Non-specific slight anterolateral ST segment elevation.Clinical correlation is suggested. Normal coronaries & LV. Normal coronaries & LV. Action: IV Nitro weaned off. Action: IV Nitro weaned off. Action: IV Nitro weaned off. Action: IV Nitro weaned off. EKG with chest burning/jaw numbness without acute ischemic changes noted. NECK: Supple with JVP not elevated CARDIAC: RR, normal S1, S2. Slight non-specific anterolateral ST segment elevation.Clinical correlation is suggested. Gastroesophageal reflux disease (GERD) Assessment: Pt denies any reflux. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. NSTEMI.Height: (in) 75Weight (lb): 198BSA (m2): 2.19 m2BP (mm Hg): 95/53HR (bpm): 72Status: InpatientDate/Time: at 10:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Given sensitivity of troponin, this most likely represents myocardial ischemia (ACS) though patient with CHF, LVH, kidney disease can have elevated troponins; this patient has none of these. Given sensitivity of troponin, this most likely represents myocardial ischemia (ACS) though patient with CHF, LVH, kidney disease can have elevated troponins; this patient has none of these. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. FINDINGS: The cardiomediastinal silhouette is within normal limits. Normal ascending aorta diameter. Plan: Continue pt on antiishemic regimen, antiplt, hold off B Blocker as HR is in low 60s currently. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Labs / Radiology [image002.jpg] Assessment and Plan # NSTEMI: Ruled-in by troponin; no ECG changes noted. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Tele sinus rhythm. Given GI cocktail less lidocaine. Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Sclera anicteric. The aortic root is mildly dilated at thesinus level. Plavix and Lipitor dc Gastroesophageal reflux disease (GERD) Assessment: Pt returned from cath c/o reflux and slight nausea. Plavix and Lipitor dc Gastroesophageal reflux disease (GERD) Assessment: Pt returned from cath c/o reflux and slight nausea. be related to eosinophilic esophagitis. be related to eosinophilic esophagitis. - Continue PPI - Recheck in AM # DYSPHAGIA/GERD: - require outpatient EGD FEN: NPO for now given possibility of cath come morning. - Continue PPI - Recheck in AM # DYSPHAGIA/GERD: - require outpatient EGD FEN: NPO for now given possibility of cath come morning. Normalaortic arch diameter. Vague c/o R sided chest pain worse with inspiration. Vague c/o R sided chest pain worse with inspiration. Vague c/o R sided chest pain worse with inspiration. Plan: Pt sent for cardiac cath. Plan: Pt sent for cardiac cath. PTT 150. vague c/o R sided chest pain worse with inspiration. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt admitted to CCU for (+) troponin leak/Chest discomfort for r/I MI w/u. NPO for possible CV cath. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Gastroesophageal reflux disease (GERD) Assessment: Action: Response: Plan: Occupation: Anesthiologist. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Response: Pt sleeping, weaning down TNG, remains on heparin 1300u. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath. Pt was treated with ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to for further eval/possible CV Cath.

15

[ { "category": "Echo", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 86704, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. NSTEMI.\nHeight: (in) 75\nWeight (lb): 198\nBSA (m2): 2.19 m2\nBP (mm Hg): 95/53\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Normal regional and global biventricular systolic function. No\npathologic valvular abnormality seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050449, "text": " 12:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with chest pain, pos trop\n REASON FOR THIS EXAMINATION:\n eval for CHF, effusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Chest pain.\n\n COMPARISONS: None available.\n\n FINDINGS: The cardiomediastinal silhouette is within normal limits. The\n hilar structures appear normal. No effusion or pneumothorax is detected.\n Minimal blunting of the left costophrenic angle likely represents scarring or\n atelectasis. Pulmonary vascularity appears within normal limits. No focal\n consolidation is detected.\n\n IMPRESSION:\n\n 1. No radiographic evidence of pneumonia or acute CHF.\n\n 2. Minimal scarring or atelectasis in the left lung base.\n\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240861, "text": "Sinus rhythm. Slight non-specific anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to tracing #3 no significant\nchange.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240862, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to tracing #2 no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2108-11-01 00:00:00.000", "description": "Report", "row_id": 240863, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. Compared to the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2108-10-31 00:00:00.000", "description": "Report", "row_id": 240864, "text": "Sinus rhythm. Non-specific slight anterolateral ST segment elevation.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648894, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648898, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in\n symptoms.PT was transferred to CCU at 4am . He arrived with\n intermittent rt sided chest discomfort, worse with deep breath and/or\n change in position and mild nausea s/p the MS dose in ER , accompanied\n by wife. Decision made to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. vague\n c/o R sided chest pain worse with inspiration.\n Action:\n IV Nitro weaned off. IV heparin off at 10am.\n Response:\n Headache improved. Less nausea.\n Plan:\n Pt sent for cardiac cath.\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648899, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration.\n Action:\n IV Nitro weaned off. IV heparin off at 10am.\n Response:\n Headache improved. Less nausea.\n Plan:\n Pt sent for cardiac cath.\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt denies any reflux.\n Action:\n Cont on prilosex.\n Response:\n Plan:\n ? further GI workup.\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648861, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648865, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath. Please refer to CCU Resident note\n for involved recent HPI.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in\n symptoms.PT was transferred to CCU at 4am d/t no CV step down beds\n available. He arrived with intermittent rt sided chest discomfort,\n worse with deep breath and/or change in position and mild nausea s/p\n the MS dose in ER , accompanied by wife.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt admitted to CCU for (+) troponin leak/Chest discomfort for r/I MI\n w/u.\n Action:\n Pt on TNG/Heparin gtt as well as ASA/Plavix. NPO for possible CV cath.\n EKG with chest burning/jaw numbness without acute ischemic changes\n noted. Pt given prilosec dose early as well as GI slurry and fell\n sleep, pain free. Cycling CPK\ns. Possible ECHO today as well for\n further w/u diagnostics. Teaching/support for wife and pt.\n Response:\n Pt sleeping, weaning down TNG, remains on heparin 1300u. Aware of plan\n of care as is his wife. Appears comfortable currently.\n Plan:\n Continue pt on antiishemic regimen, antiplt, hold off B Blocker as HR\n is in low 60\ns currently. Continue to assess each episode of\n pain/continue to decrease pt anxiety/teaching/support. c/o to 3\n once bed available. Check labs 8am- cycle CPK\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt with hx GERD admitted for r/I MI, continues with GI symptoms.\n Action:\n Pt developing chest burning with jaw numbness- given prilosec/slurry .\n EKG done as well.\n Response:\n Pt becoming more comfortable and falling asleep. VS remain stable.\n Plan:\n Continue to w/u GERD/Gi as possible etiology of some of pt\ns symptoms.\n Continue to support, decrease anxiety.\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648940, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration. Cardiac echo shows nl LV\n function.\n Action:\n IV Nitro weaned off. IV heparin off at 10am. To cath lab.\n Response:\n Headache improved. Less nausea.\n Plan:\n To cardiac cath lab. Normal coronaries & LV. Plavix and Lipitor dc\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt returned from cath c/o reflux and slight nausea.\n Action:\n HOB ^\nd to 15 & reverse trendelenberg. Given dry crackers. Prilosec ^\n to \n Response:\n Pt presently sleeping.\n Plan:\n ? further GI workup. To follow up with PCP.\n" }, { "category": "Physician ", "chartdate": "2108-11-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 648846, "text": "TITLE:\n Chief Complaint: NSTEMI\n HPI:\n Dr. is a 43 year-old man with a history of GERD who presents with\n pleuritic pain and elevated troponin.\n Approximately 6 weeks prior to admission patient hurt his low back\n afters slipping; he began using high doses of NSAIDs (ibuprofen 800mg\n TID with toradol). On , he noted a \"warm\" feeling in his chest\n which lasted seconds; there may have been some associated nausea but no\n SOB or overt CP. From he was in during which time he\n experienced two further episodes, similar in nature.\n Approximately 1.5 weeks prior to admission, he began also feeling\n abdominal pain and occasional sensations that something was getting\n stuck in his throat. He spoke with his cardiologist who ordered an\n ETT. This was done on and returned normal (13 minutes with HR up\n to 160+). The following day he felt burning and reflux and induced\n vomiting to alleviate the symptoms. Two days later he spoke with a\n gastroenterologist and was told he may have eosinophilic esophagitis.\n Over the last couple days he has experienced right lower pleuritic\n chest pain. On the day of admission he was at work and ate stir fry.\n He began feeling as though \"food was lined up in the stomach\" though he\n was hungry. He then presented to the ED at his place of work.\n At the OSH ED he was found to have a troponin I of 0.51 and CK of 89;\n aspirin, plavix and heparin gtt were started and he was transferred for\n further evaluation.\n In the ED, VSS with HR in the 60s and blood pressure in 120s systolic.\n Given persistent chest pain, nitro gtt was started.\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n He denies recent fevers, chills or rigors. He denies exertional buttock\n or calf pain. He reports frequent \"gas\" and recent low back pain with\n radiation down the right leg, improved of late.\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.5 mcg/Kg/min\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS:\n (-) Diabetes\n (-) Dyslipidemia\n (-) Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None.\n -PCI: None.\n -PACING/ICD: None.\n 3. OTHER PAST MEDICAL HISTORY:\n - GERD\n - Exercise induced asthma\n - Psoriasis\n - s/p tonsillectomy, bilateral hernia repair\n - Colonoscopy at age 40; normal\n Brother and father with . No history of early CAD. Father is\n otherwise healthly at age 70. GF with leukemia; other GF with prostate\n v. colon cancer.\n Occupation: Anesthiologist.\n Drugs: None.\n Tobacco: None.\n Alcohol: Rare.\n Other:\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea\n Flowsheet Data as of 05:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 65 (63 - 72) bpm\n BP: 98/59(69) {98/50(64) - 108/65(75)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 34 mL\n PO:\n TF:\n IVF:\n 34 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 34 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, Rash: Prosiaris plaques on LE\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n # NSTEMI: Ruled-in by troponin; no ECG changes noted. Given\n sensitivity of troponin, this most likely represents myocardial\n ischemia (ACS) though patient with CHF, LVH, kidney disease can have\n elevated troponins; this patient has none of these. Elevations may\n also be seen in PE/myocarditis/pericarditis; these also appear unlikely\n in this patient. Without CK elevations, this may represent very early\n (2-3 hours) myocardial injury or late (days).\n - Trend CE\n - Continue with anti-platelets (aspirin/plavix)\n - Continue with heparin gtt\n - Continue with nitro gtt though unclear if benefitting\n - Try morphine PRN\n # PUMP: Euvolemic.\n # RHYTHM: NSR.\n # ANEMIA: Mild; will follow while on triples\n # EOSINOPHILIA: Mild with absoluate count of ~1000. Unclear\n etiology. be related to eosinophilic esophagitis.\n - Continue PPI\n - Recheck in AM\n # DYSPHAGIA/GERD:\n - require outpatient EGD\n FEN: NPO for now given possibility of cath come morning.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin\n -Pain managment with nitro gtt and morphine\n CODE: Presumed full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:18 AM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2108-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648851, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt. having right sided jaw discomfort and chest burning this am. Given\n GI cocktail less lidocaine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.5 mcg/Kg/min\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 65 (63 - 72) bpm\n BP: 98/59(69) {98/50(64) - 108/65(75)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 141 mL\n PO:\n 100 mL\n TF:\n IVF:\n 41 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 141 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n GENERAL: Lying in bed, mildly groggy after receiving morphine. In no\n distress.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP not elevated\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Cyst noted on lateral knee\n on the left.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n # NSTEMI: Ruled-in by troponin; no ECG changes noted. Given\n sensitivity of troponin, this most likely represents myocardial\n ischemia (ACS) though patient with CHF, LVH, kidney disease can have\n elevated troponins; this patient has none of these. Elevations may\n also be seen in PE/myocarditis/pericarditis; these also appear unlikely\n in this patient. Without CK elevations, this may represent very early\n (2-3 hours) myocardial injury or late (days).\n - Trend CE\n - Continue with anti-platelets (aspirin/plavix)\n - Continue with heparin gtt\n - Continue with nitro gtt though unclear if benefitting\n - Try morphine PRN\n # PUMP: Euvolemic.\n # RHYTHM: NSR.\n # ANEMIA: Mild; will follow while on triples\n # EOSINOPHILIA: Mild with absoluate count of ~1000. Unclear\n etiology. be related to eosinophilic esophagitis.\n - Continue PPI\n - Recheck in AM\n # DYSPHAGIA/GERD:\n - require outpatient EGD\n FEN: NPO for now given possibility of cath come morning.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin\n -Pain managment with nitro gtt and morphine\n CODE: Presumed full\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:18 AM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2108-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648903, "text": "This is a 43 yr old pt with hx GERD who presented to OSH with (+)rt\n sided pleuritic CP and (+)troponin/ (-)CPK. Pt was treated with\n ASA/plavix/Heparin gtt for ACS as well as GI Slurry and sent to \n for further eval/possible CV Cath.\n In ER, pt was noted to have troponin of 0.11 and CPK (-) without acute\n EKG changes. HE was started on TNG gtt for persistant pleuritic type\n pain and then given 4 mg MSO4 as well without much change in symptoms\n was transferred to CCU at 4am . He arrived with intermittent rt sided\n chest discomfort, worse with deep breath and/or change in position and\n mild nausea s/p the MS dose in ER , accompanied by wife. Decision made\n to bring pt to cath lab.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Tele sinus rhythm. SBP >90. c/o headache and nausea. PTT 150. Vague\n c/o R sided chest pain worse with inspiration. Cardiac echo shows nl LV\n function.\n Action:\n IV Nitro weaned off. IV heparin off at 10am. To cath lab.\n Response:\n Headache improved. Less nausea.\n Plan:\n To cardiac cath lab. Normal coronaries & LV. Plavix and Lipitor dc\n Gastroesophageal reflux disease (GERD)\n Assessment:\n Pt returned from cath c/o reflux and slight nausea.\n Action:\n HOB ^\nd to 15 & reverse trendelenberg. Given dry crackers.\n Response:\n Pt presently sleeping.\n Plan:\n ? further GI workup.\n" } ]

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The patient was admitted on . She underwent preoperative placement of a pulmonary artery catheter to monitor pulmonary artery pressures. She was taken to the Operating Room on where she underwent an exploratory thoracotomy with multiple lymph node biopsies and biopsy of right diaphragmatic plaque. Intraoperatively it was found that the patient had extensive nodal involvement and it was determined that a lobectomy should not be undertaken and the patient was taken to the post anesthesia care unit. In the post anesthesia care unit she developed some respiratory difficulties and required reintubation and also required vaso active pressors and fluids to improve her low blood pressure and heart rate. Nitroglycerin was used for elevated pulmonary artery pressures. On postoperative day one the patient remained intubated and was noted to have a significant rise in creatinine at 2.7. Nephrology was consulted and determined that this was acute renal failure superimposed upon a history of chronic renal problem and advised gentle diuresis and avoidance of agents that induce renal vaso constriction. Neurology was also consulted for mental status changes. The patient had undergone an examination and was nonfocal and had no further recommendations or indications of acute neurological pathology appearing at that time. The patient was weaned to extubation on the course of postoperative day two and on postoperative day three was placed on CPAP. By postoperative day four the patient had weaned off all drips and had been extubated and was doing well and was therefore transferred to the floor. During her period on Far 2 she experienced some confusion as a result of her narcotics, which were subsequently stopped, but otherwise her course was unremarkable. She continued aggressive incentive spirometry and pulmonary toilet with ambulation and her respiratory examination improved and she was able to maintain good O2 sats on room air. On postoperative day six the patient was weaned down from her O2 and given the ability to ambulate and her respiratory condition she was discharged to home and asked to follow up with Dr. in three days at his clinic. She was also told to follow up with her primary care physician in one week. To note laboratories at the time of discharge showed a hematocrit of 29.9 with a BUN and creatinine of 46 and 1.6 respectively with a potassium of 4.1.

DENIES SHORTNESS OF BREATH.GI: NPO AFTER MID NOC. Neo gtt weaned off. Pt gently hyperventilated to normalize ABG. Sinus bradycardiaNormal ECG except for rateSince previous tracing of : supraventricular tachycardia has reverted tosinus rhythm Lungs clear, slightly diminished upper right.NEURO: Alert, oriented, follows commands, MAE equally.GU: Foley, adequate UOP.GI: Reglan given x 2 for nausea. Neo gtt to tx hypotension. SBP 130'S TO 168/ ,NITRO WEANED TO OFF . Volume given, atropine given with good effect, briefly. OG tube d/c'd with extubation. POST CXR DONE. Plan to cont vent support, labile hemodynamics. Hemodynamically NTG infusing. Sinus bradycardiaNormal ECG except for rateNo previous tracing for comparison BP immediatley recovers when converts back to NSB. Antiobiotic therapy changed.PAIN: Epidural catheter intact, site WNL. CT draining scant serosang fluid. SBP RANGED 78 TO 180'S AND REMAINS DEPENDENT ON NEO DRIP. Breathing became labored, Sa02 dropped, anesthesia called STAT. Resp Care Note, Pt weaning on cpap/psv ps 10cmh2o for vt's 3-400. will cont to wean as tol Resp Care Note, Pt reains on current vent settings T 100.2 weaning neo,Given bicarb for met acidosis. STARTED ON CLONIDINE TID. Started on nitro gtt for elevated PA pressures. Pt slowly stabilized and dopamine weaned off and Neo at 2mcg/kg/min. focus: status update.NEURO: ALERT AND ORIENTED X3 MAE ON COMMAND, PERL, NO APPARENT NEURO DEFICIT.CV: PA LINE PLACED AFTER FEW ATTEMPTS. Maintaing good PaO2, metabolic acidosis on first post-extubation gas. ONE AMP OF DEXTROSE AND REG INSULIN FOR ELEVATED K. C/ IMPROVEMENT.RESP: LUNG SOUNDS COARSE TO CLEAR. NEO BEING WEANED OFF AS TOLERATED. OGT PLACED AFTER PT STARTED ON PROPROFOL AND TO LWS DRAINING MINIMAL BILIOUS DRAINAGE.GU; PT WITH LOW URINE OP AND DR AND DR WITH NO ORDERS WRITTEN. MAE.CV: NSR no VEA.Palp DP. Dilaudid gtt, weaned to off to assess neuro status. Pt reintubated. PT DENIES NAUSEA. WAKE PT TO WEAN TO EXTUBATE IF REMAINS STABLE. CREATININE > 2.0 THIS AM.COMFORT; PT WITH EPIDURAL CATH IN BACK BUT NOT IN USE AT THIS TIME PER PAIN TEAM. ABG SHOWED ACIDEMIA, ONE AMP OF BICARB C/ IMPROVEMENT IN ABG, CT DRAINING SMALL TO MODERATE AMOUNTS OF S/S DRAINAGE. tolerating meds and water.GU: urine output adeaquet. RT PLEURAL CHEST TUBE WITH INTERMITTENT SM AIR LEAK DR AND DRAINING MINIMAL THIN SEROSANQ DRAINAGE.CARDIOVAS; HR AND BP VERY LABILE MOST OF THE . PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 63Weight (lb): 155BSA (m2): 1.74 m2BP (mm Hg): 164/49HR (bpm): 52Status: InpatientDate/Time: at 03:06Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. In the mean time hemdynamic instability continued, pt required dopamine and neo to maintain SBP. See adm history for PMH. PT IN AND OUT OF ACC. Since dopa gtt stopped, NSB consistently and BP much more stable. Dilauded infusion started for pain management, epidural on hold per pain service. Resp. Resp. CT Site D/I , no redness or break down.A pt is stable epidural is functioning.PAS and SBP are highP continue with lopressor and titrate up nitroglercerine for PAS < 60. note labs replete lytes as needed. NITRO GTT STARETD IN HOPES THAT PAS WOULD IMPROVE C/ LITTLE EFFECT. Regular supraventricular rhythmLead(s) unsuitable for analysis: V1ST junctional depression is nonspecificSince previous tracing of : supraventricular tachycardia is seen PAIN MANAGEMENT: EPIDURAL FENTANYL/BUPIVICAINE AT 12 CC ..PT DENIES PAIN. ID: Afebrile. PH WNL. C-XRAY, CARDIOLOGY CONSULT, AND CARDIAC ECHO DOWN FOR INSTABILITY AND INCREASED CK/MB AND TROPONIN. U/O qs, +BS. Bicarb given for most recent ABG.GI: Abd. Left ventricular systolic function ishyperdynamic (EF>75%).AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened.PERICARDIUM: There is a small pericardial effusion. PULSES PALPABLE.RESP: LUNG SOUNDS CLEAR. Shift NoteNeurologically pt intact, MAE to command. PT ON DILAUDID GTT AND TITRATED BETWEEN 0.75MG TO 1 MG/HR WITH GOOD EFFECT.PLAN; CONT TO MONITOR AND ASSESS MONITOR URINE OP AND POTASSIUM LEVEL POSS. Pt continued to be labile, ABG revealed profound Resp. CONT C/ LOW GRADE FEVER. OG TUBE IN PLACE--CLAMPPED.GU: FOLEY CATH PATENT DRAINING YELLOW CLEAR URINE SEE FLOW SHEET FOR SPECIFICS.PAIN: PT DENIES PAIN.ENDO: BS WNL. Intubated with 7.5 ETT and placed on vent with settings as per carevue. foley to gravity.Skin: thoracotomy Dsg D/I. Failed RSBI 166.7. TRACKS C/ EYES. Very little extra movement to painful stimuli.CV: At beginning of shift, alternating between junctional rhythm 40-50s and NSB rate 50s. Pt then became hemodynamically unstable, JR 30's, SBP 60's. gtt, but SBP increased 170's, nitro. MAE EQUAL STRENGTH BIL LOWER EXTREMITIES AND UPPER EXTREMITIES. Resp: Lungs cta, SAO2 100% ra. CONTINUE C/ CURRENT PLAN OF CARE Pt returned extubated but required intubation shortly after arrival back to unit for resp. Cont vent support. 2 Units PRBC given for low Hct.PULM: Metabolic acidosis during the day. Care NotePt to OR today for thoracotomy. good wave PA pressures high nitroglycerine started to decrease PAS. IVF D5W with sodium bicarbonate at 40.Lungs : coarse in upper lobes coarse to wheezing in bases. MAE and follows commands.CV: SB/NSR with no ectopy, SWAN dc'd, introducer to LSC, team wanted to d/c nitro. PT NOW SEDATED OVER ON PROPROFOL AT 30 MCG/KG/MIN DUE TO ANY MANIPULATION PT WOULD ATTEMPT TO SIT UP, GAGGING ON ETT, MAKING BP,HR, AND PA NUMBERS VERY LABILE.RESP; LUNGS SOUND VERY COARSE THRUOUT AND SUCTION FOR MOD AMTS THICK BLOODY SPUTUM. There is a small pericardial effusion. PT WITH MAINT. CI WNL. NITRO OFF PA PRESSURES UNCHANGED. PERRL. 7a-7pCV: NSR, rare PAC. Renal: HNV Heme: Bloodwork to be drawn when SG placed. SKin: Intact.A: Stable, awaiting SG insertion and lobectomy.P: As above. NEURO: A/O X 3. BLD CULTURES X2 DONE AND AT THIS TIME PT NEEDS URINE CULTURE AND SPUTUM CULTURE. Pt with met. MAINT FLUID STARTED, NS @60 ML/H.

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[ { "category": "Echo", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 100211, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 155\nBSA (m2): 1.74 m2\nBP (mm Hg): 164/49\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 03:06\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%).\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Left ventricular systolic function is hyperdynamic\n(EF>75%). Right ventricular chamber size is normal with preserved free wall\nmotion. The aortic valve leaflets are mildly thickened. The mitral valve\nleaflets are mildly thickened. There is a small pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 274934, "text": "Sinus bradycardia\nNormal ECG except for rate\nSince previous tracing of : supraventricular tachycardia has reverted to\nsinus rhythm\n\n" }, { "category": "ECG", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 274935, "text": "Regular supraventricular rhythm\nLead(s) unsuitable for analysis: V1\nST junctional depression is nonspecific\nSince previous tracing of : supraventricular tachycardia is seen\n\n" }, { "category": "ECG", "chartdate": "2177-06-30 00:00:00.000", "description": "Report", "row_id": 274936, "text": "Sinus bradycardia\nNormal ECG except for rate\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421443, "text": "Shift Note\nNeurologically pt intact, MAE to command. Hemodynamically NTG infusing. U/O qs, +BS. Pt sent to OR with anesthesia.\n\nPatient admitted to the CSRU S/P R. thoracotomy. Pt arrived extubated with Sa02 99% on face mask, pt C/O severe pain, APS into see patient and adjust epidural. Pt's pain continued to escalate and pt became increasingly restless, thrashing in the bed and hypertensive, SBP >200mmHg, Team in room to assess patient, NTG and SNP started to reduce BP. Breathing became labored, Sa02 dropped, anesthesia called STAT. Pt reintubated. Pt then became hemodynamically unstable, JR 30's, SBP 60's. Volume given, atropine given with good effect, briefly. Pt continued to be labile, ABG revealed profound Resp. acidosis, PCO2 111. Pt gently hyperventilated to normalize ABG. In the mean time hemdynamic instability continued, pt required dopamine and neo to maintain SBP. Pt slowly stabilized and dopamine weaned off and Neo at 2mcg/kg/min. Dilauded infusion started for pain management, epidural on hold per pain service. Pt is sleeping comfortably in bed, arousable adn neurologically intact, denies pain. See flow sheet for details. Vitals documented q 5 minutes while unstable.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421444, "text": " CSRU 7P-7A SHIFT SUMMARY;\n\nNEURO; SEDATED ON DILAUDID FOR PAIN BUT EASILY ARROUSABLE BY VOICE DID FOLLOW COMMANDS AND MOVED ALL EXTREMITIES. PERRL. PT NOW SEDATED OVER ON PROPROFOL AT 30 MCG/KG/MIN DUE TO ANY MANIPULATION PT WOULD ATTEMPT TO SIT UP, GAGGING ON ETT, MAKING BP,HR, AND PA NUMBERS VERY LABILE.\n\nRESP; LUNGS SOUND VERY COARSE THRUOUT AND SUCTION FOR MOD AMTS THICK BLOODY SPUTUM. ABG'S WNL EXCEPT C02 33 THIS AM. PH WNL. 02 SAT'S 100% NO VENT CHANGED OVER AND PT REMAINS ON SIMV 50% 16 X 500 . RT PLEURAL CHEST TUBE WITH INTERMITTENT SM AIR LEAK DR AND DRAINING MINIMAL THIN SEROSANQ DRAINAGE.\n\nCARDIOVAS; HR AND BP VERY LABILE MOST OF THE . C-XRAY, CARDIOLOGY CONSULT, AND CARDIAC ECHO DOWN FOR INSTABILITY AND INCREASED CK/MB AND TROPONIN. PT IN AND OUT OF ACC. JUNCTIONAL RHYTHMS TO SB 40'S- 50'S TO SVT 130 AND THEN SR 60'S. THIS AM PT MOSTLY SB 40'S. SBP RANGED 78 TO 180'S AND REMAINS DEPENDENT ON NEO DRIP. PT GIVEN 250CC LR BOLUS AND A PARTIAL 250CC BOLUS FOR LOW BP'S AND LOW URINE WITH NO REMARKABLE EFFECT. DOPAMINE DRIP AT 5MCG/KG/MIN AND DOWN TO 3MCG/KG/MIN PER ORDERS. PAS AND PAD REMAIN 50-60'S /20'S. CI >2.00 ALL SHIFT. POTASSIUM CLIMBING UP TO 5.8 TX WITH 30 GMS KAYXYLATE/SORBITAL PER ORDERS DOWN OGT. TEMP SPIKE TO 102.7 DR AND PT TX WITH 1000MGS TYLENOL GIVEN PR. BLD CULTURES X2 DONE AND AT THIS TIME PT NEEDS URINE CULTURE AND SPUTUM CULTURE. PT WITH MAINT. IV OF LR AT 70CC HR BUT STOPPED PER ORDERS DURING THE .\n\nGI; BS ABSENT. PT WITHOUT OGT AND ATTEMPTED TO PLACE ONE BUT PT BECAME VERY AGGITATED AND DID NOT TOLERATE. OGT PLACED AFTER PT STARTED ON PROPROFOL AND TO LWS DRAINING MINIMAL BILIOUS DRAINAGE.\n\nGU; PT WITH LOW URINE OP AND DR AND DR WITH NO ORDERS WRITTEN. CREATININE > 2.0 THIS AM.\n\nCOMFORT; PT WITH EPIDURAL CATH IN BACK BUT NOT IN USE AT THIS TIME PER PAIN TEAM. SITE CDI. PT ON DILAUDID GTT AND TITRATED BETWEEN 0.75MG TO 1 MG/HR WITH GOOD EFFECT.\n\nPLAN; CONT TO MONITOR AND ASSESS MONITOR URINE OP AND POTASSIUM LEVEL POSS. WAKE PT TO WEAN TO EXTUBATE IF REMAINS STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421445, "text": "Respiratory Care:\nPatient remained on ventilatory support with no changes made throughout the night. ABG's show that the patient is receiving adequate oxygenation with a compensated metabolic acidemia.\n\nNo RSBI performed due to patient's cardiac instability.\n\nPlan is to eliminate sedation and allow patient to be weaned from ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421446, "text": "NEURO: , , weaned off propofol and dilaudid to assess neuro status, hands and feet move on own but not to command, gets restless and agitated at times, Has nodded head to questions a couple of times. Looks at speaker, but does not follow most of time. Very little extra movement to painful stimuli.\n\nCV: At beginning of shift, alternating between junctional rhythm 40-50s and NSB rate 50s. When junctional, becomes very hypotensive quickly. BP immediatley recovers when converts back to NSB. Neo gtt to tx hypotension. Dopamine gtt weaned off per Dr. is dopa may be counterproductive due to diastolic dysfunction. Since dopa gtt stopped, NSB consistently and BP much more stable. Started on nitro gtt for elevated PA pressures. CI WNL. Cardiology in to see patient.\n\nRESP: Lungs coarse throughout, CT with SS drainage, no air leak, suctioned small amounts of thick blood tinged secretions. Several vent changes made due to ABG results, see flowsheet for changes. Bicarb given for most recent ABG.\n\nGI: Abd. soft. OGT clamped. Absent BS\n\nGU: U/O 20-25cc/hr, 500 NS fluid bolus given, CR 2.7 this afternoon.\n\nID: Febrile. Urine and sputum cx sent, blood sent previous shift. Antiobiotic therapy changed.\n\nPAIN: Epidural catheter intact, site WNL. Dilaudid gtt, weaned to off to assess neuro status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421447, "text": "Resp. Care Note\npt remains intubated and vented on settings as per carevue. Please see flowsheet for changes made. Pt with met. acidosis on ABG's. Cont vent support.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-02 00:00:00.000", "description": "Report", "row_id": 1421448, "text": "Pt beginning to answer questions by nodding head more consistently and seems to be gripping hands and moving feet to command instead of just at random.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-30 00:00:00.000", "description": "Report", "row_id": 1421440, "text": "CSRU Admission\nS/O: 73 yo woman admitted preop RU Lobectomy for SG evaluation. See adm history for PMH.\n Neuro: Alert and oriented.\n CV: SB 50s, 160/50.\n Resp: Lungs cta, SAO2 100% ra.\n Renal: HNV\n Heme: Bloodwork to be drawn when SG placed.\n ID: Afebrile.\n GI: Not much appetite.\n Endo: Awaiting bloodwork.\n SKin: Intact.\nA: Stable, awaiting SG insertion and lobectomy.\nP: As above. Preop teaching.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421441, "text": "focus: status update.\nNEURO: ALERT AND ORIENTED X3 MAE ON COMMAND, PERL, NO APPARENT NEURO DEFICIT.\n\nCV: PA LINE PLACED AFTER FEW ATTEMPTS. HIPERTENSIVE TO 160'S, PA PRESSURES SYSTOLIC 40'S TO 50'S. NITRO GTT STARETD IN HOPES THAT PAS WOULD IMPROVE C/ LITTLE EFFECT. MAINT FLUID STARTED, NS @60 ML/H. PT . PULSES PALPABLE.\n\nRESP: LUNG SOUNDS CLEAR. SATS 98 TO 100 AT RA. DENIES SHORTNESS OF BREATH.\n\nGI: NPO AFTER MID NOC. BOWEL SOUNDS PRESENT. ABD SOFT NON TENDER TO PALPATION.\n\nGU: VOIDS YELLOW CLEAR URINE.\n\nENDO: BS COVERED C/ REG INSULIN AS PER PROTOCOL.\n\nSOCIAL: FAMILY CALLED. FAMILY COMING IN TODAY IN AM.\n\nPLAN: PRE-OP TEACHING, OPTIMIZED LAVEL OF COMFORT PROVIDE EMOTIONAL SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-01 00:00:00.000", "description": "Report", "row_id": 1421442, "text": "Resp. Care Note\nPt to OR today for thoracotomy. Pt returned extubated but required intubation shortly after arrival back to unit for resp. failure. Intubated with 7.5 ETT and placed on vent with settings as per carevue. Please refer to flowsheet for parameters and changes made. Plan to cont vent support, labile hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-05 00:00:00.000", "description": "Report", "row_id": 1421455, "text": "CV: HR 70'S TO 80'S SR OCCASIONAL PVC. SBP 130'S TO 168/ ,NITRO WEANED TO OFF . STARTED ON CLONIDINE TID. REQUIRED HYDRALAZINE 10 MG IV TIMES 2.\nRESP: EXPIRATORY WHEEZES BILATERAL ALBUTEROL TX BY RESP Q 6 PRN WITH SOME EFFECT BUT WHEEZING CONTINUES.O2 SATS 96-97 % ON 2 LNC. LASIX 20 MG IV TIME ONE WITH NO EFFECT. LASIX 40 MG IV WITH GOOD RESPONSE SEEE FLOW SHEET.CHEST TUBE D.C.'D. POST CXR DONE.\n\n PAIN MANAGEMENT: EPIDURAL FENTANYL/BUPIVICAINE AT 12 CC ..PT DENIES PAIN. MAE EQUAL STRENGTH BIL LOWER EXTREMITIES AND UPPER EXTREMITIES. PT CAN LIFT BOTH ARMS OFF BED AND HOLD. CAN BEND BOTH LEGS TO ASSIST WITH LIFTING UP IN BED.\nGU FOLEY DRAINING CLEAR YELLOW URINE. DIURESING WITH LASIX.\nGI; BOWEL SOUNDS PRESENT.\nMENTAL STATUS: PATIENT INITIALLY REFUSING TO TAKE MEDS.SHE LATER AGREED TO TAKE PILLS SHE WAS ALERT AND ORIENTD BUT STATED THAT SHE DIDNOT KNOW ME AND WAS CONCERNED ABOUT TAKING MEDS FROM SOMEONE SHE DID NOT RECOGNIZE.\n" }, { "category": "Nursing/other", "chartdate": "2177-07-04 00:00:00.000", "description": "Report", "row_id": 1421453, "text": "D Neuro: Alert and oriented. MAE.\nCV: NSR no VEA.Palp DP. Swan in Lsc. good wave PA pressures high nitroglycerine started to decrease PAS. titrated up to 2mcg/kg PAs continued to be consistantly > 60 Nitroglercerine order,\n increased . currently at 3mcg with pas high 50\"s.CVP 10-12. IVF D5W with sodium bicarbonate at 40.\nLungs : coarse in upper lobes coarse to wheezing in bases. TCDP,CPT and IS done every 2 hour with effect pt able to cough up thich bloody sputum. on 5L NC pt does not tolerate a FT well finds it very uncomfortable.RT cheat tube to suction draining straw colored Fld to suction as ordered.\nPain: pt has a thoracic epidural in place insertion site is clear and dry. Epidural drip was changed at about 2200 .Fentanyl was added with bupivicaine. Initially drip at 5cc but pt having pain increased to 10cc with effect pt able to tolerate TCDP and CPT . At 5am pt started having increased pain at incision site repositioning did not help insertion site intact called pain service .Order 5cc bolus with a repeat if needed and to increase drip to 12cc.Pt is now resting comfortablly.\nGI: ABD slightly distended , BS present. No N/V/D. tolerating meds and water.\nGU: urine output adeaquet. foley to gravity.\nSkin: thoracotomy Dsg D/I. CT Site D/I , no redness or break down.\nA pt is stable epidural is functioning.PAS and SBP are high\nP continue with lopressor and titrate up nitroglercerine for PAS < 60. note labs replete lytes as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-04 00:00:00.000", "description": "Report", "row_id": 1421454, "text": "NEURO: A/O X 3. MAE and follows commands.\n\nCV: SB/NSR with no ectopy, SWAN dc'd, introducer to LSC, team wanted to d/c nitro. gtt, but SBP increased 170's, nitro. gtt titrated up to 5 mcg/kh/hr with additional hydralazine 10 mg X3 given, SBP decreased to 150's, afebrile, received 1 UPRBC\n\nRESP: CT to water seal with minimal drainage, lungs coarse with occasional expiratory wheeze, 02 @ 2l via NC, sat's 99%, thoracotomy dressing D/I, instructed on IS use, coughing up blood tinged sputum,\n\nGI: BS +, abd soft, tolerated house diet\n\nGU: foley patent and draining clear yellow urine, good UO\n\nPAIN: Thoracic epidural in place with fentanyl and marcaine, pain well controlled, site intact.\n\nPLAN: Monitor and control BP, wean off Nitro., encourage pulmonary toilet, possible d/c CT?\n\nACTIVITY: OOB to Chair and up with PT walking today.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421449, "text": "focus: status update.\nNEURO: PT ALERT MAE ON COMMAND--INCONSISTENTLY, BUT MORE FREQUENTLY. PERL. ABLE TO RESPOND TO YES/NO QUESTIONS. TRACKS C/ EYES. MOUTHS WORDS. NO SEDATION. NO APPARENT NEURO ISSUES. EPIDURAL IN PLACE NOT BEING USED.\n\nCV: NSR TO SINUS BRADY--NO JUNCTIONAL RHYTHM. NITRO OFF PA PRESSURES UNCHANGED. NEO BEING WEANED OFF AS TOLERATED. CI >2 SEE FLOW SHEET. CONT C/ LOW GRADE FEVER. ONE AMP OF DEXTROSE AND REG INSULIN FOR ELEVATED K. C/ IMPROVEMENT.\n\nRESP: LUNG SOUNDS COARSE TO CLEAR. ABG SHOWED ACIDEMIA, ONE AMP OF BICARB C/ IMPROVEMENT IN ABG, CT DRAINING SMALL TO MODERATE AMOUNTS OF S/S DRAINAGE. SX FOR LARGE AMOUNTS OF THICK BLOODY TINGED SPUTUM.\n\nGI: PT TOLERATING PO MEDS. NO BM NO FLATTUS. PT'S ABD SOFT OBESE. NON TENDER TO PALPATION. PT DENIES NAUSEA. OG TUBE IN PLACE--CLAMPPED.\n\nGU: FOLEY CATH PATENT DRAINING YELLOW CLEAR URINE SEE FLOW SHEET FOR SPECIFICS.\n\nPAIN: PT DENIES PAIN.\n\nENDO: BS WNL. NO INSULIN REQUIRED. 10 MG IV REG INSULIN GIVEN C/ DEXTROSE.\n\nSOCIAL: FAMILY CALLED FOR UPDATE ON PT.\n\nPLAN: WEAN OFF VENT TO EXTUBATION, WEAN OFF NEO, MONITOR K LEVELS, MONITOR HEMODYNAMICS. CONTINUE C/ CURRENT PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421450, "text": "Resp Care Note, Pt reains on current vent settings T 100.2 weaning neo,Given bicarb for met acidosis. ABG'S improving. Failed RSBI 166.7. Not ready for extubation\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421451, "text": "Resp Care Note, Pt weaning on cpap/psv ps 10cmh2o for vt's 3-400. will cont to wean as tol\n" }, { "category": "Nursing/other", "chartdate": "2177-07-03 00:00:00.000", "description": "Report", "row_id": 1421452, "text": "7a-7p\nCV: NSR, rare PAC. Normal temp in a.m., starting to have low grade fever in afternoon. CI >2. PA pressures continue to be elevated. Neo gtt weaned off. 2 Units PRBC given for low Hct.\n\nPULM: Metabolic acidosis during the day. Kept on CPAP all day. Extubated at 1500. Maintaing good PaO2, metabolic acidosis on first post-extubation gas. Currently on 50% face tent, attempted NC but patient stated she felt she could breath easier with face tent although pulse ox was 96-97% on NC. Strong cough, raising thick yellow, blood tinged sputum. CT draining scant serosang fluid. Lungs clear, slightly diminished upper right.\n\nNEURO: Alert, oriented, follows commands, MAE equally.\n\nGU: Foley, adequate UOP.\n\nGI: Reglan given x 2 for nausea. OG tube d/c'd with extubation. Hypo bowel sounds.\n\nPAIN: Pain service tested epidural this morning and reordered epidural. After extubation and coughing, pain level has increased. Increased epidural rate, now at 10cc/hr which is max rate ordered by pain service.\n\nPLAN: Pulmonary toilet, monitor ABGs.\n" } ]

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In summary, this is a 88 year old female with DM, HTN who presented with STEMI and was brought emergently to cath lab, was transferred to the CCU following procedure with IABP given hypotension. Hospital course was complicated by upper GI bleed, slow afib requiring cardiopulmonary resusitation. The pt was made DNR during the admission and passed on at 12:08 AM while in the CCU, cause of death noted to be cardiogenic shock following STEMI. . # CORONARIES: Patient presented with STEMI. During cath patient had successful thrombectomy of proximal LAD occlusion with 20% residual stenosis. However, developed acute occlusion of OM (due to an embolus) treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion but restoration of flow. Patient was unstable during procedure and consequently was intubated and IABP placed. No stent was placed during procedure. She was transferred to the CCU on IABM, integrillin, hepain. Attempts were made to wean the balloon pump but were unsuccessful due to hypotension. On day 3 of the hospitalization, family meeting was held and pt was made CMO, IABP weaned, pt started on morphine gtt. . # PUMP: ECHO performed on the showed EF of 30% to 35% with mild regional left ventricular systolic dysfunction and dilated right ventricle with moderate regional systolic dysfunction. New changes secondary to ACS. . # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on Verapamil for rate control. No anti-coagulation had been given in the past due to prior history of GI bleed. During this admission, she developed slow afib and the family was called and decided to make DNR after the first code, no escalation of care. . # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at GE junction. Patient's HCT and hemodynamics currently stable. Due to ballon pump patient was initially placed on heparin, started on IV PPI. Crits were followed. . # Diabetes: Insulin sliding scale . # Hypertension: Outpatient Lisinopril, Lasix and Verapamil were held due to hypotension after cath . # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 - 1.9. During this admission, pt developed with creatinine rising to 2.3, unclear etiology but concerning for pre-renal vs cholesterol emboli vs contrast-induced nephropathy (less likely due to timing of onset). . # Shock: on day 2 of the admission, pt developed mixed cardiogenic/septic shock, 2 blood cxs growing gram + cocci, was started on vanc/cefepime for broad coverage. . # Coagulopathy: Pt with declining platelets, hct, concerning for DIC, platelet distruction in the setting of IABP. . # Asthma: Patient intubated. . # Gout: Hold Allopurinol in acute setting. . # GERD: IV PPI given UGI bleed.

# Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. There is a trivial/physiologicpericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w LADdisease. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. Pt systemically vasodilated. Pt systemically vasodilated. Action: Blood sugars q 1 hr. High LDH, abnormally high PTT on low amts heparin --> sent DIC labs, periph smear. High LDH, abnormally high PTT on low amts heparin --> sent DIC labs, periph smear. # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . Pt taken emergent cath; initially showed thrombus with occlusion in proximal LAD; wiring of this lesion restored flow, export removed clot, however it appear to travel to LCx, this was exported; during the latter, pt began having recurrent CP, respiratory distress, and hypotension. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. # Gout: Hold Allopurinal in acute setting. # Gout: Hold Allopurinal in acute setting. Blood in the lower third of the esophagus and gastroesophageal junction Friability in the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to duodenal bulb ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression lead III, aVR. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: s/p stemi, s/p thrombectomy of prox lad occlusion, thrombectomy & ptca to occluded OM. Pt systemically vasodilated. cont with Bair Hugger to achieve normothermia. Hyperglycemia Assessment: Action: Response: Plan: Hematemesis (upper GI bleed, UGIB) Assessment: Action: Response: Plan: IVF as needed. Requiring ^ pressor support Response: Stbale bp w dopamine support. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. DISPO: CCU for now ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 12:04 PM Arterial Line - 12:28 PM IABP line - 12:28 PM Sheath - 12:29 PM PA Catheter - 01:46 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt s/p STEMI with thrombectomy of TO LAD, OM. Shock, other Assessment: Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC Action: Cont on Dopamine, IV ABs: vanco and cepepime Response: Remains pressor dependent Plan: Will cont current level of care, will not add pressor, increase Dopa and given IVFs, blood as indicated. # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now . # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now . - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. - IV PPI , carafate slurry 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy. Pt systemically vasodilated. Pt systemically vasodilated. Pt systemically vasodilated. Pt systemically vasodilated. Blood in the lower third of the esophagus and gastroesophageal junction Friability in the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to duodenal bulb ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression lead III, aVR. - IV PPI , sucralafate 1 g QID, reglan per GI - appreciate GI recs -> if UGIB recurs, will contact GI for possible repeat endoscopy.

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[ { "category": "Echo", "chartdate": "2130-09-02 00:00:00.000", "description": "Report", "row_id": 97987, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 82/34\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 11:05\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIntra-aortic balloon pump was in position during the study.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. [Due to acoustic shadowing, the severity of MR may\nbe significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThere is moderate regional left ventricular systolic dysfunction with\nhypokinesis of the mid to distal septum, anterior wall and lateral wall. Right\nventricular chamber size is normal. with focal hypokinesis of the apical free\nwall. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. The\npulmonary artery systolic pressure could not be determined. There is a small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , overall LV\nfunction is slightly more depressed, particularly in the lateral wall. The\nother findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 97988, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 115/15\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIntraaortic balloon pump was at 1:1 during this study.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Mild regional LV systolic\ndysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Focal apical hypokinesis of RV\nfree wall.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is small and underfilled. There is\nmild regional left ventricular systolic dysfunction with septal akinesis. The\nremaining segments contract normally (LVEF = 45%). The right ventricular\ncavity is moderately dilated with focal akinesis of the apical one-half of the\nfree wall. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w LAD\ndisease. Dilated right ventricle with moderate regional systolic dysfunction,\nc/w CAD.\n\nCompared with the prior study (images reviewed) of , regional\nbiventricular systolic dysfunction is new.\n\n\n" }, { "category": "General", "chartdate": "2130-09-04 00:00:00.000", "description": "ICU Event Note", "row_id": 388557, "text": "Clinician: Resident\n Family meeting held with patient's children, grandchildren, , and\n Dr. regarding overall decline in clinical status. Patient\n had previously expressed to her family that she would not want\n prolonged mechanical/artifical support. After discussing poor prognosis\n and overall deteriorating condition, decision was made to focus on\n comfort care and withdraw support. Will hold all medications including\n dopamine and turn IABP to 1:8, start morphine for comfort.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2130-09-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388360, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ABG 7.35/34/154/19/5. RSBI=no resps\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved; Comments: presently still\n on balloon pump\n" }, { "category": "Respiratory ", "chartdate": "2130-09-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388443, "text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue on present settings. Pt arrested during noc,\n compABG 7.26/22/95ressions performed, some improvement in bp.\n 7.26/22/95\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388446, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hyperglycemia\n Assessment:\n Blood glucose trending down while on insulin gtt. Please see\n metavision for data.\n Action:\n Blood sugars q 1 hr. insulin gtt off as blood glucose down to 50.\n given 1 amp d50. cont blood sugars q1 hr,\n Response:\n Blood glucose now 132, insulin gtt off.\n Plan:\n Cont to follow blod glucose, restart insulin gtt if blood sugars high.\n Impaired Skin Integrity\n Assessment:\n Excoriation noted under both breasts. Site red, oozing small amt of\n sero/sang fluid.\n Action:\n Sites cleaned with foam cleanser and adaptic with duoderm gel applied.\n Response:\n Wound sites remain unchanged.\n Plan:\n Cont with good skin care, adaptic and duoderm gel to excoriation.\n Coagulopathy\n Assessment:\n Less bleeding noted from puncture sites. Heparin cont as ordered.\n Small amt of bloody drainage from ett and ogt. Small amt of bleeding\n from oral cavity.\n Action:\n Following ptt, 2400 ptt 36, heparin rate increased to 400 units/hr as\n per protocol.\n Response:\n Am ptt pending\n Plan:\n Follow ptt, inr and adjust heparin gtt accordingly\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n pt in rapid af, rate 150\ns, hypotensive with sbp 40\ns pt.\n becoming unresponsive- code blue initiated with chest compressions. 1\n amp epinephrine, ns fluid w/o. dopa cont at 12.5 mcg/kg/min. returned\n to sr with several run of accelerated af with hypotension. Family\n called and updated on serious situation. Decision made not to\n cardiovert and no further chest compressions. Pt. now DNR. Pt. now\n in SR with occ pvc, IABP 1:1\n Action:\n IABP 1:1, dopa gtt @ 12.5 mcg/kg/min, 1 unit prbc given for hct 22, 3l\n NS fluid bolus given overnight.\n Response:\n Maintaining MAP60-65, pad increased to 19-20 after receiving blood and\n fluid\n Plan:\n Cont to monitor hct, hemodynamics, PAD/CVP. ? wean IABP if tol.\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388451, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n SHOCK, OTHER\n COAGULOPATHY\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388452, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388454, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur, IABP heard obscuring some heart sounds.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l. Right femoral A line with pressure\n dressing in place. Left femoral IABP in place.\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388428, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on 1:1\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor.\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388429, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 ,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388430, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 , EKG\ns to assess for\n signs of impending CHB\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388431, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage. IABP\n on at 1:1, dopamine @ 10mcg/kg/min, PA 32/15 CVP 9 CO/CI 5.3/2.9 on\n 1:1, good augmentation and unloading. Unable to Doppler pulses, normal\n capillary refill. Increasing BUN/Creat with scant urine output. Cardiac\n enzymes are bouncing around, 900\ns to 6000\ns down to 900\ns and now\n 3000.\n Action:\n Numerous EKG\ns throughout day per EP\n s request as at risk for\n developing CHB, Lifepak 12 with pads in room, on aspirin,\n plavix,lipitor. Dopamine increased to 12.5 for decreased MAPS. IABP\n changed to 1:2, fluid boluses to increase PAD to >20, 3 liters in\n boluses.\n Response:\n Repeat CO/CI on 1:2 7.7/4.2 SVR 589, dopamine remains at 12.5 , no\n further EKG changes , hemodynamically stable on IABP and dopamine,\n PAD\ns around 20., no improvement in urine output\n Plan:\n Wean IABP as tolerated. Monitor hemodynamics , wean dopa if able\n maintaining MAPS >55, fluid boluses if PAD\ns < 20 , EKG\ns to assess for\n signs of impending CHB\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Coagulopathy\n Assessment:\n Received with heparin off due to PTT>150,decreased drip by 400 units/hr\n to 500, repeat PTT , bleeding profusely from IABP and , also\n bleeding from all finger sticks even through dressings. LFT\ns elevated\n Action:\n Kept heparin off for 4hrs, two hrs off heparin PTT 98.6, pressure\n dressing applied to IABP/PA site\n Response:\n No change in bleeding from sites.\n Plan:\n Heparin restarted after being off x 4hrs, now at 100 units/hr ,repeat\n PTT 6hrs from start. Check all sites for bleeding.\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388539, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388546, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Call family as patient not improving, discuss poor prognosis as\n patient not improving. Discuss withdrawal of care.\n - Will pull IABP, as patient not improving on balloon pump and\n platelets low, possibly balloon pump, also with possible\n bacteremia. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - Will continue to monitor Hct and Plts\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388338, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received from cath lab on integrillin, IABP and PA line.\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388339, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics,\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)/ cardiogenic shock\n Assessment:\n Received from cath lab on integrillin, IABP and PA line. Dopamine at\n 5mcg/kg/min, initial temp 92.9 po. No pulses on left side dopplerable\n on left. Ext all cold.\n Action:\n Good augmentation and unloading with IABP. MAPS 88-94 dopamine\n titrating to maintain MAPS >55, heparin started at 900 units/hr. Bair\n hugger placed.\n Response:\n Temp is slowly increasing still below 35. now there are no pulses on\n either foot. Adequate capillary refill. MAPS maintained above 55 on\n dopamine.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388340, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n HCT in cath lab 24. Around 3pm pt\nburped\n? cuff leak. Then vomited\n bright red blood with clots. Team called.\n Action:\n Intern attempted OGT unsuccessful, then vomited more blood with clots,\n resident placed OGT and aspirated blood. GI called. EGD done at\n bedside. Esophagus denuded and tear at base of esophagus currently not\n bleeding. A clot is present at esophageal gastric juncture. Transfused\n one unit packed cells and second now hanging. IV protonix.\n Response:\n Hemodynamically stable. most recent HCT 26\n Plan:\n Check HCT\ns q4, transfuse as necessary.monitor hemodynamics,\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)/ cardiogenic shock\n Assessment:\n Received from cath lab on integrillin, IABP and PA line. Dopamine at\n 5mcg/kg/min, initial temp 92.9 po. No pulses on left side dopplerable\n on left. Ext all cold.\n Action:\n Good augmentation and unloading with IABP. MAPS 88-94 dopamine\n titrating to maintain MAPS >55, heparin started at 900 units/hr. Bair\n hugger placed.\n Response:\n Temp is slowly increasing still below 35. Now there are no pulses on\n either foot. Adequate capillary refill. MAPS maintained above 55 on\n dopamine. Most recent CO/CI 5.5/3.0 SVR 1000\n Plan:\n Cont with current med plan, IABP, PA line, titrate dopamine to maintain\n MAPS >55. cont with Bair Hugger to achieve normothermia.\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388426, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Has new RBB with left ant fascicular block and decreased voltage.\n Action:\n Numerous EKG\ns throughout day per EP\n s request, on aspirin,\n plavix,lipitor.\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388529, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n SHOCK, OTHER\n COAGULOPATHY\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388530, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-01 00:00:00.000", "description": "Cardiology Fellow Admission Note Addendum", "row_id": 388330, "text": "TITLE: Cardiology Fellow Admission Note Addendum\n Pt examined, discussed with CCU team. For full details please refer to\n housestaff note.\n 88 yo F w/ DM, HTN in USOH until this am when suddenly had intense CP\n and diaphoresis. Initially found to be hypotensive with BP 83/43. EKG\n demonstrated SR at 75, ST elevations lead I, aVL, V1, V2; ST\n depressions III, aVR. Pt taken emergent cath; initially showed thrombus\n with occlusion in proximal LAD; wiring of this lesion restored flow,\n export removed clot, however it appear to travel to LCx, this was\n exported; during the latter, pt began having recurrent CP, respiratory\n distress, and hypotension. She was intubated and an IABP was placed. A\n small amount of residual thrombus remained in the LCx near the OM1. No\n stents were placed as no underlying plaque apparent. Started on\n integrilin and heparin. This afternoon developed UGIB\nEGD revealed\n hematomas in esophagus, small amount of blood in stomach with clots.\n PE\n VS T 34.8C, BP 100/28 on IABP, P 80, RR 19, 100% AC 500/20/5/100%\n Intubated, sedated\n No JVD apparent\n Coarse bs bilat\n RRR, mechanical IABP sounds\n Abd soft, ND\n LE no edema, warm\n Labs notable for CK 999, MB 50, Tn 0.72; Hct stable at 26\n ECG as described above, post-procedure improved ST elevations, slight\n residual in I, L, and present in V2-V4 with depression in II,\n III, F\n Echo today showed EF 45-50%, basal anterior HK, mild symm LVH, +MR,\n 1+TR\n Imp: Anterior STEMI, s/p thrombectomy + antiplt agents, with small\n residual LCx thrombus; GIB esophageal tears in setting of\n anticoagulation, hemodynamically stable\n Plan:\n 1. Continue integrilin and heparin\n 2. Keep active T+C, 4u; check hct now and q8h for now (but will\n see via OGT if GIB increases), if stable can decrease frequency of hct\n check\n 3. Wean IABP tonight, once d/c\nd will be able to d/c heparin\n 4. Wean pressors\n 5. Cont ASA, statin; begin plavix, BB, ACEI when able\n 6. Consider hypercoagulability workup given thrombus without\n underlying plaque, though would be unusual to present with first\n unprovoked thrombus at this point in life; would ensure up to date on\n general malignancy recommendations\n 7. Remainder of plan as per housestaff note.\n 8. Electronically signed by , MD 18:38\n 9.\n 10.\n" }, { "category": "Nursing", "chartdate": "2130-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388334, "text": "88 yo in usual state of health until this morning when she awoke with\n chest pain, family called life line assessed pt and brought to ED. In\n ED alert and oriented x3, chest pain, bloused with heparin and\n integrillin and drips started. In cath lab Hypotensive to 70/30\n dopamine started, RCA chronically occluded, LAD occluded thrombectomy\n and export cath flow\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388414, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: No vent changes.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388417, "text": "Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388418, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood.\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388343, "text": "TITLE: CCU Admission Note\n Chief Complaint: Chest pain\n HPI:\n 88 year old female with PMH significant for HTN, DM who was brought by\n EMS to ER for chest pain and diaphoresis. Per ED intake BP in\n field 68/p, ASA given. Patient's presenting vitals in ED were HR 92, BP\n 148/91, 100 NRB, however shortly after presentation patient became\n hypotensive with BP 50/30. EKG demonstrated ST elevations lead I, lead\n aVL, V1, V2; ST depression lead III, aVR. Patient was taken emergently\n to cardiac cath which demonstrated thrombus with occlusion in proximal\n LAD; wiring of this lesion restored flow, export removed clot, however\n it traveled to LCx. Patient then began having recurrent chest pain,\n respiratory distress, and hypotension. She was intubated and an IABP\n was placed. A small amount of residual thrombus remained in the LCx\n near the OM1. No stents were placed as no underlying plaque apparent.\n Patient was started on integrilin and heparin and transferred to the\n CCU for further care.\n .\n While in the CCU RN noticed blood in the oropharynx, while placing an\n OG patient regurgitated approximately 25 cc of bright red blood with\n clots. Upon placement of OG approximately 10 cc of bright red blood was\n suctioned. Patient was transfused 2 units pRBC, started on IV PPI and\n GI consulted. EGD demonstrated diffuse friable mucosa with clotted\n blood in the lower third of esophagus and GE junction. Blood clot felt\n to be partially tamponading the bleed. For full report please see\n reports below. GI recommended conservative care unless clinical picture\n changes overnight.\n .\n Unable to do review of systems as patient intubated.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Eptifibatide (Integrilin) - 1 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, + Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 1.)Coronary angiography of this codominant system showed single vessel\n coronary artery disease. The left main was without significant\n stenosis, and the LAD was also without stenosis, but the first diagonal\n had an ostial 50% lesion. The circumflex had no\n significant disease. The RCA was also without any significant\n stenoses.\n 2.) Resting hemodynamics showed normal right and left sided filling\n pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac output\n was normal at 5.5 with an SVR of 1207 and a PVR of 58.\n 3.) Left ventriculograpy revealed a normal ejection fraction of 62%\n with mild mitral regurgitation and no significant wall motion\n abnormalities.\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n - diverticulosis requiring 8 units transfusion with\n negative angiogram.\n - grade 1 internal hemorrhoids\n - sigmoid diverticulitis with an adjacent abscess \n - Afib: not on coumadin\n - Chronic diarrhea\n - Asthma\n - Gout\n - Recurrent urinary tract infections\n - gastroesphogeal reflux\n - Tremor: essential tremor, followed previously by Dr. \n - Chronic Renal Failure\n - Choledocholithiases/cholangitis (): found to have\n pseudomonas bacteremia, treated with ceftazidime and flagyl, and\n referred for cholecystectomy but patient refused\n - Neuropathic pain\n - Right hip fracture\n - bilateral knee replacements\n - right leg pins\n - cataract repair\n Unable to obtain as patient intubated.\n Unable to obtain as patient intubated.\n Review of systems: Unable to obtain\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 82 (80 - 94) bpm\n BP: 146/66(106) {91/31(60) - 154/66(106)} mmHg\n RR: 18 (16 - 25) insp/min\n SpO2: 100%\n Height: 64 Inch\n CVP: 6 (4 - 7)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 3,901 mL\n PO:\n TF:\n IVF:\n 3,526 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 345 mL\n Urine:\n 245 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,556 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.40/28/171/17/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 342\n Physical Examination\n VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1\n GENERAL: Opens eyes to name. Intubated.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET tube.\n NECK: No JVP appreciated.\n CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,\n gallops.\n LUNGS: Coarse breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Cold feet, pulses not palpable.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 165 K/uL\n 8.7 g/dL\n 365 mg/dL\n 2.0 mg/dL\n 62 mg/dL\n 17 mEq/L\n 106 mEq/L\n 4.8 mEq/L\n 137 mEq/L\n 34.2 %\n 11.2 K/uL\n [image002.jpg]\n \n 2:33 A9/25/ 09:53 AM\n \n 10:20 P9/25/ 10:00 AM\n \n 1:20 P9/25/ 10:18 AM\n \n 11:50 P9/25/ 11:10 AM\n \n 1:20 A9/25/ 03:05 PM\n \n 7:20 P9/25/ 03:14 PM\n 1//11/006\n 1:23 P9/25/ 05:34 PM\n \n 1:20 P9/25/ 09:45 PM\n \n 11:20 P9/25/ 10:07 PM\n \n 4:20 P\n WBC\n 6.9\n 11.2\n Hct\n 26\n 24.8\n 25\n 29\n 26.5\n 32\n 34.2\n Plt\n 169\n 165\n Cr\n 1.9\n 2.0\n TropT\n 0.72\n TC02\n 17\n 19\n 18\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:13.7/43.9/1.2, CK / CKMB /\n Troponin-T:999/50/0.72, Differential-Neuts:56.4 %, Lymph:40.6 %,\n Mono:1.7 %, Eos:1.1 %, Lactic Acid:2.5 mmol/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:4.0 mg/dL\n 2D-ECHOCARDIOGRAM : The left atrium is mildly dilated. There\n is mild symmetric left ventricular hypertrophy. The left ventricular\n cavity is small and underfilled. There is mild regional left\n ventricular systolic dysfunction with septal akinesis. The remaining\n segments contract normally (LVEF = 45%). The right ventricular cavity\n is moderately dilated with focal akinesis of the apical one-half of the\n free wall. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. Mild to moderate (+)\n mitral regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is mild pulmonary artery systolic hypertension. There\n is a trivial/physiologic pericardial effusion. IMPRESSION: Mild\n regional left ventricular systolic dysfunction, c/w LAD disease.\n Dilated right ventricle with moderate regional systolic dysfunction,\n c/w CAD.\n .\n CARDIAC CATH:\n 1. Selective coronary angiography in this right dominant system\n demonstrated two vessel disease. The LMCA was normal. The LAD had a\n 100% proximal thrombotic occlusion and a 50% stenosis in the\n mid-portion. The Cx had a 30% mid-vessel stenosis.\n 2. Resting hemodynamics revealed elevated right and left sided filling\n pressures with RVEDP of 19mm Hg and mean PCW of 28mm Hg. Cardiac index\n was preserved at 4.0L/min/m2. There was systemic hypotension with SBP\n of 96mm Hg and DBP of 41mm Hg.\n 3. Successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis.\n 4. Acute occlusion of OM (due to an embolus) treated with thrombectomy\n and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion\n but restoration of TIMI 3 flow.\n 5. Cardiogenic shock requiring placement of an IABP via the right\n femoral artery.\n EGD :\n Normal mucosa in the duodenum\n Normal mucosa in the stomach\n Blood in the stomach body and fundus\n Blood clot extended from GE junction was noticed in gastric cardia\n area.\n Blood in the lower third of the esophagus and gastroesophageal junction\n Friability in the lower third of the esophagus and gastroesophageal\n junction\n Otherwise normal EGD to duodenal bulb\n ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression\n lead III, aVR.\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n - Patient will require ACE-I and B-blocker as outpatient, however held\n today due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed.\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - Daily EKG\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n - IV PPI , carafate slurry 1 g QID\n - q4hr HCT\n - cross match 4 units\n - wean ballon pump overnight in order to stop heparin\n - if patient decompensates overnight contact GI, IR aware for possible\n embolization. Patient may require Sang- tube.\n .\n # Diabetes: Insulin sliding scale\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9.\n - renal dose all meds\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n : , \n .\n DISPO: CCU for now\n ICU Care\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n FEN: NPO\n .PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .CODE: Full Code - confirmed with \n .: , \n .DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388519, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388422, "text": "Hyperglycemia\n Assessment:\n FS over 300 up to 393, insulin dependent diabetic\n Action:\n Insulin drip started, titrating protocol\n Response:\n Drip now at 13 units/hr, FS on 11 units/hr 272\n Plan:\n Cont with q1 FS and titrate insulin to achieve goal of 150-200\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n No further vomiting of blood. HCT down to 26.5 from 29.4, still\n suctioning blood from mouth, remains on heparin for IABP\n Action:\n Transfused one unit packed cells, reglan added to assist the clot that\n sits @ esophageal gastric junction to pass into the stomach, protonix\n , and sucralfate\n Response:\n Repeat HCT 28.2\n Plan:\n Cont with current med plan, follow HCT\ns and transfuse as needed.\n Remains NPO\n Impaired Skin Integrity\n Assessment:\n Has a skin tear under each breast, red base, due to heparin bleeding.\n Multiple hematomas on fingers from finger sticks,\n Action:\n Cleansed with wound cleanser and adaptic placed & covered with 4x4,\n turned frequently, heels elevated off bed, aloe vesta applied to back\n and heels\n Response:\n No real change in skin integrity other than currently not bleeding.\n Plan:\n Assess skin tears frequently, document any changes.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388520, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: 7.23/32/117/13\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: pt is dnr, balloon pump continues\n Reason for continuing current ventilatory support: Hemodynimic\n instability\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388523, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic/septic\n Assessment:\n Con\nt on iabp @ 1:1 sbp 90-100 w assisted map\ns > 65. cvp 12-15. wbc\n 12.3. temp max 99.5. has GPC bld cult.\n Action:\n Con\nt on contact precautions hx mrsa. Receiving renal dose cefepime and\n vanco. Requiring ^ pressor support\n Response:\n Stbale bp w dopamine support.\n Plan:\n Am vanco level pending. Pt currently DNR. No new pressors, but may\n titrate dopamine to max if needed. support w fluid if needed.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n s/p stemi, s/p thrombectomy of prox lad occlusion, thrombectomy & ptca\n to occluded OM. Hr 75-110. multiple rhythm chgs from nsr- a-fib. (pt\n has hx a-fib on verapamil @ home for rate control) has short bursts of\n a-fib w rates 100-120, than back to 80-90. slight drop in bp\ns overnoc\n related to rate chgs. Ptt 44.5\n Action:\n ^ dopamine to 15mcg/kg/min, dopamine rate increased per ss to 550u/hr\n Response:\n Improving bp w map\ns > 60 con\nt from nsr to a-fib w varying rates.\n Plan:\n Con\nt to monitor am ptt pending.\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Received pt on 6 units reg insulin via gtt. BS 79.\n Action:\n Gtt decreased to 3 units BS from 63-125. insulin further decreased to\n 0.5-1u/hr md aware of bs\n Response:\n Currently bs 146 @ 1u/hr\n Plan:\n Con\nt q 1/hr bs may chg to ssi today pending am bs results\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Abd soft but distended. Bs +. No stool overnoc. While assessing\n placement of ogt, aspirated dk red blood from tube. Dr .\n Hct overnoc 28.7 no vomiting noted. Tol meds via ogt.\n Action:\n Ogt clamped.\n Response:\n Hct stable hemodynamically stable\n Plan:\n Follow hct. Con\nt carafate, raglan per GI. GI following if further\n bleed may scope again. Clott sent to BB this am.\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388619, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388620, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388621, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Assumed care of Pt. at 2300, HR 39-70\ns NSR/SB, with Maps 36-19 with\n IABP in place, IV Morphine at 5mg/hour with Pt. unresponsive, family at\n bedside, at approx. 0005, Pt. bradycardic to asystole within minutes\n Action:\n Comfort measures provided, family at bedside with Pt. at time of death,\n CCU team in to assess and pronounce Pt\ns death\n Response:\n Unresponsive, Pt. passed away with time of death 0008\n Plan:\n Additional family in to spend time with Pt. Autopsy declined.\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388508, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388393, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n CXR\n IABP noted to be in proximal position near great vessels, PA\n catheter in good position, OG tube in gastric fundus\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388320, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388507, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoritated areas noted under breasts, area draining serous fluids. Has\n large bruise on L AC site. Hands and ft edematous 2-4mm.\n Action:\n Elevated arms on pillows. Areas under breasts treated w wound cleanser.\n Duoderm gel applied and covered w 4x4. meticulous skin care to back\n and buttocks. Aloe vista applied to all areas.\n Response:\n No significant chg. No new areas of breakdown noted.\n Plan:\n Freq turning . meticulous skin care esp under breasts and fold of abd.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388609, "text": "Family meeting with pt\ns 2 daughters, son, grandchildren, Dr. and\n Dr. ; . Decision made to make pt .\n At 1315 morphine gtt started at 5 mg/hr, all other medications\n including dopamine d/c, IABP turned down to 1:8.\n BP has bee 50-60/ 30-40\ns since, hr dropping to 50\ns sr,.\n Pt appears very comfortable on 5 mg morphine. Family at bedside.\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388615, "text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Unresponsive, sr to sb, sbp 60\ns-50\ns, iabp 1:8, right and left fem\n sites d+I, +pp. warm to touch . family with patient. Morphine gtt @\n 5mg.\n Action:\n Repositioned, morphine gtt continues at 5,\n Response:\n Remains unresponsive, sr 70\ns , sbp 50\n Plan:\n CMO, family present in room, questions answered , support given.\n" }, { "category": "General", "chartdate": "2130-09-05 00:00:00.000", "description": "ICU Event Note", "row_id": 388618, "text": "TITLE: Death Note\n Clinician: , MD\n Called to bedside by nursing staff for asystole at 12:00 AM on\n . Pt was made CMO this AM after extensive discussion with the\n family. Pt examined and found to be pulseless, without heart sounds or\n pupillary reflex. Family at bedside. Time of death 12:08 AM.\n Cause of death determined to be cardiogenic shock following myocardial\n infaction earlier this week. Family to discuss whether they would like\n autopsy when additional family members arrive. Admitting notified.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388489, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cefepime given today(renally\n dosed)\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA. Last CO/CI 7/3.8/svr 592 on IABP 1:2\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Hep gtt restarted @400\n units/hr. PTT due @2200. Cont to monitor, titrate Dopa to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Cont to follow hct, goal Hct 25, NPO, protonix , carafate\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic applied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388368, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Vomited x1 dark red blood with many clots. Ogt draining small amt of\n dark red blood with small clots. Received 2 units prbc, hct 34-30\n following transfusion.\n Action:\n Started on carafate slurry via ogt q 6 hrs. continues on protonix iv q\n 12 hrs. monitoring hct q3hrs.\n Response:\n No further vomiting,\n Plan:\n Continue to follow serial hct, cont carafate and protonix as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt on IABP 1:1 ratio, MAP >60. on dopamine 7 mcg/kg/min.\n right groin oozing with small hematoma, Doppler pulses on right PT\n only. Left groin with small hematoma, no bleeding noted. Weaned IABP\n to 1:2 with adequate bp control. Able to wean IABP to 1:4 for approx.\n 1 hr, however pt MAP down to 50. Placed back on 1:2. dopamine\n increased to 10 mcg/kg/min. Please refer to metavision for\n hemodynamics/PA #\ns. am cpk 6000.\n Action:\n Increased dopamine to 10 mcg/kg/min, weaned IABP to 1:2, attempted to\n wean to 1:4. integrilin d/c\nd. heparin off x1 hr.\n Response:\n MAP < 50 following IABP wean to 1:4.\n Plan:\n ? wean IABP to 1:4 as plan is to d/c balloon. Follow HCT, ck, trop\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388371, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388479, "text": "Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388482, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved LAD, large\n OM occluded probably from embolus, thrombectomy and PTCA improved flow\n w/ residual 60% thrombotic lesion, IABP and intubated due to severe\n hypotension & resp distress, echo mildly depressed EF, severe rt\n hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388483, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved LAD, large\n OM occluded probably from embolus, thrombectomy and PTCA improved flow\n w/ residual 60% thrombotic lesion, IABP and intubated due to severe\n hypotension & resp distress, echo mildly depressed EF, severe rt\n hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given atropine, regained pulse\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cepepime\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA.\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OPGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic appilied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388484, "text": "88 yo woman presented with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED given integrillin, , heparin and\n plavix load, received aspirin in field. Cath lab-hypotensive 50/30\n dopamine started, RCA chronically occluded, LAD occluded\n -thrombectomy done, large OM occluded probably from embolus,\n thrombectomy and PTCA improved flow w/ residual 60% thrombotic lesion,\n IABP and intubated due to severe hypotension & resp distress, echo\n mildly depressed EF, severe rt hypokensis, mild to mod MR.\n Coded last eve: started as RAF, then slowed and pt became hypotensive,\n pulseless, CPR initiated, given epi, regained pulse, rapid af.,\n decision made by family not to shock, code status changed to DNR but to\n cont present level of care, no added pressors.\n Attempted wean of IABP today, tolerated wean but by the time ACT\n acceptable for pull pt\ns BP became more unstable and decision made to\n leave IABP in for the night.\n Shock, other\n Assessment:\n Pt with evidence of septic shock, with CO/CI 10.5/5.8, +BC\n Action:\n Cont on Dopamine, IV AB\ns: vanco and cefepime given today(renally\n dosed)\n Response:\n Remains pressor dependent\n Plan:\n Will cont current level of care, will not add pressor, increase Dopa\n and given IVF\ns, blood as indicated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt s/p STEMI with thrombectomy of TO LAD, OM. No evidence of ongoing\n ischemia. Heart rhythm in and out of a.fib/NSR with PAC\ns, PVC\ns. On\n IABP 1:1, PA cath slipped out to RV with pt turn, consequently pulled\n back to RA. Last CO/CI on IABP 1:2\n Action:\n Tolerated wean of IABP this am, was down to 1:4 for ~1hr and maintained\n MAP\ns 58-60. Hep stopped in preparation to dc\n balloon pump\n Response:\n While waiting for ACT to come down pt began dropping MAP, correlations\n between HR and Map as HR drops to 70\ns, MAP drops to 50, HR up to 100,\n MAP comes up to 60\n Plan:\n Decision to leave IABP in for the night. Cont to monitor, titrate Dopa\n to MAP 55.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt with hct of 26 this AM, cont to have blood in stomach upon\n aspiration of OGT.\n Action:\n Transfused with 1 U PRBC\n Response:\n Post hct 29.6 (drawn on completion of transfusion)\n Plan:\n Cont to follow hct, goal Hct 25, NPO\n Impaired Skin Integrity\n Assessment:\n Excoriation under each breast\n Action:\n Cleansed, duoderm gel and adaptic applied to folds\n Response:\n unchanged\n Plan:\n Cont care to skin as stated above.\n" }, { "category": "Physician ", "chartdate": "2130-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388388, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2130-09-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388477, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2130-09-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388586, "text": "Family meeting with pt\ns 2 daughters, son, grandchildren, Dr. and\n Dr. ; . Decision made to make pt .\n At 1315 morphine gtt started at 5 mg/hr, all other medications d/c,\n IABP turned down to 1:8.\n" }, { "category": "Respiratory ", "chartdate": "2130-09-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 388587, "text": "Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours: Comfort measures only\n :\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388588, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarcic\n Head, Ears, Nose, Throat: ET tube in place\n Cardiovascular: irregular rate, no MRG\n Peripheral Vascular: 2+ radial pulses\n Respiratory / Chest: CTA bilaterally anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: 1+ bilateral LE edema\n Skin: Warm\n Neurologic: Opens eyes to voice, cannot follow commands.\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Poor prognosis discussed with family, pt made .\n - Will wean IABP. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, on Verapamil for rate\n control. No anti-coagulation due to prior history of GI bleed. ECG\n now showing left axis deviation and RBB block -> pt likely has left\n anterior fascicular block and RBB block, and is at high risk to develop\n complete heart block. Overnight, patient intermittently in A fib with\n fast then slow ventricular response. Tends to become hypotensive when\n rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts, however\n now stable in high 40s\n - Will continue to monitor Hct and Plts, expect improvement with d/c of\n IABP\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Holding outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Continue ASA 325 mg\n - Continue plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1.\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no signs of volume\n overload currently\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , sucralafate 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - follow crit, has been stable\n - 4 units cross-matched\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: continue insulin gtt\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now\n .\n #Acute on Chronic Renal Failure: Recent creatinine range as outpatient\n 1.3 - 1.9. Pt now with creatinine to 2.8. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position). Renal failure is likely contributing to acidotic state.\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor creatinine\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: IV pantoprazole\n VAP: elevate HOB\n Comments:\n Communication: Comments: Daughters , \n \n Code status: DNR/DNI, \n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Above discussed extensively with patient. Above discussed extensively\n with family member, next of or health care proxy.\n Total time spent on patient care: 35 minutes. Greater than 50% time\n counseling / coordinating care.\n Additional comments:\n Due to overwhelming nature of patient's illness and near-impossibility\n of chance of reasonable recovery, along with her stated wishes\n (confirmed by family) to not have extreme end of life measures, we will\n withdraw the current intensive level of care and make the patient\n comfortable. Family meeting (including Dr. and Nurse )\n during which family agreed with this plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:48 ------\n" }, { "category": "Nursing", "chartdate": "2130-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388366, "text": "88 yo woman woke this am with severe chest pain, hypotensive in the\n field, alert and oriented x3, in ED bolused with integrillin, drip\n started, heparin drip started, plavix load received aspirin in field.\n sent to cath lab-hypotensive 50/30 dopamine started, RCA chronically\n occluded, LAD occluded -thrombectomy &export cath improved\n LAD,largeOM occluded probably from embolus, thrombectomy and PTCA\n improved flow w/ residual 60% thrombotic lesion, IABP and intubated\n due to severe hypotension &resp distress.echo mildly depressed EF,\n severe rt hypokensis, mild to mod MR,\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Vomited x1 dark red blood with many clots. Ogt draining small amt of\n dark red blood with small clots. Received 2 units prbc, hct 34-30\n following transfusion.\n Action:\n Started on carafate slurry via ogt q 6 hrs. continues on protonix iv q\n 12 hrs. monitoring hct q3hrs.\n Response:\n No further vomiting,\n Plan:\n Continue to follow serial hct, cont carafate and protonix as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt on IABP 1:1 ratio, MAP >60. on dopamine 7 mcg/kg/min.\n right groin oozing with small hematoma, Doppler pulses on right PT\n only. Left groin with small hematoma, no bleeding noted. Weaned IABP\n to 1:2 with adequate bp control. Able to wean IABP to 1:4 for approx.\n 1 hr, however pt MAP down to 50. Placed back on 1:2. dopamine\n increased to 10 mcg/kg/min. Please refer to metavision for\n hemodynamics/PA #\ns. am cpk 6000.\n Action:\n Increased dopamine to 10 mcg/kg/min, weaned IABP to 1:2, attempted to\n wean to 1:4. integrilin d/c\nd. heparin off x1 hr.\n Response:\n MAP < 50 following IABP wean to 1:4.\n Plan:\n ? wean IABP to 1:4 as plan is to d/c balloon. Follow HCT, ck, trop\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388457, "text": "TITLE: CCU Admission Note\n Chief Complaint: Chest pain\n HPI:\n 88 year old female with PMH significant for HTN, DM who was brought by\n EMS to ER for chest pain and diaphoresis. Per ED intake BP in\n field 68/p, ASA given. Patient's presenting vitals in ED were HR 92, BP\n 148/91, 100 NRB, however shortly after presentation patient became\n hypotensive with BP 50/30. EKG demonstrated ST elevations lead I, lead\n aVL, V1, V2; ST depression lead III, aVR. Patient was taken emergently\n to cardiac cath which demonstrated thrombus with occlusion in proximal\n LAD; wiring of this lesion restored flow, export removed clot, however\n it traveled to LCx. Patient then began having recurrent chest pain,\n respiratory distress, and hypotension. She was intubated and an IABP\n was placed. A small amount of residual thrombus remained in the LCx\n near the OM1. No stents were placed as no underlying plaque apparent.\n Patient was started on integrilin and heparin and transferred to the\n CCU for further care.\n .\n While in the CCU RN noticed blood in the oropharynx, while placing an\n OG patient regurgitated approximately 25 cc of bright red blood with\n clots. Upon placement of OG approximately 10 cc of bright red blood was\n suctioned. Patient was transfused 2 units pRBC, started on IV PPI and\n GI consulted. EGD demonstrated diffuse friable mucosa with clotted\n blood in the lower third of esophagus and GE junction. Blood clot felt\n to be partially tamponading the bleed. For full report please see\n reports below. GI recommended conservative care unless clinical picture\n changes overnight.\n .\n Unable to do review of systems as patient intubated.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Eptifibatide (Integrilin) - 1 mcg/Kg/min\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 900 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, + Hypertension\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 1.)Coronary angiography of this codominant system showed single vessel\n coronary artery disease. The left main was without significant\n stenosis, and the LAD was also without stenosis, but the first diagonal\n had an ostial 50% lesion. The circumflex had no\n significant disease. The RCA was also without any significant\n stenoses.\n 2.) Resting hemodynamics showed normal right and left sided filling\n pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac output\n was normal at 5.5 with an SVR of 1207 and a PVR of 58.\n 3.) Left ventriculograpy revealed a normal ejection fraction of 62%\n with mild mitral regurgitation and no significant wall motion\n abnormalities.\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n - diverticulosis requiring 8 units transfusion with\n negative angiogram.\n - grade 1 internal hemorrhoids\n - sigmoid diverticulitis with an adjacent abscess \n - Afib: not on coumadin\n - Chronic diarrhea\n - Asthma\n - Gout\n - Recurrent urinary tract infections\n - gastroesphogeal reflux\n - Tremor: essential tremor, followed previously by Dr. \n - Chronic Renal Failure\n - Choledocholithiases/cholangitis (): found to have\n pseudomonas bacteremia, treated with ceftazidime and flagyl, and\n referred for cholecystectomy but patient refused\n - Neuropathic pain\n - Right hip fracture\n - bilateral knee replacements\n - right leg pins\n - cataract repair\n Unable to obtain as patient intubated.\n Unable to obtain as patient intubated.\n Review of systems: Unable to obtain\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 82 (80 - 94) bpm\n BP: 146/66(106) {91/31(60) - 154/66(106)} mmHg\n RR: 18 (16 - 25) insp/min\n SpO2: 100%\n Height: 64 Inch\n CVP: 6 (4 - 7)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 3,901 mL\n PO:\n TF:\n IVF:\n 3,526 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 345 mL\n Urine:\n 245 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,556 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.40/28/171/17/-5\n Ve: 7.9 L/min\n PaO2 / FiO2: 342\n Physical Examination\n VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1\n GENERAL: Opens eyes to name. Intubated.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET tube.\n NECK: No JVP appreciated.\n CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,\n gallops.\n LUNGS: Coarse breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Cold feet, pulses not palpable.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 165 K/uL\n 8.7 g/dL\n 365 mg/dL\n 2.0 mg/dL\n 62 mg/dL\n 17 mEq/L\n 106 mEq/L\n 4.8 mEq/L\n 137 mEq/L\n 34.2 %\n 11.2 K/uL\n [image002.jpg]\n \n 2:33 A9/25/ 09:53 AM\n \n 10:20 P9/25/ 10:00 AM\n \n 1:20 P9/25/ 10:18 AM\n \n 11:50 P9/25/ 11:10 AM\n \n 1:20 A9/25/ 03:05 PM\n \n 7:20 P9/25/ 03:14 PM\n 1//11/006\n 1:23 P9/25/ 05:34 PM\n \n 1:20 P9/25/ 09:45 PM\n \n 11:20 P9/25/ 10:07 PM\n \n 4:20 P\n WBC\n 6.9\n 11.2\n Hct\n 26\n 24.8\n 25\n 29\n 26.5\n 32\n 34.2\n Plt\n 169\n 165\n Cr\n 1.9\n 2.0\n TropT\n 0.72\n TC02\n 17\n 19\n 18\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:13.7/43.9/1.2, CK / CKMB /\n Troponin-T:999/50/0.72, Differential-Neuts:56.4 %, Lymph:40.6 %,\n Mono:1.7 %, Eos:1.1 %, Lactic Acid:2.5 mmol/L, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:4.0 mg/dL\n 2D-ECHOCARDIOGRAM : The left atrium is mildly dilated. There\n is mild symmetric left ventricular hypertrophy. The left ventricular\n cavity is small and underfilled. There is mild regional left\n ventricular systolic dysfunction with septal akinesis. The remaining\n segments contract normally (LVEF = 45%). The right ventricular cavity\n is moderately dilated with focal akinesis of the apical one-half of the\n free wall. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. Mild to moderate (+)\n mitral regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is mild pulmonary artery systolic hypertension. There\n is a trivial/physiologic pericardial effusion. IMPRESSION: Mild\n regional left ventricular systolic dysfunction, c/w LAD disease.\n Dilated right ventricle with moderate regional systolic dysfunction,\n c/w CAD.\n .\n CARDIAC CATH:\n 1. Selective coronary angiography in this right dominant system\n demonstrated two vessel disease. The LMCA was normal. The LAD had a\n 100% proximal thrombotic occlusion and a 50% stenosis in the\n mid-portion. The Cx had a 30% mid-vessel stenosis.\n 2. Resting hemodynamics revealed elevated right and left sided filling\n pressures with RVEDP of 19mm Hg and mean PCW of 28mm Hg. Cardiac index\n was preserved at 4.0L/min/m2. There was systemic hypotension with SBP\n of 96mm Hg and DBP of 41mm Hg.\n 3. Successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis.\n 4. Acute occlusion of OM (due to an embolus) treated with thrombectomy\n and PTCA (2.5x12mm balloon) with a 60% residual thrombotic occlusion\n but restoration of TIMI 3 flow.\n 5. Cardiogenic shock requiring placement of an IABP via the right\n femoral artery.\n EGD :\n Normal mucosa in the duodenum\n Normal mucosa in the stomach\n Blood in the stomach body and fundus\n Blood clot extended from GE junction was noticed in gastric cardia\n area.\n Blood in the lower third of the esophagus and gastroesophageal junction\n Friability in the lower third of the esophagus and gastroesophageal\n junction\n Otherwise normal EGD to duodenal bulb\n ECG: Pre-Cath 8:40: HR 75, ST elevation I, aVL, V1, V2; ST depression\n lead III, aVR.\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n SHOCK, CARDIOGENIC\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n - Patient will require ACE-I and B-blocker as outpatient, however held\n today due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed.\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - Daily EKG\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n - IV PPI , carafate slurry 1 g QID\n - q4hr HCT\n - cross match 4 units\n - wean ballon pump overnight in order to stop heparin\n - if patient decompensates overnight contact GI, IR aware for possible\n embolization. Patient may require Sang- tube.\n .\n # Diabetes: Insulin sliding scale\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9.\n - renal dose all meds\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n : , \n .\n DISPO: CCU for now\n ICU Care\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n FEN: NPO\n .PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .CODE: Full Code - confirmed with \n .: , \n .DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n Critically ill due to acute anterior MI, acute systolic and diastolic\n CHF, need for IABP, acute respiratory faiulre, acute renal failure.\n Date/time was 9/25/9 at 2300\n ------ Protected Section Addendum Entered By: , MD\n on: 08:17 ------\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388459, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 12:28 PM\n IABP LINE - START 12:28 PM\n SHEATH - START 12:29 PM\n INVASIVE VENTILATION - START 12:45 PM\n PA CATHETER - START 01:46 PM\n ENDOSCOPY - At 05:03 PM following hematemesis -> possible\n lower esophageal tears, ? -, no active bleeding, no\n intervention; GI service will follow closely\n Attempted to wean IABP overnight, at 1:4 BP started dropping, unable to\n wean\n Increased dopamine overnight, gave small 250 cc bolus of NS for SBPs in\n 60s -> improved with volume and increased dopamine\n Integrelin off this morning\n History obtained from Family / Medical records\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 500 units/hour\n Dopamine - 10 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 05:58 AM\n Carafate (Sucralfate) - 05:58 AM\n Other medications:\n Changes to medical and family history:\n none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unable to assess sedation\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 79 (67 - 94) bpm\n BP: 92/35(60) {60/13(34) - 154/66(106)} mmHg\n RR: 13 (13 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 6 (2 - 10)mmHg\n PAP: (35 mmHg) / (15 mmHg)\n CO/CI (Fick): (5.5 L/min) / (3 L/min/m2)\n SvO2: 64%\n Mixed Venous O2% Sat: 64 - 66\n Total In:\n 4,230 mL\n 402 mL\n PO:\n TF:\n IVF:\n 3,855 mL\n 402 mL\n Blood products:\n 375 mL\n Total out:\n 385 mL\n 100 mL\n Urine:\n 285 mL\n 100 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,845 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.35/34/154/19/-5\n Ve: 6.4 L/min\n PaO2 / FiO2: 308\n Physical Examination\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: dopplerable), (Left DP pulse: dopplerable)\n Skin: warm\n Neurologic: Responds to: name/voice, Movement: Not assessed, Tone:\n normal\n HEENT\n PERRLa, EOMi, OG and ET tube in place\n CV\n heart sounds difficult to auscultate IABP, systolic murmur\n noted at base and apex\n Pulm\n CTA anteriorly, coarse breath sounds on vent\n Abd\n soft, NT, ND, active BS, IABP heard. Right groin with small\n hematoma, oozing from catheter site\n Ext\n no evidence of edema, 2+ pulses UEs, warm feet, <2 sec cap refill\n CXR\n IABP noted to be in proximal position near great vessels, PA\n catheter in good position, OG tube in gastric fundus\n Labs / Radiology\n 132 K/uL\n 10.1 g/dL\n 327 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.2 mEq/L\n 68 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.4 %\n 10.8 K/uL\n [image002.jpg]\n 11:10 AM\n 03:05 PM\n 03:14 PM\n 05:34 PM\n 09:45 PM\n 10:07 PM\n 11:12 PM\n 01:33 AM\n 04:23 AM\n 04:52 AM\n WBC\n 11.2\n 10.8\n Hct\n 29\n 26.5\n 32\n 34.2\n 30.7\n 30.8\n 29.4\n Plt\n 165\n 132\n Cr\n 2.0\n 2.3\n TCO2\n 18\n 18\n 18\n 20\n Glucose\n 365\n 327\n Other labs: PT / PTT / INR:15.3/150.0/1.3, CK / CKMB /\n Troponin-T:6036/316/0.72, ALT / AST:318/741, Alk Phos / T Bili:88/1.6,\n Differential-Neuts:56.4 %, Lymph:40.6 %, Mono:1.7 %, Eos:1.1 %, Lactic\n Acid:2.5 mmol/L, LDH: IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:5.3\n mg/dL\n Assessment and Plan\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. Repeat ECG this morning showed left axis deviation and RBB\n block -> pt likely has left anterior fascicular block and RBB block,\n and is at high risk to develop complete heart block\n - will consult EP RE: ? indication for temp pacer wire placement ->\n appreciate recs\n - Hold VERAPAMIL 120 mg in setting of hypotension\n - serial ECGs\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: Full Code - confirmed with \n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). and (admission\n notes from yesterday)\n I would add the following remarks:\n Total time spent on patient care: 45 minutes of critical care time.\n Additional comments:\n Critically ill due to acute anterior MI, acute systolic and diastolic\n CHF, need for IABP, acute respiratory faiulre, acute renal failure.\n Date/time was 9/26/9 at 1300\n ------ Protected Section Addendum Entered By: , MD\n on: 08:20 ------\n" }, { "category": "Physician ", "chartdate": "2130-09-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388470, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:47 AM\n CARDIAC ARREST - At 07:32 PM\n FeNa 0.33 % --> prerenal\n tanked up with fluid to increase PAd prior to weaning IABP. weaned to\n 1:2.\n Plts dropping rapidly. High LDH, abnormally high PTT on low amts\n heparin --> sent DIC labs, periph smear. (will be low yield given 2\n units blood)\n rapid then slow a fib -- no pulse. code called, cpr initiated.\n patient regained pulse. unclear from strip whether v tach or a fib\n with aberrancy so no shock. family called and informed -- came in\n overnight and stated DNR status...not cmo but do not escalate care.\n Dopamine continued, BP stabilized. Midnight labs showed Hct drop from\n 28 --> 22. given 1 unit blood. (26.4 this AM).\n Given 3 L IVF overnight (after code)\n BCx Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. (2 of 4 bottles).\n Had 1 dose vancomycin yesterday AM.\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Cefipime - 12:27 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Heparin Sodium - 400 units/hour\n Dopamine - 12.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:16 AM\n Pantoprazole (Protonix) - 05:26 AM\n Carafate (Sucralfate) - 05:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 102 (69 - 135) bpm\n BP: 104/41(75) {60/24(40) - 179/68(114)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 18 (8 - 18)mmHg\n PAP: (61 mmHg) / (18 mmHg)\n CO/CI (Fick): (10.5 L/min) / (5.8 L/min/m2)\n Mixed Venous O2% Sat: 64 - 82\n Total In:\n 6,901 mL\n 2,831 mL\n PO:\n TF:\n IVF:\n 6,526 mL\n 2,505 mL\n Blood products:\n 375 mL\n 276 mL\n Total out:\n 260 mL\n 115 mL\n Urine:\n 260 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,641 mL\n 2,716 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n ABG: 7.26/32/95./14/-11\n Ve: 7.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), Irregular\n Unable to appreciate murmur, IABP heard obscuring some heart sounds.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: ), Anterior exam only\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, UE edema b/l. Right femoral A line with pressure\n dressing in place. Left femoral IABP in place.\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 64 K/uL\n 9.0 g/dL\n 156 mg/dL\n 2.4 mg/dL\n 14 mEq/L\n 4.7 mEq/L\n 69 mg/dL\n 115 mEq/L\n 138 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 04:23 AM\n 04:52 AM\n 09:38 AM\n 09:43 AM\n 12:36 PM\n 04:10 PM\n 08:02 PM\n 10:46 PM\n 04:36 AM\n 05:01 AM\n WBC\n 10.8\n 10.9\n 8.5\n 10.5\n Hct\n 29.4\n 26.5\n 28.2\n 22.4\n 26.5\n Plt\n 132\n 99\n 66\n 64\n Cr\n 2.3\n 2.3\n 2.4\n TropT\n 21.69\n TCO2\n 20\n 19\n 13\n 15\n Glucose\n 327\n 286\n 156\n Other labs: PT / PTT / INR:14.5/53.2/1.3, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:242/424, Alk Phos / T Bili:61/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:447 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1314 IU/L, Ca++:7.6\n mg/dL, Mg++:2.4 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - will attempt to wean IABP: will discuss with family prior to pulling\n pump, as it could precipitation bradycardia, vagal reflex, bleeding,\n etc.\n - will continue dopamine, titrate to MAP in 60s. IVF as needed. Per\n discussion with family, will not add another pressor if needed for BP\n support\n - will transfuse PRBCs as needed\n - continue abx with vanc/cefepime for now, plan to pull lines when\n patient more stable\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - will continue to monitor Hct and Plts, replete as needed\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388574, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarcic\n Head, Ears, Nose, Throat: ET tube in place\n Cardiovascular: irregular rate, no MRG\n Peripheral Vascular: 2+ radial pulses\n Respiratory / Chest: CTA bilaterally anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: 1+ bilateral LE edema\n Skin: Warm\n Neurologic: Opens eyes to voice, cannot follow commands.\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Poor prognosis discussed with family, pt made CMO.\n - Will wean IABP. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, on Verapamil for rate\n control. No anti-coagulation due to prior history of GI bleed. ECG\n now showing left axis deviation and RBB block -> pt likely has left\n anterior fascicular block and RBB block, and is at high risk to develop\n complete heart block. Overnight, patient intermittently in A fib with\n fast then slow ventricular response. Tends to become hypotensive when\n rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts, however\n now stable in high 40s\n - Will continue to monitor Hct and Plts, expect improvement with d/c of\n IABP\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Holding outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Continue ASA 325 mg\n - Continue plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1.\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no signs of volume\n overload currently\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , sucralafate 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - follow crit, has been stable\n - 4 units cross-matched\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: continue insulin gtt\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil for now\n .\n #Acute on Chronic Renal Failure: Recent creatinine range as outpatient\n 1.3 - 1.9. Pt now with creatinine to 2.8. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position). Renal failure is likely contributing to acidotic state.\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor creatinine\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: IV pantoprazole\n VAP: elevate HOB\n Comments:\n Communication: Comments: Daughters , \n \n Code status: DNR/DNI, CMO\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2130-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388473, "text": "Shock, other\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2130-09-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 388566, "text": "Patient screened per ICU policy. Noted plan to focus on comfort.\n Will sign off at this time, please consult if needed. *\n PM\n" }, { "category": "Physician ", "chartdate": "2130-09-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388571, "text": "TITLE:\n Chief Complaint: ST elevation MI s/p cath with evidence of LAD clot\n which traveled to left circ during cath procedure. Currently with\n intra-aortic balloon pump. Also with hx of UGI bleed and cardiac\n arrest during this hospitalization. Now with septic physiology.\n 24 Hour Events:\n -platelets stable in high 40s\n Allergies:\n Vioxx (Oral) (Rofecoxib)\n Wheezing;\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Codeine\n Lightheadedness\n Aspirin\n Unknown;\n Ranitidine\n Abdominal pain;\n Last dose of Antibiotics:\n Vancomycin - 10:28 AM\n Cefipime - 11:45 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Heparin Sodium - 550 units/hour\n Dopamine - 15.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.4\nC (99.3\n HR: 90 (76 - 110) bpm\n BP: 107/43(70) {84/25(57) - 119/43(85)} mmHg\n RR: 7 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n CVP: 17 (11 - 19)mmHg\n PAP: (14 mmHg) / (11 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 69 - 69\n Total In:\n 4,551 mL\n 607 mL\n PO:\n TF:\n IVF:\n 3,875 mL\n 487 mL\n Blood products:\n 626 mL\n Total out:\n 695 mL\n 75 mL\n Urine:\n 695 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,856 mL\n 534 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.23/32/117/13/-13\n Ve: 6.6 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 9.5 g/dL\n 138 mg/dL\n 2.8 mg/dL\n 13 mEq/L\n 4.8 mEq/L\n 79 mg/dL\n 111 mEq/L\n 133 mEq/L\n 27.4 %\n 11.1 K/uL\n [image002.jpg]\n 10:46 PM\n 04:36 AM\n 05:01 AM\n 01:27 PM\n 03:58 PM\n 09:22 PM\n 09:59 PM\n 10:15 PM\n 04:10 AM\n 04:12 AM\n WBC\n 8.5\n 10.5\n 11.4\n 12.3\n 11.1\n Hct\n 22.4\n 26.5\n 29.6\n 28.7\n 27.4\n Plt\n 66\n 64\n 52\n 49\n 48\n Cr\n 2.4\n 2.8\n TCO2\n 15\n 15\n 14\n 14\n 14\n Glucose\n 156\n 138\n Other labs: PT / PTT / INR:13.7/66.7/1.2, CK / CKMB /\n Troponin-T:1872/75/21.69, ALT / AST:176/191, Alk Phos / T Bili:68/0.9,\n Differential-Neuts:80.5 %, Lymph:13.7 %, Mono:5.3 %, Eos:0.2 %,\n Fibrinogen:633 mg/dL, Lactic Acid:0.9 mmol/L, LDH:1148 IU/L, Ca++:7.9\n mg/dL, Mg++:2.3 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 88 year old female with DM, HTN who presented with\n STEMI and was brought emergently to cath lab, currently intubated on\n pressors being weaned off a balloon pump, also with coag positive staph\n bacteremia.\n .\n # Shock with mixed cardiogenic and septic physiology -> CO and CI high,\n SVR low. Pt systemically vasodilated.\n - Call family as patient not improving, discuss poor prognosis as\n patient not improving. Discuss withdrawal of care.\n - Will pull IABP, as patient not improving on balloon pump and\n platelets low, possibly balloon pump, also with possible\n bacteremia. Will not escalate care after pulling IABP.\n - Will titrate down dopamine.\n - Will not further transfuse PRBCs\n - continue abx with vanc/cefepime for now\n .\n # RHYTHM: Sinus. Patient has history of A Fib, patient presumably on\n Verapamil for rate control. No anti-coagulation due to prior history of\n GI bleed. ECG now showing left axis deviation and RBB block -> pt\n likely has left anterior fascicular block and RBB block, and is at high\n risk to develop complete heart block. Overnight, patient\n intermittently in A fib with fast then slow ventricular response.\n Tends to become hypotensive when rapid or brady.\n - EP consulted, recs appreciated. No indication for pacemaker at\n present.\n - serial ECGs\n - will continue to monitor and hold off on starting antiarrhythmics at\n present\n .\n # Blood Cx positive: As above, will continue abx, IV fluids for now.\n Will pull lines when patient more stable.\n .\n # Coagulopathy: labs reflect low grade DIC with declining plts.\n - Will continue to monitor Hct and Plts\n # CORONARIES: Patient presented with STEMI. During cath patient had\n successful thrombectomy of proximal LAD occlusion with 20% residual\n stenosis. However, developed acute occlusion of OM (due to an embolus)\n treated with thrombectomy and PTCA (2.5x12mm balloon) with a 60%\n residual thrombotic occlusion but restoration of flow. Patient was\n unstable during procedure and consequently was intubated and IABP\n placed. No stent was placed during procedure.\n - Continue integrillin 18 hours post cath -> now discontinued\n - Continue heparin while on IABP\n - Patient on Atorvastatin 10 mg outpatient, increase to 80 mg in\n setting of ACS\n - Continue dopamine for goal MAP 60, attempt to wean -> unable to wean\n overnight\n - will attempt to wean IABP today, will reach goal PA diastolic\n pressure of 25 via volume, then attempt to wean to 1:2, obtain SvO2,\n PaO2, and Hb and calculate cardiac index; if data shows stability, will\n continue 1:4, 1:8 as able\n - if pt tolerates 1:8 for 2 hours, will switch off heparin, switch to\n 1:1, and remove IABP\n - Hold outpatient Lisinopril 10 mg due to hypotension\n - No B-blocker due to hypotension\n - Start ASA 325 mg\n - Start plavix in am for 12 months (however no stent placed)\n .\n # PUMP: ECHO s/p cath demonstrates EF 45% with mild regional left\n ventricular systolic dysfunction and dilated right ventricle with\n moderate regional systolic dysfunction. New changes secondary to ACS.\n Repeat TTE shows little change while on IABP 1:1\n - Patient will require ACE-I and B-blocker as outpatient, however cont\n to hold due to hypotension\n - Held outpatient Lasix 20 mg qd due to hypotension, no sign of volume\n overload\n .\n # Upper GI bleed: EGD demonstrates friable esophagus with blood clot at\n GE junction. Patient's HCT and hemodynamics currently stable. Due to\n ballon pump patient must remain on heparin anti-coagulation.\n Integrelin stopped this AM.\n - IV PPI , carafate slurry 1 g QID, reglan per GI\n - appreciate GI recs -> if UGIB recurs, will contact GI for possible\n repeat endoscopy. Patient may require Sang- tube\n - IR aware of pt, can contact if need for emergent embolization\n - q4hr HCT -> 26 this AM, will transfuse 2 units today\n - cross match 4 units\n - wean ballon pump today in order to stop heparin .\n .\n # Diabetes: Insulin drip\n .\n # Hypertension: Hold outpatient Lisinopril, Lasix and Verapamil\n .\n # Chronic Renal Failure: Recent creatinine range as outpatient 1.3 -\n 1.9. Pt now has this morning. Possible etiologies include\n pre-renal physiology, cholesterol emboli, contrast-induced nephropathy,\n ATN, and IABP renal artery obstruction (unlikely given current\n position)\n - renal dose all meds\n - will ensure volume repletion with goal PA diastolic pressure of 25\n mmHg\n - monitor crea\n .\n # Asthma: Patient intubated.\n .\n # Gout: Hold Allopurinal in acute setting.\n .\n # GERD: IV PPI fo now, transition to po when stable.\n .\n FEN: NPO\n .\n PROPHYLAXIS:\n -DVT ppx with heparin drip, pneumo boots when heparin drip\n discontinued\n -Bowel regimen with senna, colace\n .\n CODE: DNR - confirmed with . discussed with family\n escalation of care, but will not withdraw any care at present. Not\n CMO. Continue current management.\n .\n COMM: , \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:04 PM\n Arterial Line - 12:28 PM\n IABP line - 12:28 PM\n Sheath - 12:29 PM\n PA Catheter - 01:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "ECG", "chartdate": "2130-09-02 00:00:00.000", "description": "Report", "row_id": 266376, "text": "Possible ectopic atrial rhythm. Right bundle-branch block with left anterior\nfascicular block. Q waves in leads V1-V3. Small R wave in lead V4-V5. Consider\nanterior myocardial infarction of indeterminate age. Compared to tracing #2\nof right bundle-branch block and left anterior fascicular block are\nnew. There is a new Q wave in lead V2 and tiny R wave in V3-V4, all consistent\nwith an evolving myocardial infarction.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 266377, "text": "Sinus rhythm. Poor R wave progression with biphasic T waves in leads V2-V3.\nT flattening in lead I and inverted T wave in lead aVL. Possible myocardial\nischemia. Compared to tracing #1 of earlier the same day the ST segment\nelevation has resolved. The inferior ST segment depression has also resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2130-09-03 00:00:00.000", "description": "Report", "row_id": 266374, "text": "Sinus tachycardia. Poor R wave progression consistent with an anterior wall\nmyocardial infarction which, based on the prior recent tracings, is\nrecent/evolving. Non-specific inferolateral T wave flattening. Compared to\ntracing #4 earlier the same day the P-R interval is shorter and the\nventricular premature beat is absent.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2130-09-03 00:00:00.000", "description": "Report", "row_id": 266375, "text": "Sinus tachycardia with first degree A-V conduction delay and ventricular\npremature beat. Poor R wave progression. Low QRS voltage in the limb leads and\nthe precordial leads. Compared to tracing #3 of right bundle-branch\nblock and left anterior fascicular block are now absent. Ventricular premature\nbeat is new. There is loss of precordial R wave and sinus tachycardia is new.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2130-09-01 00:00:00.000", "description": "Report", "row_id": 266378, "text": "Sinus tachycardia. ST segment elevation in leads I, aVL and V1-V4 suggesting a\nmyocardial infarction with Q waves in leads VI-V2 and loss of R wave in\nlead V3. Reciprocal ST segment depression in leads II, III and aVF.\nLow QRS voltage in the precordial leads. Compared to the previous tracing\nof ST segment elevation is new with Q wave in lead V2 and loss of R wave\nin V3 suggesting an acute/evolving myocardial infarction.\nTRACING #1\n\n" } ]

10,861

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This 83 year old male was admitted with a history of colonic adenoma, status post right hemicolectomy and prostate cancer, status post radiation therapy, presented with new onset melena on . History is not fully clear but patient says melena began that day only. The patient had associated diaphoresis and lightheadedness. The patient's wife notes that he appeared pale and tired over the prior week. The patient denies headache, abdominal pain, cough, hematuria, shortness of breath, coughing or vomiting. The patient also denied any bright red blood per rectum. The patient went to the Emergency Department on where he was not found to be orthostatic on examination. Gastric lavage was performed and was negative for blood. The patient had another bowel movement that was dark and guaiac positive. The patient was admitted to Firm on . In the PM of after dinner, the patient's hematocrit dropped to 24.7% from 33.8%. The patient was then admitted to the Medical Intensive Care Unit where he received 2 units of packed red blood cells. Later the patient was admitted for esophagogastroduodenoscopy. Esophagogastroduodenoscopy on reported no tears, positive gastritis of the antrum, positive erosion of the stomach body, positive erosion of the duodenal bulb. The patient was then started on intravenous Protonix but the hematocrit dropped under 4%. The patient then received another 2 units of packed red blood cells and was observed. Hematocrit then remained stable over the next two days and the patient was then deemed stable for transfer to the floor. The patient's hematocrit post transfusion was 31.5%. The patient was transferred to the Medicine Service where he remained stable with his current hematocrit 32.7%. In preparation for discharge, the patient's intravenous Protonix was discontinued and he was started on 40 mg p.o. q.d. of oral Protonix. Also the patient's outpatient hypertensive medications were initiated first starting with Atenolol 25 mg p.o. q.d. with a plan to restart Losartan 50 mg p.o. q.d. prior to discharge. The patient will be encouraged to restart the Coumadin which he last took six months prior to admission, to restart that after his discharge as per his primary medical doctor.

HR UP TO 120'S WHEN ASSISTED TO EDGE OF BED TO VOID, HOWEVER BACK TO BASELINE WITH REST. PT ARRIVED TO MICU WITH ONE UNIT PRBC'S INFUSING. DR MADE AWARE.CV- HR 60-70'S AFIB. KEPT NPO FOR REPEAT EGD THIS AM TO FOLLOW UP ON ULCERS SINCE HCT DROPPED. DENIES SOB.CV- HR 60-70'S AFIB. CALCUIM LEVEL AT WAS 7.9 AND WAS REPLETED WITH 2GM IV.RESP- LUNG SOUNDS CLEAR. Sleeping/resting intermittently.CV- VSS- 98-1121/50-60, HR 80-90's afib w/ ^ 100 when standing/ @ commode.F/E- IV changed to D5.45NS @100/hr; u/o adequate/voiding. KEPT NPO FOR EGD IN AM SCHEDULED FOR 0730. MAINTENANCE IVF AT 150CC/HGI- ABD SOFT NT ND POSTIVE BS. BOLUS DOSE WAS GIVEN. No c/o dizziness, mild c/o of very slight lightheadedness when changing position to void or commode wh/ resolves <2 min. nsg addendum:pt was assisted to edge of bed to void. CALL-OUT WAS CANCELLED, RECEIVED BLOOD TRANSFUSION X2 AND REPEAT EGD TO BE DONE IN AM. MAE, PERLA.RESP- LS CLEAR SATS 98-100% RA.CV- HR 70-80'S AFIB, SBP 98-120'S. CONTINUES TO RECEIVE IVF AT 100C/H. TRANSFUSED WITH PRBC'S FOR LOW HCT, REPEAT TO BE DRAWN. WITH VAGUE COMPLAINTS EARLY IN NOC. NURSING NOTE:7P-7AEVENT: PT HAD BEEN CALLED OUT TO TRANSFER TO FLOORS HOWEVER CHECK OF HCT WAS 24.7 FROM 29.1. NO PERIPHERAL EDEMA NOTED.GI- ABD SOFT NT ND POSITIVE BS. CALL OUT TO FLOOR TODAY. 5am HCT 29.5, 12n=26.7. HCT CHECKED AT 11PM WAS 24.7 DOWN FROM 29.1. SBP 78-120. REPEAT EGD THIS MORNING. SATS HIGH 90'S.GI- ABD SOFT POSITIVE BS. NSG ADDENDUMPT WAS ASSISTED OOB TO COMMODE, WITH MINIAML ASSISTANCE. IV as above, protonix IV 8mg/hr cont. PT ASSISTED TO EDGE OF BED TO VOID IN URINAL Q2-4H. HCT CHECK AT 7PM AND MIDNOC STABLE AT 31. CONSENT OBTAINED FOR TLCL HOWEVER HELD OFF FOR THE MOMENT SINCE PERIPHERAL ACCESS MAINTAINED, BE PLACED IN AM PER TEAM. EGD IN AM. SBP 80'S-120. Atrial fibrillationModest inferior T wave changes are nonspecificSince previous tracing , no significant change REPEAT LABS TO BE DRAWN AT 0500. REPEAT LABS TO BE DRAWN AT 0500. Nursing Note 0700-1900See Nursing Transfer Note for shift note DR AWARE.DISPO- REMAINS IN MICU, FULL CODE. Pt informed that stress and overwork is a strong possibility in contributing to his present GI status.A/P-- Very stable yet HCT decreasing despite transfusion. Micu -B Nursing Progress NoteNeuro- Alert and oriented x3, appropriate, compliant. etiology of cont decreasing HCT., wife and daughter visiting this am and late this afternoon. +~1000 cc today including IV + blood products.GI- Remains NPO. PT ALERT AND ORIENTED X3. STARTED ON PROTONIX GTT AT 8MG/H. Transfused w/ 2uPRBC over 2-3 hr each.Post HCT to be drawn p end 2nd unit infuses ~1800. Atrial fibrillationInferior T wave changes are nonspecificRepolarization changes may be partly due to rhythmLeft axis deviationSince previous tracing, no significant change PT STATES HX OF AFIB HAS BEEN OFF COUMADIN APPROX 6 MONTHS. pm HCT to be done p 2u transfusion completed.Endoscopy this evening.Stongly encourage stress management w/ patient/family. NURSING NOTE: 7P-7A PT ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. URINAL AT BEDSIDEACCESS- THREE #18 GAUGE PIV'S INTACT. TRANSFUSED TWO UNITS PRBC'S. PT HAS NOT VOIDED SINCE ARRIVAL TO UNIT. REPEAT HCT TO BE DRAWN AT APPOX 6AM. CONTINUESON PROTONIX GTT AT 8MG/H. IVF NS AT 100CC/H ALSO STARTED LAST EVENING DUE TO NPO STATUS. VERY PLEASANT AND COOPERATIVE WITH CARE.FOLLOWS COMMANDS, PERLA, MAE.RESP- LUNG SOUNDS CLEAR SAT 96-100% RA. PT 500 CC FLUID BOLUS X1 FOR LOW BP WITH EFFECT. PT WAS TO THE MICU FOR FALLING HCT FROM 33 IN ED TO 25 A FEW HOURS LATER. NO C/O NAUSEA. SPOKE TO GI TEAM. DAUGHTER CALLED TO CHECK UP ON PATIENT.DISPO/ PT REMAINS IN MICU, FULL CODE. MEDS AT HOME INCLUDE NORVASC, ATENOLOL, COZAAR NKDAROS:NEURO- ALERT AND ORIENTED X3. NEEDS TO DANGLE AT BEDSIDE IN ORDER TO VOID. IF HCT STABLE ? NO PERIPHERAL EDEMA NOTED. GI TEAM SAW PATIENT LAST EVENING AND DEFERRED REPEAT EGD DUE TO NO NEW S/S BLEEDING, AND HCT STABLE. RR 12-20. CLEAR YELLOW URINE ADEQUATE AMONUTS.ACCESS- TWO #18 PIV. SECOND UNIT NOW INFUSING. PT AND MD SPOKE TO WIFE, UPDATED ON TRANSFER AND NEED FOR BLOOD AND AN EGD IN AM.DISPO- IN MICU, FULL CODE. ASSITED BACK TO BED WITHOUT INCIDENCE. ADEQUATE CLEAR YELLOW URINE OUTPUT.ACCESS- 2 #18 PIV'S PATENT, SITES WNL. HCT CHECKS Q6H, DUE AT 6AM. NO STOOL SINCE ARRIVAL. NGT LAVAGED ON FLOOR FOR BRB.PMH: PROSTATE CA S/P XRT, S/P R HEMICOLECTOMY FOR COLON LESION, AFIB, HTN, GOUT, COLON POLYPS. C/O DIZZINESS, WEAKNESS AND COOL SWEATS. DENIES N&V. Plan to re-endoscope this evening to visualize ? RR 16-20. PT VOIDS IN URINAL. CONTINUE TO MONITOR. POOR VENOUS ACCESS FOR BLOOD DRAWS OR FUTRUE IV'S IF NEEDED. voided 450cc clear yellow urine without difficulty DAUGHTER, WIFE AND BROTHER AT BEDSIDE LAST EVENING. NO COMPLAINTS VOICED. PATIENT AND FAMILY SPOKE TO GI TEAM, AND PT WILL BE RESCOPED TODAY IF HIS HCT FALLS AGAIN OR SHOWS ACTIVE BLEED. NURSING NOTE: TRANSFER TO MICUTHIS IS A 83 YEAR OLD MALE PATIENT ADMITTED TO 7 VIA THE ED LAST EVENING WITH C/O BLACK TARRY STOOLS AND WEAKNESS. 4 black tarry stools out/small to mod amt. NO OBVIOUS SIGNS OF BLEEDING OVER NOC. Conversing w/ family and business contacts by phone most of day. Pt has very active occupational lifestyle; runs own construction business. NO STOOL. NO STOOL . HE HAD A LARGE BLACK TARRY STOOL, GUIAC POSITIVE.

9

[ { "category": "ECG", "chartdate": "2143-07-06 00:00:00.000", "description": "Report", "row_id": 302291, "text": "Atrial fibrillation\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nLeft axis deviation\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2143-07-10 00:00:00.000", "description": "Report", "row_id": 302290, "text": "Atrial fibrillation\nModest inferior T wave changes are nonspecific\nSince previous tracing , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405330, "text": "NURSING NOTE: TRANSFER TO MICU\nTHIS IS A 83 YEAR OLD MALE PATIENT ADMITTED TO 7 VIA THE ED LAST EVENING WITH C/O BLACK TARRY STOOLS AND WEAKNESS. PT WAS TO THE MICU FOR FALLING HCT FROM 33 IN ED TO 25 A FEW HOURS LATER. NGT LAVAGED ON FLOOR FOR BRB.\n\nPMH: PROSTATE CA S/P XRT, S/P R HEMICOLECTOMY FOR COLON LESION, AFIB, HTN, GOUT, COLON POLYPS.\n MEDS AT HOME INCLUDE NORVASC, ATENOLOL, COZAAR NKDA\nROS:\nNEURO- ALERT AND ORIENTED X3. VERY PLEASANT AND COOPERATIVE WITH CARE.\nFOLLOWS COMMANDS, PERLA, MAE.\n\nRESP- LUNG SOUNDS CLEAR SAT 96-100% RA. RR 16-20. DENIES SOB.\n\nCV- HR 60-70'S AFIB. SBP 78-120. NO PERIPHERAL EDEMA NOTED. PT STATES HX OF AFIB HAS BEEN OFF COUMADIN APPROX 6 MONTHS. PT ARRIVED TO MICU WITH ONE UNIT PRBC'S INFUSING. SECOND UNIT NOW INFUSING. REPEAT HCT TO BE DRAWN AT APPOX 6AM. PT 500 CC FLUID BOLUS X1 FOR LOW BP WITH EFFECT. MAINTENANCE IVF AT 150CC/H\n\nGI- ABD SOFT NT ND POSTIVE BS. NO STOOL SINCE ARRIVAL. KEPT NPO FOR EGD IN AM SCHEDULED FOR 0730. DENIES N&V. STARTED ON PROTONIX GTT AT 8MG/H. BOLUS DOSE WAS GIVEN.\n\n PT HAS NOT VOIDED SINCE ARRIVAL TO UNIT. URINAL AT BEDSIDE\n\nACCESS- THREE #18 GAUGE PIV'S INTACT. CONSENT OBTAINED FOR TLCL HOWEVER HELD OFF FOR THE MOMENT SINCE PERIPHERAL ACCESS MAINTAINED, BE PLACED IN AM PER TEAM.\n\n PT AND MD SPOKE TO WIFE, UPDATED ON TRANSFER AND NEED FOR BLOOD AND AN EGD IN AM.\n\nDISPO- IN MICU, FULL CODE. TRANSFUSED WITH PRBC'S FOR LOW HCT, REPEAT TO BE DRAWN. EGD IN AM. CONTINUE TO MONITOR.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405331, "text": "nsg addendum:\npt was assisted to edge of bed to void. voided 450cc clear yellow urine without difficulty\n" }, { "category": "Nursing/other", "chartdate": "2143-07-09 00:00:00.000", "description": "Report", "row_id": 1405336, "text": "NURSING NOTE: 7P-7A\n PT ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. NO COMPLAINTS VOICED. MAE, PERLA.\n\nRESP- LS CLEAR SATS 98-100% RA.\n\nCV- HR 70-80'S AFIB, SBP 98-120'S. HCT CHECK AT 7PM AND MIDNOC STABLE AT 31. CONTINUES TO RECEIVE IVF AT 100C/H. NO PERIPHERAL EDEMA NOTED.\n\nGI- ABD SOFT NT ND POSITIVE BS. NO STOOL . NO C/O NAUSEA. GI TEAM SAW PATIENT LAST EVENING AND DEFERRED REPEAT EGD DUE TO NO NEW S/S BLEEDING, AND HCT STABLE. PATIENT AND FAMILY SPOKE TO GI TEAM, AND PT WILL BE RESCOPED TODAY IF HIS HCT FALLS AGAIN OR SHOWS ACTIVE BLEED.\n\n PT ASSISTED TO EDGE OF BED TO VOID IN URINAL Q2-4H. ADEQUATE CLEAR YELLOW URINE OUTPUT.\n\nACCESS- 2 #18 PIV'S PATENT, SITES WNL.\n\n DAUGHTER, WIFE AND BROTHER AT BEDSIDE LAST EVENING. SPOKE TO GI TEAM. DAUGHTER CALLED TO CHECK UP ON PATIENT.\n\nDISPO/ PT REMAINS IN MICU, FULL CODE. HCT CHECKS Q6H, DUE AT 6AM. IF HCT STABLE ? CALL OUT TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-07 00:00:00.000", "description": "Report", "row_id": 1405332, "text": "Nursing Note 0700-1900\nSee Nursing Transfer Note for shift note\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405333, "text": "NURSING NOTE:7P-7A\nEVENT: PT HAD BEEN CALLED OUT TO TRANSFER TO FLOORS HOWEVER CHECK OF HCT WAS 24.7 FROM 29.1. CALL-OUT WAS CANCELLED, RECEIVED BLOOD TRANSFUSION X2 AND REPEAT EGD TO BE DONE IN AM.\n\n PT ALERT AND ORIENTED X3. WITH VAGUE COMPLAINTS EARLY IN NOC. C/O DIZZINESS, WEAKNESS AND COOL SWEATS. DR MADE AWARE.\n\nCV- HR 60-70'S AFIB. HR UP TO 120'S WHEN ASSISTED TO EDGE OF BED TO VOID, HOWEVER BACK TO BASELINE WITH REST. SBP 80'S-120. HCT CHECKED AT 11PM WAS 24.7 DOWN FROM 29.1. TRANSFUSED TWO UNITS PRBC'S. REPEAT LABS TO BE DRAWN AT 0500. IVF NS AT 100CC/H ALSO STARTED LAST EVENING DUE TO NPO STATUS. CALCUIM LEVEL AT WAS 7.9 AND WAS REPLETED WITH 2GM IV.\n\nRESP- LUNG SOUNDS CLEAR. RR 12-20. SATS HIGH 90'S.\n\nGI- ABD SOFT POSITIVE BS. NO STOOL. KEPT NPO FOR REPEAT EGD THIS AM TO FOLLOW UP ON ULCERS SINCE HCT DROPPED. NO OBVIOUS SIGNS OF BLEEDING OVER NOC. CONTINUESON PROTONIX GTT AT 8MG/H.\n\n PT VOIDS IN URINAL. NEEDS TO DANGLE AT BEDSIDE IN ORDER TO VOID. CLEAR YELLOW URINE ADEQUATE AMONUTS.\n\nACCESS- TWO #18 PIV. POOR VENOUS ACCESS FOR BLOOD DRAWS OR FUTRUE IV'S IF NEEDED. DR AWARE.\n\nDISPO- REMAINS IN MICU, FULL CODE. REPEAT LABS TO BE DRAWN AT 0500. REPEAT EGD THIS MORNING.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405334, "text": "NSG ADDENDUM\nPT WAS ASSISTED OOB TO COMMODE, WITH MINIAML ASSISTANCE. HE HAD A LARGE BLACK TARRY STOOL, GUIAC POSITIVE. ASSITED BACK TO BED WITHOUT INCIDENCE.\n" }, { "category": "Nursing/other", "chartdate": "2143-07-08 00:00:00.000", "description": "Report", "row_id": 1405335, "text": "Micu -B Nursing Progress Note\nNeuro- Alert and oriented x3, appropriate, compliant. Conversing w/ family and business contacts by phone most of day. Sleeping/resting intermittently.\nCV- VSS- 98-1121/50-60, HR 80-90's afib w/ ^ 100 when standing/ @ commode.\nF/E- IV changed to D5.45NS @100/hr; u/o adequate/voiding. +~1000 cc today including IV + blood products.\nGI- Remains NPO. IV as above, protonix IV 8mg/hr cont. 5am HCT 29.5, 12n=26.7. Transfused w/ 2uPRBC over 2-3 hr each.\nPost HCT to be drawn p end 2nd unit infuses ~1800. 4 black tarry stools out/small to mod amt. No c/o dizziness, mild c/o of very slight lightheadedness when changing position to void or commode wh/ resolves <2 min. Plan to re-endoscope this evening to visualize ? etiology of cont decreasing HCT.\n, wife and daughter visiting this am and late this afternoon. Pt has very active occupational lifestyle; runs own construction business. Family has verbalized in the past the need to decrease his workload but pt is reluctant due to his desire to be busy and cont to run business. Pt informed that stress and overwork is a strong possibility in contributing to his present GI status.\nA/P-- Very stable yet HCT decreasing despite transfusion. pm HCT to be done p 2u transfusion completed.\nEndoscopy this evening.\nStongly encourage stress management w/ patient/family.\n" } ]

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58-year-old gentleman admitted for treatment of a complex pancreatic pseudocyst situation secondary to gallstone pancreatitis. He had been at an outside hospital for 2 weeks prior to his transfer to us where he had evidence of a lower extremity DVT. Upon transfer to us, he had clear-cut pulmonary embolism identified and this was treated with anticoagulation. In the antrum we accessed the pancreas via CT and found it to be stable with a complex multi-loculated cystic architecture that appears to be growing slightly in size while here at . We also recognized a bile duct stone on imaging and he had an ERCP performed prior to this procedure. He was doing well except from a respiratory standpoint where he had decompensation and evidence of an advancing pulmonary embolism. For this reason, a DVT filter was placed 3 to 4 days prior to this procedure. He continued to have respiratory distress but was doing well other than that. On the night prior to this operation, he had an acute decompensation and moved from an alkalotic state to an acidotic state. He required massive amounts of fluid resuscitation and had a progressive lactic acidosis. He had a tender tense abdomen as well.He was seen early in the morning of the and felt that he had an acute abdominal catastrophe requiring emergent exploration. He went to the operating room on the morning of with the intent of performing exploratory laparotomy. The presumed diagnosis was ruptured pseudocyst with secondary diagnosis of dead bowel. Over the next three weeks patient remained in ICU for postop care. On patient was transfered to the floors for further care. remainder of hospital course was uneventful, he continued to be stable on TPN, tolerating regular diet. On POD 51/39 patient was cleared for discharge to rehabilitation center for further recovery.

hct 27.7. on iv leprudin infusing with q6hr ptt. RSC TLC and R radial aline . Midline incision w/ lg. LLL bronchial/diminished.GI: abd firm, distended, tender. Cont Lepiruden for DVT, titrated to PTT. DP/PT pulses dopplerable. DP/PT pulses dopplerable. CA REPLETED W/ TUMS. no bm, sounds present.gu: good response to lasix.incision: dsgs changed, small amt sero-sang from upper midline incision, small amt -sang from around rt side Jp insertion site. Abdomen firmly distended; +BS. Pt w/ general anasarca; pitting edema. Pt w/ general anasarca; pitting edema. G/J tubes .GU: foley patent, cyu, lasix as above. Cont SIMV onoc. febrile to 102.2. cvp 16-18.pulm: bs clear. Cont vent wean and diuresis as tolerated. Resp CarePt. One unit ffp infusing, one more ordered. Vasopressin weaned off as MD. Pt w/ generalized edema. SICU NN: See carevue for specifics. Dr. notified. amts.Plan: diurese, wean support as tolerated. ^^ standing lopressor dose ..DSG changes CONDITION UPDATEVSS. U/O QS VIA FOLEY - DIURESED W/ LASIX MD' ORDERS. Resp. Ativan PRN. NGT to lcws. ABD CONT TO BE SOFTLY DISTENDED. Trazodone and lorazepam w/ +effect. Aline dampens.Resp: Weaned to PS 5-PEEP- 5,MD aware of ABG. Resp CarePt remains on PSV, ps weaned tol well. Doppler pulses. Right PT dopplerable. ABG: pH 7.41, PaCO2 56, PaO2 166, bicarb 37, BE 9. Started trazodone to relieve agitation. Resp Care,Pt. Resp Care,Pt. ET to vent, cpap. Swann and cordis d/ by MD. Patient afebrile. resp. to wean as tol. SICU NN: See carevue for specifics. SICU NN: See carevue for specifics. NGT to lcws. Converted to afib this am. Dr. notified. JP 1 and 2 with serosanguinous drainage. HEparin currently given sq.GI/ Abd: NPO. carept. HCT stable. Lepirudin infusing as ordered. remains intubated/vented/sedated.continue with high ph...resp. J tube with tube feeds, tolerating. continue towean as toerated. wound tid. See carevue. See carevue. abd wound tid. Respiratory CarePt changed to cpap/ps tol well 735/63/138/36/7. PAC noted. Afebrile.GI: Tube feed tolerated at goal via PEJ. PERRL. BP wnl. Pt w/ generalized edema (+). Pt in A.fib this AM, but converted to sinus brady/NSR (Dr. aware). ABG: pH 7.36, PaCO2 60, PaO2 160, bicarb 35, BE 6 (Dr. aware of ABG). ABG's showing gradual correction of Metabolic Alkilosis. hypo bs x4, fib on with liq soft stool.Heme- rec 2 prbc this am for hct 23- post hct this pm 28- rec 2 ffp for inr >2.5- pm inr 2.2, cont lepirudin gtt.Plan- cont wean vent as tol, ativan and dilaudid prn- wean as tol. Suctioned for tan thick secretions in moderate amount.Please refer to careview for abg's.CV: SR to ST no ectopy, Concurrent with temp spike to 102.5 became tachycardic and hypertensive. RESTARTED ON LEPRIDUM GTT. Updated Dr. and will cont. Cont lepirudin gtt as indicated. CXR done. Hct stable, some a-fib noted. Self extubated in pm, and immed Reintubated. MDI's given. Remains with generalized edema. Mouth care Q2hours. RLE>LLE. Pan cx'd. intubated. FOLLOW PTT FOR LEPRIDUM GTT. Dopplerable pulses. LS CLEAR TO COARSE WITH OCC WHEEZES. +PP VIA DOPPLER. HIT status noted. Tolerating tube feedings thus far. : pt with open area on right heal. Dsg changed X1 By RN. Cont with DSD as indicated. Anticoagulated on lepirudin . WILL FOLLOW COAGS.RESP-REMAINS INTUBATED. Tolerating well. SICU NN: See carevue for specifics. +BS Mult BM's today. REspiratory CarePT. W+D. PERRL. PERRL. Remains on amiodorone and lopressor given through NGT. Resp CarePt. Resp CarePt. Afebrile with normal wbc. to make spont. AM ABG, PCO2 ~ hich and Pt starting to chronically compensate. Suctioning mod. SICU NN: See carevue for specifics. suction with bilious returns. CONDITION UPDATEVSS. ABd wound still drng mod amts of sersang drng. FOCUS UPDATEVSS. REMAINS ON AMIO IN NSR. BP wnl. Perrl. no BM.gu: u/o qs.plan: wean vent as tol. WEAN FROM VENT AS TOLERATES. Sxn'd for mod amts. pt continues in afib and icu resident Dr aware. BS are clear & dim more to bases ant. Occ. Occ. Clamped prn meds. AFEBRILE. +PP via doppler only.Resp: Remains on CPAP . Hemodynamics stable.P: F/U w/ repeat ABG. Normalregional LV systolic function. Mild mitral annularcalcification.TRICUSPID VALVE: Mild [1+] TR. Noaortic regurgitation is seen. MAE.CV: HR-NSR no noted ectopy. IndeterminatePA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Lungs remain coarse to diminshed at the bases.GI/GU: Unchanged.Endo: RISSID: Remains on mult abx WBC's normal afebrile.Plan: Cont with current plan of care. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. There is moderate global right ventricular free wallhypokinesis. Moderate global RV free wallhypokinesis.AORTA: Simple atheroma in ascending aorta. A small amount of free intraabdominal ascites and a significant periportal edema is noted. CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: At the visualized portions of the lung bases, again seen are bilateral lower lobe pulmonary arterial filling defects consistent with pulmonary emboli. Within the abdomen, there has been interval removal of a left-sided drainage catheter with a partial fistulous tract which does not appear to connect with the intraperitoneal cavity. There remains a left retrocardiac opacity and some hazy opacity within the left upper lung. Left basilar atelectais and moderate- sized left pleural effusion. Thus, bilateral, mostly basal densities persist in the vasculature give the impression of perivascular haze. Right subclavian catheter terminates in the SVC. Normal heart size, some coronary artery calcification noted, the central line tip is included at the distal SVC level. Unchanged fluid collection posterior to the pancreatic head. A left subclavian catheter has been placed, terminating within the superior vena cava. CT ABDOMEN WITH ORAL AND IV CONTRAST (CT ANGIOGRAM PROTOCOL): Small right and left basal pleural effusions, moderate atelectasis of the left lower lobe posteriorly and to a lesser extent the dependent portion of the right lower lobe. SUPINE CHEST RADIOGRAPH: A right-sided subclavian line is now seen with its tip terminating in the right superior vena cava. Unchanged intrahepatic biliary ductal dilatation and attenuation of a patent portal vein.

164

[ { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512592, "text": "please see careview for details.\n\nneuro: \n\ncv: remains on , occasional pause. no a fib.\n febrile to 102.2. cvp 16-18.\n\npulm: bs clear. sx q 2 for thick white small amts. alkalotic this am, plan is to switch from Lasix to diamox for future diuresis.\n\ngi: tol tube feeds at 80/hr. no bm, sounds present.\n\ngu: good response to lasix.\n\nincision: dsgs changed, small amt sero-sang from upper midline incision, small amt -sang from around rt side Jp insertion site. other dsgs clean when changed.\n\nplan: ct today to evaluate abdomen in face of fever.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512593, "text": "SICU-B NPN 7a-7p\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nNo events\nNEURO: no focal neuro deficits noted. Fentanyl gtt changed to midaz gtt w/ fentanyl boluses PRN for pain w/ increased pt. comfort. Occasional c/o pain r/t ETT and positioning, relieved w/ fentanyl.\n\nCV: HD stable. HR NSR 60s-80s, frequently flipping into Afib, 90s-110s, cont on amio gtt 0.5mg/min pending discussion w/ primary team re: changing to POs. Cont Lepiruden for DVT, titrated to PTT. Diuresed w/ lasix 20mg x 1, good response. PM lytes pending w/ diuresis.\n\nRESP: changed to CPAP w/ PS 12, peep weaned to 5, abg w/ cont contraction alkalosis->becoming more acidotic on CPAP. LSCTA bilaterally.\n\nGI: TFs increased q6ht. Goal 110cc/hr. Abd obese, firm, nontender. +BS/-BM. Dulcolax supp x 1, effects pending.\n\nGU: foley draining CYU, excellent response to laisx, to recieve 250mg diamox this pm.\n\nENDO: humalog sliding scale PRN.\n\nID: tmax 102.3, 650mg tylenol w/ some reduction. Starting linezolid and increasing levoflax dose, cultures pending.\n\n: grossly edematous, no breakdown noted. RSC TLC and R radial aline . Midline abd incision c/d w/ sm amt s/s drainage, JPs, G and J tube .\n\nSOC: family in to visit, updated on POC and pt. condition. Spoke w/ social work.\n\nA: tolerating CPAP after diuresis, now w/ contraction alkalosis, HD stable. ^ comfort w/ versed gtt.\nP: cont to monitor for pain, fentanyl PRN as needed. F/u pm labs. Monitor fever curve, f/u culture data. Cont vent wean and diuresis as tolerated. Support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512669, "text": "NPN (NOC):\n\nRESP: PT RESTED ON \"5&5\". RR TEENS TO 20'S, VT'S 300'S TO 400'S. AM ABG: 144/69/7.40/44/+14. BS'S COURSE AT THE BASES. SX'D FOR MOD TO LG AMTS OF SECRETIONS. AFEBRILE.\n\nCV: HEMODYNAMICALLY STABLE . LEPIRUDEN CONTINUES. AM PTT 52. NO S/ OF BLEEDING NOTED BUT AM HCT IS 23% DOWN FROM 28% YESTERDAY. DR. IS AWARE. SPECIMEN SENT TO BB.\n\nNEURO: PT HAS BEEN AWAKE MUCH OF THE NIGHT. IS OREINTED. STATES HE IS HOPEFUL THAT HE CAN BE OFF VENT BY TODAY.\n\nGI: TOL STR TF WELL. NOW AT GOAL (90 CC PER HR.) NO FURTHER STOOL .\n\nF/E: UO AQEQUATE. CA AND MG REPLACED IN AM.\n\nPLAN: ? TM TRIAL IN AM?\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512670, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiratory acidemia with excellent oxygenation.\n\nRSBI = 64.1 on 0-PEEP and 5 cm PSV.\n\nPlan: continue trach collar trials.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512671, "text": "npn\nPt is a+o and follows commands, tol oob to chair via but able to pivot back to bed with phys. therapy. jpx 2 to bulb sxn, g tube to gravity- bili drg- feedng via j tube. bm x2. lasix 20 mg x1 with good response. trach collar since 830 am- tol well, ? to rest . + cough- thin white mucous. lungs clear upper- bases. care to cover abd wound with ostomy drg bag. Plan: cont to , trach collar as tol, transfer when stable, labs pr md orders\n" }, { "category": "Nursing/other", "chartdate": "2187-04-13 00:00:00.000", "description": "Report", "row_id": 1512672, "text": "Respiratory Therapist\nBreath sounds diminished, coarse crackles, suctioned for moderate thick yellowish, Trach Mask trial started at 0900 am per nurse request, patient claims doing okay after starting, Passy Muir Valve on, sat 99 f22, up to now patient is still on Trach Mask doing fine, Requested the ventilator to be pulled away and orders not to put patient back on ventilator without having a resident seing patient first.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-14 00:00:00.000", "description": "Report", "row_id": 1512673, "text": "NPN (NOC):\n\nRESP: PT OFF VENT . RR TEENS, REG, NONLABORED. BS'S FAIRLY CLEAR, NO SPUTUM NOTED. AFEBRILE. AM PCO2 90, BUT THIS WAS TAKEN WHILE PT WAS SLEEPING. REPT PCO2 AFTER PT AWAKE FOR ~ 45 MINUTES DOWN TO THE LOW 70'S.\n\nCV: NO RUNS OF AD NOTED. SBP'S 180'S TO 190'S VIA ART LINE BUT SIGNIFICANTLY BY CUFF. PTT 52, LEPIRUDIN CONT. NO S/ OF BLEEDING NOTED.\n\nNEURO: SLEPT MUCH BETTER TONOC THAN LAST NOC.\n\nGI: TOL TF WELL. LOOSE STOOL X2.\n\nGU: UO ADEQUATE. CA REPLETED W/ TUMS.\n\n: ABD DSG CAHNGED X 1 AS OUTLINED BY NURSE.\n\nPLAN: OOB AGAIN TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-14 00:00:00.000", "description": "Report", "row_id": 1512674, "text": "npn\nPt remains a+o and mae- oob to chair- pivot with assist. tube feed at goal via j tube- tol well, g tube to gravity. bm x2. trach collar with passamir valve on, lungs clear upper- bases- suction prn, thick tan, also coughing up thick sputum. abd wound w-d packing changed prn- about q 4-6 with aquaseal at base and 4x4 over that- edges pink- drg brown. covered with ostomy bag.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512601, "text": "Respiratory Therapist\nNo significant improvements today this morning patient was in rapid A-Fib Albuterol MDI hold off first round per nurse request, patient went to CT today at noon, suctioned throughout the day for small thick white, treated once with albuterol MDI, breath sound mostly diminished, had an episode of hypotension while down in CT, will stay vented until most issues are dealt with.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512602, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt on midazolam gtt @ 4mg/hr. Easily to voice. Opens eyes spontaneously at times. PERRLA (3mm; brisk). Pt moves all extremities and follows commands. Cooperative w/ care. Pt mouthing that he has \"back pain.\" Fentanyl 50mcg IV x2 and 100mcg IV x1 given w/ + effect. Tmax 100.1. HR 70-80s (NSR) w/ frequent bursts of rapid A.fib (hr 120-130s); SBP (blood pressure cuff) drops to 60-80s when in rapid A.fib. Total of 7.5mg IV metoprolol given per Dr. for rapid A.fib (5mg metoprolol IVP by HO prior to going to CT; and 2.5mg IV metoprolol pushed by RN when pt back in SICU). HR converted back to 70s (NSR), but then would go back into rapid A.fib after few minutes. Upon returning from CT/CTA of abdomen/pelvis, A-line waveform very dampened; systolic 70-80s (Dr. at bedside); per Dr. , not start levophed gtt d/t ?accuracy of . Pt w/ strong radial pulses at that time and uo adequate; also pt very edematous. HO at bedside to monitor. Dr. and Dr. attempted to place new A-line; unsuccessful after multiple attempts. At approx 1630, Dr. came up to SICU to place A-line. SBP cont to be 70-80s; per Dr. , levophed gtt started and NS 500cc IVB x1 given for hypotension. Dr. able to place A-line in left brachial artery. Levophed gtt infused for approx 2hrs; titrated off at 1840 (goal MAP >60). CVP 7-15. Pt w/ general anasarca; pitting edema. DP/PT pulses dopplerable. Diuretics not ordered. Lepirudin gtt cont; decreased to 0.1mg/kg/hr this AM for PTT >80. PTT this afternoon was 75.3. Venodyne boot on LLE only; DVT on RLE. Lungs coarse; clear at times. Suctioned for small amount thick, white secretions. SIMV 50%, Vt 650x18, PEEP 5, PS 15. Pt does not breath over the vent. Weak cough. Abdomen firmly distended; +BS. TF held this AM for CTA; resumed post CTA. No emesis. No BM/flatus. G-tube to gravity bag w/ 400cc liquid, brownish-yellow drainage. TF at goal rate via J-tube. Insulin gtt cont @ 5units/hr; fs checked q1hr. Foley w/ clear, amber urine. UO >/= 35cc/hr. Midline abdominal incision w/ staples ; 4small open areas (wound bed pink; large amount serosang drainage). Abdominal wound packed w/ NS wet to dry dsg (done this AM). DSD over packing changed x2. DSD over G/J/and left JP drain changed x2 d/t large amount thick, brown drainage around insertion site. JP drain x2 w/ small amount dark brown, liquid drainage. wife calledx1; updated w/ plan of care. (social worker) spoke w/ pt's wife. ?family meeting tomorrow or Monday w/ pt's wife, 3 sons, Dr. , and Dr. .\n Plan: Monitor VS, I's and O's, labs. Cont insulin, lepirudin, midazolam gtt. Fentanyl prn for pain. FS q1hr when on insulin gtt. Monitor coags q6hr. Keep MAP >60. Follow up CTA, culture results. Update pt and family w/plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512603, "text": "SICU-B NPN 7p-7a\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nNo events\nNEURO: remains on versed gtt, fentanyl PRN for pain w/ good effect. Cont to c/o pain in abd upon palpation, also w/ intermittent back pain. PERRL, no focal neuro deficits noted.\n\nCV: HD stable, MAP 62-70 w/o further fluid bolusing or levophed. HR NSR 70s, no ectopy noted. Cont grossly edematous, no diuresis d/t borderline BP. Lepiruden adjusted for supratherapeutic PTT.\n\nRESP: Remains of SIVM, FiO2 decreased to 40% w/ adequate oxygenation, rate down to 16, ABG pending. Not overbreathing vent. LS coarse, not suctioning much. LLL bronchial/diminished.\n\nGI: abd firm, distended, tender. Cont TF via J tube @ goal. No BM, +BS. JPs w/ dk red/brown output, cont to ooze copious amt thick brown drainage from drain sites. Midline incision w/ lg. amt brown s/s drainage, DSD changed frequently; incision w/ staples , pink w->dry changed.\n\nGU: u/o borderline, no further diuresis or fluid given. Grossly positive LOS.\n\nENDO: cont insulin gtt\n\nID: tmax 102.5, tylenol given, pan cultured, plan to tap abd fluid collection seen on CT yesterday. Cont abx, unchanged.\n\n: no breakdown noted, incisions as above.\n\nSOC: no calls\n\nA: HD stable, cont full vent support, ? worsening infection/sepsis.\nP: follow up am labs, monitor fluid balance. Goal MAP >60, levophed if needed. Monitor temps, cont abx, plan to tap and culture abd fluid today. F/u family meeting, support to pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512604, "text": "Resp Care\nPt remains on MV in SIMV mode with changes as documented on Careview. No RSBI this am due to hyptotension/hypercarbia. BBS-CTA and diminished. No change post BD therapy. Sx'ed for scant amt thick white secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512605, "text": "Respiratory Therapist\nPatient stays on the same setting no wean done went to CT again today for about one hour, got regular MDI treatment, breath sounds coarse bilateral rhonchi, ETT tube retaped and rotated from right to left side of the mouth, suctioned for copious thick white.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-23 00:00:00.000", "description": "Report", "row_id": 1512606, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt lightly sedated on midazolam gtt @ 4mg/hr. Easily to voice. Opens eyes spont at times. PERRLA (3mm; brisk). Follows commands and moves all extremities. Pt unable to lift up BLE d/t edema. Tmax 101.7; Tylenol 650mg given x2 via J-tube. SBP 90-110s/40-60s. Pt in and out of A.fib. HR up to 110-120s at times (A.fib) and SBP drops to 88-90s; MAP maintained >60 off levophed. Metoprolol 2.5mg IV q6hr ordered. RN notified Dr. that pt's SBP decreased to high 80-90s after metoprolol given. 200mg . Cont to monitor. CVP 10-18. Hct 23.7; transfused 2units PRBC. Lepirudin off since 0500 for percutaneous drainage of RUQ abd fluid collection. 2units FFP given prior to procedure d/t elevated PTT. Procedure done in CT; pigtail drain placed; +dark blood drainage (Dr. and pt's primary team aware). Pt w/ general anasarca; pitting edema. DP/PT pulses dopplerable. Venodyne boot on LLE only. Calcium repleted. Pt on metronidazole, linezolid, and levofloxacin. Lactic acid 4.6; Dr. notified. Lungs coarse; suctioned for small amount thick, white secretions. Vent setting changed to AC: 40%, Vt 650x16, PEEP 5. ABG showed compensated metabolic alkalosis. Sputum sent for culture and Gram stain. Abdomen firmly distended; very tender to palpation. Fentanyl 50mcg IV given x5 w/ + effect. TF has been on hold since 0800 for procedure. Insulin gtt off. J-tube clamped. G-tube to gravity bag w/ large amount yellow-brown drainage. Fecal incontinence bag changed x1; large amount liquid brown stool (guaiac negative). Foley w/ clear, amber urine. UO qs. Abdominal incision w/ staples ; 4 small open areas w/ pink wound bed. Open areas packed w/ 2x2 gauze soaked in NS and covered w/ DSD; large amount brown drainage. DSD over J/G tubes changed x2 d/t copious amount brown drainage. JP drains x2 w/ small amount dark brown drainage; DSD changed. RUQ pigtail drain w/ large amount dark, bloody output. Paper tape used for dsg. Pt T&R freq to maintain integrity. wife, 2 sons, and brother visited; updated w/ plan of care. wife and sons spoke w/ primary team. ?family meeting on Monday w/ Dr. , Dr. , (social worker), and RN.\nPlan: Monitor VS, I's and O's, labs. Monitor drainage from wound, around drain sites, and in pigtail drain. Monitor BP after metoprolol given. Follow up on cultures. Cont antibiotics and midazolam gtt. Cont to hold Lepirudin gtt per primary team d/t large amount dark bloody drainage from pigtail drain. Update family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512598, "text": "SICU-B NPN 7a-7p\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nEVENTS: ? midline abd incision dehiscence\nNEURO: Comfortably sedated on 4mg/hr, occas boluses fent for pain. No focal neuro deficits.\n\nCV: HD stable, BP trending down t/o day, MAP alwaly >65, CVP 12-18. Diuresed x 1 w/ fair effect, further diuresis held d/t ? sepsis. Cont grossly edematous. HR NSR 60s-70s, no ectopy, cont PO amio. Lepiruden w/ therapeutic PTT.\n\nRESP: Attempted CPAP trial 15/5, pt. tachypnic w/ c/o difficulty breathing, resumed SIMV @ prior settings, not overbreathing, ABG w/ good oxygenation/ventilation. LS coarse, dim @ bases. Sxn'd for thick white sputum.\n\nGI: abd firm, distended, tender to palpation along r side of midline incision, incision draining s/s fluid, SICU team in to eval, ? dehiscence w/ tracking, awaiting surgical resident. TFs @ goal, changed to 2/3 strength. +BS/+RF No stool, starting colase and milk of mag. G/J tubes .\n\nGU: foley patent, cyu, lasix as above. +1.5L since MN.\n\nENDO: to start insulin gtt for consistently ^'d BG.\n\nID: febrile, 101.4, pan cultured. WBC trending up.\n\n: incisions as above. Mild erythema surrounding JP and G/J tube sites. All dsgs changed. No breakdown noted.\n\nSOC: family in to visit, to arrange family meeting w/ Dr. and all involved diciplines.\n\nA: HD stable, cont full vent support, unable to adequately diurese. ? of wound dehiscence and worsening sepsis.\nP: f/u pm labs, monitor hemodynamics, goal MAP >65. F/u surgical eval of abd incision. Cont versed/fent for comfort. regimen. Cont SIMV onoc.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512599, "text": "RESP CARE: Pt remains intubated/on vent per carevue. On SIMV all shift. Lungs dim bilat. Sxd thick white/pale yellow. RSBI-181. continue on full support\n" }, { "category": "Nursing/other", "chartdate": "2187-03-22 00:00:00.000", "description": "Report", "row_id": 1512600, "text": "focus hemodynmics\ndata: neuro: opens eyes to name and attempts to pull at et tube when untied. mouthing words and asking to pass his water. informed he had a catheter and nodded he forgot. perla #3 bilaterally. moves all extremities with help due to extremities being edematous.\n\nresp: remains intubated. on simv with ips. suctioned for thick yellow sputum. 02sats 96-100%. abgs good. wgt continues to up.\n\ncardiac: in nsr no ectopy seen. hct 27.7. on iv leprudin infusing with q6hr ptt. wbc 11.3. amiordone 400mg via tube fdg.\n\ngu: foley patent and draining amber colored urine. scrotum edematous and elevated on towel. urine amber in color.\n\ngI abd grossly distended and taut to touch. jp's oozing lg amt of bloody ?purelent drainage around the tubes. dr aware. tube fdgs at 110cc/hr. 2/3str impact with fiber. open abd incision with wet to dry dsg. stool x1 very large brown stool.\n\naction: labs as ordered. fentanyl for pain x2.on flagyl and linzolid iv. tube fgs at 110cc/hr. versed gtt infusiing insulin gtt with q1hr blood sugars. temp 102.4 and tylenol via tube given. update to wife this am. wife wishes to have 3 sons at the family mtg.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512594, "text": "Respiratory Therapy\n\nPt remains orally intubated weaned to PSV. Currently on +15PSV/+5PEEP w/ Vt ~500 RR ~20 maintaining Ve ~10-11L. BS slightly coarse, suctioned for small amounts of thick white sputum. SpO2 remained 90s. ABG acceptable. Remains fluid overloaded +17L. See resp flowsheet for specifics.\n\nPlan: maintain support; continue to wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512595, "text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt cont on versed gtt increased for agitation including tonguing and biting on ETT and attempting to pull it out. Easily awakens to voice and spontaneously awakens and opens eyes at times. Follows commands. Denies pain except on turning and repositioning. HR NSR 70s and BP wnl. Leperudine gtt continues with PTT at goal. Abdomen very firm and distended. Ducolax suppository with no results (+flatus) and then fleet enema also with no results. Dr. aware. Pt denies abdominal discomfort, nausea, or constipation. Tube feeds at goal via J-tube and only small amounts green bilious out of G-tube. Lungs clear with diminished bases and suctioned for small amounts of thick white secretions-mostly with yankaar in back of throat. PaCO2 high on gases and Dr. aware. No changes on vent at this time. Abdomen with staples pink and oozing serosanguinous drainage. Dressing changed with dry sterile dressing. Emotional support provided. Please refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512596, "text": "Resp Care\nPt. remains intubated/sedated overnight on PSV for most of the evening. Resp. acidois worsening overnight, Dr. aware.\nThis morning switched back to SIMV with good effect abgs normalizing, hyperoxygenated.\nBs: coarse bilat. sxn'd for thick white, sm-mod. amts.\nPlan: diurese, wean support as tolerated. Would recommend resting on SIMV overnight, PSV wean during the day.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-21 00:00:00.000", "description": "Report", "row_id": 1512597, "text": "Respiratory Care Note\nPt received on SIMV as noted. BS clear bilaterally, but diminished with increased aeration after MDI. BS are slightly coarse at the end of shift than earlier. Pt placed on PSV 15/5 for 1 hour, but placed back on SIMV secondary to tachypnea of 30. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-15 00:00:00.000", "description": "Report", "row_id": 1512675, "text": "Nursing Progress Note\n7 pm - 7 am\nCV\n converting to afib at 2200..rates in the 100-110's...given 5 mg iv lopressor times 2 ..Dr. aware... SBP 120-130's/60's...\nRESP\non 70% trach collar..C02 range 77-94..( higher when asleep ) But awake and conversant throughout night...FI02 decreased to 50% at 0600..lungs diminished at bases .. using yankauer ..suctioned via trach for minimal amounts of sputum ..requesting P-M valve during the night\nGI\nRemains on goal tube feedings ..bedpan times 2 but without stool\nGU\ndiuresed with 40 mg of iv lasix .. D/T decreased urine output\nEndocrine\nsliding scale ..fixed insulin dose ..\n\nABD dsg changed times 2 for large amounts of foul smelling drainage ..JP on left to bulb sxn ..~~100 cc output ..G-tube to gravity with minimal drainage\n\ndenies pain during dsg changes ..25 mg of trazadone for sleep\nA/P AFIB ..? ^^ standing lopressor dose ..DSG changes\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512649, "text": "CONDITION UPDATE\nVSS. LOWGRADE TEMP. ALERT,FOLLOWING COMMANDS. DENIES PAIN. VERY RESTLESS, CONSTANTLY MOVING ON BED. PRN ATIVAN GIVEN MD'S ORDERS W/ LITTLE EFFECT. LUNGS COARSE TO CLEAR UPPER BASES, DIMINISHED AT BASES. NO VENT CHANGES - ABG ACCEPTABLE THIS AM. OCC SUCTIONING FOR THICK, TAN SPUTUM. ABD CONT TO BE SOFTLY DISTENDED. NO CHANGE IN ABD WOUND BASED ON PREVIOUS DOCUMENTATION AND REPORT. MIN BROWN DRAINAGE OUT JP 1, SM AMT OF BILIOUS DRAINAGE OUT GTUBE. NO DRAINAGE NOTED FROM PIGTAIL. TOLERATING TFEED AT GOAL VIA JTUBE. U/O QS VIA FOLEY - DIURESED W/ LASIX MD' ORDERS. LOOSE STOOL X2.\nCONT TO MAINTAIN PT - PT HIGH RISK FOR FALLS. PAIN MANAGEMENT. MAINTAIN INTEGRITY. MONITOR FOR S/S OF INFECTION OR BLEEDING. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512650, "text": "Resp Care\nPt remains on MV as noted on Careview with no vent changes this shift. RSBI 76. BBS-slightly coarse, improving with sx for thick, tan secretions. Bases diminished. Pt very active throughout night. Bag and mask at . Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512651, "text": "nursing note\nneuro: Pt alert,agitated and restless throughout day. Started trazodone to relieve agitation. Pt appear less agitated although still attempting to pull at lines remains restrained for safety.\nCV: Pt SR with rare PAC's. HR within the 70's. Lepirudin gtt continued at same rate. Aline dampens.\nResp: Weaned to PS 5-PEEP- 5,MD aware of ABG. Suctioned for thick white-yellow.\nInteg: , reddened buttocks from loose stool.\nGI/GU: BM X2,soft and large.BSX4. Ab incision irrigated TID with NS. Lasix PRN for goal negative 2L. JP#1 drainage small amounts of cloudy drainage.\nPsychosocial: wife and family member visited with pt in afternoon. Case manager in to address family about rehab options and further plan of care.\n\nPlan: Continue with trazodone administration for agitation. Ativan PRN. Wean vent as tolerated, await speech consult for PMV. Question with team about conversion to coumadin. Wound care. Lasix for goal negative 2L.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-04-03 00:00:00.000", "description": "Report", "row_id": 1512652, "text": "Resp Care\nPt remains on PSV, ps weaned tol well. Pt had PMV trial with speech tol well. Plan to place pt on TM.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512653, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Trazodone and lorazepam given for restlessness/anxiety. Pt very restless in bed; pt pulling at JP drains and foley catheter. Pt attempting to sit up in bed and putting left leg over siderails. Pt closely monitored by RN overnight. Bilat wrist restraints in place; CSM on BUE (see CareVue for documentation). Trazodone and lorazepam w/ +effect. Pt opens eyes spont; opens eyes to voice when asleep. Follows commands. MAE. PERRLA (3-4mm bilat; brisk). Mouths words. Pt asked for wife several times overnight; RN explained to pt that it is night-time and that his wife will visit tomorrow. Emotional support provided.\nCV: Low grade temp (99.8). Pt in NSR w/ occasional PAC's (HR 60-70s), but at approx 2430 pt went into A.fib (HR 90-110s). Dr. notified. Metoprolol 5mg IV x2 w/ +effect; pt converted back to NSR w/ PAC's. A-line waveform very dampened; A-line flushed without effect. 100-140s/40-80s. QTc 0.33 sec. CVP 6-11. Continue Lepirudin gtt at 0.05mg/kg/hr. Pt w/ generalized edema. RLE>LLE; BLE warm to touch. Left DP/PT and right DP pulses weakly palpable. Right PT dopplerable. Furosemide 20mg IV BID ordered. Per Dr. , goal is for pt to be negative 1L/24hrs. Pt's 24hr net I&O balance: negative approx 1,131cc.\nPulm: Lungs clear, diminished at bases. Pt tolerated CPAP 40%, PEEP 5, PS 5. RR 17-20s. O2 sat >/= 98%. Pt suctioned for small amount thick, white secretions.\nGI: Abdomen softly distended w/ +BS. 3/4 strength Impact w/ fiber @ 90cc/hr via J-tube; no residuals noted. Loose/liquid BM x2 overnight; brown/golden stool (guaiac negative).\nEndo: FS q6hr w/ RISS. NPH 5units .\nGU: Foley w/ clear, yellow urine. UO >/= 45cc/hr.\nInteg: Pt's abdominal wound open w/ large amount brown drainage. Upper part of wound covered w/ DSD; lower part covered w/ Xeroform and DSD (dsg order from Dr. and primary team). Hydromorphone 1mg given for abdominal/incisional pain w/ good effect per pt. JP #1 w/ cloudy, liquid output. Right heel w/ abrasion; pink; no drainage noted. Venodyne boot on LLE only. MPB off all night d/t pt becomes more restless/agitated when MPB on. Pt's buttocks reddened, but . Aloe Vesta cream applied. T&R frequently to maintain integrity.\nPlan: Monitor VS, I's and O's, labs. Monitor neuro/resp status. Goal negative 1L/24hrs. Cont Lepirudin gtt; goal PTT 50-70. Trazodone/ Ativan for restlessness and anxiety. Provide emotional support. Pt needs to be reminded frequently that he is in the hospital. Update pt and family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512654, "text": "Resp Care\nPt remains on MV in CPAP/PS mode. BBS-Clear, diminished bases. No change post BD therapy. Pt very agitated/restless and pulling at tubes. RSBI 46. POC: Pt to be placed on ATC again today as tolerated. PMV trial to be repeated as tolerated. Bag and mask at . Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512655, "text": "Addendum to NPN:\nHct 28.2. PTT 53.5 (no change in lepirudin gtt rate). CPAP 40%, PEEP 5, PS 5 overnight. ABG: pH 7.41, PaCO2 56, PaO2 166, bicarb 37, BE 9. ?trach collar today w/ Passe Muir valve. Mg 1.9; repleted w/ 2grams magnesium sulfate. NSR w/ PAC's after 5mg metoprolol x2. Abd dsg changed x2.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512656, "text": "Resp Care\nPt was placed had 1st TM trial tol very well. Plan to continue on TM as tol. Sx for small wht.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512623, "text": "Addendum to NPN\nRepeat abg revealed PO2 of 76 and CO2 of 76. Discussed w/ Resident and plan to increase support to 15PS w/ 5PEEP. Will discuss plan to place tracheostomy tomorrow with wife. Versed increased since no plan to extubate and 1mg dilaudid given for turning/ changing sheets.\n\nA: Worsening ventilation.\n\nP: Increase vent support. ? trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512624, "text": "Resp Care\n\nPt received on PSV 15/5 and was placed on SBT with possible attempt to extubate however pt became more labored with slight respiratory acidosis present on repeat ABG. Pt currently vented on previous vent settings with Vt around 500cc and RR in the low 20s. BS clear to slightly course sxing for small amts of loose white secretions. ETT secured/patent. Will cont with vent support with possible trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512554, "text": "Admit note\nPt admitted from floor with sudden onset SOB and sats 60's.\nSee Careview for details...\nNeuro: Pt arrived AAOx3, MAE, pleasant and cooperative, remains alert throughout night and easily awakened when sleeping.\n\nCV: Aline inserted by Dr on arrival without difficulty. VSS, HR 70-90 Afib with bursts of 120-130's, Trace edema to LE's good pulses, Pt denies CP, EKG done on arrival and seen by Dr , 2gms Calcium Gluconate given for Ionized calcium 1.12, Heparin cont at 1600units/hr\n\nResp: Pt put on Bipap on arrival. See careview for settings, sats 98-99%, denies SOB, Lungs with crackles at bases, Pt to CT scan for chest CT, positive for bilat PE's, Dr aware, AM ABG 7.26/104/158/14 Dr and Dr notified. Fio2 to 40% and PS increased to 12, Pt alert, ABG to be drawn 1hr after changes\n\nGI: Abd lrg and firm, nontender, +BS, no BM, NPO\n\nGU: Adequate clear yellow urine via foley\n\nSkin warm dry and intact, turn pt throughout night, PM care given\n\nPlan: Monitor resp status, ABG, VS, Neuro status\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512555, "text": "Respiratory Care Note:\n Received patient from floors this shift. Patient remains on NIV this shift. For specific settings, please see carevue. Patient taken to CT without incident, positive for bilateral PE's. CXR this am is pending. CXR showed bibasilar and r. middle lobe atelectasis. Patient remained afebrile. BS are diminished. Both tanks switched out on vent. Plan is to continue support.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512556, "text": "Resp Care\nPt on NIV, then intubated in unit due to PCO2 of 115. PT transport4ed to Cath Lab for filter placement. Pt is a retainer and team would like to keep PCO2 around 60-70. Weaned FIO2 to 60%. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512617, "text": "Resp Care\nPt remains on MV as noted on Careview with no setting changes this shift. BBS-coarse and diminished, with no change post BD therapy. Sx'ed for thick, white secretions. Pt currently in a-fib, resting quietly in NAD. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512618, "text": "Rsp Care\n\nPt's mode of ventilation was changed to CPAP/PSV. PS was eventually was weaned to with adequate MV and TV's. However follow op 7.29/62/85/31 and was placed back on 15 of PSV. BS are with scattered rhonchi and suctioning thick white sputum\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512570, "text": "SICU NN: See carevue for specifics. Patient sent to OR at 0800 for exploratory lap, open chole, pancreas debridment, drainage of pancreatic pseudocyst, placement of G and J tubes. Patient returned at 1215. Patient sedated on propofol. When propofol held patient follows simple commands and nods head appropriately. Patient denies pain by nodding head. Patient moves all extremities weakly. Pupils equal round and briskly reactive. Patient remains intubated. Frequent abg's following lactate levels and metabolic acidosis. Rate increased to decrease CO2 and compensate for met. acid. with good result. FIO2 decreased from 100% to 60% following abg's with adequate PO2 levels. Lungs coarse throughout. Small amount secretions present. Ganz maintained as per policy. Cardiac outputs done as MD. . Central line intact. Levophed titrating to maintain map >60. Vasopressin weaned off as MD. started as ordered. RSR on cardiac monitor. TEE done at bedside by cardiology. Doppler pulses. One unit ffp infusing, one more ordered. NPO. NGT to lcws. G and J tubes to gravity. Bowel sounds hypoactive. Midline abdominal incision clean, dry and intact. Two to abdomen draining serosanguinous drainage. Foley intact, decreased urine outputs, md's aware. Fluid bolus given at 1400 as ordered. Skin intact. Blood sugars wnl. Magnesium repleted as ordered. MD's aware of all lab results. Family in to visit today, spoke with md's. Restraints in place as ordered for patient safety.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512571, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: opens eyes when propofol off and follows commands. PERRL. MAE. Please refer to flowsheet.\n\nResp: Breath sounds coarse and equal bilaterally. Sat's >97%. Suctioning through ETT for thick white secretions in moderate amount. Overnight following abg's, lactate, and mixed venous sat's. Lactate trending down, and mixed venous sat. 72-75%. Mouth with poor dentition is unchanged. Peak pressures in 30's.\n\nCV: SR occ. PAC noted. Aline intact with good waveform. Well perfused with brisk cap refill < 2sec's. Pulmonary htn with PA pressures decreasing mildly overnight. Cont to CO and wedge q 4 hours MD request. PA cath. with good waveform. REmains on levophed, currently tolerating slow wean with goal of MAP 65-75. Amiodorone continues at 0.5 mg/ min.\n\nHEme: INR 1.9 and transfused 2 units of FFP. Well tolerated. HCT stable. Cont to follow PT/INR q 6 hours. possibly restart heparin today. DVT right leg. Sequential on left and multipodis boots. HEparin currently given sq.\n\nGI/ Abd: NPO. Hypo active bowel sounds. Abd dressing with moderate amount of serosanguinous drainage (OR dressing intact). JP 1 and 2 with serosanguinous drainage. J and G tube to gravity. G tube with bilious drainage ~100cc. Jtube scant amount of bilious drainage. NGT to Low cont. wall suction in good placement and draining bilious. No stool thus far today. Firmly distended though improved.\n\nGU: Foley cath to gravity UOP >50cc/hour amber to yellow in color.\n\nEndo: Following glucose q 6 hours, RISS. No insulin required overnight.\n\nID: Cultures with no growth thus far. On vancomycin, flagyl, levofloxacin, fluconazole. Need to repeat sputum culture.\n\nSocial: Wife called and updated, verbalizing understanding. Will cont to update and support.\n\nPLan: Cont to follow glucose q 6 hours, RISS. Cont to follow abg/lactate, and mixed venous labs MD order. Lactate trending down. ABG cont to improve overnight. PT/ INR q 6 hours. Cont to wean levophed as tolerated with Map 65-75. Cont to update and support family. D/C plan is ongoing.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512572, "text": "SICU NN: See carevue for specifics. Patient intubated on fentanyl for pain control. Patient following commands. Pupils equal round and briskly reactive. Moving all extremities. Vent assist control, no issues. ABG's Q4h as ordered. Lactate decreasing. Converted to afib this am. Dr. notified. rate increased and bolus given. Patient remains in afib. Low dose levophed infusing to maintain map's 60-65. NPO. NGT to lcws. G and J tube to gravity. Abdominal incision with dsd intact, no drainage. Foley intact with adequate urine outputs. Skin intact. Restraints in place for patient safety. Low grade temps, antibiotics as ordered. Sliding scale for insulin coverage. Family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-14 00:00:00.000", "description": "Report", "row_id": 1512573, "text": "resp. care\npt. remains intubated/vented/sedated.\ncontinue with high ph...resp. rate weaned\nto 18 with no spont. efforts. continue to\nwean as toerated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512640, "text": "Respiratory Care\nPt changed to cpap/ps tol well 735/63/138/36/7. Plan to continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512581, "text": " 15/07\n NEURO PT REMAINS ON FENT AT 100 MCG PER HOUR FOR REELAXATION AND PAIN CONTROLL AND TO TOL VENT SUPPORT PT ON HAND RESTRAINTS TO REMIND NOT TO PULL TUBES TOL WELL ORDER IN POE PT MAE IN GOOD SPIRITS PLEASE CAREVIEW FOR DETAILS\n HEART S1S2 SB ALT WITH AF RATES 80 TO 90 DURING AF POOR BP AND CO SELF LIMITING K DEPENDENT ON GOOD SUPPRESSION M 2/6 M AREA PRESSURES ELEVATED BUT STABLE CO FAIR 4.8 TO 5.6 SIDE DEPENDENT RIGHT SIDE UP BETTER RESULTS NOTED MD AWARE OF ALL RESULTS 3 PLUS EDEMA THRU OUT FLUID OVERLOADED POSSIBLY AM LASIX MD VSS LOW GRADE TEMP PLEASE SEE CAREVIEW\n RESP ON CMV PAP 32 TO 38 LUNGS RALES FINE AT BASES NOTED ABG WNL SCANT SPUTUM NOTED CPT TOL WELL\n GI POS B/S JP IN PLACE TOL T/F WELL G TUBE DRAINAGE FAIR AMOUNT U/ LOW MD RED BUTT AREA TIGHT FLUID FILLED\n PLAN SUPPORTIVE LASIX MONITOR WEAN LEVO TO OFF FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512582, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on ventilatory support, easily awaken, sleepy. WE only weaned FI02 from 50 to 40%. AM ABG acceptable. We are sxtn rotinely and as needed small to mod amt of thick white from ETT and occ orally, strong assist cough. Plan: Try fluid removal, and wean vent settings as tolerate. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512583, "text": "Nursing Note\nPlease see Carevue for complete assessment and specfics:\n\nNEURO: On fentanyl gtt, Open eyes spontaneously. PERRLA 3 and brisk. Nods and shakes head appropriately to questions asked. Follows commands with all 4 ext.\n\nGI: Abd obese soft, +BS. TF thru J tube adv to 30cc/hr. G-tube to gravity draining bilious fluid. JP #1 draining grey thick liquid. No drainage from JP#2.\n\nCARDIAC: TMax 100.8 by blood. Swann and cordis d/ by MD. HR 60-70's NSR no ectopy. Continues with gtt and Heparin gtt.\n\nGU: Foley draining qs clear yellow urine. Lasix 20mg x1 with good effect.\n\nRESP: LS clear. Deep sxn for small amts of thick white secretions. Mouth sxn for large amts of clear secretions.\n\nINTEG: Scrotum extremely edematous elev on towel. Inc staples with no drainage. JP sites cdi.\n\nPSYCH/SOCIAL: Son at bedside in the am, pt more interactive and calm with his presence. 2mg x1 for anxiety.\n\nPLAN: Continue to diurese, Possibly wean vent tomorrow, Monitor hemodynamics, Provide extra reassurance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512584, "text": " 1530\n NEURO A/O COMMUNICATES WELL AROUND ETT MAE LIMITATION EDEMA AT LIMBS DECREASING ROM RELAXED GOOD PAIN CONTROL WITH FENT AT 100 SLEEPS SHORT PERIODS\n RESP VENT CMV TOL WELL REMAINS INTUBATED FOR FLUID OVERLOAD RESOLVING SCAT SPUTUM CLEAR FIELDS\n HEART S1S2 SB CONTROLED DOPPLER PULSES VSS M PR .14 QRS .08 QTC WNL FOR AGE AND GENDER\n ABD POS B/S NO STOOL TOL T/F WELL NO ISSUES DRAINS IN PLACE HEALING\n PLAN SUPPORTIVE MONITOR FLUID LOSS ROM AND T/P\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512659, "text": "Resp Care\nPatient required ventilation overnight due to increasing co2. Currently on simv 550 x 12 40% 5/5 with improved abgs. Plan is to switch back to trach collar later today.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512660, "text": "Resp Care\nPt was placed on TM tol well, plan to monitor abg's, may stay on TM ph<7.30.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-26 00:00:00.000", "description": "Report", "row_id": 1512619, "text": "see careview for details\nfocus data update\n\nNEURO: pain med changed to dilaudid with improved pain control\n\nRESP: vent setting's changed from cmv to cpap, pt weaned from to finally pt tol for 1 1/2 hr's, returned to over noc to rest pt, trach planned for am, pt's wife request that we wait 24 hr's to see if we can extubate pt, ICU team aware, MIS team aware, Anesthesia aware and will notify OR, ABG's monitored closely\n\nCV: lasix gtt increased, pt tol diuresis well, lepirudin theraputic level,\n\nGI: inc of large amt's liq feces, fecal inc bag applied peri-rectal area excoriated, pt on theraputic bed, banna flakes added to tube feeds, abd wound continues to drain copius amt's of purulent/sangernous drg\n\nGU: diuresising well\n\nA/P: continue emotional and educational support to both pt and family, continue to wean pt\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512620, "text": "SICU NN: See carevue for specifics. Patient sedated on versed . Dilaudid for signs and symptoms of pain prn with good result. Patient moves all extremities. Patient follows simple commands. ET to vent, cpap. RSR. BP wnl. Abdominal incision with dehisence, multiple pouches covering incision with serosanguinous drianage. One pigtail catheter and two jp's in place to abdomen. G tube to gravity. J tube with tube feeds, tolerating. One soft bm this shift. Foley-lasix infusing titrating with goal of making patient one to two liters negative. . Restraints in place for patient safety related to et tube and multiple lines. Triadyne rotating bed in rotation mode. Pneumatic boot on left leg only due to dvt in right. No visitors or phone calls. Lytes repleted as ordered. Lepirudin infusing as ordered. Administered antibiotics as ordered. Patient afebrile. Patient sleeping comfortably.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512621, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on spontaneous ventilation. No vent changes done. RSBI done ~52. BS are dim more to bases and clear. Plan: Continue to diurese and likely assess for etubation or trach?. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512641, "text": "Nursing Update\nCV/HEME: No A Fib, but sinus brady in 50's x2hours after receiving lopressor. BP stable. Labs stable. Cont on lepuridin gtts.\n\nPAIN/SEDATION: Dilaudid effective for abdominal pain, ativan for restlessness with only fair effect.\n\nID: Contact precautions maintained. Afebrile.\n\nGI: Tube feed tolerated at goal via PEJ. GT draining bile, JP's 1&2 draining greyish serous fluid, no drainage via pigtail. Abdominal incision draining maroon fluid to collection device. sounds auscultated over 4 quads. Sm liquid brown BM.\n\nMonitored closely overnoc, DR in close attendance.\nSee carevue flowsheets for detailed data.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512642, "text": "Resp Care,\nPt. changed to A/C overnoc after periods of apnea on IPS. Changed back to IPS 15 this am. VT 500's RR 8. RSBI 38 this am. Cont. to wean as tol. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512643, "text": "npn\n pt cont freq agitated- ativan prn, facial grimace with activity- dilaudid prn, Haldol started this am. bilat wrist rest. on. follows commands and mae on bed.\n\nResp- tol ips of 15 and peep 5- cont metabolic alk- diamox tid. lungs clear upper- bases, suction thick tan secretions via trach.\n\nGI- tube feed at 110/hr - 2/3 strength impact with fiber. tol well, f.i.b - small amount loose stool. plan pr surgical team to irrigate abd. wound tid. jp x2, pigtail x1 and g tube to gravity. with bili drg- tube feed via j tube.\n\nPlan wean vent as tol, decrease ativan as tol irrg. abd wound tid.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-01 00:00:00.000", "description": "Report", "row_id": 1512644, "text": "Respiratory Care Note\nPt received on PSV 15/5 as noted with no vent changes this shift. BS diminished throughout with increased aeration after MDI. VT's 700's with RR 8-12. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512645, "text": "NURSING UPDATE\nCV/HEME: NO ARRYTHMIAS, BP STABLE. HCT 26.9. K+ REPLETED.\n\nRENAL/GU: RESPONDED VERY WELL TO LASIX 20MG IV, RESULTED IN 1400CC NEGATIVE FLUID BALANCE FOR YESTERDAY.\n\nGI: TUBE FEED TOLERATED @ GOAL. JP'S AND PIGTAIL DRAINING GREYISH SEROUS, GT DRAINING BILE, MAROON SLUDGE DRAINING VIA ABDOMINAL WOUND, IRRIGATED WITH N/SALINE X1.\n\nPAIN SEDATION: AGITATED MOST OF NOC, SETTLED FOR 3 HOURS ONLY. ATIVAN FOR AGITATION, AND DILAUDID FOR ADOMINAL DISCOMFORT WITH MODERATE TO POOR EFFECT.\n\nNURSE THROUGHOUT NOC FOR CONTINOUS SAFETY MONITORING.\nDR IN CLOSE ATTENDANCE.\nSEE CARVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512646, "text": "Resp Care,\nPt. remains on IPS 15 overnoc. Periods of prolonged apnea during noc after sedation. ABG 7.32/60/133/32. VT 700's, RR 10. Agitated most of noc. RSBI 46 this am. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512647, "text": "Respiratory Care Note\nPt received on PSV 15/5 as noted. PS weaned to 10 - follow up ABG 7.36/60/160/35/6. Pt tolerating well with VT 500's and RR high teens. BS are coarse bilaterally and decreased which clear and improve in aeration after suctioning and MDI's. Plan to continue on PSV and wean PS as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-02 00:00:00.000", "description": "Report", "row_id": 1512648, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt restless/anxious in bed. Attempting to pull at trach, IV lines, foley, and drains. Pt also attempting to sit up bed; repositioned frequently. Pt restrained bilat wrists; see CareVue for documentation. Total 8mg lorazepam given. Hydromorphone given for abdominal pain (total 5mg given). PERRLA (2-3mm bilat; brisk). Pt follows commands; MAE. Mouths words at times, but difficult to understand. Emotional support given to pt. RN monitored pt closely during shift. Afebrile. HR 50-90s. Pt in A.fib this AM, but converted to sinus brady/NSR (Dr. aware). When in A.fib, SBP decreased to 80-90s (SICU team aware). ABP 90-150s/50-90s. QTc 0.42 sec. CVP 10-22. Pt w/ generalized edema (+). DP/PT pulses dopplerable. Furosemide 20mg IVx2; goal neg 2L/24hrs. Lepirudin gtt cont @ 0.05mg/kg/hr. Lungs clear, diminished at bases. CPAP 40%, PEEP 5, PS decreased to 10. ABG: pH 7.36, PaCO2 60, PaO2 160, bicarb 35, BE 6 (Dr. aware of ABG). Pt w/ strong cough; productive for small amount thick, tan secretions. O2 sat >/= 98%. No c/o SOB. Abdomen softly distended w/ +BS. 2/3 strength Impact w/ fiber at 110cc/hr via J-tube; no residuals noted. G-tube to gravity bag w/ 100cc green, bilious drainage. Fecal incontinence bag came off this AM; stool is softly formed. BMx2; soft, golden-color stool. FS checked q6hr w/ RISS; BS 133-151. NPH 5units ordered . Abdominal wound irrigated x2 w/ NS; large amount of liquid, mucoid, dark-brown drainage noted. Large drainage bag over abdominal incision . JPx2 to bulb suction. JP#1 w/ small amount light-brown drainage. JP#2 w/ small amount cloudy, light tan drainage. Right pigtail drain w/ dark brown drainage. DSD over all drains changed x1. Triadyne bed changed to Atmos-air (SICU) bed. ; no redness/breakdown noted on pt's back/sacral area. T&R frequently to maintain integrity. wife, son, and sister-in-law visited. Family spoke to RN and Dr. regarding pt's condition and plan of care. Emotional support provided.\n Plan: Monitor VS, I's and O's, labs. Goal negative 2L today. Monitor for A.fib. Lorazepam for restlessness/anxiety. Hydromorphone for pain. Irrigate abdominal wound w/ NS TID (done at 1000 and 1800 this shift). Cont Lepirudin gtt; goal PTT 50-70. Wean vent settings as tolerated. Update pt and family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512661, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nOverall status unchanged. Placed on trach mask this am. Pt cont with ^^ PC02's when sleeping Pt aroused and ABG rechecked current PC02 is 63 no noted change in mental status. Cont to be diuresed goal 1-1.5 liters negative. S/P CT scan today. Plan: Cont to monitor resp status and Heme status cont to monitor diuresis and check lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-06 00:00:00.000", "description": "Report", "row_id": 1512662, "text": "Nursing note (1900-0700) 04:30\n\n\nNeuro.\nPt alert, mouthing words, periods of aggitation noted, medicated with Trazadone and Ativan with slight effect. Pt making confused statements, not always able to express needs.\n\nResp.\nPt remains on trach mask with good SpO2 and adequate abg. Able to expectorate white thick secretions easily.\n\nCVS.\nHR 80's A-Fib, on Lopressor and .\nBP 120's/80's, a-line dampened, nibp in place also.\n\nGI/GU.\nPt tollerating TF's well, +BS with loose brown stool managed via mushroom cath.\nFoley patent for clear yellow urine, pt with good response to extra dose of lasix overnight, pt 1100cc -ve at 12mn.\n\n.\nWound dressing to abdomen left overnight.\n\nSocial.\nNo calls or visits overnight.\n\nID.\nContinues on anti-biotic coverage, WCC 8, pt a-febrile.\n\nPlan.\nRepleat lytes as needed.\nPt to go to OR at some point for wound closure.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-06 00:00:00.000", "description": "Report", "row_id": 1512663, "text": "Neuro:Pt alert but confused. Able to make needs known. Denies pain.\n\nCV: afebrile, HR 90-110's, A-fib. Med with lopressor 5mg IVP with no response for a-fib. SBP 140-150's\n.\nRESP: pt on trach mask, Continues to have CO2 >70. O2 sats >96%. Tolerating Passy muir valve.\n\nGI: NPO for ? ct scan.\n\nGU: foley draining adequate amounts of clear yellow urine.\n\nENDO: blood sugars WNL.\n\n: abd dressing to be changed q4hrs. packing with sterile gauze. ? vac dressing.\n\nPLAN: Awaiting VAC placement on abdominal dressing. ? transfer to floor or rehab.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512664, "text": "update\nNeuro: mae, awake and alert, not always oriented to time or place. when passe muir valve in, pt stated he wanted to go to the nuclear power plant at the beach.\n\ncv: A fib all shift, bp stable, see flow sheet for details.\n\nPulm: bs clear, decr in left base. sx q 2-3 hrs for thin white, coughing , regurgitated green bile, did not aspirate it. trach cuff up for protection of airway from aspiration. po2 132, pco2 68, fio2 decr to 40%. albuterol tx q 6hr.\n\ngi: gt to gravity, draining green bilious. sounds present, tube feeds restarted at 90 cc without problem. mushroom cath in place, draining liquid stool hem neg.\n\ngu: lasix with good response.\n\nwound: dsg changed q 4 and packed with ls gauze, large amts brown mucous ddrainage from wound.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512611, "text": " 19/07\n NEURO ALERT COMMUNICATES WELL NO ACUTE DISTRESS LOW DOSE SEDATION TOL WELL VERSED MAE WELL NO PAIN ON MOTION OPENLY STATES WANTS ETT OUT IF UN TIED WILL PULL TUBE OUT\n RESP ETT CMV 12/650 PEEP 5 .40 FI02 CLEAR FIELDS NOTED THICH SPUTUM NOTED STRONG COUGH\n HEART S1S2 PULES POS 2 THRU OUT NSR BP WNL EDEMA REMAINS 3 PLUS TIGHT EXTREMITES\n GI POS B/S STOOLING NO ISSUES NOTED FIRM ABD WITH WEAPING ABD WOUND JP AND PIG TAIL IN PLACE TOL T/F WELL\n PLAN SUPPORTIVE PLEASE SEE CAREVIEW FOR DETAILS T/P CPT P/T FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512612, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. RSBI 260 with desat to 89%. Returned to AC w/sat 99% without further intervention. BBS-coarse, improving with sx for thick white secretions. Diminished BS t/o w/no changed noted post BD therapy. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512613, "text": "see careview for details\nfocus data update\n\nNEURO: OPENING EYES SPONTANEOUSLY, MOVING B/L UPPER EXT'S, FENTANYL FOR PAIN, VERSED GTT FOR COMFORT\n\nRESP: VENT SETTINGS UNCHANGED, R/T GENERALIZED ANASARCA, SX FOR COPIOUIS AMT'S OF THICK WHITE SECRETIONS BOTH ORALLY AND ETT,\n\nCV: TMAX 101.5, BOTH ICU AND SURGICAL TEAMS AWARE, CX'S STILL PENDING, NO NEW CULTURES ORDERED, MED WITH TYLENOL, LEPIRUDEN GTT AND LASIX GTT INFUSING\n\nGI: FIRM AND ABD DISTENDED. UPPER POLE OF INCISION FISTULA NOTED THAT COMMUNICATES WITH PIGTAIL, DRAINAGE BAG APPLIED TO INCISION\n\nGU: ADEQUATE HOURLY U/O, AWAITING LASIX GTT\n\nA/P: CONTINUE PLAN OF CARE, GOAL LITER'S NEG FOR 24 WITH LASIX GTT, CONTINUE BOTH EDUCATRIONAL AND EMOTIONAL SUPPORT TO BOTH PT AND FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512614, "text": " 1500\n NEURO PT ALERT WILL FOLLOW COMANDS MAE WITH RESTRICTIONS OF TIGHT FLUID FILLED EXTREMITES C/O ABD PAIN ON VERSED WITH FENT SUPPLEMENTS DOES WELL\n RESP VENT ETT CMV .40 FIO2 12/650 5 TOL WELL THICK SPUTUM BROWN IN COLOR RHONCHI THRU OUT\n HEART S1S2 DISTANT TONES POOR PULSES THRU OUT NSR VSS LOW GRADE TEMP PLEASE SEE CAREVIEW FOR DETAILS\n GI POS HYPOACTIVE B/S NOTED TOL T/F AT THIS TIME STOOLING ABD WOUND OPEN IN 3 MAJOR AREAS WITH DARK RED FLUID FOUL ORDOR COVERED WITH BAGS FOR COLLECTION LG AMOUNTS MD AWARE U/O FAIR ON LASIX TITRATING TWO JP SCANT PIG TAIL LG AMOUNTS NOTED SAME AS FLUID FROM ABD WOUNDS\n SHOWING SIGNS OF WEARING NEW BED ORDERED Q2 SIGN CARE AND ROTATION SUPPORTIVE CARE FAMILY CARE\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512615, "text": "Respiratory Therapist\nBreath sounds coarse bilateral crackles, suctioned for moderate thick white, treated three times with Albuterol MDI, ABGs at 1539 showed fully compensated respiratory acidosis with hyperoxemia, started on lasix, still has edematous limbs, will stay intubated, and monitored.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-25 00:00:00.000", "description": "Report", "row_id": 1512616, "text": "Respiratory Therapist\nUpdate: Patient tried on CPAP at 1730, after 20 minutes had to be put back on previous initial settings: AC 650 x 12 40% +5.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512568, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: Lightly sedated on propofol drip awakens to name, follows commands consistently. MAE. PERRL. Currently sedated on propofol drip at 50 mcg/kg/min. ativan 2mg IV, and morphine 2mg given overnight.\n\nEvents:\n\nResp: Vent changes made accordingly, and remains on AC, TV 650, peep 8, RR 18, fi02 .70. Breath sounds coarse and equal bilaterally. sat's .98% until 0100, Temp spiked to 102.5 po. Rigors noted, biting on ETT with sat drop to 88 %. Suctioned for tan thick secretions in moderate amount.\nPlease refer to careview for abg's.\n\nCV: SR to ST no ectopy, Concurrent with temp spike to 102.5 became tachycardic and hypertensive. 10 mg IV lopressor given with good effect and bp came down to 140/60. Probable sepsis, given total of 4 liter NS, and levophed drip started and currently at 0.5 mcg/kg/min.\nHCT 25.9 and given one unit PRBC's due to bp persistently decreasing to lowest of 73/40 briefly. Mean bp >60 with levo and NS. Heparin increased to 1600 units /hour earlier in shift for goal of 60-80. Currently off at 0700 due to scheduled OR time of 0830. Aline with good waveform.\n\nPA line placed at 0630. CXR done at 0730 to confirm line placement.\n\nGI/ Abd: Active bs. NGT to low cont suction with bilious color drainage. Bruising noted around umbilicus and abdomen with increased firmness and guarding to examination this morning. Lactate increased to 7.2 from 1.4 earlier in shift. No stool.\n\nGU: UOP ,30cc/hour. Foley to gravity.\n\nID: TMAx 104.2 po. Tylenol given at 0100. Cooling blanket on at 0100. ON levofloxacin, flagyl, and vancomycin.\n\nEndo: glucose q 6 hours, RISS. no insulin required.\n\nSocial: Wife called and updated by surgeon. Cont to update and support family.\n\nPlan: Cont to follow abgs, labs. Provide abx coverage as ordered. Hemodynamics monitor keep map >60. Plan to go to OR this am for exploratory laparotomy.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512569, "text": "Respiratory Care\nPt continues to be orally intubated/ventilated at this time. Pt to this OR this am after spiking temps. S/P choylecystecomy/pancreatic debridement/placement of G/J tube. Pt returned w/o incident. Currently on A/C 650/18/8/.80. BS: coarse bilaterally. Suctioned for scant bld-tinged secretions. Poor Pa02/Fi02 ratio at this time. Hope to wean Fi02 further t/o the night. Will continue to closely monitoer and support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512635, "text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. Pt to OR today for trache, #8 portex placed. No vent changes made so far this shift. Sxn for white secretions. Albuterol MDI given Q4. Cont current support, ? back to PSV soon.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512636, "text": "Neuro: Pt alert but remains slightly sedated on versed gtt at 4mg/hr. MAE, follow directions consistantly. Pt med with dilaudid at noon for transfer to OR for trach with good effect.\nCV: afebrile, HR initially 70's NSR with no ectopy, presently 100's Afib. SBP 90-100, CVP 11-13. Extremities with edema, dopplerable pulses. Lytes repleated this eve. Lepirudin to restart at 1800.\nRESP: lungs coarse to dim at bases. Remains on AC 550X18 40% Peep-5. Occasional suctioning of frothy secretions. Pt to OR at 12noon for trach. Tol well, ABG acceptable.\nGI: Tol tube feed at goal, restarted on return from OR. No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nENDO: blood sugars WNL.\nPLAN: Attempt to wean vent overweekend. Cont to monitor coags with liperudin.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512637, "text": "Respiratory Care\nPt. trached and remains on ventilatory support. ABG's showing gradual correction of Metabolic Alkilosis. Tol RSBI trial this a.m. Suctioned for min-mod amounts of thick yellow secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512638, "text": "NURSING UPDATE\nCV:\nEPISODE OF AFIB X2HOURS EARLY NOC, CONVERTED TO NSR RATE 60'S AND REMAINED STABLE SINCE. LEPIRUDIN GTTS CONT, INR 2.4 AND HCT 22 THIS AM, FFP 2U AND PRBC'S 2U TRANSFUSED. K+ AND MG+ REPLETED.\n\nRESP:\nBS FAIRLY CLEAR THROUGHOUT, SXN SMALL WHITE. NO VENT CHANGES. METABOLIC ALKALOSIS PERSISTS. SCANT AMOUNT OF PINK DRAINAGE @ TRACH SITE.\n\nNEURO:\nALERT AND FOLLOWING COMMANDS, ORIENTATION UNDETERMINED. RESTLESS AND FIDGETY ON VERSED GTTS, WEANED OFF AND MEDICATED WITH ATIVAN PRN WITH MUCH BETTER EFFECT. BIL WRIST RESTRAINTS MAINTAINED.\n\nGI:\nTUBE FEED TOL @ GOAL VIA PEJ. MEDICATED WITH DILAUDID PRN FOR C/O ABDOMINAL/INCISIONAL PAIN WITH GOOD EFFECT. JP#1 DRAINING GREYISH SLUDGE, JP#2 DRAINING GREYISH SEROUS, PIGTAIL DRAINING MAROON, GT DRAINING GREEN BILE, ABDOMINAL WOUND DRAINAGE DEVICE COLLECTING SLUDGY MAROON. SOUNDS HYPOACTIVE. INCONTINENT X2 SLIGHTLY GUAIAC POSITIVE STOOL, FIB APPLIED.\n\nGU:\nHUO 70-140CC CLEAR YELLOW.\n\nPT MONITORED CLOSELY @ BEDSIDE. CONTACT PRECAUTIONS MAINTAINED.\nDR IN CLOSE ATTENDANCE THROUGHOUT SHIFT.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-31 00:00:00.000", "description": "Report", "row_id": 1512639, "text": "npn\n pt opens eyes spont, mouths words like \"water\" \"hot\". mae on bed. Frequently anxious and pulling at drains and taking gown off. bilat soft wrist rest. on. ativan prn. facial grimace with activity- dilaudid prn.\n\nResp- tol cmv vent weaned to ips of 15 with peep 5- abg metabolic alkalosis- ph wnl, md aware- lungs clear upper- decrased at bases, suction thick tan to white secretions via trach.\n\nAbd- tol tube feed via j tube, cont abd jp x2, pigtail drain x1 and g tube to gravity. abd wound covered with ostomy type drsg to drg bag- pink to dark red thick drg. hypo bs x4, fib on with liq soft stool.\n\nHeme- rec 2 prbc this am for hct 23- post hct this pm 28- rec 2 ffp for inr >2.5- pm inr 2.2, cont lepirudin gtt.\n\nPlan- cont wean vent as tol, ativan and dilaudid prn- wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512607, "text": "condition update\nD: pt remains on versed at 4mg/hr. pt openes eyes and follows commands. pupils are equal and reactive to light. pt moves all extremities.\ncardiac: pt remains off levo and map is greater than 60. pt switches between afib and nsr with rate of 110-68. most of the night pt remained in nsr. cvp 16-18.\nresp: abg's are unchanged. please see flowsheet. pt remains on cmv with rate of 12. breath sounds are clear after suctioning and mdis. pt suctioned for thick yellow sputum.\n: pt with open area on right heal. 2 x 1 in size. right foot elevated on pillow. no other areas of breakdown noted. abd wound continues to drain a large amt of red/brown drainage. pigtail continues to drain a large amt of maroon thick drainage. hct of pigtail fluid was 11. serial hcts done and hct remains stable at 26.\ngi: tube feeds restarted and pt with no residual. gtube drained large amts of green/brown drainage. bilateral jp's patent and draining minimal drainage.\ngu: urine output remains adequate 40-100cc/hr.\na: medicate for pain as needed with fentanyl. continue to monitor pigtail drain and hcts as ordered. ? reevaluate to restart anticoagulation therapy today.\nr: 50mcgs of fentanyl effective in relieving pain. hct remains stable at this time. pt appears comfortable on current vent settings. pigtail continues to drain large amounts of maroon drainage.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512608, "text": "Resp Care\nPt remains on MV w/settings as noted on Careview. RSBI 120's this am, pt returned to AC mode. Hct stable, some a-fib noted. BBS-CTA and diminished w/no change post BD therapy. Sx'ed for sm amts thick white secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512609, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT LIGHTLY SEDATED ON MIDAZ GTT. OPENS EYES SPONT. PERRL. FOLLOWS COMMANDS.\n\nCV-HR 70'S, SINUS, NO ECTOPY. SBP STABLE. W+D. +PP VIA DOPPLER. + PITTING EDEMA THROUGHOUT. RESTARTED ON LEPRIDUM GTT. WILL FOLLOW COAGS.\n\nRESP-REMAINS INTUBATED. NO VENT CHANGES MADE TODAY. O2 SAT 98%. LS CLEAR TO COARSE WITH OCC WHEEZES. SXN PRN FOR THICK WHITE SPUTUM.\n\nGI-ABD OBESE, FIRM, DISTENDED. +BS. TOL TF AT GOAL VIA J-TUBE. G-TUBE TO GRAVITY WITH BROWN BILIOUS DRG. JP AX WITH SM AMT BROWN DRG. PERC DRAIN WITH DARK MAROON DRG. SPEC SENT FOR AMYLASE. ABD DSG REINFORCED. HAS FIB IN PLACE WITH LOOSE BROWN STOOL.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS AMBER URINE. + SCROTAL EDEMA.\n\nCOMORT-FENT PRN.\n\nENDO-REMAINS ON INSULIN GTT.\n\nID-TMAX 100.6. REMAINS ON ABX.\n\nA-VENTED, ALT IN GI.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. ASSESS PAIN. DSG CHANGES. INSULIN GTT. FOLLOW PTT FOR LEPRIDUM GTT. CARE. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-24 00:00:00.000", "description": "Report", "row_id": 1512610, "text": "Respiratory Therapist\nNo vent changes made at this point, ABGs at 1640 showed fully compensated metabolic alkalosis with mild hyperoxemia. Breath sounds coarse expiratory rhonchi, suctioned for moderate thick white,extremities exhibit pitting edema, patient was treated today in three occasion with Albuterol inhaler.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512577, "text": "see careview for details\nfocus data update\n\nneuro: awake and anxious at times, medicated with ativan and fentanyl gtt, mae's, perla\n\nresp: abg's monitored, vent setting's unchanged, increase suctioning noted for thick white secretions\n\ncv: increased anasarca noted, a-line restarted in right radial, left subclavian multi-lumen patent, right pa cath patent, c.o. improved\nlevo d/c, decreased, pt converted into nsr, heperin gtt titatrated to ptt, lyte replacement given, am labs pending\n\ngi: tol tropic tube feeds into j-tube, g-tube to gravity, jp's to ssx,\nabd dsg's changed, minimal billary drainage noted @ g-tube site, all other dressing's clean, dry and \n\ngu: urine remains amber, adequate hourly u/o\n\na/p: continue to assess and tx, continue both educational and emotional support\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512578, "text": "resp care note\n\nPt is better sedated today as intubation may continue for few days. AC 18 x 650\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512564, "text": "SICU NPN 0700-1900.\nS: Pt. intubated. Nodding head appropriately to questions.\nO:\nCV- HR 60-80 SR with very occasional PVCs. BP 120-170/60-80. Hypertensive event with minimal response to 7.5 mg IV Lopressor. Also given hydralazine and morphine with minimal response. Hypertension appeared to normalize when placed back on AC ventilation.\n\nPulm- On CPAP RR 17-30. ABG showed metabolic alkalosis. MV increased with fever and placed back on AC of 50% 650x16 PEEP 5. ABG much improved on this setting. Spo2 96-100% on AC ventilation. Breath sounds throughout the day have become increasingly diminished as abdominal girth increases. Lactic acid 1.2 Pt was on HCL gtt for 5 hours. Labs have improved. Suction q2h for thick yellow secretions.\n\nID- Febrile. T max 103.4. Pan cx'd. 1 gm Tylenol given pngt with moderate response. Ice packs to groin. Cooling blanket on.\n\nLine Access- Left SC TLC placed this am. CXR done. Left femoral TLC d/c.\n\nNeuro- On propofol. Continually follows commands and moves all extremities.\n\nGI- Abdomen very firm and distended appearing to increase as day progresses. Team aware. Bladder pressure 26. Positive BS x4Q. No stool. No flatus.\n\nNutr- Awaiting feeding tube placement tomorrow.\n\nGU- Foley draining greater than 30cc/hour clear amber urine.\n\nPain- Occasionally complaining of abdominal pain. Medicated with morphine for relief.\n\nEndo- ssri coverage. Calcium and potassium repleated.\n\n Three Sons in to visit today and updated with plan of care. Son took pt's wedding band home this afternoon. Wife in to visit this evening and updated with plan of care.\n\nA: Hyperthermic and hypertensive. Pan cx'd.\n\nP: Continue to measure temperature and assess for signs and symtoms of infection. Cooling blanket prn. Continue to assess bladder pressures. Continue to monitor ptt while on heparin gtt. Offer support to patient and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512565, "text": "Resp Care\nPt remains intubated on A/C. MDI's given. Pt placed on PSV, but after 2 hrs had to be placed back on A/C. No other changes made.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512566, "text": "SICU NURSING PROGRESS NOTE 0700-1900\nTHE ABOVE NOTE WRITTEN BY IS ACCURATE AND CORRECT OF THE EVENTS FOR THE DAY. MR N. HAS IMPROVED IN HIS RESP STATUS . HE REMAINS WITH FUO.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 1512567, "text": ",rrt\npt. remained on current settings until ~ 0100 hrs when became anxious, biting et tube, sats < to low 90's, rr>40's, placed oral airway, temp shown to be @ 104, began breath stacking, b/l b.s. noted/diminished b/l/coarse/wet attempted to bag with no difficulty after peak pressure > to >40's, inhaler given, placed nss ~10cc down tube to check for mucus plug, sx'd small white/thick mucus, *placed on heated circuit earlier @ 2300-2/20, due to coarse b.s. thick beige sc's noted*,fi02 > per abg's along with peep > to +8, will monitor fi02 @ 70%/peep@ +8.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512629, "text": "REspiratory Care\nPT. intubated on ventilatory support. Pt. started shift on CPAP/PS 5/5 gradually over shift CO2 climbed , PS increased to 15, CO2 remained high and pt. began to experience periods of apnea, ventilatory support returned to A/C mode. Sx numerous times for copious clear/white frothy secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512579, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info:\n\nNeuro: No changes and consistent with previous assessment. MAE on command. PERRL. Opens eyes spontaneously. Anxious at times and medicated with prn lorazapam with good effect. Pain management is with fentanyl currently infusing at 100 mcg/hour.\n\nResp: Breath sounds clear and equal bilaterally. Coarse at times and suctioned for thick cream color secretions. Orally suctioned for thick clear secretions. Sat's >98%. Abg sent and no changes made on current settings.\n\nCV: SR to afib. Currently on amiodorone at 0.5mg/min. AMiodorone 150mg bolus given x 1 for consistent afib, now going in and out of afib with rate response of 70-80's. BP drops r/t decrease in atrial kick to 80's/40's. Levophed restarted at 0.02 mcg/kg/min with good effect and bp returned to 116/60 range. SR rate 50-60's. Aline with good waveform. Well perfused with brisk cap refill. PA line is at 50 cm.\n\nHEme: To check HCT this afternoon. Following PTT q 6 hours, currently on heparin at 1800 units/hour.\n\nGI/ Abd; Abdomen is firmly distended. Tube feedings are currently impact with fiber infusing at 20cc/hour through Jtube. Gtube is to gravity, amber color drainage. No stool thus far. sounds are hypoactive.\n\nGU: Foley to gravity, amber color urine. UOP is 25-60cc/hour at present. Updated Dr. and will cont. to follow closely.\n\nID: On vancomycin, flagyl, and levofloxacin.\n\nEndo: Cont to follow glucose q 6 hours, RISS.\n\nSocial: Wife / spokesperson in and updated at bedside. Verbalizing understanding. cont to update, support, educate.\n\nPlan: Cont to follow PT/PTT q 6 hours. Glucose q 6 hours, RISS coverage. Cont to follow PA line/ CO q 4 hours. Possible to begin diuresing tomorrow r/t + 22.5L at present, ? intravascularly depleted r/t low UOP and BP. Tolerating tube feedings thus far. Cont to update and support family/ spokesperson. D/C plan is ongoing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-16 00:00:00.000", "description": "Report", "row_id": 1512580, "text": "Respiratory Therapist\npatient awake and alert most of the day, breath sounds coarse, regular MDI treatments given, patient has fluid overload issues,will be diuresed tommorrow, no vent changes have been made, no wean, patient will stay on the vent at least until the above issue get resolved.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512630, "text": "Resp care\nABGs in Met Alk, Ventilation satisfactory, Copious frothy secretions. Self extubated in pm, and immed Reintubated.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512631, "text": "Neuro: Pt alert despite versed gtt at 4mg/hr. Mouthing words, follows directions. Having abd/incisional pain with movement, Med with dilaudid X3 today with moderate effect.\nCV: low grade temp 99.3,HR initially 80's NSR with occasional PVC, presently 100-110's Sinus tach, SBP 90-100's most of day. Presently high 80's-low 90's. Extremities with generalized edema. Dopplerable pulses. CVP 10-13. Continues on lasix gtt at 7mg/hr, unable to increase due to SBP 80's this eve. Continues on lepirudin gtt, Remains in sinus.\nRESP: lung coarse to dim at bases, Pt extubated self at 1600, Pt reintubated imediately, Remains on AC 100% since extubation, 550X18 peep 5. ABG pending. Occasional suctioning of thick tan secretions.\nGI: tol tube feed at goal, 2 very small stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nENDO: blood sugars elevated, Requiring coverage per RISS.\nPLAN: NPO after midnight for trach tomorrow. Continue to monitor SBP and output for goal 1-2 liters negative lasix gtt.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512632, "text": "SICU NN: See carevue for specifics. Patient alert at times, sedated on versed and dilaudid iv push prn. Patient appears comfortable and pain free. Patient moves all extremities. Patient follows all commands. Patient does attempt to pull out lines and tubes when restraints removed. Safety maintained. ET to vent. Plan trach tomorrow. Patient alternates between afib and rsr on monitor. Anticoagulated on lepirudin . BP wnl. Central line and arterial line. Peg gravity bilious. Pej tube feeds held at midnight for trach in am. Two . One pigtail catheter. Midline abdominal incision with dehisence, some staples . Large drainage pouch covering incision with creamy serosanguinous drainage in moderate to large amounts. Abdomen obese. Foley and patent. . Generalized anasarca, upper extremites with decreased edema from previous shifts. Lasix infusing as ordered. Electrolytes repleted as ordered. Afebrile. No phone calls or visitors this pm. Patient sleeping. HIT status noted. Bed in rotation mode. Mouth care Q2hours. Compression sleeve to left leg only. Comfort measures provided.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512633, "text": "Respiratory Care\nPT trach on ventilatory support, tol CPAP/PS well all shift. Good RSBI this a.m. RSBI = 80. Sx for thin yellow secretions\n" }, { "category": "Nursing/other", "chartdate": "2187-03-30 00:00:00.000", "description": "Report", "row_id": 1512634, "text": "Respiratory Care\nNote above written on wrong pt.\n\nCorrected note:\nPt. intubated on ventilatory support. ABG's still indicate a metabolic alkalosis. Suction for small to mod. amounts thin white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 1512657, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt is alert. Given prn trazadone X2 for agitation with good results. Medicated with dilaudid X2 for pain. Follows commands appropriately. Pt pulls at lines and tubes redirects well. No ativan given this shift.\nCV: Remains on lepirudin gtt. HR 70-110's. Pt flipping in and out of NSR and afib. lopressor increased to 25mg . Afebrile. Remains with generalized edema. RLE>LLE. +PP bilate +CSM.\nResp: Pt on Trach mask since 8am. Tolerating well. ABG's remain with ^ PC02's. Lungs clear to coarse in Bilat upper lobes. Sats remain >95%.\nGI/GU: Remains on TF at goal tolerating 34/str well. ABD remains soft and distended. +BS Mult BM's today. Foley patent drng clear yellow urine.\nEndo: RISS\nInteg: Abd dsg c/d/i. Dsg changed X1 By RN. Wound bed drng mod amts brown drng no foul odor noted + granulation to site. Cont with DSD as indicated. Change PRn.\nPlan: Cont with trach mask as tolerated. Cont lepirudin gtt as indicated. Cont to monitor heme status and monitor abd wound bed for infection. Cont with current plan of care as indicated.\nSoc: Family requested to speak with MD or a member of MD team. MD but unit this pm called pt's wife's home # and got no response. Email sent to MD today re: Family request to speak with him. cont to monitor\n" }, { "category": "Nursing/other", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 1512658, "text": "SICU NN: See carevue for specifics. Patient alert and oriented x . Communicates by mouthing words. Ativan and dilaudid given twice this shift for pain control and agitation. Patient putting legs over side rails and pulling at lines and tubes. Restraints in place for safety and patient reoriented as needed. Safety maintained. Tolerated trach collar until 0200 when abg showed CO2 74, patient placed back on vent, imv 12 as per Dr. to rest patient for remainder of shift. Patient oxygenating well with PO2 of 112. While on trach collar patient able to effectively expectorate thick white secretions. RSR with pac's with occasional brief episodes of afib. Patient maintained on lepirudin with therapeutic coag's as per am labs. BP wnl. Arterial line brachial and positional at times. Abdominal incision open packing with guaze, moderate to large amount of maroon/pink creamy drainage, shown to Dr. . Two and one pigtail catheter . G tube to gravity and tolerating tube feeds via J tube. One bm and patient was able to ask for bedpan. . Generalized edema though decreased from prior shifts with patient. Lasix around the clock with good response. Turn and positioned x 2. Afebrile with normal wbc. No phone calls or visitors. measures provided.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512559, "text": "Respiratory Therapy\nPt remains orally intubated on AC. Please see carevue for specifics. BS clear with very diminished LLL. Pt awake, not breathing over set rate and minimally over set volume.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512560, "text": "npn\nNeuro- propofol gtt- opens eyes to voice, withdraws to stim, bilat wrist restraints on 2nd to ett\n\nResp- cmv vent- pco2 66 this am- weaned fio2 to .40, lungs cont coarse bilat and at bases, suction thick white secretions. ct this pm showing cont bilat pe.\n\n\nABD- abd obese- ngt placed with bilat drg, abd ct done this pm- see radiology report. npo. + bs.\n\nHeme- heparin gtt at 1250u/hr- ptt 60-69- goal 60-80, 1 unit prbc this am for hct 23- repeat hct 26 post prbc.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512561, "text": "Respiratory Care Note:\n Patient remains intubated and sedated on full vent support. Transported to CT scan today of abdomen. BS=bilat, decreased lower lobes bilat. Suctioned for small amounts of pale secretions. Plan to maintain supportive care at this time.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512562, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported on AC. Few changes made overnight. ABG's remain persistently metabolic alkalotic. BS's some coarseness, sxing small amts white secretions. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-17 00:00:00.000", "description": "Report", "row_id": 1512585, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 37/28. BLBS diminished but coarse, suctioned for small to moderate amounts of thick white sputum; copious amounts of white oral secretions. MDI given as ordered to good effect. RSBI attempted this AM = >150 w/ notable desaturation to high 70s, SpO2 increased rapidly when returned to current vent settings. Remains fluid +. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 1512563, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info\n\nNeuro: Sedated on propofol drip, opens eyes to name and follows commands. MAE. Perrl. No changes from previous assessment. Appears Comfortable.\n\nResp: Breath sounds clear to coarse and equal bilaterally. ABG's with compensated metabolic alkalosis. Cont to follow and adjust vent accordingly. Sat's >98% all shift. Suctioning mod. amount thick white secretions through ETT q 2 hours and prn.\n\nCV: SR no ectopy. Well perfused with brisk cap refill < 2seconds. Aline with good waveform. Remains on amiodorone and lopressor given through NGT. BP stable with mean >60.\n\nHeme: PT/PTT q 6 hours, goal PTT 60-80, heparin drip currently at 1300 units/ hour. HCT stable at 25.\n\nGI: NPO. Obese with active bowel sounds. NGT to low cont. suction with bilious returns. Clamped prn meds. No stool thus far.\n\nGU/ Lytes: Foley to gravity, uop >30cc/hour. Electrolytes replenished.\n\nEndo: Follow glucose q 6 hours, RISS.\n\nSocial: No contact from family thus far tonight.\n\nPlan: Cont to follow glucose q 6 hours, RISS. Cont to follow pt/ptt and adjust heparin drip to maintain goal PTT 60-80. possibly travel today r/t fluid collection in abdomen ?drain placement. Cont to follow labs/ electrolytes. Maintain bp mean >60. Cont to update and support family/ spokesperson. D/c plan is ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512625, "text": "Nursing Progress NOte\nPlease see carvue for specifics:\nNeuro: Pt remains on versed gtt for sedation. Pt is to voice and follows simple commands and localize pain.\nCV: HR NSR no noted ectopy. SBP 95-110's. MAP >60. Remains on lasix gtt goal is to be 2Liters negative. Lytes repleted as needed. ABd wound still drng mod amts of sersang drng. Current crit is 27.7. PT remains grossly fluid overloaded. +PP via doppler only.\nResp: Remains on CPAP . Despite PC02 in 60's which pt is beginning to compensate for. Rsbi this am 87. ? Possible trach tomorrow. Lungs remain clear to diminised at the bases. Sats >95%.\nGi/Gu: Abd soft and distended. + BS no BM over noc. Pt remains on TF at goal. Gastric tube to gravity drng bilious drng. Foley patent drng light yellow urine\nEndo: RISS\nID: Remains on mult abx\nInteg: Open abd wound still drng mod amts of serosang drng.\nPlan: Cont with current plan of care. ? Trach tomorrow. Cont to monitor respiratory status and hemodynamics.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512626, "text": "Respiratory Care Note:\n\nPt remain orally intubated and sedated on spontaneous ventilation. No vent change done during shift. RSBI done ~ 88. BS are clear & dim more to bases ant. AM ABG, PCO2 ~ hich and Pt starting to chronically compensate. Plan: ? another elect extubation or Trach tomorrow. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-18 00:00:00.000", "description": "Report", "row_id": 1512586, "text": "Respiratory Therapist\nPatient still on assist control, start diuresing but still positive,breath sounds: bilaterally coarse, suctioned for moderate thick yellow, a few MDI treatment given, Patient desaturated at several occasions, RSBI not possible on him, when tried Apnea ventilation quicks in.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-18 00:00:00.000", "description": "Report", "row_id": 1512587, "text": "FOCUS UPDATE\nVSS. REMAINS ON AMIO IN NSR. NO VENT CHANGES. DIURESED W/ 20MG IV LASIX W/ GOOD RESPONSE. 2.5 L NEGATIVE. TOLERATES TFEED AT INCREASED RATE. CONT ON HEPARIN AND FENTANYL. , BUT GROSS ANASARCA.\nCONT CLOSE CARDIAC MONITOR. WEAN FROM VENT AS TOLERATES. ADVANCE TFEED TO GOAL. STRICT I/O'S. ORDER THERAPEUTIC BED. C\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512588, "text": "Resp Care\nPt. remains intubated/sedated with no change overnight. Occ. sets off high pressure alarms coughing.\nBs: coarse bilat.with scattered rhonchi, improve with sxn. Sxn'd for mod amts. of thick white q4.\nno abgs.\nPlan: rsbi dc'd d/t only 3 breaths noted in 1 min.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512589, "text": "neuro: \n\ncv: continuous with pt in NSR, no ectopy. vss. cvp 16-18.\n\npulm: sx 2 2-3 hrs for sm-mod amts thick white. sats 96-100%. bs clear,\n\ngi: tube feeds acvanced to 60/hr, tol well, no resid. no BM.\n\ngu: u/o qs.\n\nplan: wean vent as tol. pulm toileting\n" }, { "category": "Nursing/other", "chartdate": "2187-03-19 00:00:00.000", "description": "Report", "row_id": 1512590, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Attempted PSV wean (w/ PEEP increase necessary d/t desaturation to high 80s on PSV (+10PSV/+8PEEP)). ABG revealed mild respiratory acidosis, pt placed back on SIMV/PSV per team. Currently on SIMV 650/18/+10PSV/+5PEEP/.50% Fio2; appears comfortable. BS slightly coarse, suctioned for small amounts of thick white sputum from ETT, copious amounts of thick white oral secretions suctioned ~q4. PIP/Pplat = 29/24. ETT secure/patent. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; continue to assess readiness to wean...\n" }, { "category": "Nursing/other", "chartdate": "2187-03-20 00:00:00.000", "description": "Report", "row_id": 1512591, "text": "Resp Care\nPt. remains intubated/sedated on SIMV mode. Occ. noted to be overbreathing when stimulated, otherwise no efforts noted.\nBs: coarse bilat. Sxn'd q4 for thick white.\nabgs: metabolic alkalosis with adequate oxygenation.\nPlan: cont. to support. Possibly cut rate back to allow pt. to make spont. efforts.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512665, "text": "CONDITION UPDATE\nVSS. AFEBRILE. AFIB RATE CONTROLLED, CONVERTED TO NSR THIS EVENING. ALERT AND ORIENTED TO PERSON/PLACE - NOT TIME. PASSE MUIR VALVE ON ENTIRE SHIFT, W/O INCIDENT. DENIES SOB. O2 SAT ACCEPTABLE ON TRACH MASK. LUNGS CLEAR TO COARSE. ABLE TO COUGH UP LG AMTS OF THICK, WHITE SPUTUM. ABD SOFTLY DISTENDED - POSITIVE SOUNDS. LG AMT OF LOOSE, THICK STOOL OUT VIA MUSHROOM CATH. ABD INCISION OPEN - TISSUE PINK, LG AMT OF BROWN, MUCOUS LIKE DRAINGE. DRESSING CHANGED TO VAC DRESSING BY DR . JP'S , PATENT. GTUBE TO GRAVITY W/ BILIOUS DRAINAGE OUT. U/O QS VIA FOLEY. ONE TIME LASIX, 20MG IVP X1.\nMONITOR FOR S/S OF INFECTION. MAINTAIN INTEGRITY. PAIN MANAGEMENT. PT . CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2187-04-07 00:00:00.000", "description": "Report", "row_id": 1512666, "text": " \n NEURO PT A/O MOST OF THE TIME OCC PERIODS OF MILD AGITATION AND COFUSION REGARDING SITUATION DOES WELL WITH CONVERSATION\n HEART S1S2 NSR VSS A LINE IN PLACE NO TEMP NOTED PULSES POS 3 THRU OUT W/D\n ABD OPEN ABD WOUND DRESSED D/I DRAINS IN PLACE FIRM NO ISSUES U/O QS\n RESP NON LABORED CLEAR STRONG COUGH NOTED T/C SAO2 100\n PLAN SUPPORTIVE IN NATURE MONITOR FLUID STATUS I/O CLOTTING STUDIES FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2187-04-12 00:00:00.000", "description": "Report", "row_id": 1512667, "text": "admit note\nplease see flowsheet for details\n\npt arrived to unit at approx 0830 from 9. Pt had been on 9 was found to be pale this am, a blood gas was sent and pco2 was 116. Pt was transferred to sicu. On arrival to sicu pt's temp was 94.9 and bair hugger was placed on pt, as well as warm blankets. temp increased to 96 by 0830. otherwise vs were stable pt was transiently in/out of afib with rate 60s-120. po was given and iv lopressor. pt continues on lepirudin gtt and ptt was 56 today which is with in goal, gtt was not titrated. pt continues in afib and icu resident Dr aware. pt given po lopressor 25 mg at 1800. aline plaved at admission to unit, lytes repleated\n\npt initially placed on ventilator a/c mode, frequent abgs were assessed and co2 decreased to 60-65 on cpap with pressure support, ls are coarse bilaterally, suctioned periodically for moderate tan thick drainage, o2dat 100%, pt had cxr today and CTA of chest-awaiting results.\n\nGu: abd CTA awaiting results, pt stooling brown liquid stool ? secondary to 2 bottles baricat given prior to CTA, abd obese BS present, yellow clear urine > 30cc hr.\n\n: wound RN up to evaluate wounds, recommendations are allyvn to left buttock open area, to abd wound aqacel to heavily draining areas covered by damp ns dressing (not saturated) followed by dsd using hypofix tape which is all in pt 's room.\n\nplan: continue to monitor resp status, wean ventilator as tolerated, continue with care program, awaiting CTA results of chest and abd\n" }, { "category": "Nursing/other", "chartdate": "2187-04-12 00:00:00.000", "description": "Report", "row_id": 1512668, "text": "Respiratory Care: Pt remains on current vent settings, PS 5 P 5 .40. Will do RSBI in early am and plan to place pt on trach collar as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-10 00:00:00.000", "description": "Report", "row_id": 1512557, "text": "npn\nNeuro- a+o despite increasing pco2 this am- mae on bed, mso4 prn, ativan prn started after pt intubated. bilat soft wrist rest. on after intubated.\n\nResp- Resp acidosis abg with comp- bipap mask on until the noon abg when pco2 increased to 115- had been 80's and 90's- intubated by anesthesia and cxr done post intubation. multi vent changes done to get pco2 down. _ see resp flow sheet. lungs coarse bilat and at bases. suction thick white to clear secretions.\n\nHemodynamics- a line sbp 90's to 120's with map >60, in and out of a fib with some sinus runs mixed with pac's then back to a fib- pt had been in a fib pre transfer to sicu. Groin line placed by md x2 leaking or clotted off.\n\nHeme- heparin gtt 1200 u/hr with 10 am ptt 80.1- gtt off when pt in the cath lab for ivc filter then unable to restart 2nd to need for ctr line- heparin gtt restarted 1200u at 6pm. to cath lab 130 pm for ivc filter -tol well. right groin cdi, + right dp/pt.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-28 00:00:00.000", "description": "Report", "row_id": 1512627, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile. HR was in NSR for most of the shift. Went into afib for a few hours with rate 100-120 lopressor 5mg iv was given with no effect and BP did dip down to a systolic 88-90's so evening dose was held. Lasix gtt was increased to make goal of negative 1.5-2L, lytes were checked this afternoon and repleted per orders.\n Vent was weaned down to CPAP 5/5 and when pt went into afib O2 sat also noted to drop to 90's abg was drawn, primary surgical team was notified and no vent changes were made. CPT done and O2 sats back up to 97%. Pt has required frequent suctioning for frothy white/clear secretions.\n Wife came in this morning and spoke with surgical resident re:plan for trach-she is aware that pt will be re-evaluated in am if plan will be to extubate or to schedule trach.\n Wound nurse came by to evaluate pt's incision. Wound pouch was placed and put to gravity d/t lge output.\nPLAN:\n lasix gtt titrate to negative 1.5-2L by midnight\n Pulmonary toilet with rotating bed\n Replete lytes prn while diuresing\n ?extubate in am\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2187-03-29 00:00:00.000", "description": "Report", "row_id": 1512628, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Unchanged. Remain on versed gtt. Follows commands. Is to voice. MAE.\nCV: HR-NSR no noted ectopy. SBP stable. Remains on lasix gtt at 7cc/hr. Goal is to be 1-2liters negative.\nResp: Pt with increased secretions. PC02 in 70's Vent changed to Cpap which increased CO2 to 62 pt began to have episodes of apnea and placed back on rate. Lungs remain coarse to diminshed at the bases.\nGI/GU: Unchanged.\nEndo: RISS\nID: Remains on mult abx WBC's normal afebrile.\nPlan: Cont with current plan of care. ? possible trach vs extubation. Family meeting today.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512574, "text": "see careview for details\nfocus data update\n\n\nNEURO: PT EASILY , NODS APPRORIATELY TO QUESTIONS, MAE'S\nPERLA, FENTANYL GTT DECREASED TO 59 MCG, PT DENIES PAIN\n\nRESP: B/L BS DECREASED, CPAP TRIAL PT DESATURATED QUICKLY, VENT SETTINGS REMAIN ON CMV, PT REQUESTING ETT BE REMOVED, REASSURED WE'LL REMOVE TUBE AS SOON AS POSSIBLE, AND WE'LL RETRAIL CPAP LATER IN DAY\nSX'D FOR THICK WHITE SECRETIONS,\n\nCV: A-LINE DAMPEND, CHANGED OVER WIRE, A-LINE CONTINUES TO BE POSITIONAL, SWANZ LINE PATENT, TX WITH I UPRBC', LABS MONITORED CLOSELY, LYTE REPLETION GIVEN, TYLENOL GIVEN X1, REMAINS IN A-FIB, AMIORARONE GTT , PT , COMPRESSION BOOT ONLYON LEFT LOWER EXT, UNABLE TO WEAN LEVO GTT R/T DECREASED MAP\n\nGI: NGT TO LWS FOR THICK BILIARY DRG FLUSHED X1 WITH NS, G-TUBE TO GRAVITY DRG, J-TUBE TO GRAVITY, ABD JP'S TO SSX, ABD DSG CLEAN,DRY AND INTACT, ABD DISTENDED\n\nGU: BLADDER PRESSURE 24, HOURLY U/O MARGINAL, AMBER IN COLOR\n\nA/P: INPROVED CARDIAC OUTPUT, STABLE CONTINUE TO MONITOR AND TX, BOTH EMOTIONAL AND EDUCATIONAL SUPPORT GIVEN TO PT\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512575, "text": "Respiratory Therapist\nPatient remains vented, is on Assist-Control, FiO2 kept at 50% although ABGs showed PaO2 around 130, no reduction in FiO2 was not made due to the fact that patient had Oxygenation issue due to PE, an issue for not moving toward extubation is the patient's hemodynamics. Breath sounds clear, patient produced very minimal secretions, was treated with Albuterol MDI twice.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-15 00:00:00.000", "description": "Report", "row_id": 1512576, "text": "SICU NN: See carevue for specifics. Patient sedated on a fentanyl infusion. Patient is easily . Patient follows commands and is trying to talk around et tube. Patient nodding head appropriately to questions. Ativan prn for comfort. Restraints for patient safety. ET to vent. ABG's done as ordered. RSR alternating with afib frequently, MD's notified. BP labile depending on rhythm, titrating levophed to maintain map >60-65. Febrile, pan cultured, tylenol prn, md notified. Trophic tube feeds started as ordered, tolerating. G to gravity. Tube feeds to J. NGT by md. sounds. Dressing clean dry and to abdominal incision. Two JP's draining brown liquid. Foley , urine output decreased to 20-30/hr. CVP decreased from patient baseline. Fluid boluses and albumin given as ordered. CO/CI obtained as ordered and results relayed to md. . Patient denies pain by nodding. Repleting lytes as ordered. Family visited today. Sliding scale insulin coverage. All lines . Bladder pressures q shift. Administering antibiotics as ordered. Safety maintained.\n" }, { "category": "Nursing/other", "chartdate": "2187-03-11 00:00:00.000", "description": "Report", "row_id": 1512558, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: Alert and following commands consistently. No changes from previous assessment.\n\nResp: Breath sounds clear and equal bilaterally. Suctioning via ETT for thick white secretions. Cont to monitor blood gases and make vent changes accordingly. Sat's consistently >99%.\n\nCV: Afib to SR overnight with variable HR 120 to as low as 64 while in SR. Bursts of RAF to 140's with BP 78/40. Examined by DR. and Bolus NS 500cc x 1, Phenylephrine drip started at very low dose and titrated to keep mean bp >60. Diltiazem 10mg given x 1. Lopressor 10mg IV q 6hours. Well perfused with brisk cap. refill. Aline with good waveform. Stable throughout the shift.\n\nHeme: HCT 23.3 this am. Dr. updated and team, no new orders at this time. On heparin at 1250 units /hour. Cont to follow Pt/Ptt q 6 hours.\n\nGI: Abd obese, active bowel sounds. No stool thus far. NPO.\n\nGU: UOP dropped off to 30's, bolus 500cc NS x 1 given with good effect UOP increased to >50cc/hour.\n\nEndo: Follow glucose q 6 hours with RISS.\n\nSocial: Wife called and updated, verbalizing understanding. Planning on visiting today at some point.\n\nPlan: cont to follow abg's q 6 and prn, follow pt/ptt q 6 hours. Cont to monitor I and O and hemodynamic status, possible cardioversion in morning. Cont to update and support wife/ spokesperson. D/c plan is ongoing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-03-27 00:00:00.000", "description": "Report", "row_id": 1512622, "text": "NPN: Review of Systems\nNeuro: Pt initially on 4mg/hr versed. Sedated. Did not follow commands consistently, or interact at all. Versed decreased to 3mg/hr. Pt opens eyes spontaneously, moves all extremities and communicates by mouthing words and nodding. Denies pain, but very fidgety in bed. Soft wrist restraints on d/t ETT and Pt moves hand torward it.\n\nResp: Currently on 5PS and 0 peep, with FIo2 of 40%. Breathing unlabored in the 20s w/ tidal volumes approx 350. Sao2 decreased over the course of the day from upper nineties to 93-95%. Pt denies SOB.Sxning thin white seretions. Decreased BS on left side. Initial ABG approx. 45 minutes after vent change=7.31/66/81 and 35/3. New ABG pending.\n\nCV: Tmax=99.4 NSR w/ MAP 60s-70s. No ectopy. K+ and CA++ being repleted. DP/PT pulses palpable bilaterally.\n\nGI: Abdomen obese. Gastric tube to gravity and draining bilious fluid. 2/3 strength impact w/ fiber infusing at goal rate of 110cc/hr. No BM. Continues to get intermittent octreotide. Abdominal incision w/ drainage bags over open sites-> s/s fluid. Scant drainage from pigtail drain and JPS to bulb suction.\n\nGU: LAsix increased to 6mg/hr from 5mg/hr. Urine light yellow. (-) approx 1400cc so far.\n\nID: Continues on antibiotics,\n\nHeme: Lepirudin infusing as ordered.\n\nEndo: Blood sugar=199-> 8 units regular insulin given .\n\n: No pressure wounds present. Triadyne roation turned off right now b/c Pt uncomfortable with it.\n\nSocial: Wife and sister at bedside. Wife feels communication btwn her and the staff has been good.\n\nA: Breathing comfortably on decreased support. Hemodynamics stable.\n\nP: F/U w/ repeat ABG. Monitor per plan.\n" }, { "category": "Echo", "chartdate": "2187-03-13 00:00:00.000", "description": "Report", "row_id": 80325, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Recent pulmonary embolism.\nBP (mm Hg): 85/60\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:46\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npropofol given for sedation, as patient was intubated.\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA and extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Simple atheroma in ascending aorta. There are complex (>4mm) atheroma\nin the aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Indeterminate\nPA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. The patient appears to be in sinus rhythm.\nEvaluation of the left atrial appendage were suboptimal due to limited\nvisualization of the LAA.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. Views of the left atrial appendage are\nsuboptimal. The right atrium is dilated. No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses and cavity size are\nnormal. . Overall left ventricular systolic function is mildly depressed.\nThere are no focal wall motion abnormalities. The right ventricular cavity is\nmoderately dilated. There is moderate global right ventricular free wall\nhypokinesis. There are simple atheroma in the ascending aorta. There are\ncomplex (>4mm) atheroma in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets are mildly thickened. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Biventricular systolic dysfunction with mild global hypokinesis of\nthe left ventricle and moderate global hypokinesis of the right ventricle.\n\n\n" }, { "category": "Echo", "chartdate": "2187-03-05 00:00:00.000", "description": "Report", "row_id": 80362, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 67\nWeight (lb): 235\nBSA (m2): 2.17 m2\nBP (mm Hg): 144/90\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 12:01\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\nModerately dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\n1.The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic arch is moderately dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n6.The mitral valve leaflets are mildly thickened. No mitral regurgitation\nseen.\n7.There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2187-04-21 00:00:00.000", "description": "Report", "row_id": 204377, "text": "Atrial fibrillation./ atrial flutter\nDiffuse nonspecific low amplitude T waves\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2187-04-18 00:00:00.000", "description": "Report", "row_id": 204378, "text": "Atrial fibrillation. Non-specific ST-T wave changes. Compared to the previous\ntracing of the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2187-04-16 00:00:00.000", "description": "Report", "row_id": 204379, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2187-04-11 00:00:00.000", "description": "Report", "row_id": 204380, "text": "Atrial fibrillation with rapid ventricular response with PVCs\nExtensive ST-T changes may be due to myocardial ischemia\nSince previous tracing,rapid atrial fibrillation, ventricular premature\ncomplexes, and ST-T wave changes are present\n\n" }, { "category": "ECG", "chartdate": "2187-03-12 00:00:00.000", "description": "Report", "row_id": 204381, "text": "Sinus rhythm. Normal ECG. Since the previous tracing of atrial ectopy\nis absent and the QTc interval appears less prolonged.\n\n" }, { "category": "ECG", "chartdate": "2187-03-09 00:00:00.000", "description": "Report", "row_id": 204382, "text": "Sinus rhythm\nSupraventricular extrasystoles\nLong QTc interval\nSince previous tracing, long Q-Tc interval and atrial premature complexes seen\n\n" }, { "category": "ECG", "chartdate": "2187-03-04 00:00:00.000", "description": "Report", "row_id": 204383, "text": "Sinus rhythm\nModest low amplitude inferior T waves - are nonspecific and could be within\nnormal limits\nSince previous tracing of , atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2187-03-03 00:00:00.000", "description": "Report", "row_id": 204384, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response although baseline artifact\nmakes assessment difficult\nDiffuse nonspecific ST-T wave changes\nSince previous tracing of , atrial fibrillation and sinus tachycardia\npresent\n\n" }, { "category": "ECG", "chartdate": "2187-02-27 00:00:00.000", "description": "Report", "row_id": 204615, "text": "Sinus rhythm\nNormal ECG\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2187-03-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 903016, "text": " 4:33 PM\n CT ABDOMEN W/O CONTRAST; CT GUIDANCE DRAINAGE Clip # \n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL\n Reason: please drain anterior liver collection. please leave drain i\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst and markedly distended abd\n\n REASON FOR THIS EXAMINATION:\n please drain anterior liver collection. please leave drain in\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE OF AN INTRA-ABDOMINAL FLUID COLLECTION.\n\n CLINICAL HISTORY: Pancreatic pseudocyst, intraabdominal fluid\n collection, drain.\n\n PREPROCEDURE ABDOMEN FINDINGS: Images of the abdomen were obtained without\n contrast. Images of the lower thorax demonstrate bilateral pleural effusions\n and consolidation involving the left lower lobe. There is an intra-abdominal\n fluid collection anterior to the liver extending across midline and extending\n to the inferior aspect of the liver. High-density material seen layering\n within it in the dependent position suggesting the presence of blood. Two\n drains are present within the region of the pancreas.\n\n CT-GUIDED DRAINAGE PLACEMENT: The patient was unable to give consent, and so\n the patient's wife, , was contact and she gave consent via the\n telephone. She was notified of the risks and benefits of the procedure. The\n fluid collection was identified using CT guidance. 1% lidocaine was used as a\n local anesthetic. A nurse fentanyl to ensure patient\n comfort. An 8 French drainage catheter was inserted into the fluid\n collection. CT fluoroscopy images were obtained, which confirmed the proper\n placement of the catheter. Approximately 150 cc of bloody fluid were\n aspirated. The patient tolerated the procedure satisfactorily. There were no\n complications. The attending physician, . , was present throughout\n the entire procedure.\n\n IMPRESSION:\n 1. Successful placement of an 8 French drainage catheter into an intra-\n abdominal fluid collection.\n 2. Left lower lobe consolidation, which may represent either pneumonia or may\n be infarct related to the patient's recent pulmonary emboli.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-11 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 901383, "text": " 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst\n REASON FOR THIS EXAMINATION:\n please eval pancreas and pseudocyst for evolving cyst, infection, and necrosis.\n PLEASE USE CT PANCREATIC PROTOCOL C FINER CUTS/HIGHER RESOLUTION and GIVE PO\n AND IV CONTRAST.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatic pseudocyst, please evaluate for evolving cyst\n infection and necrosis.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained through the abdomen prior to and\n following the administration of 150 ml of intravenous Optiray in the arterial\n and venous phases. Venous images were obtained to the level of the pubic\n symphysis. Coronal and sagittal reformations are provided.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: At the visualized\n portions of the lung bases, again seen are bilateral lower lobe pulmonary\n arterial filling defects consistent with pulmonary emboli. In comparison with\n the examination of , the thrombus burden within the left lower lobe\n pulmonary artery appears to have propagated somewhat with new thrombus\n visualized more proximal within the left lower lobe pulmonary artery. There\n is progression of atelectasis and opacities at the lung bases bilaterally with\n small pleural effusion, left greater than right, and wedge shaped hypodense\n area in left lower lobe subpleural region. Although these findings may\n represent atelectasis, evolving pulmonary infarct cannot be entirely excluded.\n The visualized portions of the heart and pericardium appear unremarkable.\n\n There is continued focal biliary ductal dilatation within the left lobe, a\n finding that is approximately unchanged. The portal vein and splenic veins\n appear markedly narrowed, a finding that is new since the previous\n examination, but appear patent. The gallbladder is collapsed and edematous\n with enhancing mucosa. There is interval increase in perihepatic fluid,\n including a new loculated fluid collection about the tip of the left lobe of\n the liver seen indenting the liver capsule and additional collections\n extending along the falciform ligament and within the hepatic hilum.\n\n A nasogastric tube is in place within the gastric body. The stomach is\n displaced anteriorly by a large pancreatic pseudocyst. In comparison with the\n examination of , the size of multiple pseudocysts has\n (Over)\n\n 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n increased. A pseudocyst located dorsal and superior to the pancreatic body\n measures 7.1 x 10.2 cm (previously 9.0 x 5.2 cm). A pseudocyst located\n inferior to the pancreatic body (series 4, image 61), measures 6.9 x 10.8 cm\n (previously 9.6 x 8.5 cm). A pseudocyst located posterior to the pancreatic\n head measures 8.5 x 4.8 cm (previously 7.1 x 3.2 cm). Again, noted is a\n heterogeneous pattern of enhancement of the pancreatic parenchyma, with a\n focal area of hypoenhancement in the pancreatic body just to the left of\n midline suggestive of an area of focal pancreatic necrosis.\n\n The superior mesenteric artery, celiac trunk and its branches are patent. The\n aorta is normal in caliber.\n\n CT appearance of the kidneys is unchanged with symmetric nephrograms\n bilaterally and with stable round, hypodense lesions that are too small to\n accurately characterize within the left kidney. An IVC filter is in place.\n\n The spleen and splenule appear unremarkable. There is interval increase in\n ascites located adjacent to the spleen and tracking within the left paracolic\n gutter. Additional fluid is seen within the right paracolic gutter and\n layering between loops of bowel in the low abdomen.\n\n The large and small bowel loops are normal in caliber. There is no free\n intraperitoneal air. A small fat containing umbilical hernia appears\n unchanged.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\n catheter and air consistent with Foley catheter insertion. The prostate and\n seminal vesicles, rectum and sigmoid colon appear unremarkable. Since the\n examination of , there is increase in ascites layering within the\n pelvis and low abdomen. A left femoral venous access catheter has been placed\n in the interval.\n\n There is increase in diffuse subcutaneous fat stranding consistent with\n anasarca.\n\n BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or\n sclerotic osseous lesions.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate interval\n increase in size and multiple pancreatic pseudocysts. The narrowing of the\n portal vein at its confluence with the superior mesenteric vein, as well as\n narrowing of the splenic vein, are well appreciated on the multiplanar\n reformations.\n\n (Over)\n\n 2:30 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval pancreas and pseudocyst for evolving cyst, infec\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Continued pulmonary embolus involving the right and left lower lobe\n pulmonary arteries, with evidence of probable propagation of clot within the\n left pulmonary artery.\n\n 2. Severe pancreatitis with interval increase in size of multiple individual\n pancreatic pseudocysts. Continued focal area of hypoenhancement within the\n pancreatic body consistent with pancreatic necrosis.\n\n 3. Interval increase in ascites and perihepatic fluid collections.\n\n 4. Marked narrowing of the portal vein and splenic vein, possibly due to\n inflammation and mass effect from adjacent pseudocysts, without evidence of\n frank occlusion.\n\n 5. Mild segmental intrahepatic biliary ductal dilatation within the left lobe\n appears stable.\n\n 6. Anasarca.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 901580, "text": " 7:14 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new R IJ PAC, eval position, r/o PTX\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n new R IJ PAC, eval position, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:24 A.M., \n\n HISTORY: Pulmonary emboli and pancreatitis. Right IJ line.\n\n IMPRESSION: AP chest compared to and 21:\n\n Tip of a new right transjugular Swan-Ganz catheter projects over the right\n descending pulmonary artery. Mild pulmonary edema has worsened. There is no\n pneumothorax. Bibasilar atelectasis and small left pleural effusion are\n stable. Tip of the endotracheal tube at the thoracic inlet is approximately 7\n cm above the carina, 3 cm above optimal placement. Tip of left central venous\n catheter projects over the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902227, "text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess lungs, difficulty maintaining PaO2 on previous\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n please assess lungs, difficulty maintaining PaO2 on previous vent setting post\n diuresis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 58-year-old man with prior episodes of pulmonary emboli. Patient\n with difficulty with ventilation.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube tip has migrated more distally and is 4 cm above the\n carina. There is a left-sided central venous catheter with the distal tip\n slightly perpendicular to the wall of the mid SVC. The Swan-Ganz catheter has\n been removed. Feeding tube has also been removed. The cardiac silhouette and\n mediastinum are within normal limits and unchanged from prior. There are low\n lung volumes due to poor inspiratory effort. There remains a left\n retrocardiac opacity and some hazy opacity within the left upper lung. No\n signs of overt pulmonary edema is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902385, "text": " 1:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pneumonia\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis now w/ fever to 101.9F\n REASON FOR THIS EXAMINATION:\n Please assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58-year-old man with pulmonary emboli and pancreatitis.\n\n CHEST, AP SUPINE: Film is somewhat underpenetrated. The position of the\n endotracheal line and right subclavian line is unchanged. The left subclavian\n line has been removed.\n\n Atelectasis in the left lung is present and there are probably bilateral\n effusions. Atelectasis in the left base is seen, no obvious infiltrates\n present but a left posterior infiltrate cannot be entirely excluded.\n\n IMPRESSION: Probable bilateral effusions, infiltrates not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901239, "text": " 6:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pahtology\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n REASON FOR THIS EXAMINATION:\n Assess for pahtology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with pulmonary emboli, chronic pancreatitis.\n Desaturating in the 60s.\n\n COMPARISON: .\n\n CHEST AP: The left costophrenic angle has been excluded from this study.\n There is interval improvement in the linear atelectasis previously seen in the\n right lower lobe. There is persistent right middle lobe and left basilar\n linear opacities. No frank consolidation is visualized. There are no pleural\n effusions. The heart size, mediastinal and hilar contours are unremarkable.\n There is no pleural effusion on the right side.\n\n IMPRESSION:\n\n Multifocal atelectasis and/or infarcts.\n\n" }, { "category": "Radiology", "chartdate": "2187-03-09 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 901254, "text": " 10:07 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/o PE\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hx PE with acute desat\n REASON FOR THIS EXAMINATION:\n R/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old man with history of pulmonary emboli and acute\n desaturation.\n\n TECHNIQUE: Multidetector axial images of the chest were obtained without and\n with IV contrast. 150 cc Optiray. Multiplanar reformatted images were\n obtained.\n\n COMPARISON: Abdominal CT of .\n\n CT CHEST: There are multiple bilateral pulmonary emboli. On the right, there\n is embolus in the interlobar branch right pulmonary artery. Filling defects\n are observed in the right upper and lower lobe lobar, segmental and\n subsegmental vessels. On the left, there is an embolus filling the lingular\n artery. Emboli are also seen extending into the left lower lobe segmental and\n subsegmental arteries. Correlation with the patient's recent abdominal CT\n demonstrates patency of the segmental left lower lobe pulmonary arteries. On\n this exam, they are filled with embolus. The heart size is at upper limits of\n normal. Aortic and coronary calcifications are identified. There is no\n axillary, mediastinal, or hilar lymphadenopathy. Wedge-shaped opacities in\n the lingula and bilateral lower lobes are consistent with infarcts. There is\n also a small amount of subsegmental atelectasis at the bases. There are no\n pleural or pericardial effusions. Visualized portions of the upper abdomen\n are remarkable for a large amount of ascites and partial visualization of a\n pancreatic pseudocyst. These findings are better evaluated on the recent\n abdominal CT.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n Bilateral pulmonary emboli involving interlobar, lobar, segmental and\n subsegmental vessels, with associated pulmonary infarcts. Although right lower\n lobe emboli wre present on the prior abdominal CT of , the\n left lower lobe emboli are new.\n\n These findings were discussed with Dr. at 11 p.m., .\n\n\n (Over)\n\n 10:07 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/o PE\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2187-03-02 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 900635, "text": " 2:26 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: R/O CBD stone\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatitis. Imaging suggests CBD stone\n ERCp performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with pancreatitis.\n\n ERCP: 14 ERCP images were obtained by Dr. and demonstrated a small\n filling defect in the upper third portion of the CBD. Otherwise,\n cholangiogram was normal. The pancreatic duct was normal. By report,\n sphincterectomy was performed, and a small amount of sludge was extracted.\n\n Please also refer to the official ERCP report by endoscopist.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901291, "text": " 12:42 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 1256\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Intubation.\n\n An endotracheal tube is in place, terminating about 4 cm above the carina. The\n lung volumes are slightly low. There has been interval worsening of bibasilar\n areas of opacification, and there are probable small pleural effusions.\n\n IMPRESSION:\n\n 1. Worsening bibasilar opacities, which may relate to atelectasis,\n aspiration, or evolving pneumonia.\n\n 2. Endotracheal tube in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2187-02-27 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 899815, "text": " 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst\n REASON FOR THIS EXAMINATION:\n please evaluate pnacreas area\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND INTRAVENOUS CONTRAST (CT\n ANGIOGRAPHY PROTOCOL).\n\n TECHNIQUE: Multidetector, multiphasic CT scan of the abdomen and pelvis with\n oral and intravenous contrast:\n\n RECONSTRUCTIONS: Reconstructed images in the sagittal and coronal plane are\n also included.\n\n CLINICAL DETAILS: Transfer from outside hospital, recent pancreatitis.\n Comparison is made with preceding ultrasound of .\n\n CT ABDOMEN (MULTIPHASIC SCAN):\n\n Low-density filling defect noted in the included portion of the right lower\n lobe pulmonary artery and at least one of the segmental branches to the left\n lower lobe (posteromedial) in keeping with acute pulmonary embolus.\n\n Minor left posterobasal atelectasis, minimal dependant atelectasis at the\n right lung base and minor rim of left basal pleural fluid. Wedge-shaped area\n of subpleural atelectasis noted in the left lateral lung base.\n\n Within the abdomen, there is gross edema of the pancreas throughout its\n length. Though edematous, most of the gland shows heterogenous post-contrast\n enhancement. There is a focal area measuring up to 3 cm along the proximal\n anterior portion of the pancreatic body just to left of midline does not show\n contiguous postcontrast enhancement and contains a heterogenous areas of low\n and fat density consistent with an area of focal pancreatic necrosis . The\n more distal oedematous body and tail show enhancement.\n There are several acute peripancreatic fluid collections, the largest extend\n anteriorly and slightly inferiorly from this area in the proximal body towards\n the lesser sac and measures up to 9.6- cm AP x 7.5-cm transverse and also\n tracts more cranially in the retrogastric area where it measures up to 9- cm\n transverse x 5.1-cm AP. Smaller peripancreatic fluid collections present\n anterior and posterior to the pancreatic head and neck, measuring up to 7-cm\n transverse x 3.2-cm posterior to the pancreatic head. No well- organized\n collection is demonstrated. No pancreatic main ductal dilatation or\n pancreatic calcification on the unenhanced CT.\n\n (Over)\n\n 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Though attenuated by the pancreatic edema and peripancreatic fluid\n collections, the splenic vein, portal veins are patent. The superior mesentry\n vein widely patent. The adjacent arterial structures are patent and\n unremarkable. A small amount of free intraabdominal ascites and a significant\n periportal edema is noted.\n\n The liver is normal in size, no focal lesion demonstrated. Two minor (3mm)\n areas of intrahepatic segmental biliary dilatation noted in segment II of the\n liver without obvious cause. The central right and left bile ducts are\n nondilated, CBD is nondilated, proximal CBD to lower hepatic duct measures\n less than 5 mm in diameter. Mild circumferential rim enhancement of the\n visible portion of the upper CBD which may be reactive to the periportal edema\n and pancreatitis. In the mid CBD there is a 2-mm calcific density, likely\n represent a small non obstructing calculus. The gallbladder is contracted, no\n obvious gallstones, there is circumferential edema of the wall measuring up to\n 8 mm, which maybe secondary to the current pancreatitis.\n\n Spleen is normal in size, incidental 1.5-cm splenule noted in the left upper\n quadrant, both adrenal glands. Kidneys are normal apart from a subcentimeter\n cyst in the posterior interpolar cortex of the left kidney. Normal caliber\n abdominal aorta with moderate atherosclerotic plaque.\n\n No abnormal large or small bowel loop dilatation. Transition point suggest\n obstruction.\n\n CT SCAN OF PELVIS WITH ORAL AND INTRAVENOUS CONTRAST: Moderate amount of\n pelvic ascites.\n\n No bone lesions demonstrated on bone window settings.\n\n CONCLUSION:\n\n 1. Pulmonary embolus involving the included portion of the right lower lobe\n pulmonary artery and at least one segmental branch in the left lower lobe.\n These findings have been discussed with the referring resident Dr. \n . We gather that the patient is on anticoagulation treatment for a\n known deep venous thrombosis.\n\n 2. Severe pancreatitis with generalized edema of the pancreatic gland and an\n area of focal pancreatic necrosis in the proximal anterior body measuring up\n to 3 cm. Several adjacent acute peripancreatic fluid collections as described,\n the largest measures up to 10 cm.The remainder of the pancreas though\n oedematous shows post contrast enhancement.\n\n (Over)\n\n 10:02 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: please evaluate pnacreas area\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. No gallstones or pancreatic ductal calculi or dilation.\n A 2-mm nonobstructing calculus noted in the mid portion of the non dilated\n CBD.\n\n 4. Two areas of mild (<3mm) segmental intrahepatic biliary dilatation in\n segment II without obvious underlying cause.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 901280, "text": " 8:32 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: please assess for presence and position of DVT clot. patient\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with\n REASON FOR THIS EXAMINATION:\n please assess for presence and position of DVT clot. patient has evolving PEs\n and is planned for filter placement today.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old male with pulmonary embolism and concern for deep venous\n thrombosis.\n\n FINDINGS: Grayscale and Doppler son of the bilateral common femoral,\n superficial femoral, deep femoral, and popliteal vessels were performed. There\n is intraluminal echogenic material within the right popliteal vein which also\n demonstrates absence of flow and abnormal waveform consistent with thrombosis.\n The vessels of the left lower extremity demonstrate normal compressibility,\n augmentation, waveform and flow.\n\n IMPRESSION: Right popliteal DVT. No evidence of DVT in the left lower\n extremity.\n\n The results of this study were discussed with Dr. at time 9:30 on\n .\n\n" }, { "category": "Radiology", "chartdate": "2187-02-27 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 899786, "text": " 9:04 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: HX OF PANCREATITIS\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic psuedocyst and continued ab pain\n REASON FOR THIS EXAMINATION:\n RUQ - please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdominal ultrasound.\n\n INDICATION: Patient with pancreatic pseudocyst and ongoing abdominal pain.\n For evaluation.\n\n TECHNIQUE: Grayscale imaging of the abdomen was performed.\n\n COMPARISON: None.\n\n REPORT: There is moderate ascites present. The liver is markedly echogenic.\n Portal vein is patent with hepatopetal flow. The gallbladder is abnormal and\n appears markedly thick-walled. In addition, within the gallbladder there is\n evidence of some ring-down artifact. No discrete pericholecystic fluid is\n seen and there is no evidence of gallstones. The gallbladder is not\n distended. No intra- or extra-hepatic biliary dilatation is seen. No focal\n hepatic masses are seen, though some focal areas of hepatic sparing or fat\n sparing are seen. The right kidney measures 12.1 cm. The left kidney\n measures 13.8 cm. The spleen is not enlarged and measures 10.9 cm.\n The pancreas is not seen due to overlying gas.\n CONCLUSION:\n 1. Markedly echogenic liver consistent with fatty infiltration. More severe\n forms of liver disease including cirrhosis or fibrosis cannot be excluded by\n this examination.\n 2. Markedly thick-walled gallbladder with ring-down artifact. While this may\n reflect the patient's generalized hypoproteinemic or fluid overload state\n (given presence of ascites), the ring-down artifact at least raises the\n possibility of diffuse adenomyomatosis of the gallbladder wall.\n 3. Moderate ascites.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 901094, "text": " 5:15 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate, effusion.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man transfer from OSH for pancreatic pseudocyst, PE. desat at\n rest.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transfer from outside hospital for pancreatic pseudocyst and PE.\n Patient desaturated at rest. Evaluate for effusion or infiltrate.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: Again, the lung volumes are low. Allowing for this\n factor, the heart size is normal. Mediastinal and hilar contours are normal.\n There is bibasilar linear atelectasis, increased compared to . No\n frank consolidation or congestive failure. There is likely a small left\n effusion posteriorly. Osseous structures are unremarkable.\n\n IMPRESSION: Slightly increased atelectasis compared to .\n Otherwise unchanged appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2187-02-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 899757, "text": " 10:46 PM\n CHEST (PA & LAT) Clip # \n Reason: baseline cxr, r/o infiltrate.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man transfer from OSH for pancreatic pseudocyst with fevers.\n REASON FOR THIS EXAMINATION:\n baseline cxr, r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST OF \n\n CLINICAL INDICATION: Fevers. Pancreatic pseudocyst.\n\n There are no prior films for comparison.\n\n The lung volumes are low. Allowing for this factor, the heart size is normal.\n The aorta is tortuous, and the pulmonary vascularity is normal. There are\n bibasilar atelectatic changes. Note is also made of a small left pleural\n effusion posteriorly.\n\n IMPRESSION: Bibasilar atelectasis and small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901269, "text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n evaluate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Pulmonary embolism. Oxygen desaturation.\n\n The heart is upper limits of normal in size and stable allowing for rightward\n patient rotation. Atelectatic changes in the right lung base have nearly\n resolved in the interval. There are worsening patchy opacities in the left\n lower lobe, for which the differential diagnoses include atelectasis,\n aspiration, and evolving pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905771, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute pulmonary process\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n REASON FOR THIS EXAMINATION:\n eval acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Tracheotomy, decreasing oxygen saturation, evaluate acute\n pulmonary process.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n semi-upright position. Comparison is made with a previous similar examination\n dated . Position of the tracheostomy cannula is unchanged and\n no pneumothorax is identified. Also a right subclavian approach central\n venous line is in unchanged position. The patient is slightly rotated to the\n right, but paying attention to this change in position, no significant\n interval change can be found in the appearance of the lungs. Thus, bilateral,\n mostly basal densities persist in the vasculature give the impression of\n perivascular haze. Also a left-sided pleural density conceals partially the\n diaphragmatic contours.\n\n IMPRESSION: No significant interval change in a patient with history of\n pulmonary embolic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 904730, "text": " 11:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancr\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst s/p cystectomy now w/ open wound\n draining necrotic material\n REASON FOR THIS EXAMINATION:\n PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancreatico-cutaneous\n fistula\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with pancreatic pseudocyst, status post\n cystectomy, now with open wound draining necrotic material. Assess for\n pancreaticocutaneous fistula.\n\n COMPARISON: CTA abdomen dated .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases through the\n pubic symphysis following administration of oral and 50 cc of IV Optiray\n contrast. Multiplanar reformations were performed.\n\n CT ABDOMEN WITH IV CONTRAST: Images of the lower thorax again demonstrate\n bilateral pleural effusions, left greater than right, with consolidation\n involving the left lower lobe. Within the abdomen, there has been interval\n removal of a left-sided drainage catheter with a partial fistulous tract which\n does not appear to connect with the intraperitoneal cavity. Two right-sided\n JP drains remain in place with their tips located in the pancreatic bed. In\n the upper abdomen, there is a 4-cm defect in the ventral wall which appears to\n have communication with the inferior small fluid collection representing a\n draining open wound. The previously identified large fluid collection in the\n right upper quadrant anterior to the liver has significantly decreased in size\n measuring 18 x 6 cm transverse x approximately 6 cm AP, previously 22 cm x 8\n cm. Fluid collections within the pancreatic bed and left lower quadrant are\n also smaller. There is remaining enhancing pancreatic parenchyma in the\n anterior head, neck and distal body and tail. Small areas of decreased\n enhancement in the tail measuring 1.1 x 1.4 cm is consistent with necrosis.\n The SMA, celiac axis, and their branches appear patent. There is stable\n moderate periportal edema. The liver is normal in size without focal mass.\n The hepatic portal veins and inferior vena cava are patent. The spleen,\n adrenal glands, and opacified loops of large or small bowel are normal.\n Kidneys enhance symmetrically and excrete contrast normally. There are two\n hypoattenuating lesions within the left kidney which are too small to\n characterize, but likely small cysts. Note is made of diffuse inflammatory\n stranding throughout the mesentery. There are numerous retroperitoneal and\n mesenteric lymph nodes which do not meet CT criteria for pathologic\n enlargement. There is no free intraperitoneal air. IVC filter is identified\n below the level of the right renal vein.\n\n (Over)\n\n 11:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEAS OBTAIN SCAN W/ PO+IV CONTRAST. Please assess for pancr\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH IV CONTRAST: There has been interval decrease in fluid\n within the pelvis and cul-de-sac. A Foley catheter is seen in a nondistended\n bladder. The rectum, sigmoid colon, and pelvic loops of bowel are normal.\n There is no inguinal or pelvic lymphadenopathy.\n\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are identified.\n\n Again identified is generalized subcutaneous edema likely due to third space\n loss or anasarca.\n\n CT RECONSTRUCTIONS: Sagittal and coronal reconstructions were essential in\n delineating the anatomy and pathology.\n\n IMPRESSION:\n 1. Interval decrease in size of a fluid attenuating collection in the right\n upper quadrant anteriorly adjacent to the liver edge and extending to the left\n of midline. Fluid collections within the pancreatic bed and pelvis are also\n decreased in size.\n 2. 4-cm midline defect in the upper abdominal wall with connection to an\n inferior fluid collection likely representing a draining wound. No evidence\n of extraluminal air to indicate a pancreaticocutaneous fistula.\n 3. Persistent left lower lobe consolidation/collapse with associated\n bilateral pleural effusions, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907001, "text": " 10:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process, mucus plug\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n\n REASON FOR THIS EXAMINATION:\n acute process, mucus plug\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, decreasing oxygen saturation.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: In the interval, there has been near total\n complete opacification of the left hemithorax. Allowing for the degree of\n patient rotation, there is no shift of the mediastinal structures. These\n findings are consistent with a combination of an increasing moderate/large\n left pleural effusion with left lung atelectasis. Tracheostomy tube remains in\n stable position. There appears to be perihilar haziness on the right\n suggestive of mild congestive heart failure, which is improved in the\n interval. Probable left pleural effusion persists. No pneumothorax is seen.\n\n IMPRESSION:\n 1. New near total opacification of the left lung, likely due to combination of\n an increasing moderate/large pleural effusion and atelectesis.\n 2. Mild improvement in right lung pulmonary edema.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2187-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907026, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy tube, decreasing oxygen saturation, status post\n aggressive pulmonary toilet.\n\n COMPARISON: at 23:13.\n\n UPRIGHT AP VIEW OF THE CHEST: There has been interval improvement in aeration\n of the left upper lung field since the prior examination consistent with\n interval lung re-expansion. There continues to be opacification of the left\n lung base consistent with a moderate-sized left pleural effusion and basilar\n atelectasis. There is upper zone vascular redistribution and perihilar\n haziness consistent with mild pulmonary edema. There is no pneumothorax.\n\n IMPRESSION: Interval improvement in aeration of the left lung with re-\n expansion. Left basilar atelectais and moderate- sized left pleural effusion.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2187-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 903972, "text": " 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach - check position\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm, severe pancreatitis s/p trach\n REASON FOR THIS EXAMINATION:\n s/p trach - check position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 58-year-old man, status post withdrawal of the line by 6 cm.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n There is new tracheostomy tube seen in place. The tip of the right subclavian\n IV catheter is identified in the distal SVC.\n\n No evidence of pneumothorax is identified. There are continued opacities in\n both lower lobes indicating pneumonia versus aspiration. There is continued\n small left pleural effusion. The heart is normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-04-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 905846, "text": " 1:21 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n Reason: PE??\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hx PE with pCO2 of 119\n\n REASON FOR THIS EXAMINATION:\n PE??\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia. Pancreatic pseudocyst with rupture, status post\n drainage and partial pancreatic resection.\n\n TECHNIQUE: Axial CT imaging of the chest, abdomen, and pelvis performed after\n the intravenous administration of 150 cc of Optiray. Nonionic contrast was\n used due to patient debility. Comparison made to .\n\n CT OF THE CHEST WITH CONTRAST: An endotracheal tube ends in the lower\n trachea. No pulmonary embolism is seen on this examination limited by patient\n body habitus, streak artifact, and a slightly suboptimal timing of contrast\n administration. The heart, pericardium, and great vessels are unremarkable.\n Scattered mediastinal lymph nodes are seen, none reaching pathologic size by\n CT criteria. Small bilateral hilar lymph nodes are seen, presumably reactive\n in nature. Pulmonary parenchymal opacity is seen at both lung bases (left\n greater than right) representing atelectasis and/or consolidation. A small\n effusion is present on the left.\n\n CT OF THE ABDOMEN WITH CONTRAST: Surgical change related to the patient's\n history of exploratory laparotomy with external drainage of a pancreatic\n pseudocyst and pancreatic necrosectomy are seen. A percutaneous gastrostomy\n tube is in place.\n\n The degree of pancreatic enhancement in the remaining pancreatic head, body,\n and tail are unchanged. A fluid collection in the anterior peritoneal cavity\n inferior to the liver with a percutaneous drainage catheter in place has\n decreased in size (3B:173), measuring 17.3 x 3.9 cm (18.6 x 5.7 cm on\n ). A separate fluid collection in the left abdomen tracking along\n the left mesentery into the more central mesentery has also decreased in size\n (3B:207). A fluid collection in the expected location of the distal body of\n the pancreas (3B:163) that also contains a percutaneous drainage catheter has\n slightly increased in size measuring 4.1 x 3.4 cm (3.6 x 2.6 cm ). A\n small collection posterior to the head of the pancreas is unchanged in size\n and configuration.\n\n Intrahepatic biliary ductal dilatation is unchanged. The portal vein appears\n slightly attenuated at the porta hepatis; however, portal venous flow is seen\n in the liver.\n\n (Over)\n\n 1:21 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST\n Reason: PE??\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The spleen, adrenal glands, and kidneys are normal in appearance. An IVC\n filter is in place.\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder and rectum are normal in\n appearance.\n\n No bone lesions worrisome for malignancy are seen.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Interval decreased size of fluid collections inferior to the liver and the\n left central abdomen. Unchanged fluid collection posterior to the pancreatic\n head. A fourth fluid collection in the distal pancreatic bed containing a\n percutaneous drainage catheter has slightly increased in size.\n\n 3. Bilateral pulmonary parenchymal opacity (left greater than right)\n suggestive atelectasis or consolidation with small bilateral effusions.\n\n 4. Unchanged intrahepatic biliary ductal dilatation and attenuation of a\n patent portal vein.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 902430, "text": " 5:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line plcmt\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis now w/ fever to 101.9F and s/p new\n Right subclavian line\n REASON FOR THIS EXAMINATION:\n line plcmt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with PEs and pancreatitis and fever, now with new\n right-sided subclavian line placement.\n\n Comparison is made to the prior study of , at 1:20 p.m.\n\n SUPINE CHEST RADIOGRAPH\n\n A right-sided subclavian line is seen with its tip terminating in the right\n atrium. Recommend withdrawal by 6 cm. There is no evidence of pneumothorax.\n Allowing for technical differences, the chest radiograph is unchanged compared\n to the prior study performed six hours earlier.\n\n IMPRESSION:\n 1. Right-sided subclavian line with tip ending in right atrium. Recommend\n withdrawal by 6 cm. No evidence of pneumothorax.\n\n These findings were discussed with the houseofficer.\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901570, "text": " 2:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP single view.\n\n INDICATION: Pulmonary embolism, pancreatitis, evaluate for infiltrates.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position and is analyzed in direct comparison with a similar previous\n study of . The patient remains intubated, the ETT in unchanged\n position. The same holds for a previously described left subclavian approach\n central venous line and an NG tube. No evidence of pneumothorax. Cardiac and\n mediastinal structures are unchanged. As before, hazy densities exist in the\n lung bases partially obliterating the diaphragmatic contour and resulting in\n slight blunting of the lateral pleural sinuses.\n\n IMPRESSION: Stable chest findings in patient with history of pulmonary\n embolism.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902688, "text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post withdrawal of subclavian line for interval change.\n\n PORTABLE AP CHEST. The right subclavian line appears to terminate in the SVC.\n The ET tube is in good position. Left basilar atelectasis persists. There\n are no effusions. There is no pneumothorax.\n\n IMPRESSION:\n 1. Right subclavian catheter terminates in the SVC.\n 2. Left basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 901487, "text": " 11:07 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatits desaturating into 60s.\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n COMPARISON: .\n\n INDICATION: Line placement.\n\n A left subclavian catheter has been placed, terminating within the superior\n vena cava. There is no evidence of pneumothorax. An endotracheal tube\n remains in satisfactory position. Nasogastric tube is in place and terminates\n in the stomach. Cardiac and mediastinal contours are stable. There has been\n interval worsening of opacity in the left retrocardiac region. Small pleural\n effusions and a right basilar opacity are without interval change.\n\n IMPRESSION:\n 1. Central venous catheter and nasogastric tube in satisfactory position. No\n pneumothorax.\n 2. Bibasilar opacities and small pleural effusions with interval worsening of\n left lower lobe opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 902448, "text": " 8:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess for proper CVL placement\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm\n REASON FOR THIS EXAMINATION:\n Please assess for proper CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man status post withdrawal of central venous line by\n 6 cm.\n\n COMPARISON: , at 17:45.\n\n SUPINE CHEST RADIOGRAPH: A right-sided subclavian line is now seen with its\n tip terminating in the right superior vena cava. There is no evidence of\n pneumothorax. The remainder of the chest radiograph is unchanged.\n\n IMPRESSION:\n 1. Right-sided subclavian line with tip ending in the right superior vena.\n Otherwise, unchanged chest radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 902242, "text": " 7:51 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check CVL\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest.\n\n HISTORY: Status post central line placement.\n\n FINDINGS: Compared to prior study from three hours earlier.\n\n There has been interval placement of a right subclavian central line with the\n distal tip at the cavoatrial junction. No pneumothoraces are seen. The left-\n sided central venous catheter, and endotracheal tube are in unchanged position\n and appropriately sited. There remains very low lung volumes crowding the\n pulmonary vascular markings at the bases. There is likely an underlying\n element of pulmonary edema. There remains some hazy opacity within the left\n lung, however this is obscured by the overlying ventilation apparatus.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-22 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 902842, "text": " 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pancreatic pseudocyst and markedly distended abd\n REASON FOR THIS EXAMINATION:\n Please evaluate pancreatic bed and abdomen/pelvis. PLEASE GIVE PO AND IV\n CONTRAST\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MULTIDETECTOR CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND INTRAVENOUS\n CONTRAST (CT ANGIOGRAM PROTOCOL).\n\n RECONSTRUCTIONS: Multiplanar reconstructions in sagittal and coronal planes\n are also included.\n\n CLINICAL DETAILS: Post-drainage of pancreatic pseudocyst. Comparison is made\n with previous imaging.\n\n CT ABDOMEN WITH ORAL AND IV CONTRAST (CT ANGIOGRAM PROTOCOL):\n\n Small right and left basal pleural effusions, moderate atelectasis of the left\n lower lobe posteriorly and to a lesser extent the dependent portion of the\n right lower lobe. As on preceding recent CTs, there is evidence of some\n filling defects in segmental branches in the left lower lobe in keeping with\n recent pulmonary embolus. Normal heart size, some coronary artery\n calcification noted, the central line tip is included at the distal SVC level.\n\n Within the abdomen, there is a large amount of fluid in the right upper\n quadrant anteriorly medial to the liver and anterior to the pancreatic bed. At\n its largest, this measures up to 22 cm transverse x approximately 8 cm AP,\n extending to the left of the midline. There is a possible contiguous\n component tracking along the inferior posterior aspect of the liver which\n measures up to 10 cm x 6 cm transverse.\n\n Interval upper midline laparotomy and drainage of the large pancreatic\n pseudocyst the region of the proximal pancreatic body.\n\n There is remaining enhancing pancreatic parenchyma in the anterior head, neck,\n distal body and tail. A small residual cystic area along the anterior aspect\n of the proximal pancreatic body measures up to 4.8 cm transverse x 3.1 cm AP\n (series 5, image 59) and also small residual peripancreatic fluid attenuating\n collections along the posterior inferior aspect of the pancreatic head which\n measure up to 5.7 cm transverse x 2.9 cm AP (much smaller than on the prior\n CT). No abnormal dilatation of the main pancreatic duct. A hypoattenuating\n rim of fluid is noted along the anterior aspect of the pancreatic head (series\n 5, image 52).\n\n (Over)\n\n 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are two percutaneously placed JP drains. The tip of one lies in the\n left upper quadrant and inferior to the pancreatic tail (series 5, image 70)\n and the second located in the region of the lesser sac at the midline (series\n 5, image 70). The proximal portion of these drainage catheters pass through\n the largest anterior abdominal collection described above but there may not be\n side hole drainage points at that level.\n\n The liver is normal in size. The collection described in the anterior right\n upper quadrant exerts mass effect on the left lobe of the liver. Patent\n hepatic portal veins and inferior vena cava. Mild periportal edema noted. No\n intrahepatic biliary dilatation on the current CT. The spleen, both adrenal\n glands are normal. Both kidneys are normal in size, two sub 8-mm ovoid\n hypodensities in the left kidney are unchanged, too small to characterize but\n likely small cysts.\n\n An IVC filter in situ, the superior tip of which lies below the level of the\n renal vein.\n\n No abnormal large or small bowel loop dilatation. Incidental 5-cm splenule\n noted in the left upper quadrant inferior to the spleen.\n\n CT ANGIOGRAM:\n\n Atherosclerotic abdominal aorta. Celiac, superior mesenteric, inferior\n mesenteric, both renal arteries are patent. Splenic artery, splenic vein and\n superior mesenteric veins are patent.\n\n CT SCAN PELVIS (WITH ORAL AND IV CONTRAST):\n\n Urinary catheter in the bladder which was empty at the time of scanning. A\n small localized fluid collection in the right inferior pelvis measures up to\n 5.4 cm transverse x 3.2 cm AP.\n\n No bone lesions demonstrated on bone window setting.\n\n Generalized subcutaneous edema noted, likely due to third space loss or\n anasarca.\n\n RECONSTRUCTIONS: Multiplanar reconstructions in sagittal and coronal planes\n are also included.\n\n CONCLUSION:\n\n 1. Large fluid attenuating collection in the right upper quadrant anteriorly\n (Over)\n\n 11:34 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: Please evaluate pancreatic bed and abdomen/pelvis. PLEASE G\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n Field of view: 57 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adjacent to the liver edge and extending to the left of midline.\n\n Small residual fluid attenuating collection along the anterior aspect of the\n proximal pancreatic body and posterior to the pancreatic head improved\n compared to previous imaging. If required CT guided percutaneous of this\n right anterior collection should be possible.\n\n 2. The remaining pancreatic tissue in the body, distal tail and anterior head\n shows post-contrast enhancement. There remains a hypoattenuating area in the\n region of the residual collection, likley an area of necrosis in the\n pancreatic body measuring up to 4 cm.\n\n 3. Filling defects in segmental arterial branches in the left lobe in keeping\n with a previously documented pulmonary embolus. Small bibasilar pleural\n effusions and moderate posterior bibasilar atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 901635, "text": " 12:41 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval pac position\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PEs, pancreatitis\n\n REASON FOR THIS EXAMINATION:\n eval pac position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pulmonary emboli and pancreatitis, evaluate pulmonary artery\n catheter position.\n\n COMPARISON: at 7:24 a.m.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube terminates 7.8 cm from the carina.\n Nasogastric tube and left subclavian venous access catheter in unchanged\n position. The pulmonary artery catheter has been pulled back and now\n terminates in the intrapericardial right pulmonary artery. Mild pulmonary\n edema has improved in the interval with continued linear and nodular opacities\n within the left lung, possibly representing residual asymmetric pulmonary\n edema or consolidation. Bibasilar atelectasis and small left pleural effusion\n are stable. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 903833, "text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT position, lung collapse\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p withdrawl of line 6cm, severe pancreatitis post\n self-extubation now reintubated\n REASON FOR THIS EXAMINATION:\n ETT position, lung collapse\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Reintubation.\n\n An endotracheal tube is present, with the tip terminating approximately 2.5 cm\n above the carina. Cardiac and mediastinal contours are stable. There has\n been interval worsening of left lower lobe opacity and development of patchy\n opacities in the left mid and right lower lung zones. There is also a new\n layering left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2187-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907122, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change.\n Admitting Diagnosis: PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man trach, decreasing O2 sat, opacification of LLL.\n\n REASON FOR THIS EXAMINATION:\n interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:56 a.m., \n\n HISTORY: Tracheostomy. Decreasing oxygen. Left lower lobe opacification.\n\n IMPRESSION: AP chest compared to at 4:27 a.m.\n\n Perihilar opacification in the left mid and upper lung and interstitial edema\n in the right lung have decreased, consistent with improving heart failure.\n Persistent left lower lobe consolidation could be pneumonia or atelectasis.\n Small left pleural effusion decreased. Moderate cardiac enlargement stable.\n Tracheostomy tube in standard position. No pneumothorax.\n\n\n" } ]

19,879

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A/P: 56m with HTN, DM2, ESRD on HD presents with lightheadedness and hypotension likely due to volume shifts and hypovolemia. . #Hypotension: The most likely explanation is a combination of dialysis, diarrhea, and multiple blood pressure medications. He had no additional signs to support sepsis or adrenal insufficiency. His exam, ECG, and enzymes don't support ACS or cardiogenic shock. A TTE showed mild LVH, normal EF, and diastolic dysfunction. After IVFs and withholding his medications, his blood pressure became normo-, then hypertensive. The hypertension was eventually controlled by re-instituting his regular medications and increasing his dose of lisinopril. . #Chest pain: His ECG showed T wave changes consistent with LVH and these changes were not dynamic with the pain. In addition though he had mildly elevated troponin, he had no CK elevation and has concurrent renal failure. He was continued on asa and labetalol and atorvastatin was started. . #Diarrhea: A C. Diff toxin assay was negative, and his diarrhea did not continue during his hospitalization. . # ESRD: He tolerated HD without further hypotension or complications. . # DM2: He continued his home regiemn of glargine and sliding scale insulin; diet.

Left ventricular hypertrophy and consider alsobiventricular hypertrophy. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. The left ventricular inflow pattern suggests impaired relaxation.There is a trivial/physiologic pericardial effusion. Left atrial abnormality.Right axis deviation. Left ventricular hypertrophy and consider biventricularhypertrophyy. Left ventricularhypertrophy and consider biventricular hypertrophy. Left ventricularhypertrophy and consider biventricular hypertrophy. Left ventricularhypertrophy and consider biventricular hypertrophy. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. There is mild symmetric left ventricularhypertrophy. Left ventricular hypertrophy and consider also biventricularhypertrophy. Rightaxis deviation. Rightaxis deviation. Borderline first degree A-V delay. Borderline first degree A-V delay. Borderline first degree A-V delay. Trivial mitral regurgitationis seen. Atrial premature beat. The aortic valve leaflets are mildlythickened. Right axis deviation. Right axis deviation. Clinical correlation issuggested. Clinical correlation issuggested. Sinus bradycardia. Diffuse St-T waveabnormalities could be due to left ventricular hypertrophy, ischemia orpossibly hyperkalemia. HYPERKALEMIC K+ 6.4 -> 5.7 POST TREATMENT. Sinus rhythmLeft atrial abnormalityLeft ventricular hypertrophyST-T wave abnormalities consistent with left ventricular hypertrophySince previous tracing of , no significant change EKG DONE, 2 SLNTG GIVEN W/O EFFECT. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ST-T wave abnormalities arenon-specific and could be due to left ventricular hypertrophy or possibleischemia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 73Weight (lb): 145BSA (m2): 1.88 m2BP (mm Hg): 462/65HR (bpm): 70Status: InpatientDate/Time: at 10:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. Since the previous tracing nosignificant change.TRACING #6 Diffuse ST-T wave abnormalities could be due to left ventricularhypertrophy, ischemia or possibly hyperkalemia. Since the previous tracing of further ST-T waveabnormalities are present.TRACING #2 add: k = 6.1. kayexalate given ekg done HO aware. Pulmonary vasculature is within normal limits. ST-T wave abnormalities arenon-specific but could be due to left ventricular hypertrophy or ischemia.Clinical correlation is suggested. KAYEXALATE GIVEN IN EW X2. Clinicalcorrelation is suggested. (REG DAYS M/W/F)S/O:SEE CARVUE FOR COMPLETE OBJ DATA.NEURO: A&O X3, MAE.CV: ARRIVED TO CCU W/ C/O CP AND SOB. DSD QD, CHANGED EVE.ACCESS: 2 #18 PERIPHERALSA: HYPOTENSIVE, HYPERKALEMIA, S/P VOLUME RESUSITATION W/ ESRD ON HD.CHEST PAIN AND SOB RESOLVED W/ MORPHINE AND NTG GTT. Since the previous tracing of T waves are less prominent.TRACING #5 The left ventricular cavity size is normal. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Diffuse ST-T wave abnormalities could be due to leftventricular hypertrophy, ischemia or possibly hyperkalemia. PT PAIN FREE. Diffuse ST-T wave abnormalities could be due in part to leftventricular hypertrophy, ischemia or hyperkalemia. Clinical correlation is suggested. Clinical correlation is suggested. No AS. The soft tissue and osseous structures are within normal limits. Normal LV cavity size. Right ventricular chambersize and free wall motion are normal. IMPRESSION: No acute pulmonary process identified. The heart and mediastinal contours are normal. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. ON HD SINCE AFTER FAILED RENAL TRANSPLNT, HAS NON-WORKING FISTULAS IN BOTH UPPER EXTREMITIES.D/C'D FROM TO HOME W/ SERVICES AFTER RECENT SURGICAL AMPUTATIONS.AT HOME THIS AM W/ HYPOTENSION (SBP 60) EMS-> EW. no significant change.TRACING #4 Since the previous tracing earlier this date ST-T wave changes havedecreased.TRACING #3 NO BM SINCE ARRIVAL. BS W/ BIBASILAR CRACKLES. REC'D 4 LITERS IN EW. PAIN , 6MG OF IV MORPHINE GIVEN W/ GOOD EFFECT. PLACED ON PRECAUTIONS, PT WAS RECENTLY EXPOSED TO C-DIFF AT REHAB.GU: ANURIC ON HDSKIN: INC WOUNDS HEALING WELL. COMPARISON: None. NOW HYPERTENSIVE CONTROLLED W/ IV NTG GTT.P: AWAITING HD ON MONDAY, MONITOR CARDIO PULM STATUS, FOLLOW K+. CK MB SENT, K+ 5.7.RESP: O2 SAT 100% ON 2-3LNC. ADMIT TO CCU, NEEDS HD ON MONDAY. SBP CLIMBING TO 170'S STARTED ON IV NTG. Overall leftventricular systolic function is normal (LVEF>55%). Evaluate for pneumonia or CHF. No previous tracing available for comparison.TRACING #1 CCU NPN 1900-070056 Y/O MALE W/ DM, HTN, ESRD, DIABETIC NEUROPATHY, SEVERE PVD S/P MULTIPLE AMPUTATIONS. Since the previoustracing earlier this date. The lungs are clear. SEE ADMIT NOTE FOR FULL DETAIL. PORTABLE AP CHEST RADIOGRAPH: There is a hemodialysis catheter within the right subclavian vein, with the tip positioned in the right atrium. There is no aortic valve stenosis. No pleural effusion or pneumothorax is seen. LEFT TOE REMOVED, AND LEFT INDEX FINGER REMOVED D/T OSTEOMYLITIS 3 WEEKS AGO AT . O2 OFF, SAT REMIANS 98%.GI: TOLERATING PO'S, REPORTEDLY HAD DIARRHEA FOR "5 DAYS".

11

[ { "category": "Nursing/other", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 1523590, "text": "add: k = 6.1. kayexalate given ekg done HO aware.\n" }, { "category": "Nursing/other", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 1523591, "text": "CCU NPN 1900-0700\n56 Y/O MALE W/ DM, HTN, ESRD, DIABETIC NEUROPATHY, SEVERE PVD S/P MULTIPLE AMPUTATIONS. ON HD SINCE AFTER FAILED RENAL TRANSPLNT, HAS NON-WORKING FISTULAS IN BOTH UPPER EXTREMITIES.\n\nD/C'D FROM TO HOME W/ SERVICES AFTER RECENT SURGICAL AMPUTATIONS.\n\nAT HOME THIS AM W/ HYPOTENSION (SBP 60) EMS-> EW. SEE ADMIT NOTE FOR FULL DETAIL. HYPERKALEMIC K+ 6.4 -> 5.7 POST TREATMENT. REC'D 4 LITERS IN EW. ADMIT TO CCU, NEEDS HD ON MONDAY.(REG DAYS M/W/F)\n\nS/O:\nSEE CARVUE FOR COMPLETE OBJ DATA.\n\nNEURO: A&O X3, MAE.\nCV: ARRIVED TO CCU W/ C/O CP AND SOB. EKG DONE, 2 SLNTG GIVEN W/O EFFECT. SBP CLIMBING TO 170'S STARTED ON IV NTG. PAIN , 6MG OF IV MORPHINE GIVEN W/ GOOD EFFECT. PT PAIN FREE. CK MB SENT, K+ 5.7.\n\nRESP: O2 SAT 100% ON 2-3LNC. BS W/ BIBASILAR CRACKLES. O2 OFF, SAT REMIANS 98%.\n\nGI: TOLERATING PO'S, REPORTEDLY HAD DIARRHEA FOR \"5 DAYS\". NO BM SINCE ARRIVAL. KAYEXALATE GIVEN IN EW X2. PLACED ON PRECAUTIONS, PT WAS RECENTLY EXPOSED TO C-DIFF AT REHAB.\nGU: ANURIC ON HD\nSKIN: INC WOUNDS HEALING WELL. LEFT TOE REMOVED, AND LEFT INDEX FINGER REMOVED D/T OSTEOMYLITIS 3 WEEKS AGO AT . DSD QD, CHANGED EVE.\nACCESS: 2 #18 PERIPHERALS\n\nA: HYPOTENSIVE, HYPERKALEMIA, S/P VOLUME RESUSITATION W/ ESRD ON HD.\nCHEST PAIN AND SOB RESOLVED W/ MORPHINE AND NTG GTT. NOW HYPERTENSIVE CONTROLLED W/ IV NTG GTT.\nP: AWAITING HD ON MONDAY, MONITOR CARDIO PULM STATUS, FOLLOW K+.\n\n\n" }, { "category": "Echo", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 82661, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 73\nWeight (lb): 145\nBSA (m2): 1.88 m2\nBP (mm Hg): 462/65\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The left ventricular inflow pattern suggests impaired relaxation.\nThere is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2156-09-21 00:00:00.000", "description": "Report", "row_id": 198214, "text": "Sinus rhythm\nLeft atrial abnormality\nLeft ventricular hypertrophy\nST-T wave abnormalities consistent with left ventricular hypertrophy\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 198215, "text": "Sinus rhythm. Left atrial abnormality. Right axis deviation. Left ventricular\nhypertrophy and consider biventricular hypertrophy. ST-T wave abnormalities are\nnon-specific and could be due to left ventricular hypertrophy or possible\nischemia. Clinical correlation is suggested. Since the previous tracing no\nsignificant change.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2156-09-20 00:00:00.000", "description": "Report", "row_id": 198216, "text": "Sinus rhythm. Atrial premature beat. Left atrial abnormality. Left ventricular\nhypertrophy and consider biventricular hypertrophy. ST-T wave abnormalities are\nnon-specific but could be due to left ventricular hypertrophy or ischemia.\nClinical correlation is suggested. Since the previous tracing of \nT waves are less prominent.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198217, "text": "Sinus rhythm. Left atrial abnormality. Right axis deviation. Left ventricular\nhypertrophy and consider biventricular hypertrophy. Diffuse St-T wave\nabnormalities could be due to left ventricular hypertrophy, ischemia or\npossibly hyperkalemia. Clinical correlation is suggested. Since the previous\ntracing earlier this date. no significant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198218, "text": "Sinus rhythm. Borderline first degree A-V delay. Left atrial abnormality. Right\naxis deviation. Left ventricular hypertrophy and consider also biventricular\nhypertrophy. Diffuse ST-T wave abnormalities could be due to left ventricular\nhypertrophy, ischemia or possibly hyperkalemia. Clinical correlation is\nsuggested. Since the previous tracing earlier this date ST-T wave changes have\ndecreased.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198219, "text": "Sinus rhythm. Borderline first degree A-V delay. Left atrial abnormality. Right\naxis deviation. Left ventricular hypertrophy and consider biventricular\nhypertrophyy. Diffuse ST-T wave abnormalities could be due in part to left\nventricular hypertrophy, ischemia or hyperkalemia. Clinical correlation is\nsuggested. Since the previous tracing of further ST-T wave\nabnormalities are present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-09-19 00:00:00.000", "description": "Report", "row_id": 198460, "text": "Sinus bradycardia. Borderline first degree A-V delay. Left atrial abnormality.\nRight axis deviation. Left ventricular hypertrophy and consider also\nbiventricular hypertrophy. Diffuse ST-T wave abnormalities could be due to left\nventricular hypertrophy, ischemia or possibly hyperkalemia. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2156-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 924689, "text": " 3:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man on HD hypotensive with dry cough\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man on hemodialysis, hypertensive with dry cough.\n Evaluate for pneumonia or CHF.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: There is a hemodialysis catheter within the\n right subclavian vein, with the tip positioned in the right atrium. The heart\n and mediastinal contours are normal. Pulmonary vasculature is within normal\n limits. The lungs are clear. No pleural effusion or pneumothorax is seen.\n The soft tissue and osseous structures are within normal limits.\n\n IMPRESSION: No acute pulmonary process identified.\n\n" } ]

54,911

173,885

SICU course - Mr. was admitted to the SICU with fulminant liver failure following a TIPS procedure complicated by a bleed requiring embolization of segment 8 and revision of his TIPS. On initial admission, his GCS was 3. He was transferred from Hospital intubated and on levophed for blood pressure support. A full workup for transplant listing was initiated which included serologies, liver duplex, ECHO, CT Torso, CT head and placement of a Dobhoff tube postpyloric for feeding. An initial CT scan of his head was negative for any significant pathology and it was felt that his current mental status was likely due to his liver failure. Neurology was consulted for evaluation of his mental status and during that time he had a tonic-clonic seizure for which he was loaded and maintained on Keppra. An initial diagnostic paracentesis of his abdomen excluded spontaneous bacterial peritonitis and CVVH was initiated for his acute renal failure after his acute decompensation at Hospital. He was intially treated with zosyn at Hospital during his decompensation and shortly after the start of zosyn, he developed neutropenia. His zosyn was discontinued here, and cefepime was started emprically for his pneumonia. A BAL culture eventually grew yeast and he was started on fluconazole for coverage. Hematology was consulted regarding his neutropenia and a bone marrow biopsy was performed on which eventually showed agranulocytosis, likely acute reaction to acute illness or medication. He continued to remain neutropenic and coagulopathic from his liver disease with intermittent need for trasnfusions. He also remained on CVVH for fluid removal, with an inability to tolerate HD due to labile blood pressures. His mental status improved and on , he was arousable and able to follow commands. On he continued to require ventilatory support, but was awake and following commands. He underwent a therapeutic paracentesis for 7 liters of ascitic fluid. The cefepime was discontinued with no positive culture data and levofloxacin was started for neutropenic prophylaxis. He underwent a second paracentesis on for 2.2 liters. He continued to remain neutropenic with a WBC of 0.7 with the continuation of his neupogen and he continued to require intermittent CVVH for fluid removal. Attempts to wean him from ventilatory support failed and he continued to remain coagulopathic from his liver disease. A repeat bone marrow biopsy was performed on and during this time had a hypotensive episode requiring neosynephrine for blood pressure support. He was eventually weaned from his requirement for neosynephrine. The bone marrow biopsy did not demonstrate any signs of a malignant process and on his WBC started to increase (1.4). He remained intubated with an inability to be weaned, likely secondary to his deconditioned state. His neutropenia continued to improve with a WBC of 2.7 on and 5.5 on . Although he had a normal WBC on , he remained neutropenic and developed a neutropenic fever to 101.6 that morning with hypotension requiring neosynephrine and empiric vancomycin, meropenem, and micafungin was started and later stopped without positive culture data. Multiple cultures were sent with only positive cultures growing yeast, the last of which was from a BAL. He continued to remain coagulopathic with a need for intermittent blood product transfusions and on ventilatory support for his deconditioned respiratory failure. He also remained on neosynephrine without a clear etiology. On , it was decided at liver allocation meeting that Mr. was not a liver transplant candidate. Dr. had an extensive meeting with the family to notify them that he would not be listed for liver transplant and his care was transitioned to the MICU service at this time. ===================== MICU Course

FINDINGS: The right IJ catheter ends in the mid SVC. Unchanged size of the cardiac silhouette, unchanged bilateral pleural effusions and bilateral areas of opacities in the lung parenchyma, likely corresponding to areas of atelectasis. Bilateral pleural effusions, left more than right, with subsequent areas of atelectasis. An IVC filter within the infrarenal IVC is noted. The surface morphology appears nodular, consistent with cirrhosis. The right and left internal jugular central venous catheters terminate within the SVC. There is interval significant decrease in the left pleural effusion. There are low lung volumes with bilateral pleural effusions, left greater than right. There are low lung volumes with bilateral pleural effusions, left greater than right. There are low lung volumes with bilateral pleural effusions, left greater than right. The remnant left lung tissue seen predominantly in the anterior aspect of the left hemithorax demonstrates diffuse ground-glass opacities. The Dobbhoff tube can be seen in the superior most part of the image and appears to be projecting in area consistent with left bronchus. INDICATION: Status post line placement, hepatorenal syndrome, new right IJ CVC placement. Within the right upper quadrant of the abdomen, there are two serpiginous opacities which join at their inferior extent, representing contrast medium within the biliary or portal venous system. Some air is now present within the left lung, though a large left hemothorax is still present with mediastinal shift. Moderate right pleural effusion, unchanged from exam. Moderate right pleural effusion, unchanged from exam. Moderate right pleural effusion, unchanged from exam. The distal tip of the endotracheal tube is approximately 4.2 cm proximal to the carina, similar to prior exam. The left IJ catheter ends at the junction of the right and left brachiocephalic veins. Large left pleural effusion with hemorrhagic component displacing mediastinal structures with right-sided displacement of the mediastinal structures. Large left pleural effusion with hemorrhagic component displacing mediastinal structures with right-sided displacement of the mediastinal structures. Enlarging left and stable moderate right pleural effusions. There are unchanged bilateral large pleural effusions and a left retrocardiac opacity. The right IJ catheter ends in the mid SVC. There is again seen bilateral pleural effusions and a left retrocardiac opacity. There is straightening of thoracic kyphosis. Left internal jugular line ends in the upper SVC, right internal jugular line ends close to the estimated location of the superior cavoatrial junction. FINDINGS: In comparison with the study of , the right IJ catheter has been removed. Furthermore, diffuse foci of patchy opacification are visualized throughout bilateral lungs. ET tube is in standard placement, feeding tube loops in the stomach and passes out of view, left supraclavicular dual-channel central venous line ends in the upper SVC. There is increased opacification of the left hemithorax with aerated lung is no longer visible on that side. Nasogastric tube has been removed, and a new post-pyloric tube terminates in the second portion of the duodenum. Unchanged moderate right pleural effusion. Left jugular line ends near the junction of brachiocephalic veins. Left jugular line ends at the thoracic inlet. CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are bilateral moderately sized pleural effusions with adjacent relaxation atelectasis. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is a large amount of intra-abdominal fluid with density suggestive of a combination of ascites and hemoperitoneum. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Large amount of free fluid is again visualized in the pelvis, with Hounsfield units suggesting a combination (Over) 7:32 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: evaluate pleural effusions and ?PNA Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL FINAL REPORT (Cont) of ascites and hemoperitoneum. Bilateral parenchymal opacities are unchanged and likely represent a combination of pulmonary edema and atelectasis. IMPRESSION: Unchanged pulmonary edema and atelectasis. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Unchanged bilateral parenchymal opacities, likely to represent a combination of pulmonary edema and atelectasis. FINDINGS: Indwelling devices are unchanged in position except for slight advancement of the endotracheal tube, which now terminates 3 cm above the carina. Mild left pleural effusion with retrocardiac atelectasis. Borderline size of the cardiac silhouette with minimal pulmonary edema. A left internal jugular catheter tip projects over the midline in the brachiocephalic vein, unchanged. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Left pleural effusion. IMPRESSION: Nodular cirrhotic liver, TIPS stent in situ, which is patent with normal flow. Mild (1+) MR. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets. The main portal vein is patent with normal hepatopetal flow. Right ventricular function.Height: (in) 72Weight (lb): 215BSA (m2): 2.20 m2BP (mm Hg): 119/70HR (bpm): 60Status: InpatientDate/Time: at 11:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The gallbladder is distended without gallstones. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV wall thickness. Mild atelectasis at the right lung base. Visualized portions of the IVC are unremarkable in appearance, with normal flow. Normal tricuspid valvesupporting structures. A right internal jugular catheter tip projects over the mid to low SVC. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right ventricular function.Height: (in) 72Weight (lb): 215BSA (m2): 2.20 m2BP (mm Hg): 119/70HR (bpm): 60Status: InpatientDate/Time: at 11:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Conclusions: Residual multifocal patchy and linear opacities in the mid and lower lungs, probably reflecting foci of atelectasis.

45

[ { "category": "Radiology", "chartdate": "2166-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172767, "text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with left hemothroax.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n End-stage liver disease, left hemothorax, evaluate for change.\n\n Some air is now present within the left lung, though a large left hemothorax\n is still present with mediastinal shift.\n\n IMPRESSION: Some re-expansion of left lung. Mediastinal shift persists.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1171996, "text": " 12:36 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p line placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatorenal syndrome. New right IJ CVC\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH.\n\n INDICATION: Status post line placement, hepatorenal syndrome, new right IJ\n CVC placement.\n\n COMPARISON: Chest radiograph , at 04:15.\n\n FINDINGS:\n\n Frontal chest radiograph performed at 12:57 was reviewed. Radiograph was\n performed with patient supine. The patient is intubated. The distal tip of\n the endotracheal tube is approximately 4.2 cm proximal to the carina, similar\n to prior exam. Left internal jugular venous catheter is present, tip of which\n projects over the left brachiocephalic vein. New right internal jugular\n venous catheter is present. The tip of this projects over the right\n cavo-atrial junction. Nasogastric tube is in place, the tip of which is\n outside the field of view, below the hemidiaphragm. TIPS shunt within the\n right upper quadrant is demonstrated. Unchanged branching densities adjacent\n to this are noted. There is bilateral basal atelectasis. Bilateral pleural\n effusions, moderate on the right and large on the left are seen. Volume loss\n on the left appears somewhat worse, though this may be exaggerated by\n projection. Density along the lung apices are compatible with pleural\n calcification.\n\n IMPRESSION: Support hardware similar to prior examination with the additional\n finding of a new right IJ central venous catheter, the tip of which is\n projected over the right cavo-atrial junction. Pleural effusions, larger on\n the left than the right with associated volume loss again seen, somewhat more\n prominent on the left than on the earlier radiograph.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171153, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with decompensated liver failure s/p TIPS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHER\n\n INDICATION: Decompensated liver failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient position is\n substantially changed. With this limitation in mind, there is no relevant\n change. Bilateral pleural effusions, left more than right, with subsequent\n areas of atelectasis. Small lung volumes. No signs of overt pulmonary edema.\n The monitoring and support devices are unchanged, tips projects over the\n expected position. No focal parenchymal opacities have newly occurred in the\n interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170068, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, evaluate for interval change.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Bilateral pleural effusions are moderately large and are unchanged\n since . There is an increase in the degree of vascular indistinctness\n and perihilar opacity since suggesting worsening pulmonary edema.\n The cardiac size is at the upper limits of normal, allowing for projection.\n The nasoenteric tube tip is not included in the field of view of the\n radiograph but is well below the gastroesophageal junction. The tip of the\n right internal jugular central venous catheter is projected over the level of\n the cavoatrial junction, the tip of the left internal jugular central venous\n catheter is projected over the expected location of the upper superior vena\n cava. The endotracheal tube is in satisfactory position. Multiple biliary\n stents and contrast within the biliary system of the right lobe of the liver\n are unchanged in appearance since .\n\n IMPRESSION:\n 1. Moderately large bilateral pleural effusions.\n\n 2. Worsening pulmonary edema.\n\n 3. Satisfactory position of medical devices.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170550, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWJ 10:21 AM\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1171577, "text": " 2:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p Bronchoscopy and HD line exchange, r/o PTX\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure.\n REASON FOR THIS EXAMINATION:\n s/p Bronchoscopy and HD line exchange, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:30 P.M. .\n\n HISTORY: End-stage liver disease and respiratory failure following\n bronchoscopy and line exchange.\n\n IMPRESSION: AP chest compared to 10:37 a.m.\n\n Large left and moderate right pleural effusion persists. Consolidation at the\n right lung base has improved minimally. Heart size normal. ET tube and left\n internal jugular line are in standard placements respectively. Feeding tube\n passes into the stomach and out of view. No pneumothorax or mediastinal\n widening.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171617, "text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: End-stage liver disease and respiratory failure after\n left thoracocentesis.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 10:33 p.m.\n\n There is interval significant decrease in the left pleural effusion. Apical\n loculation of pleural effusion is re-demonstrated. No definitive pneumothorax\n is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1169065, "text": " 3:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval dobhoff placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH/HCV cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with HCV cirrhosis, presents with decompensated\n liver failure and massive bleeding after TIPS. Evaluate Dobbhoff placement.\n The Dobbhoff tube can be seen in the superior most part of the image and\n appears to be projecting in area consistent with left bronchus.\n\n COMPARISON: CT torso from .\n\n FINDINGS: One Supine abdominal radiograph demonstrates the Dobbhoff tube in a\n position projecting over the left bronchus. Significant amount of\n intra-abdominal fluid makes it difficult to discern the loops of bowel. There\n does not appear to be any significantly dilated loops to suggest ileus or\n obstruction. An IVC filter projects over the likely location. There is a\n metal stent seen in the location of the portal vein. Bilateral pedicle screws\n are seen at L1 through L3.\n\n IMPRESSION:\n 1. Dobbhoff tube projecting over the left bronchus. This finding was called\n to Dr. 4 p.m. on . NG tube seen with side port beyond\n the gastroesophageal junction and the tip curling into the greater curvature\n of the stomach.\n\n 2. Bowel gas is difficult to discern with significant amount of ascites.\n There are no clearly dilated loops of large or small bowel to suggest\n obstruction or ileus.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170660, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evaluation\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with MI and cardiogenic shock.\n REASON FOR THIS EXAMINATION:\n interval evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MI with cardiogenic shock. Evaluate interval change.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right IJ catheter ends in the mid SVC. The left IJ catheter\n ends at the junction of the right and left brachiocephalic veins. The\n endotracheal tube terminates 3 cm above the carina. A feeding tube extends\n below the diaphragm and out of the field of view. A TIPS stent with apparent\n extension stents is seen. The lumbar spinal hardware is not completely\n visualized. There are unchanged moderate bilateral pleural effusions as well\n as unchanged pulmonary edema. Bibasilar atelectasis is unchanged. Within the\n right upper quadrant of the abdomen, there are two serpiginous opacities which\n join at their inferior extent, representing contrast medium within the biliary\n or portal venous system.\n\n IMPRESSION:\n 1. Unchanged moderate bilateral pleural effusions.\n 2. Unchanged bibasilar atelectasis.\n 3. Unchanged pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1172471, "text": " 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and dropping hcts concerning for bleed (came\n in with bleeding after TIPS procedure) as well as CXR concerning for hemothorax\n where line placed.\n REASON FOR THIS EXAMINATION:\n ?hemothorax and abdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXCf 2:20 PM\n 1. Large left pleural effusion with hemorrhagic component displacing\n mediastinal structures with right-sided displacement of the mediastinal\n structures.\n 2. Moderate right pleural effusion, unchanged from exam.\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage fluid.\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of liver failure status post TIPS on\n , currently with dropping hematocrit level. Assess for bleed.\n\n COMPARISONS: CT from and serial chest x-rays dating back to\n .\n\n TECHNIQUE:\n\n MDCT-acquired contiguous images from thoracic inlet to pubic symphysis were\n obtained without IV or p.o. contrast or oral contrast at 5-mm slice thickness.\n Coronally and sagittally reconstructed images were displayed at 5-mm slice\n thickness.\n\n FINDINGS:\n\n CT OF THE CHEST: There is a large left pleural effusion, distributed in\n almost entire left hemithorax, leading to right-sided displacement of\n mediastinal structures. The remnant left lung tissue seen predominantly in\n the anterior aspect of the left hemithorax demonstrates diffuse ground-glass\n opacities. The left pleural effusion demonstrates layering of the fluid with\n dependent area measures 40 Hounsfield units in attenuation, consistent with\n hemorrhagic component. There is moderate right pleural effusion measuring 15\n in attenuation with adjacent areas of compressive atelectasis, essentially\n unchanged from exam. The visualized portions of the right\n (Over)\n\n 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lung demonstrates diffuse opacities which are likely infectious in etiology.\n The heart is of normal size without pericardial effusion. The right and left\n internal jugular central venous catheters terminate within the SVC. The\n endotracheal tube terminates several centimeters above the carina.\n\n CT OF THE ABDOMEN: There is massive ascites within the abdomen, unchanged\n from exam. There is hyperdense fluid material in the most\n dependent area within the left upper abdomen measuring 70 Hounsfield units in\n attenuation suggestive of the hemorrhagic component. The liver is markedly\n diminished in size. The surface morphology appears nodular, consistent with\n cirrhosis. A TIPS shunt is in unchanged position. Within limitations of a\n non-contrast exam, spleen, adrenal glands, and kidneys appear unremarkable.\n\n An IVC filter within the infrarenal IVC is noted. Intra-abdominal aorta is\n notable for calcified atherosclerotic disease without aneurysmal changes.\n\n CT OF THE PELVIS:\n\n A Foley catheter is in place. Large amount of fluid within the pelvis is\n noted. There is no free air. The rectum is displaced posteriorly and there\n is an adjacent area of hyperdense fluid measuring 50 Hounsfield units in\n attenuation, consistent with hemorrhagic fluid.\n\n OSSEOUS STRUCTURES:\n\n No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n\n 1. Large left pleural effusion with hemorrhagic component with right-sided\n displacement of the mediastinal structures.\n\n 2. Moderate right pleural effusion, unchanged from exam.\n\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage.\n\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n\n (Over)\n\n 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1172472, "text": ", A. MED MICU-7 11:26 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ?hemothorax and abdominal bleeding\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and dropping hcts concerning for bleed (came\n in with bleeding after TIPS procedure) as well as CXR concerning for hemothorax\n where line placed.\n REASON FOR THIS EXAMINATION:\n ?hemothorax and abdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Large left pleural effusion with hemorrhagic component displacing\n mediastinal structures with right-sided displacement of the mediastinal\n structures.\n 2. Moderate right pleural effusion, unchanged from exam.\n 3. Visualized portions of the lungs demonstrate diffuse opacities, likely\n infectious in nature.\n 4. Massive amount of ascites, unchanged from exam, however,\n there are areas of hyperdense fluid within the left upper abdomen and pelvis\n with high attenuation, consistent with hemorrhage fluid.\n 5. The liver is markedly diminished in size and nodular in morphology\n consistent with cirrhosis. A TIPS shunt is in unchanged position.\n\n Findings communicated to Dr. at 11:50 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2166-01-27 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 1170668, "text": " 8:11 AM\n DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: EVAL TIPS PATENCY\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n EVAL TIPS PATENCY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with cirrhosis, liver failure and GI bleed.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: No focal liver lesion is identified. No biliary dilatation is seen\n and the common duct measures 0.5 cm. The gallbladder is contracted. The\n pancreas is unremarkable but is only partially visualized. The spleen is\n unremarkable and measures 11.9 cm. A large amount of ascites is seen in the\n abdomen.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main portal vein is patent with a velocity of 35 cm/sec. The\n right and left portal veins are patent and demonstrate reverse flow toward the\n TIPS shunt. The TIPS shunt is patent with velocities of 114, 168, and 114\n cm/sec in the proximal, mid and distal portions respectively.\n\n IMPRESSION:\n 1. Patent TIPS shunt with appropriate flow seen in the portal veins.\n 2. Large amount of ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169680, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position.\n Unchanged size of the cardiac silhouette, unchanged bilateral pleural\n effusions and bilateral areas of opacities in the lung parenchyma, likely\n corresponding to areas of atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170551, "text": ", J. SICU-B 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n STUDY: AP chest, .\n\n HISTORY: 64-year-old male with respiratory failure.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral IJ catheters, and feeding tubes are unchanged\n in position. There are low lung volumes with bilateral pleural effusions,\n left greater than right. Opacities of the lung bases are again seen and\n overall, again there has been no change aside from the decrease in the\n inspiratory effort.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171280, "text": " 6:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for pulm edema\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with decreased oxygen saturations.\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema\n ______________________________________________________________________________\n WET READ: 9:01 PM\n Lines stable. Again seen are bibasilar opacities, with increased opacity of\n right lung which may reflect interval development of edema.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:06 P.M. \n\n HISTORY: Hypoxia. Evaluate possible pulmonary edema.\n\n IMPRESSION: AP chest compared to through 6:\n\n Large left pleural effusion has increased between and ,\n stable since earlier in the day. Focal opacification of the base of the right\n lung is more obvious now than it was on earlier studies and could be due to\n pneumonia.\n\n Heart size is normal. ET tube is in standard placement, feeding tube passes\n into the stomach and out of view. Left internal jugular line ends in the left\n brachiocephalic vein. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169133, "text": ", J. SICU-B 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fluid overload, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged pulmonary edema and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172084, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure with b/l pleural effusions\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:03 A.M. ON \n\n HISTORY: End-stage liver disease and respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n Large left pleural effusion obscures the entire left lung and exaggerates what\n could be relatively mild pulmonary edema. There is at least a small if not\n larger right pleural effusion, but a lower portion of the right lung is\n consolidated either by atelectasis or pneumonia. Heart size is normal. There\n is no pneumothorax. ET tube is in standard placement. Left internal jugular\n line ends in the upper SVC, right internal jugular line ends close to the\n estimated location of the superior cavoatrial junction. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170814, "text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change, volume overload\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver failure and volume overload, to assess for change.\n\n FINDINGS: In comparison with the study of , the right IJ catheter has been\n removed. Other monitoring and support devices remain in place. Diffuse\n bilateral pulmonary opacifications persist, consistent with bilateral pleural\n effusions and bibasilar atelectasis.\n\n TIPS stent is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170974, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change, volume overload\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver failure and pleural effusions\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:11 A.M., \n\n HISTORY: Liver failure and pleural effusions. Question volume overload.\n\n IMPRESSION: AP chest compared to through 4:\n\n Bilateral pleural effusions, large on the left moderate on the right continue\n to increase producing at least moderate atelectasis in both lower lungs. I\n doubt that there is pulmonary edema. No pneumothorax. Heart size normal. ET\n tube is in standard placement, feeding tube loops in the stomach and passes\n out of view, left supraclavicular dual-channel central venous line ends in the\n upper SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172414, "text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n alcoholic cirrhosis, acute renal failure and pneumonia transfered from OSH for\n evaluation for liver transplant now s/p 23 days in the SICU with respiratory\n failure, liver failure, renal failure, transferred to MICU for further\n management.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiorgan failure with pneumonia. Evaluate for interval change.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The ET tube ends 4.5 cm above the carina. The right IJ catheter\n ends in the mid SVC. The left IJ catheter ends in the left brachiocephalic\n vein. The feeding tube passes into the stomach and out of the field of view.\n The TIPS stent is again seen in the right upper quadrant of the abdomen. The\n right pleural effusion has markedly increased in size and now compresses the\n left lung and shifts the midline structures to the right. The degree of\n increase in size of the effusion over two days raises concern for hemothorax.\n The moderate right pleural effusion is unchanged. Right basilar atelectasis\n is unchanged.\n\n IMPRESSION:\n\n 1. Drastically increased left pleural effusion, raising concern for\n hemothorax.\n\n 2. Unchanged moderate right pleural effusion.\n\n 3. Unchanged right basilar atelectasis.\n\n These findings were reported to Dr. at 2:35 p.m. via telephone on\n the day of the study.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171906, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD and respiratory failure s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:15 A.M., \n\n HISTORY: End-stage liver disease and respiratory failure following left\n thoracentesis.\n\n IMPRESSION: AP chest compared to :\n\n Large left pleural effusion has increased relative to . This\n obscures much of the left lung which may be more consolidated. There is\n persistent consolidation at the right base. No pneumothorax. Feeding tube\n passes into the stomach and out of view. Left jugular line ends near the\n junction of brachiocephalic veins. ET tube in standard placement. Heart is\n normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172670, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ESLD, ventilator dependence, possible hemothorax from CVL\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Possible hemothorax, assess for change.\n\n One view. Comparison with the previous study done . There is\n increased opacification of the left hemithorax with aerated lung is no longer\n visible on that side. Pleural calcification is projected in the mid left\n chest. A moderate right pleural effusion is unchanged. Increased density in\n the underlying lower right lung is stable. Mediastinal structures are shifted\n to the right as before. An endotracheal tube, feeding tube and bilateral\n internal jugular catheters remain in place.\n\n IMPRESSION: Opacification of the left hemithorax likely due to accumulation\n of pleural fluid as well as increased density in the underlying left lung.\n There is a stable moderate right pleural effusion and persistent increased\n density in the lower right lung which may represent parenchymal consolidation\n as well.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171550, "text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with EtOH and HCV cirrhosis with decompensated liver failure s/p TIPS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:37 A.M., \n\n HISTORY: Alcoholic and HCV cirrhosis. Liver failure. Status post TIPS.\n\n IMPRESSION: AP chest compared to through 6:\n\n Large left pleural effusion is stable, moderate right pleural effusion may\n have increased, and there may be more consolidation at the base of the right\n lung. Heart is normal size and mediastinal veins are not particularly\n distended suggesting that the pleural effusion could be due to ascites rather\n than volume overload. Findings in the right lung are concerning for\n pneumonia. The left lung base is obscured by a combination of overlying heart\n shadow and pleural effusion.\n\n Feeding tube passes into the stomach and out of view. ET tube is in standard\n placement. Left jugular line ends at the thoracic inlet. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1171208, "text": " 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP**\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, transferred with decompensated liver failure and\n massive bleeding after TIPS\n REASON FOR THIS EXAMINATION:\n **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP**\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:21 PM\n Increasing large L and stable moderate R pleural effusions.\n Bibasilar consolidation.\n Cirrhosis with severe ascites. Conventional vascular anatomy.\n TIPS, no active extravasation.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with alcoholic cirrhosis, liver failure and\n massive bleeding after TIPS.\n\n COMPARISON: \n\n TECHNIQUE: Helical MDCT images were acquired from the lung bases through the\n iliac crests without and with intravenous contrast, per the triphasic liver\n protocol. Three-minute delayed images were also obtained through the abdomen.\n Sagittal and coronal multiplanar reformations were generated. 3D\n volume-rendered images and liver/splenic volume calculations were performed at\n a separate workstation by the Advanced Imaging Lab.\n\n FINDINGS: Again noted are multifocal opacities at the lung bases, consistent\n with pneumonia. Increasing large left and stable moderate right pleural\n effusions are present. These measure 20-30 in attenuation, suggestive of\n complex proteinaceous or hemorrhagic fluid. There is associated compressive\n atelectasis.\n\n The heart size is normal, without pericardial effusion. The visualized lower\n lobe pulmonary arteries are patent. Calcifications are present in the left\n anterior descending coronary artery.\n\n ABDOMEN: Again noted is severe ascites, which has decreased from 30-15 in\n attenuation, suggesting resolving hemoperitoneum. The liver is markedly\n nodular, shrunken, and heterogeneous, consistent with cirrhosis. A few\n nonspecific hypodensities are noted in the liver, but there are no suspicious\n arterially enhancing foci. A TIPS shunt extends from the portal vein to the\n IVC, with contrast opacification of the lumen, and no evidence of active\n extravasation. Note is made of a recanalized umbilical vein, as well as\n numerous periportal, gastrohepatic, perisplenic, and periesophageal venous\n collaterals. Hepatic vascular anatomy is conventional. The main, right, and\n (Over)\n\n 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP**\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left hepatic and portal veins, superior mesenteric vein, splenic vein, and IVC\n are patent.\n\n The gallbladder is partially collapsed, with mild reactive wall edema. There\n is mild fatty infiltration of the pancreas. There is no intra- or\n extra-hepatic biliary ductal dilatation. The spleen is borderline enlarged at\n 13 cm.\n\n The adrenals are normal. The kidneys enhance and excrete contrast promptly\n and symmetrically. A 6-mm hyperdense focus in the left interpole (2:45) does\n not demonstrate significant contrast enhancement, and likely represents a\n hemorrhagic cyst. There are no renal stones, masses, or hydronephrosis. A\n large exophytic cyst at the right upper pole measures 6.7 x 4.0 cm.\n\n Nasogastric tube has been removed, and a new post-pyloric tube terminates in\n the second portion of the duodenum. Evaluation of the bowel is limited by\n extensive ascites, which results in centralization of bowel loops, with\n diffuse reactive wall edema. There is no transition point to suggest\n obstruction. No extraluminal air collections are identified.\n\n PELVIS: A Foley catheter is noted within a collapsed bladder. The colon is\n filled with fluid. Rectal tube is in place. Ascitic fluid is noted tracking\n into the scrotal sacs, right greater than left. Diffuse body wall edema is\n also present.\n\n Scattered calcifications are noted in the abdominal aorta and iliac arteries,\n with patent branch vessels. IVC filter is in place below the level of the\n renal arteries. Multiple prominent retroperitoneal nodes are present, likely\n reactive.\n\n The bones are diffusely demineralized. There are no suspicious lytic or\n sclerotic osseous lesions. There is straightening of thoracic kyphosis.\n Bridging osteophytes are present at L1-L2. Again noted is a compression\n deformity of L2, with near-complete loss of height and mild retropulsion into\n the spinal canal. The thecal sac outline is slightly flattened; please note\n that CT cannot visualize intrathecal detail. Laminectomy changes and\n posterior pedicle screws are again seen transfixing L1 and L3, without\n evidence of hardware complications.\n\n IMAGING LAB: Calculated liver volume is 954.019 cm3, and calculated splenic\n volume is 425.227 cm3.\n\n IMPRESSION:\n 1. Cirrhosis, splenomegaly, and varices. Changes of chemoembolization and\n TIPS. Resolving hemoperitoneum, without evidence of active extravasation.\n (Over)\n\n 11:08 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: **TRIPLE PHASE LIVER CT SCAN FOR TRANSPLANT WORKUP**\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Enlarging left and stable moderate right pleural effusions.\n 3. Bibasilar consolidation, consistent with pneumonia.\n 4. L2 compression fracture and L1-L3 posterior fixation.\n 5. Post-pyloric tube placement.\n\n" }, { "category": "Radiology", "chartdate": "2166-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171612, "text": " 10:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p left thoracentesis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after left thoracocentesis.\n\n Portable AP chest radiograph was reviewed in comparison to \n obtained at 2:30 p.m.\n\n The ET tube tip is 4 cm above the carina. The Dobbhoff tube tip is most\n likely in the proximal jejunum/distal duodenum. The left internal jugular\n line tip is unchanged. The TIPS catheter is in place.\n\n As compared to the prior study, there is no change in bilateral\n consolidations, bilateral pleural effusions and pulmonary edema, although the\n degree of pulmonary edema can be slightly worse than on the prior radiograph.\n No interval development of pneumothorax is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1168923, "text": " 11:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate pleural effusions/PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH cirrhosis, getting transferred with decompensated liver failure\n after TIPS\n REASON FOR THIS EXAMINATION:\n please evaluate pleural effusions/PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decompensated liver failure.\n\n FINDINGS: No previous images. There is mild enlargement of the cardiac\n silhouette with pulmonary vascular congestion. Patchy areas of opacification\n bilaterally could represent foci of pneumonia. There are bilateral pleural\n effusions with atelectatic changes at the bases.\n\n Endotracheal tube tip lies approximately 3.8 cm above the carina. Right IJ\n catheter extends to the mid portion of the SVC and the nasogastric tube\n extends well into the stomach. A TIPS shunt is in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1168960, "text": " 7:32 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate pleural effusions and ?PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n evaluate pleural effusions and ?PNA\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with hepatic encephalopathy.\n\n COMPARISON: Portable chest radiograph from .\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet\n to the pubic symphysis without intravenous contrast. Multiplanar reformatted\n images were prepared.\n\n CONTRAST: Oral contrast was administered. No IV contrast was administered.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are bilateral moderately\n sized pleural effusions with adjacent relaxation atelectasis. Furthermore,\n diffuse foci of patchy opacification are visualized throughout bilateral\n lungs. These findings are consistent with multifocal pneumonia. Otherwise,\n no discrete nodules are visualized.\n\n The cardiac silhouette is enlarged but with no pericardial effusion. The\n right internal jugular line is visualized with the catheter tip at the\n superior vena cava. An endotracheal tube tip appears in place. Within the\n confines of a non-contrast study, the great vessels and aorta appear\n unremarkable.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is a large amount of\n intra-abdominal fluid with density suggestive of a combination of ascites and\n hemoperitoneum. The liver appears shrunken and consistent with cirrhosis.\n Hyperdense foci are visualized through segments VII and VIII of the liver\n consistent with recent embolization of the region due to liver laceration. The\n TIPS catheter is visualized from the main portal vein to the inferior vena\n cava, and appears intact.\n\n An NG tube appears in place. Within the confines of a non-contrast study and\n large amount of free intra-abdominal fluid, the stomach, visualized loops of\n large and small bowel, bilateral kidneys, spleen, and pancreas appear\n unremarkable. An IVC filter appears in place. The abdominal aorta is\n unremarkable. There is no visualized overt mesenteric or retroperitoneal\n lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Large amount of free fluid is\n again visualized in the pelvis, with Hounsfield units suggesting a combination\n (Over)\n\n 7:32 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate pleural effusions and ?PNA\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of ascites and hemoperitoneum. A Foley catheter is visualized in the bladder.\n Otherwise, within the confines of a non-contrast study and large amount of\n intrapelvic fluid, the bladder and rectum appear unremarkable.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous lesions. L2\n vertebral body compression fracture with L1-L3 posterior fixation and\n bilateral pedicular screws through L1 and L3. There is grade 1\n anterolisthesis of L5 on S1.\n\n IMPRESSION:\n 1. Large amount of intra-abdominal and intrapelvic free fluid with Hounsfield\n units suggesting a combination of ascites and hemoperitoneum consistent with\n patient's known ascites and recent liver laceration.\n 2. Bilateral patchy airspace consolidations are suggestive of multifocal\n pneumonia. There is also bilateral moderate pleural effusions with adjacent\n relaxation atelectasis.\n 3. Shrunken liver consistent with cirrhosis with hyperdense material in\n segment VII and VIII consistent with recent embolization. TIPS catheter is\n visualized in place from the main portal vein to the inferior vena cava.\n 4. L2 compression fracture with L1 through L3 posterior fixation and\n bilateral pedicular screws through L1 and L3.\n 5. Gastric tube and endotracheal tube tips remain in place.\n\n These findings were discussed by Mark Ashkan with Dr. at 11:20\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2166-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170474, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 64-year-old man with respiratory failure. Evaluate for interval\n change.\n\n FINDINGS: Endotracheal tube, feeding tube, bilateral central venous catheters\n and tips are all unchanged. The cardiac silhouette is within normal limits.\n There is again seen bilateral pleural effusions and a left retrocardiac\n opacity. Overall, there has been no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170371, "text": " 4:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening effusions\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ? worsening effusions\n REASON FOR THIS EXAMINATION:\n ? worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 64-year-old male with worsening effusions.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, bilateral central venous catheters and feeding tube are\n unchanged in position. There are unchanged bilateral large pleural effusions\n and a left retrocardiac opacity. Overall, there has been no interval change.\n A TIPS is seen in the right upper abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169486, "text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with continued needs for intubation, acute liver failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: acute liver failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged monitoring and support devices. Unchanged low lung volumes\n with bilateral pleural effusions, areas of extensive basal atelectasis and\n minimal overhydration. Unchanged borderline size of the cardiac silhouette.\n No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1168958, "text": " 7:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracraneal process\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n r/o intracraneal process\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb TUE 9:51 AM\n No evidence for acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 64-year-old male with hepatic encephalopathy. Evaluate\n for acute intracranial process.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, cerebral\n edema, or mass effect. There is moderate prominence of ventricles and sulci\n due to cerebral atrophy. Calcifications are seen in the carotid and vertebral\n arteries.\n\n Visualized bones structures are grossly unremarkable. The visualized portions\n of the paranasal sinuses and mastoid air cells are well aerated. The scout\n image demonstrates -intestinal tube and an oral endo-tracheal tube.\n\n IMPRESSION: No evidence for an acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1168959, "text": ", J. MICU-7 7:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracraneal process\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n r/o intracraneal process\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n No evidence for acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-19 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1169755, "text": " 5:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p 7.5L paracentesis, with derecruitment pictures on\n ventilator\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: ENYa SUN 8:53 PM\n Interval decrease in bilateral lower lung opacities, compatible with interval\n 7.5 paracentesis. No PTX. Hazy bibasilar opacities likely atelectasis in\n etiology.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n Comparison study of earlier the same date.\n\n FINDINGS: Indwelling devices are unchanged in position except for slight\n advancement of the endotracheal tube, which now terminates 3 cm above the\n carina. Cardiomediastinal contours are within normal limits for technique.\n Increase in lung volumes and improved aeration at both lung bases. Residual\n multifocal patchy and linear opacities in the mid and lower lungs, probably\n reflecting foci of atelectasis. Small pleural effusions have apparently\n slightly improved in the interval.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169291, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man w/ ESLD, undergoing pre-transplant workup. s/p bronch \n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pre-transplant workup, evaluation for interval change\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Mild left pleural effusion with retrocardiac atelectasis. Mild\n atelectasis at the right lung base. Borderline size of the cardiac silhouette\n with minimal pulmonary edema. No evidence of pneumonia. Unchanged monitoring\n and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169779, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with continued required intubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Endotracheal tube tip terminates approximately 4 cm above the\n carina. Other indwelling devices are unchanged in position.\n Cardiomediastinal contours appear similar, but there is new pulmonary vascular\n congestion, accompanied by apparently increasing layering moderate bilateral\n pleural effusions. Band-like opacity in the right mid lung region probably\n reflects a combination of loculated fluid in the minor fissure with adjacent\n area of atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1170194, "text": " 9:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, ?mucous plugging\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with increased secretions, difficulty pulling volumes\n REASON FOR THIS EXAMINATION:\n interval change, ?mucous plugging\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:19 P.M. \n\n HISTORY: Increasing secretions. Question mucus plugging.\n\n IMPRESSION: AP chest compared to through 29:\n\n Aeration has improved slightly since probably due to a remission\n of pulmonary edema. Lung bases remain consolidated due to pneumonia or\n atelectasis. There are no findings to suggest airway impaction, but that\n diagnosis is not excluded by conventional radiographs. Moderate bilateral\n pleural effusions are slightly smaller, as is the cardiac silhouette. ET\n tube, left internal jugular line, right internal jugular line, and feeding\n tube are in standard placements respectively. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1168954, "text": " 6:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: please perform LIVER DUPLEX\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man preop for liver transplant\n REASON FOR THIS EXAMINATION:\n please perform LIVER DUPLEX\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND ABDOMEN, LIVER OR GALLBLADDER\n\n INDICATION: 64-year-old man preop for liver transplant.\n\n FINDINGS:\n\n There is a large amount of intra-abdominal ascites. The liver is small with a\n nodular contour consistent with cirrhosis. No focal liver lesions are seen.\n No intrahepatic duct dilatation is seen. The patient has a TIPS stent in\n situ, which is seen to be patent. There is reversal of flow in the left\n portal vein consistent TIPS placement. Reversed flow is also seen in the\n right anterior portal vein. The main portal vein is patent with normal\n hepatopetal flow. Normal flow demonstrated in all three hepatic veins. The\n main hepatic artery is patent with normal flow. The splenic vein was\n visualized with normal flow; however, the SMV could not be seen. Visualized\n portions of the IVC are unremarkable in appearance, with normal flow. The\n gallbladder is distended without gallstones.\n\n IMPRESSION:\n Nodular cirrhotic liver, TIPS stent in situ, which is patent with normal flow.\n The main portal vein is patent with normal flow. The hepatic veins and hepatic\n artery patent with normal flow. Large amount of intra-abdominal ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169908, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with b/l pleural effusions\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old male with bilateral pleural effusions, evaluate for\n change.\n\n COMPARISON: Chest radiograph .\n\n SINGLE PORTABLE SEMI UPRIGHT VIEW OF THE CHEST: There is interval slight\n increase in bilateral pleural effusions now large on the left and moderate on\n the right, with associated compressive atelectasis. Position of support lines\n is unchanged. Osseous structures appear unremarkable.\n\n IMPRESSION: Slight increase in now large left and moderate right effusions\n with associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169607, "text": " 10:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fulminant liver failure, intubated\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fulminant liver failure. Intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. There is minimally improved ventilation of\n the basal lung zones, right more than left. However, the pre-existing areas\n of atelectasis are visible in almost unchanged manner. Unchanged size of the\n cardiac silhouette, no newly appeared focal parenchymal opacities of the lung\n parenchyma.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1169020, "text": " 12:53 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval placement\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with line placement bilateral (RIJ switched, LIJ dialysis line)\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Line placement, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the tip of the right\n internal jugular vein catheter is now projecting over the lower SVC. A newly\n introduced left internal jugular vein catheter projects with its tip over the\n midline, obviously in the brachiocephalic vein.\n\n Unchanged bilateral parenchymal opacities, likely to represent a combination\n of pulmonary edema and atelectasis. Presence of a small left pleural effusion\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169132, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with fluid overload, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg WED 10:08 AM\n PFI: Unchanged pulmonary edema and atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fluid overload, evaluate for interval change.\n\n COMPARISON: CXR and .\n\n FINDINGS: The endotracheal tube ends 4.1 cm above the carina. A right\n internal jugular catheter tip projects over the mid to low SVC. A left\n internal jugular catheter tip projects over the midline in the brachiocephalic\n vein, unchanged. The feeding tube coils in the stomach with the tip beyond\n the inferior portion of the image. Bilateral parenchymal opacities are\n unchanged and likely represent a combination of pulmonary edema and\n atelectasis. There is probably a small left pleural effusion. No\n pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.\n\n IMPRESSION: Unchanged pulmonary edema and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-14 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1169083, "text": " 5:00 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: POSTPYLRORIC DOBHOFF for tube feeds\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64M with ETOH/HCV cirrhosis, transferred with decompensated liver failure\n REASON FOR THIS EXAMINATION:\n POSTPYLRORIC DOBHOFF for tube feeds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with alcohol and HCV cirrhosis transferred for\n decompensated liver failure.\n\n Post-pyloric Dobbhoff tube placement.\n\n FINDINGS: The patient had a Dobbhoff tube already in place by the time he\n entered the fluoroscopy suite, coiled within the body of the stomach. At this\n point, under fluoroscopic guidance, the tip of the Dobbhoff tube was advanced\n to a post-pyloric position. The tip position was confirmed with injection of\n Optiray contrast in the enteric feeding tube. The tip was seen at a location\n consistent with the third portion of the duodenum. At this point enteric tube\n was taped in place.\n\n IMPRESSION: Advancement of enteric tube into post-pyloric position likely\n projecting likely within the third portion of duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170277, "text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: CIRRHOSIS;ETOH WITHDRAWAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with liver cirrhosis; ? interval change\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:39 A.M., ON \n\n HISTORY: Cirrhosis, question interval change.\n\n IMPRESSION: AP chest compared to through 29:\n\n Large left pleural effusion has increased, moderate right pleural effusion and\n severe bibasilar atelectasis are stable. Heart size is normal. ET tube, left\n internal jugular line, right internal jugular line are in standard placements\n and a feeding tube passes into the stomach and out of view. No pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2166-01-14 00:00:00.000", "description": "Report", "row_id": 92504, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 215\nBSA (m2): 2.20 m2\nBP (mm Hg): 119/70\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Markedly dilated RV cavity. RV\nfunction depressed. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. TR present - cannot be quantified. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion. Ascites.\n\nConclusions:\n\n\n" }, { "category": "Echo", "chartdate": "2166-01-14 00:00:00.000", "description": "Report", "row_id": 92505, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 215\nBSA (m2): 2.20 m2\nBP (mm Hg): 119/70\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\n\n\n" } ]

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63 YO F w metastatic breast cancer p/w reaccumulated pleural effusion and dyspnea s/p pluerex catheter placement on the left. The patient's respiratory status worsened upon transfer to the intensive care unit and she was intubated. Goals of care discussion were ongoing and it was understood that the patient did not want to ventilated for a prolonged period. The patient was actively treated with antibiotics and also received pulse dose steroids for multiple days. There were no improvement in her symptoms. Pt respiratory condition worsened and she became more and more dependent on the ventilator. After 5 days on the ventilator, the family had another discussion with the primary team. It was understood that Ms was not going to improve in the short term and it was against her wishes to be ventilator dependent for a prolonged period of time. The patient was terminally extubated and she passed away on .

Extensive right pleural effusion with right basal atelectasis, mild left pleural effusion with retrocardiac atelectasis. PFI REPORT 1) Right IJ catheter in the mid to low SVC. As before, there is right upper lobe consolidation, large right and small left pleural effusions. FINDINGS: Right greater than left bilateral pleural effusions are unchanged in appearance with slight increase in degree of predominantly right upper and left lower lung opacities concerning for superimposed areas of pneumonia. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is unchanged; mediastinal and hilar lymphadenopathy is better appreciated on recent chest CT. A partially loculated large right pleural effusion is stable, but a moderate left pleural effusion is increased. IMPRESSION: Unchanged right greater than left pleural effusions with a slight increase in degree of widespread opacification concerning for pneumonia superimposed on malignancy features. STUDY: Right upper extremity venous ultrasound. COMPARISON: Chest radiograph of most recently . Interval development of moderate pulmonary edema and increased left effusion. The airways are patent to the segmental levels, but in the right middle and lower lobes, the middle lobar, right lower lobar, and bronchus intermedius are somewhat narrowed by circumferential soft tissue which may represent lymphadenopathy/metastatic disease. ONE VIEW OF THE CHEST: The lungs are low in volume and show a right middle and bilateral lower lobe opacities with right greater than left pleural effusions. Moderate pericardial effusion. There is unchanged appearance of left Port-A-Cath, right IJ catheter, endotracheal tube and nasogastric tube with incompletely visualized left possible PleurX catheter. Right mastectomy. Extensive right upper lobe opacities with diffuse air bronchograms. Right IJ catheter tip is at the cavoatrial junction. COMPARISON: Chest CTA on . Large right pleural effusion and small-to-moderate left pleural effusion are unchanged. Multiple dense vertebral bodies and ribs are consistent with recently discovered metastatic disease. A left chest port device has been accessed, and the catheter tip terminates in the unchanged position in the cavoatrial junction. Left pleural catheter placement appears satisfactory. Left upper and perihilar opacities have worsened from , but stable from the prior study. Left lower lobe retrocardiac atelectasis has worsened. There is a left chest port device, with the catheter terminating at the cavoatrial junction. Mild pulmonary edema. A left-sided Porta-catheter terminates in the distal SV/cavoatrial junction. Right greater than left pleural effusions are also again seen. Right IJ catheter tip remains at the cavoatrial junction. There is mild pulmonary edema. TECHNIQUE: MDCT helical acquisition was performed through the chest before and after the uneventful administration of IV contrast. The left Pleurx catheter is unchanged. A large multinodular thyroid goiter demonstrates substernal extent, and places slight mass effect on both the trachea and the esophagus. These consolidations somewhat mask the interstitial septal thickening and nodularity, especially in the right lower lobe. CTA CHEST WITH IV CONTRAST: The IV contrast bolus is adequate for assessment of pulmonary embolus. Since the previous tracing of atrial fibrillation isresolved. FINDINGS: Right upper lobe consolidation, loculated right pleural effusion, right lower lobe atelectasis, diffuse left pulmonary reticulonodular opacity probably representing the lymphangitic spread, and a small left pleural effusion are relatively unchanged since . Bilateral right greater than left pleural effusions are unchanged with a left pleural drain in place. Trivial mitral regurgitation is seen. Noaortic regurgitation is seen. FINDINGS: Right internal jugular catheter has been withdrawn and now is in the mid to low SVC. IMPRESSION: 1) Right IJ catheter in the mid to low SVC. There is moderate pulmonaryartery systolic hypertension. Prominentmoderator band/trabeculations are noted in the RV apex.AORTA: Normal aortic diameter at the sinus level. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. 3) Unchanged bilateral pleural effusions with increase in mild pulmonary edema. Mild mitralannular calcification. Mild [1+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is normal in size. Trivial pericardialeffusion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Stable small left pleural effusion with unchanged position of left Pleurx catheter. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Endotracheal tube, nasogastric tube, and left Port-A-Cath are unchanged in appearance. Sinus tachycardia, rate 120. Sinus tachycardia, rate 120. PATIENT/TEST INFORMATION:Indication: Shortness of breath.Height: (in) 62Weight (lb): 124BSA (m2): 1.56 m2BP (mm Hg): 118/72HR (bpm): 97Status: InpatientDate/Time: at 16:11Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Heart and mediastinum within normal limits. Compared to the previous tracing of therhythm is sinus. Stable right upper lobe consolidation. FINAL REPORT INDICATION: Right IJ line adjustment. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. There is a trivial/physiologic pericardialeffusion.Compared with the prior study (images reviewed) of , detectedpulmonary artery systolic hypertension is higher. Left-sided Pleurx catheter inserted. ST-T wave abnormalities are improved. Low precordial voltage. The bilateral multifocal areas of opacification persist with bilateral pleural effusions. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. The mitral valve leaflets are mildly thickened.There is no mitral valve prolapse. The left-sided Pleurx catheter has a circuitous course as it traverses the lateral chest wall, its tip is projected over the left retrocardiac space, the position is unchanged since . Sinus rhythm. Lines and tubes are unchanged in position. Thetricuspid valve leaflets are mildly thickened. Satisfactory position of medical devices. Normal tracing. Otherwise, normal tracing. Sclerotic appearance to the vertebral bodies is suggestive of metastatic disease. IMPRESSION: No change in right upper lobe, lingula, and left lower lobe pneumonia. The tips of the right internal jugular and left subclavian central venous catheters project over the lower SVC, the endotracheal tube tip is at the level of the clavicles, and the nasogastric tube tip is well below the diaphragm, not included in the field of view of the radiograph.

27

[ { "category": "Radiology", "chartdate": "2147-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163446, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pleural effusions and\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer w/ concern for lymphangitic\n spread and chronic malignant pleural effusions, with pneumonia and hypoxic\n respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pleural effusions and pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:47 PM\n Unchanged right greater than left pleural effusions with a slight increase in\n degree of widespread opacification concerning for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for change. Pleural effusion and pneumonia in patient\n with metastatic breast cancer and concern for lymphangitic spread of malignant\n effusion.\n\n TECHNIQUE: Portable supine radiograph of the chest.\n\n COMPARISON: Chest radiograph of most recently .\n\n FINDINGS: Right greater than left bilateral pleural effusions are unchanged\n in appearance with slight increase in degree of predominantly right upper and\n left lower lung opacities concerning for superimposed areas of pneumonia.\n There is unchanged appearance of left Port-A-Cath, right IJ catheter,\n endotracheal tube and nasogastric tube with incompletely visualized left\n possible PleurX catheter. Cardiomediastinal silhouette is unremarkable.\n\n IMPRESSION: Unchanged right greater than left pleural effusions with a slight\n increase in degree of widespread opacification concerning for pneumonia\n superimposed on malignancy features.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163447, "text": ", 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pleural effusions and\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer w/ concern for lymphangitic\n spread and chronic malignant pleural effusions, with pneumonia and hypoxic\n respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pleural effusions and pneumonia\n ______________________________________________________________________________\n PFI REPORT\n Unchanged right greater than left pleural effusions with a slight increase in\n degree of widespread opacification concerning for pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162812, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluation of Pulmonary process\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic Breast Ca to liver, lung spine s/p worsening\n lymphangitic spread to the lungs and intubation w/ possible overlying PNA\n REASON FOR THIS EXAMINATION:\n Evaluation of Pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic breast cancer with lymphangitic spread to the lungs.\n Superimposed pneumonia.\n\n COMPARISON: .\n\n SUPINE CHEST RADIOGRAPH: Lines and tubes are in unchanged position. There is\n no pneumothorax. The lungs are not significantly changed, particularly the\n right upper and left lower lobe opacities, loculated right-sided pleural\n effusion, right lower lobe atelectasis, diffuse left pulmonary reticular\n nodular opacity and small left-sided pleural effusion. The left Pleurx\n catheter is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1163078, "text": " 7:37 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: ? DVT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer, now with a more swollen right\n arm.\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 11:45 AM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with metastatic breast cancer, now with right arm\n swelling.\n\n STUDY: Right upper extremity venous ultrasound.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler son imaging was performed of\n the bilateral subclavian, right internal jugular, right axillary, right\n brachial, right basilic, and right cephalic veins. Normal compressibility,\n flow, and augmentation were demonstrated.\n\n IMPRESSION: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1163079, "text": ", 7:37 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: ? DVT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer, now with a more swollen right\n arm.\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-11 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1161838, "text": " 1:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: BREAST CA, TACHY, O2 REQUIREMENT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with breast cancer, recently found malignant pleural\n effusions, now with worsening oxygen requirement and persistent tachycardia\n REASON FOR THIS EXAMINATION:\n please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc MON 3:18 AM\n No evidence of pulmonary embolism to the segmental levels. Diffuse increase in\n opacification involving the entire right upper lobe, right middle lobe, and\n right lower lobe. In addition opacfication in the lef lower lobe, left upper\n lobe. Moderate loculated right pleural effusion increased since prior,\n moderate layering left effusion, increased since prior. Moderate pericardial\n effusion. Right mastectomy.\n\n Overall favor new infectious process with differential include atypical\n infections including fungal infection. An aspect of this opacity may also be\n related to radiation pneunomitis and disease burden.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female with breast cancer, malignant pleural effusions\n with worsening oxygen requirement and persistent tachycardia, evaluate for\n pulmonary embolus.\n\n COMPARISON: Chest CTA on .\n\n TECHNIQUE: MDCT helical acquisition was performed through the chest before\n and after the uneventful administration of IV contrast. Low-dose pre-contrast\n 5-mm collimation axial as well as post-contrast 2.5-mm axial images were\n reviewed as well as a series of reformation images.\n\n CTA CHEST WITH IV CONTRAST: The IV contrast bolus is adequate for assessment\n of pulmonary embolus. There is no evidence of pulmonary embolus to the\n subsegmental level on the right or in the left upper lobe, and no evidence of\n segmental PE in the left lower lobe.\n\n There has been interval significant increase in bilateral pleural effusions,\n somewhat loculated on the right and layering on the left. There is associated\n compressive atelectasis. There is new diffuse airspace consolidation, but\n especially in the right upper lobe, with a lesser degree in the right lower\n lobe and middle lobe. In the superior segment of the left lower lobe, there\n is also a new heterogeneous airspace consolidation. These consolidations\n somewhat mask the interstitial septal thickening and nodularity, especially in\n the right lower lobe. However, this suggests underlying lymphangitic spread\n of carcinomatosis.\n\n The patient has undergone remote right mastectomy. There is no axillary\n (Over)\n\n 1:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: BREAST CA, TACHY, O2 REQUIREMENT\n Admitting Diagnosis: PLEURAL EFFUSIONS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lymphadenopathy. However, mediastinal lymphadenopathy is confluent and\n extensive, making measurement of an individual node difficult. This is most\n pronounced in the subcarinal and bilateral hilar stations. The airways are\n patent to the segmental levels, but in the right middle and lower lobes, the\n middle lobar, right lower lobar, and bronchus intermedius are somewhat\n narrowed by circumferential soft tissue which may represent\n lymphadenopathy/metastatic disease.\n\n There is a left chest port device, with the catheter terminating at the\n cavoatrial junction. A large multinodular thyroid goiter demonstrates\n substernal extent, and places slight mass effect on both the trachea and the\n esophagus.\n\n Limited images of the upper abdomen demonstrate an apparent low-density left\n liver lesion measuring 2.9 x 2.5 cm (3:85).\n\n Osseous structures again demonstrate extensive metastatic disease throughout\n the thoracic spine, most pronounced in T1, T3, T5, T7, T9-L1, but also\n involving multiple ribs and the sternum.\n\n IMPRESSION:\n\n 1. New development of multifocal airspace consolidation, especially in right\n upper lobe representing pneumonia, likely explanation of increased O2\n requirement.\n\n 2. Increased bilateral pleural effusions, with loculation on the right, and a\n large left layering effusion causing compressive atelectasis.\n\n 3. Interstitial septal thickening and nodularity, especially in the right\n lower lobe as well as confluent adenopathy in the mediastinum and hila which\n is suspicious for lymphangitic spread of carcinomatosis.\n\n 4. Widespread metastatic disease in a pattern similar to two weeks ago,\n involving the bony thorax extensively and likely left lobe of the liver.\n\n Dr. the acute findings with Dr. at 3:15 a.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2147-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162068, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with malignant pleural effusions s/p pleurex \n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female with malignant pleural effusion and history of\n breast cancer.\n\n COMPARISON: Chest radiograph .\n\n SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour\n is unchanged; mediastinal and hilar lymphadenopathy is better appreciated on\n recent chest CT. A partially loculated large right pleural effusion is\n stable, but a moderate left pleural effusion is increased. Multifocal\n infectious consolidation which increased. However, perihilar opacities have\n increased in a pattern suggesting contribution by pulmonary edema. A left\n chest port device terminates with the catheter at the cavoatrial junction in\n unchanged position. Multiple dense vertebral bodies and ribs are consistent\n with recently discovered metastatic disease.\n\n IMPRESSION:\n\n 1. Increaed multifocal lung infection.\n\n 2. Interval development of moderate pulmonary edema and increased left\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163256, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in pneumonia and pleural\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer with chronic b/l malignant\n pleural effusions (also with Left pleurex), new RUL pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in pneumonia and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer with malignant effusions and right upper\n lobe pneumonia.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Monitoring and support devices remain in place. Multiple bilateral areas of\n opacification involving the right upper zone and left mid and lower zones\n persists, consistent with widespread pneumonia. Little overall change in the\n bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161958, "text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 63 yr old s/p pleurax catheter placement\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p pleurax catheter placement\n REASON FOR THIS EXAMINATION:\n 63 yr old s/p pleurax catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a 63-year-old female post-pleurx catheter placement, also\n history of breast cancer, malignant pleural effusion, new widespread pulmonary\n opacities.\n\n COMPARISON: CTA chest early the same morning and chest radiograph three days\n prior.\n\n SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is\n normal, with hilar and mediastinal lymphadenopathy better appreciated on CT\n performed earlier the same day. Multifocal widespread pulmonary opacities are\n worst in the right upper lobe, with lesser degrees in the superior segment of\n the left upper lobe, and at the right lung base. Right greater than left\n pleural effusions are also again seen. Left pleural catheter placement\n appears satisfactory. A left chest port device has been accessed, and the\n catheter tip terminates in the unchanged position in the cavoatrial junction.\n\n Osseous structures demonstrate extensive densities, which correlate with known\n blastic metastases.\n\n IMPRESSION: Post-left pleural catheter placement with otherwise no\n significant short interval change since CT chest earlier same morning.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162380, "text": " 6:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PLACEMENT OF CVL,ETT,OG TUBE S/P INTUBATION\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n Placement of CVL\n ______________________________________________________________________________\n WET READ: SPfc WED 8:54 PM\n Right IJ ends at the upper cavo-atrial junction. Left port-a-cath ends in the\n SVC. ETT ends 2.2cm above the carina. NG tube enters the stomach and extends\n beyond the field of view. There is no pneumothorax. As before, there is\n right upper lobe consolidation, large right and small left pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess lines and tubes.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Right IJ catheter tip is at the cavoatrial junction. ET tube tip is 2.5 cm\n above the carina. NG tube tip is coiled in the stomach. The tip is out of\n view. There is no pneumothorax. Multifocal consolidations and pleural\n effusions are unchanged. Cardiomediastinal silhouette is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161568, "text": " 5:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with dyspnea and hypoxia\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with dyspnea and hypoxia.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show a right middle and bilateral lower lobe\n opacities with right greater than left pleural effusions. The right\n suprahilar opacity is more prominent as compared to the prior exam. There is\n mild pulmonary edema. A left-sided Porta-catheter terminates in the distal\n SV/cavoatrial junction. Cardiac silhouette is difficult to assess due to\n adjacent pleural effusions, but is grossly stable.\n\n IMPRESSION:\n\n Right suprahilar opacity is more prominent, which could be secondary to\n increase in size of pulmonary mass/consolidation with superimposed edema.\n\n Right greater than left bilateral pleural effusions have increased since the\n prior exam.\n\n Bilateral lower lobe opacities may represent atelectasis with possible\n consolidation.\n\n\n Mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162255, "text": " 5:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression of pna\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with met breast ca, recurrent pleural effusion, and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for progression of pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Metastatic breast carcinoma, recent pleural effusion, evaluation\n of progression.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive right upper lobe opacities with diffuse air bronchograms.\n A similar pattern of opacity is noted around the left hilus and left upper\n lobe periphery. Extensive right pleural effusion with right basal\n atelectasis, mild left pleural effusion with retrocardiac atelectasis. The\n size of the cardiac silhouette is unchanged. No newly appeared focal\n parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162411, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube/line placement, interval change\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman intubated with resp failure\n REASON FOR THIS EXAMINATION:\n eval for tube/line placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure, intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is in standard position, 4.2 cm above the carina. NG tube tip is\n out of view below the diaphragm. Right IJ catheter tip remains at the\n cavoatrial junction. There is no pneumothorax. Cardiomediastinal contours\n are unchanged. Large right pleural effusion and small-to-moderate left\n pleural effusion are unchanged. Right upper lobe consolidation and right\n lower lobe opacities are stable. Left upper and perihilar opacities have\n worsened from , but stable from the prior study. Left lower lobe\n retrocardiac atelectasis has worsened. Left central catheter remains in\n place.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162514, "text": ", 2:18 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval RIJ placement.\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer.\n REASON FOR THIS EXAMINATION:\n please eval RIJ placement.\n ______________________________________________________________________________\n PFI REPORT\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162620, "text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assessment of plueral effusions, PNA\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with Metastatic Breast Ca to spine liver and lung w/\n worsening lymphangitic spread to lung seen on CT, worsening pleural effusions\n s/p pluerex on Lt as well as possible PNA now intubated\n REASON FOR THIS EXAMINATION:\n Assessment of plueral effusions, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic breast carcinoma to lungs (with lymphangitic spread),\n spine, and liver. Left-sided Pleurx catheter inserted. Evaluate for\n effusions and pneumonia.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Right upper lobe consolidation, loculated right pleural effusion,\n right lower lobe atelectasis, diffuse left pulmonary reticulonodular opacity\n probably representing the lymphangitic spread, and a small left pleural\n effusion are relatively unchanged since . The tips of the right\n internal jugular and left subclavian central venous catheters project over the\n lower SVC, the endotracheal tube tip is at the level of the clavicles, and the\n nasogastric tube tip is well below the diaphragm, not included in the field of\n view of the radiograph. The left-sided Pleurx catheter has a circuitous\n course as it traverses the lateral chest wall, its tip is projected over the\n left retrocardiac space, the position is unchanged since .\n\n IMPRESSION:\n 1. Stable small left pleural effusion with unchanged position of left Pleurx\n catheter.\n 2. Diffuse left pulmonary reticulonodular opacity likely reflects\n lymphangitic spread.\n 3. Stable right upper lobe consolidation.\n 4. Satisfactory position of medical devices.\n\n" }, { "category": "Radiology", "chartdate": "2147-12-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1162513, "text": " 2:18 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval RIJ placement.\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer.\n REASON FOR THIS EXAMINATION:\n please eval RIJ placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:37 PM\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ line adjustment.\n\n TECHNIQUE: Semi-upright portable radiograph of the chest.\n\n COMPARISON: Multiple chest radiographs most recently at\n 0:33 hours.\n\n FINDINGS: Right internal jugular catheter has been withdrawn and now is in the\n mid to low SVC. Endotracheal tube, nasogastric tube, and left Port-A-Cath are\n unchanged in appearance. Bilateral diffuse opacities have increased in\n density. Bilateral right greater than left pleural effusions are unchanged\n with a left pleural drain in place. Sclerotic appearance to the vertebral\n bodies is suggestive of metastatic disease. Patient is status post right\n mastectomy. Hazy opacity throughout both lungs is suggestive of some degree\n of pulmonary vascular congestion or edema.\n\n IMPRESSION:\n 1) Right IJ catheter in the mid to low SVC.\n 2) Worsening bilateral diffuse consolidation.\n 3) Unchanged bilateral pleural effusions with increase in mild pulmonary\n edema.\n\n These findings were relayed by Dr. to Dr. at 15:10 on .\n\n" }, { "category": "Radiology", "chartdate": "2147-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163045, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. The bilateral multifocal areas of opacification\n persist with bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162940, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in RUL infiltrate and pl\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer with possible lymphangitic\n spread, with worsening hypoxic respiratory failure secondary to possible\n lymphangitic spread, PNA, and pleural effusions\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in RUL infiltrate and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, .\n\n CLINICAL INFORMATION: Interval change, right upper lobe infiltrate,\n respiratory failure, pneumonia.\n\n Comparison is made to multiple prior examinations.\n\n There is little appreciable change. There is multifocal airspace\n opacification, right upper lobe, lingula, and left lower lobe.\n\n Lines and tubes are unchanged in position. Heart and mediastinum within\n normal limits.\n\n IMPRESSION:\n\n No change in right upper lobe, lingula, and left lower lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163018, "text": " 5:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? worsening pleural effusion or pneumonia\n Admitting Diagnosis: PLEURAL EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with metastatic breast cancer to the lungs intubated due to\n hypoxia now with worsening WBC\n REASON FOR THIS EXAMINATION:\n ? worsening pleural effusion or pneumonia\n ______________________________________________________________________________\n WET READ: AJy SUN 8:59 PM\n little interval chnage in multifocal airspace opacities and loculated right\n pleural effusion. lines and tubes similarly stable.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer with worsening WBC.\n\n FINDINGS: In comparison with the study of earlier in the date, there is\n little change. Monitoring and support devices remain in place. Multifocal\n areas of consolidation are again seen bilaterally along with the bilateral\n pleural effusions better seen on the CT of .\n\n\n" }, { "category": "Echo", "chartdate": "2147-12-12 00:00:00.000", "description": "Report", "row_id": 90207, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 62\nWeight (lb): 124\nBSA (m2): 1.56 m2\nBP (mm Hg): 118/72\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 16:11\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , detected\npulmonary artery systolic hypertension is higher. Trivial pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2147-12-13 00:00:00.000", "description": "Report", "row_id": 237867, "text": "Artifact is present. Sinus tachycardia. Otherwise, normal tracing. Compared\nto the previous tracing there is no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-11 00:00:00.000", "description": "Report", "row_id": 237868, "text": "Sinus tachycardia, rate 120. Compared to tracing #1 there is no diagnostic\ninterval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-12-10 00:00:00.000", "description": "Report", "row_id": 237869, "text": "Sinus tachycardia, rate 120. Poor R wave progression in leads V1-V3. Compared\nto the previous tracing of , except for the increase in rate, there is\nno other diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-08 00:00:00.000", "description": "Report", "row_id": 237870, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrhythm is sinus. There is no evidence of a bypass tract on the current\ntracing.\n\n" }, { "category": "ECG", "chartdate": "2147-12-18 00:00:00.000", "description": "Report", "row_id": 237864, "text": "Baseline artifact. Sinus tachycardia. Low precordial voltage. Late R wave\nprogression. Since the previous tracing of atrial fibrillation is\nresolved. ST-T wave abnormalities are improved.\n\n" }, { "category": "ECG", "chartdate": "2147-12-15 00:00:00.000", "description": "Report", "row_id": 237865, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the rhythm has changed.\n\n" }, { "category": "ECG", "chartdate": "2147-12-14 00:00:00.000", "description": "Report", "row_id": 237866, "text": "Artifact is present. Sinus tachycardia. Atrial and ventricular ectopy.\nCompared to the previous tracing ectopic beats are new.\nTRACING #2\n\n" } ]

11,242

116,244

The patient was admitted and treated for diabetic ketoacidosis. She was begun on an insulin drip and eventually weaned to subcutaneous insulin. She received aggressive IV fluid and electrolyte repletion. No precipitating event was elucidated for her diabetic ketoacidosis. A repeat chest x-ray revealed a small right pleural effusion of unclear etiology. She was discharged to home in good condition.

Left atrialabnormality. Baseline artifact. Technically limited study. Vertical axis. Compared to the previous tracing of there is no significant change.

1

[ { "category": "ECG", "chartdate": "2147-02-22 00:00:00.000", "description": "Report", "row_id": 308741, "text": "Technically limited study. Sinus tachycardia. Vertical axis. Left atrial\nabnormality. Baseline artifact. Compared to the previous tracing of \nthere is no significant change.\n\n" } ]

25,019

171,458

This is an 87 y.o. male with multi-infarct dementia who presented with 1 week of failure-to-thrive (decreased po intake, lethargy, more frequent falls, unwillingness to ambulate). U/A positive for increased WBC, gram positive organisms = Coag pos Staphlococcus. Left hip ulcer positive for multiple organisms. Mental status in setting of end-stage multi-infarct dementia, h/o neurosyphyllis, infection: Patient's mental status has improved slightly during this admission, as he is more alert and sometimes responsive to direct questioning, with treatment of underlying infections, electrolyte disturbances (hypernatremia on admission to 156) and aggressive nutrition and augmentation with TPN. His overall prognosis, however, remains extremely poor given overwhelming infection in the setting of end stage dementia. His ulcer has improved from a Grade4 ulcer to a Grade 3, still with ulcer to muscle. It has not improved over the past week and surgical options are limited given poor nutritional state/overall poor prognosis. His UTI has been treated with levofloxacin and levo has been maintained because of overwhelming infection. It is likely that his infection is static given no real change in fevers, leukocytosis but complete resolution of infection is unlikely. He appears to be at his baseline mental status which is alert and sometimes responsive to direct questioning with simple one-word answers

A final chest x-ray was obtained. A final chest x-ray was obtained. A final chest x-ray was obtained. A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. The PICC was trimmed to length and a 4 FR introducer sheath under fluoroscopic guidance into the superior vena cava. A .018 guidewire was advanced under fluoroscopy into the superior vena cava. A Stat-Lock was applied and the line was heplocked. The film demonstrates the tip to be in the lower superior vena cava, ready for use. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance into the superior vena cava. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. Since no suitable superficial veins were visible ultrasound was used for localization of a suitable vein. Hard copies of ultrasound images were obtained documenting patent vein before and after establishing an access. PROCEDURE: The procedure was performed by Drs. Needs PICC line for intravenous antibiotics. Patient needs IV line for antibiotics and TPN. Hard copy images of ultrasound scan were obtained documenting patent vein before and after establishing an access. A repeat tracing of diagnostic quality issuggested. pt is a full code.dispo-> ?transfer to medicine later today. After local anesthesia with 2 ml of 1% lidocaine the brachial vein was entered under ultrasonographic guidance with a 21 gauge needle. also of note, the pt's hypotension resolved s/p the transfusion of 2u prbc's.review of systemsrespiratory-> lung sounds diminished d/t a poor respiratory effort. The PICC line was trimmed to length and advanced over a 5 French introducer sheath under fluoroscopic guidance into the superior vena cava. FINAL REPORT HISTORY: This is a patient with osteomyelitis. currently, sbp ranging 90-110's s/p blood transfusion.neuro-> intermittently agitated and combative. After local anesthesia with 2 ml of 1% lidocaine, the basilic vein was entered under ultrasonographic guidance with a 21 gauge needle. The film demonstrates the tip to be in the superior vena cava. After local anesthesia with 3 ml of 1% Lidocaine, the right brachial vein was entered under ultrasound guidance with a 21 gauge needle. Admitting Diagnosis: FAILURE TO THRIVE ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. RADIOLOGISTS: Procedure was performed by Drs. The left upper arm was prepped in a sterile fashion. 1:11 PM PICC LINE PLACMENT SCH Clip # Reason: need for abx/TPN Admitting Diagnosis: FAILURE TO THRIVE ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 87 year old man with end stage dementia/FTT, urosepsis REASON FOR THIS EXAMINATION: need for abx/TPN FINAL REPORT INDICATION: 87 year old male with urosepsis requiring antibiotics and TPN. PHYSICIANS: The procedure was performed by Drs. The right arm was prepped and draped in the usual sterile fashion. A Stat-Lock was applied and the line was hep-locked. , , and , with Dr. attending physician present and supervising. IMPRESSION: Successful placement of a 45 cm long PICC line with tip in the superior vena cava, ready for use. the pt is currently restrained w/mitts in place. he is severely contracted but able to move his ue's.gi-> abd is soft, nontender w/+bs. and with Dr. (attending radiologist) being present and supervising throughout the procedure. The catheter was flushed. The catheter was flushed. The catheter was flushed. IMPRESSION: Successful placement of 47 cm total length double lumen PICC line with tip in the superior vena cava, ready for use. The brachial vein was patent and compressible. he is receiving free water repletion via a d5 infusion.heme-> morning hct ~30 s/p 2u prbc's. PROCEDURE AND FINDINGS: The patient was placed supine on the angiography table and his right arm was prepped in sterile fashion. Based on the markers on the guidewire, it was determined that a length of 47 cm would be suitable. Dr. , the attending radiologist, was present and supervising throughout the procedure. IMPRESSION: Successful placement of a 55 cm long PICC line with tip in the superior vena cava, ready for use. TECHNIQUE AND FINDINGS: The patient was placed supine on the angiography table. The sheath was removed. The sheath was removed. The sheath was removed. after he made several attempts to pull out his central line, he was restrained and mitts were applied for his own safety. 9:51 AM PICC LINE PLACMENT SCH Clip # Reason: iv abx. ACCESS C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** MEDICAL CONDITION: 87 year old man with end stage dementia/FTT, urosepsis/osteomyletis--iv abx REASON FOR THIS EXAMINATION: iv abx. pt is maintaining sats >96% on room air.cardiac-> hr 60-70's, sr w/no noted ectopy. The basilic vein was patent and compressible. pt did take his po meds last evening w/o incident.gu-> uop is adequate; the pt is ~3.5 liters tfb positive d/t aggressive fluid/volume repletion.f/e-> pt is hypernatremic but his sodium level is slowly coming down.

6

[ { "category": "Nursing/other", "chartdate": "2136-07-23 00:00:00.000", "description": "Report", "row_id": 1588595, "text": "pmicu npn 7p-7a\n\n\n the pt was intermittently agitated and combative this morning. after he made several attempts to pull out his central line, he was restrained and mitts were applied for his own safety. when left alone, he is calm, but the restraints remain in place. also of note, the pt's hypotension resolved s/p the transfusion of 2u prbc's.\n\nreview of systems\n\nrespiratory-> lung sounds diminished d/t a poor respiratory effort. pt is maintaining sats >96% on room air.\n\ncardiac-> hr 60-70's, sr w/no noted ectopy. currently, sbp ranging 90-110's s/p blood transfusion.\n\nneuro-> intermittently agitated and combative. the pt is currently restrained w/mitts in place. he is alert but demented and unable to consistently follow commands. he is severely contracted but able to move his ue's.\n\ngi-> abd is soft, nontender w/+bs. -bm. tolerating soft solids. pt did take his po meds last evening w/o incident.\n\ngu-> uop is adequate; the pt is ~3.5 liters tfb positive d/t aggressive fluid/volume repletion.\n\nf/e-> pt is hypernatremic but his sodium level is slowly coming down. he is receiving free water repletion via a d5 infusion.\n\nheme-> morning hct ~30 s/p 2u prbc's. there have been no overt signs of any active bleeding.\n\naccess-> #18g angio in the right arm and a right ij tl are aptent and intact.\n\nsocial-> pt's dtr stayed in the waiting area. another dtr and son visited late last noc. children were encouraged to elect a spokesperson since the family is large. in addition, the family may benefit from a social work consult since 2 of the dtrs are caring for each parent separately, and both parents appear to be significantly impaired. pt is a full code.\n\ndispo-> ?transfer to medicine later today.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-07-22 00:00:00.000", "description": "Report", "row_id": 1588594, "text": "MICU Nursing Admit Note 1800-1900\n\n87 yo man admit from home, demented, emaciated, numerous contractures, and pressure sores on lower extrem, brought to ED today for no po's for 24hrs.\n\nPMH: dementia,+RPR, h/o ETOH abuse, CAD, MI, failure to thrive,\n\nSOCIAL: lives with dtr has been his caretaker for ~20years\n\nALLERGIES: valium, ace inhibitor(angio edema)\n\nREVIEW OF SYSTEMS:\nNEURO: arrived to MICU alert orient to person, answer simple yes/no question, mental status wax/wane to mumbling incoherently, multiple contractures.\nCV: HR 60-70 SR, BP 90-100/, recieved 3L NS bolus in ED\nRESP: RR 14-18 nonlabored, breath sounds decreased\nID: temp 98 pr, wbc 8.5, fully cultured in ED, +UTI, given IV levaquin and vanco in ED\nGI: abd soft +bs\nGU: foley with cloudy yellow urine\nF/E: Na 156, free water repletion with D5W at 60cc/hr\nHEME: hct 26, type/cross send to be transfused\nSKIN: left hip with 4cmx5cm stage 2-3 douderm applied, pressure sores between knees and bony prominences where legs are rubbing\nACCESS: #18, RIJ triple lumen\nSOCIAL: lives with dtr\n\nPLAN: supportive care, replete free water deficit, palliative care consult, social work consult.\n\n" }, { "category": "Radiology", "chartdate": "2136-08-03 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 832113, "text": " 1:11 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: need for abx/TPN\n Admitting Diagnosis: FAILURE TO THRIVE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with end stage dementia/FTT, urosepsis\n REASON FOR THIS EXAMINATION:\n need for abx/TPN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 year old male with urosepsis requiring antibiotics and TPN.\n\n PROCEDURE:\n\n The procedure was performed by Drs. , , and , with Dr. \n attending physician present and supervising. The right arm was prepped and\n draped in the usual sterile fashion. Since no suitable superficial veins were\n visible, ultrasound was used for localization of a suitable vein. The basilic\n vein was patent and compressible. After local anesthesia with 2 ml of 1%\n lidocaine, the basilic vein was entered under ultrasonographic guidance with a\n 21 gauge needle. A .018 guidewire was advanced under fluoroscopy into the\n superior vena cava. Based on the markers on the guidewire, it was determined\n that a length of 47 cm would be suitable. The PICC was trimmed to length and\n a 4 FR introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final chest x-ray\n was obtained. The film demonstrates the tip to be in the lower superior vena\n cava, ready for use.\n\n A Statlock was applied and the line was locked.\n\n IMPRESSION:\n\n Successful placement of 47 cm total length double lumen PICC line with tip in\n the superior vena cava, ready for use.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2136-08-15 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 833327, "text": " 9:51 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: iv abx.\n Admitting Diagnosis: FAILURE TO THRIVE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with end stage dementia/FTT, urosepsis/osteomyletis--iv abx\n\n REASON FOR THIS EXAMINATION:\n iv abx.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a patient with osteomyelitis. Needs PICC line for intravenous\n antibiotics.\n\n RADIOLOGISTS: Procedure was performed by Drs. and \n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n TECHNIQUE AND FINDINGS: The patient was placed supine on the angiography\n table. The left upper arm was prepped in a sterile fashion. Since no suitable\n superficial veins were visible ultrasound was used for localization of a\n suitable vein. The brachial vein was patent and compressible. After local\n anesthesia with 2 ml of 1% lidocaine the brachial vein was entered under\n ultrasonographic guidance with a 21 gauge needle. Hard copies of ultrasound\n images were obtained documenting patent vein before and after establishing an\n access. A 0.018 guidewire was advanced under fluoroscopy into the superior\n vena cava. Based on the markers on the guide wire it was determined that the\n length of 55 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed. The catheter was flushed. A\n final chest x-ray was obtained. The film demonstrates the tip to be in the\n superior vena cava. The line is ready for use. A Stat-Lock was applied and the\n line was heplocked.\n\n IMPRESSION: Successful placement of a 55 cm long PICC line with tip in the\n superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2136-07-26 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 831298, "text": " 11:15 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: double lumen, could not be placed at bedside\n Admitting Diagnosis: FAILURE TO THRIVE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with urosepsis and failure to thrive\n REASON FOR THIS EXAMINATION:\n double lumen, could not be placed at bedside\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decubitus ulcer with osteomyelitis. Patient needs IV line for\n antibiotics and TPN. IV team could not advance PICC line at bedside.\n\n PHYSICIANS: The procedure was performed by Drs. and \n with Dr. (attending radiologist) being present and supervising\n throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiography table\n and his right arm was prepped in sterile fashion. Since no suitable\n superficial veins were visible, ultrasound was used for localization of a\n suitable vein. After local anesthesia with 3 ml of 1% Lidocaine, the right\n brachial vein was entered under ultrasound guidance with a 21 gauge needle.\n Hard copy images of ultrasound scan were obtained documenting patent vein\n before and after establishing an access. A 0.018 guidewire was advanced under\n fluoroscopy into the superior vena cava. Based on the markers on the guidewire\n it was determined that a length of 45 cm would be suitable. The PICC line was\n trimmed to length and advanced over a 5 French introducer sheath under\n fluoroscopic guidance into the superior vena cava. The sheath was removed. The\n catheter was flushed. A final chest x-ray was obtained. The film demonstrates\n the tip to be in the superior vena cava just above the atrium. The line is\n ready for use. A Stat-Lock was applied and the line was hep-locked. There\n were no immediate complications.\n\n IMPRESSION: Successful placement of a 45 cm long PICC line with tip in the\n superior vena cava, ready for use.\n\n" }, { "category": "ECG", "chartdate": "2136-07-22 00:00:00.000", "description": "Report", "row_id": 313410, "text": "The tracing is marred by baseline artifact precluding adequate interpretation.\nThe limb leads appear misattached. A repeat tracing of diagnostic quality is\nsuggested.\n\n" } ]

66,710

184,546

Respiratory symptoms: Cough, URI symptoms since 1-2 weeks. Patient denies noticing any dyspnea, but desatting to 80s off BIPAP. Leukocytosis, but afebrile, no tachycardia. Mets SIRS criteria. Was placed on CAP coverage and diuresed for suspected new onset CHF (BNP ), eventually broadened to vanc/cefepime and placed on a lasix gtt. Over the course of the admission, we were unable to wean the patient from bipap; he would desaturate into the low 80s/high 70s whenever on 100% FiO2 face mask. He remained tachypneic with increased work of breathing on the bipap machine with a PEEP of 10. His chest xray showed continued interval progression of his lung pathology, with worsening multifocal infiltrates and probable development of ARDS. The patient remained DNR/DNI throughout. A family meeting was held to discuss goals of care; at that point, we felt that we either needed to pursue intubation with full therapeutic management (ARDSnet volumes, aggressive suctioning for secretions, etc) or be made CMO as he was approaching 4 days on bipap without any improvement and was already maximized on other therapies. Ultimately, on the family decided in conjunction with the patient to make him CMO. He was placed on a morphine gtt and actually maintained on the bipap until his whole family arrived. Eventually, the morphine gtt was increased and his bipap was removed. He expired peacefully on at 8:15pm.

Mild mitral annularcalcification. Moderate (2+) mitral regurgitationis seen. There is nopericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.Moderate mitral regurgitation. Regular supraventricular tachycardia. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild regional LVsystolic dysfunction. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level. There is mild symmetric leftventricular hypertrophy with normal cavity size. Mild [1+]TR. There is mild regional leftventricular systolic dysfunction with basal inferior akinesis and mid-inferiorhypokinesis. There is moderate pulmonary artery systolic hypertension. Themitral valve leaflets are mildly thickened. Atrial premature beats. Sinus rhythm. Sinus rhythm. Sinus rhythm. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Compared to the previous tracing of the rate has slowed and therhythm is more clearly sinus. Calcified tips of papillary muscles. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Left bundle-branch block. Low limb leadvoltage. Moderate pulmonary hypertension.Compared with the prior study (images reviewed) of , inferiorhypokinesis is new and mitral regurgitation is more prominent. Left bundle-branchblock. Compared to the previous tracing of atrial fibrillation is new. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Compared to theprevious tracing of there is no significant change.TRACING #1 Hypertension.Height: (in) 72Weight (lb): 205BSA (m2): 2.15 m2BP (mm Hg): 131/63HR (bpm): 114Status: InpatientDate/Time: at 11:06Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Probable atrial fibrillation with a rapid ventricularresponse. Compared to the previous tracing of therhythm has changed.TRACING #3 Rightventricular chamber size and free wall motion are normal. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- akinetic; mid inferior - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Atrial fibrillation with a rapid ventricular response. The remaining segments contract normally (LVEF = 45%). Compared to theprevious tracing of the same date there is no significant change.TRACING #2 PATIENT/TEST INFORMATION:Indication: Abnormal ECG. compared tothe previous tracing of the same date the rhythm has changed.TRACING #4 Coronary artery disease. If clinically indicated, a repeat tracingmay better clarify the rhythm. Artifact is present. Artifact is present. Artifact is present. Congestive heart failure.

7

[ { "category": "Echo", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 104698, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Congestive heart failure. Coronary artery disease. Hypertension.\nHeight: (in) 72\nWeight (lb): 205\nBSA (m2): 2.15 m2\nBP (mm Hg): 131/63\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 11:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. There is mild regional left\nventricular systolic dysfunction with basal inferior akinesis and mid-inferior\nhypokinesis. The remaining segments contract normally (LVEF = 45%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nModerate mitral regurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , inferior\nhypokinesis is new and mitral regurgitation is more prominent. Findings\ndiscussed with Dr. at 1351 hours.\n\n\n" }, { "category": "ECG", "chartdate": "2198-01-28 00:00:00.000", "description": "Report", "row_id": 310424, "text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch\nblock. Compared to the previous tracing of atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2198-01-27 00:00:00.000", "description": "Report", "row_id": 310425, "text": "Sinus rhythm. Atrial premature beats. Left bundle-branch block. Low limb lead\nvoltage. Compared to the previous tracing of the rate has slowed and the\nrhythm is more clearly sinus.\n\n" }, { "category": "ECG", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 310426, "text": "Regular supraventricular tachycardia. Left bundle-branch block. compared to\nthe previous tracing of the same date the rhythm has changed.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2198-01-26 00:00:00.000", "description": "Report", "row_id": 310427, "text": "Artifact is present. Probable atrial fibrillation with a rapid ventricular\nresponse. Left bundle-branch block. If clinically indicated, a repeat tracing\nmay better clarify the rhythm. Compared to the previous tracing of the\nrhythm has changed.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2198-01-25 00:00:00.000", "description": "Report", "row_id": 310428, "text": "Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing of the same date there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2198-01-25 00:00:00.000", "description": "Report", "row_id": 310429, "text": "Artifact is present. Sinus rhythm. Left bundle-branch block. Compared to the\nprevious tracing of there is no significant change.\nTRACING #1\n\n" } ]

25,385

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She was admitted to the hospital, to the Intensive Care Unit bed. Vascular consult and medical consults were requested. She was seen by vascular surgery who recommended that she continue on subcutaneous heparin and have a Venodyne placed on the right lower extremity. The left lower extremity was to be elevated. She was to have an inferior vena cava filter placement. The medical consult did recommend coverage with antibiotics due to her elevated temperature, prior history of infection. She was started on Ceftriaxone, Gentamycin, Vancomycin and Meropenem while the cultures were pending. It was also requested that infectious disease be consulted. On , she was brought to the operating room for placement of an inferior vena cava filter. She tolerated this procedure well. Postoperatively, she was seen by infectious disease who felt that she did likely not have a pseudomonas pneumonia. She did have signs consistent with a urinary tract infection and, therefore, it was recommended that the Foley be changed and repeat urinalysis and urine culture were sent. They also recommended a dermatology consult for some bulbous formation on her left hip region. She continued to be monitored in the Intensive Care Unit. Her vital signs were stable. Her temperature did come down. She was able to be transferred to the floor on . Due to a falling hematocrit of 27, she did receive a unit of packed red blood cells on after her hematocrit rose to 33. She was restarted on her tube feedings and tolerated these well. Neurologically, she continued to be at her baseline. Infectious disease did continue to follow and on a chest CAT scan, on , this showed a new right lower lobe consolidation. All urine cultures showed yeast but grew out no bacteria. She was continued only on the Gentamycin and the other antibiotics were stopped. Dermatology did see the patient for the blisters, primarily on the left hip region and felt these were likely due to friction and pressure and recommended local wound care. The infectious disease team checked on the chest CT with cardiologist and felt that the picture was most consistent with atelectasis, and therefore, recommended that the Gentamycin could be discontinued. She continued to be afebrile with stable vital signs and neurologically stable. She will be transferred to rehabilitation hospital when a bed is available.

cxr on admission is c/w a rll infiltrate and the pt did receive abx coverage.cardiac-> hemodynamically stable. Within the right lower lobe, there has been interval development of new consolidation with air bronchograms present. RLQ suture line C&D. the pt remains on full code.dispo-> ?transfer to the floor or possibly back to s/p filter placement. NPN 0700-1900Events: Pt to OR for IVC filter placement for L DVT.Neuro: Only response to pain - opens eyes. In the imaged portion of the upper abdomen, again identified are hepatic cysts, stable since the prior study. TECHNIQUE: Helically aquired contiguous axial images were obtained from the lung apices to the lung bases before and after the administration of 100 cc of IV Optiray. S/p right IJ CVL. A tracheostomy is again noted. NPO except po meds. The visualized portion of the spleen, kidneys, adrenal glands, and stomach appear within normal limits. g-tube in place although enteral feeding is on hold pnding filter placement. The heart appears to be within normal limits as far as can be judged on portable examination. Respiratory CarePt. urine u/a c+s sent. The airways are patent to the level of segmental bronchi bilaterally. Tiny punctate calcification is noted within the pancreas, unchanged since the prior exam. Tracheostomy tube in stable position. sbp ranging 100-120's.neuro-> pt withdraws to painful stimuli and will open her eyes to noxious stimuli only. New devlopment of right lower lobe consolidation. The right sided plate atelectasis appears rather unchanged. left flank blisters some have burst.cleansed and covered with opsite. PLAN IS TO CONT ON TRACH MASK VENTILATION WITH TRANSFER BACK TO . The right lung a plate atelectasis is seen probably involving the right middle lobe area. Tracheal cannula is in place. BP 94-122/49-67. A tracheostomy tube is seen within the trachea, in stable position. Status post IVC filter placement. this is apparently the pt's baseline.gi-> abd is soft, nontender w/+bs. -bm overnoc.gu-> foley is patent and intact. R groin insertion site for IVC filter, site C&D. +500mls today.Skin: Head suture line C&D. PA AND LATERAL CHEST: AP single view portable exam has been obtained with the patient in supine position. Pupils < equal, R < L. PRL.CV: HR 80s-90s, nsr, no ectopy. Received Fentanyl 50mcg, Versed 1 mg, Kefzol 2gms and 400mls fld in OR.ID: Afebrile. Again seen are prominent lymph nodes within the prevascular and precarinal regions, which are slightly decreased in size since the prior study, and none of which meet CT criteria for pathologic enlargement. the pt was eventually after difficulty weaning from ventilatory support and a g-tube was placed as well. PT RETURNED AFTER 2HRS AT FOR LRG DVT IN LOWER EXTREMETY. Airway is paatent Available for comparison is a previous chest examination obtained on . Resp Carept was suctioned for small amts of thick yellow. the pt is receiving maintainence fluids. 2:39 PM OR VASCULAR A-GRAM Clip # Reason: IVC FILTER, DVT Admitting Diagnosis: SUBARACHNOID HEMORRHAGE ********************************* CPT Codes ******************************** * PERCU PLCT IVC FILTER S&I VENOGRAPHY IVC S&I * **************************************************************************** FINAL REPORT For complete report please see operative note in CareWeb Clinical Lookup. CT CHEST W/O&W IV CONTRAST: The pulmonary arterial vasculature is well visualized down to the segmental branches. Parenchymal densities in the left lower lobe exists could represent aspiration pneumonitis. IMPRESSION: Atelectasis right base; cannot rule out superimposed pneumonia here. L DVT: L leg elevated without venodyne boot. There are parenchymal densities in the left lower lung in retrocardiac position obliterating partially the diaphragmatic contour as well as that of the descending aorta. Nonionic contrast was used secondary to the rapid bolus requirement needed per protocol. +corneal reflexes, +gag. Movement noted in UE bilat, and RLL, not in LLL. IMPRESSION: Improved atelectasis at the right base. from antibiotics. 2) Interval improvement in consolidation within the left lower lobe. Tracheal cannula was in place already at that time. FOR IVC FILTER, AND WILL RETURN TO THE ICU FOLLOWING PROCEDURE. hr 80-90's, sr w/no noted ectopy. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in delineating the absence of a pulmonary embolism. return to rehab or transfer out to floor today. There continues to be left lower lobe consolidation, which appears slightly improved since the prior study. she was suctioned x1 for a mod amt of thick, tan sputum. PT CURRENTLY IN O.R. coccyx rash noted cleansed and zinc cream applied..plan : ? Pt receiving 75mls/hr IV NS. no stools.integ blister noted on right flank intact. There is poor definition of the left hemidiaphragm, without significant chagne from prior films. There is slight improvement in the atelectatic changes at the right base since . Multiplanar reconstructions were performed. due to her recent head bleed, the decision was made not to anticoagulate overnoc.pmh: hypothyroidism; ^chol; sah s/p craniotomy and clipping; s/p trach; s/p g-tubeallergies: amoxicillin; ?vancomycinreview of systemsrespiratory-> pt is and receiving 40% o2 via a trach mask. (Over) 9:54 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) IMPRESSION: 1) No CT evidence of pulmonary embolism.

11

[ { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593618, "text": "pmicu nsg admision/progress note 1a-7a\n\n\n the pt is an unfortunate 57yow woman who was initially admitted to on with a sah secondary to aneurysms and is s/p a craniotomy and clipping. the hospital course was c/b persistent fevers, treatment for pseudonomas pnx, evacuation of an epidural fluid collection, and a possible drug rash d/t vancomycin. the pt was eventually after difficulty weaning from ventilatory support and a g-tube was placed as well. she was transferred from to on and returned to the ew just two hours later after a left le dvt was discovered at the rehab. the pt was subsequently transferred to the micu for observation and will undergo an ivc filter placement by vascular surgery later today. due to her recent head bleed, the decision was made not to anticoagulate overnoc.\n\npmh: hypothyroidism; ^chol; sah s/p craniotomy and clipping; s/p trach; s/p g-tube\n\nallergies: amoxicillin; ?vancomycin\n\nreview of systems\n\nrespiratory-> pt is and receiving 40% o2 via a trach mask. rr 20's, nonlabored while maintaining sats >97%. she was suctioned x1 for a mod amt of thick, tan sputum. she has an excellent cough and is able to expectorate most of the sputum from her trach. cxr on admission is c/w a rll infiltrate and the pt did receive abx coverage.\n\ncardiac-> hemodynamically stable. hr 80-90's, sr w/no noted ectopy. sbp ranging 100-120's.\n\nneuro-> pt withdraws to painful stimuli and will open her eyes to noxious stimuli only. perrl @ 6mm. +corneal reflexes, +gag. no movement of extremities noted. this is apparently the pt's baseline.\n\ngi-> abd is soft, nontender w/+bs. g-tube in place although enteral feeding is on hold pnding filter placement. the pt is receiving maintainence fluids. -bm overnoc.\n\ngu-> foley is patent and intact. urine is yellow w/^sediment. uop is adequate.\n\nid-> tmax on admission to the ew was 101; the pt was in the ew and received iv abx coverage.\n\naccess-> #20g angio in the left hand.\n\nsocial-> pt's husband did speak to the ew nurse via the phone last evening and was reportedly very upset by her return to the hospital. he will be in to visit later today. the pt remains on full code.\n\ndispo-> ?transfer to the floor or possibly back to s/p filter placement.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593619, "text": "\nPT MAINTAINED ON 40% TRACH MASK AND DOING WELL IN TERMS OF VITALS AND SATURSATIONS. PT RETURNED AFTER 2HRS AT FOR LRG DVT IN LOWER EXTREMETY. PT CURRENTLY IN O.R. FOR IVC FILTER, AND WILL RETURN TO THE ICU FOLLOWING PROCEDURE. PLAN IS TO CONT ON TRACH MASK VENTILATION WITH TRANSFER BACK TO .\n" }, { "category": "Nursing/other", "chartdate": "2193-09-12 00:00:00.000", "description": "Report", "row_id": 1593620, "text": "NPN 0700-1900\nEvents: Pt to OR for IVC filter placement for L DVT.\n\nNeuro: Only response to pain - opens eyes. At times, eyes open spontaneously. Movement noted in UE bilat, and RLL, not in LLL. Pupils < equal, R < L. PRL.\n\nCV: HR 80s-90s, nsr, no ectopy. BP 94-122/49-67. L DVT: L leg elevated without venodyne boot. good pedal pulses bilat. R groin insertion site for IVC filter, site C&D. R venodyne boot in place.\nPt returned from OR at 1500. Received Fentanyl 50mcg, Versed 1 mg, Kefzol 2gms and 400mls fld in OR.\n\nID: Afebrile. ID consult to determine further antibiotics.\n\nResp: Trach to trach mask at 40% o2 humidified. o2 sats 99-100%. Pt freq coughs up mod - copius thick yellow secretions. LS coarse, diminished at bases. RR 14-21.\n\nGI: +BS, abd soft, no stool. NPO except po meds. FS 104-105, no insulin.\n\nGU/flds: uo 25-45 mls/hr, urine with sediment. Pt receiving 75mls/hr IV NS. +500mls today.\n\nSkin: Head suture line C&D. RLQ suture line C&D. Blisters on upper flank/back seen by ID. Broken blisters on coccyx as well as rash, ? from antibiotics. Cleaned with soap and water and Trip abx cr.\n\nSocial: husband here all day, and daughter joined later. Very supportive family.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593621, "text": "Respiratory Care\nPt. remained on 40% trach collar overnight with O2 sats 97-99%, NARD Breath sounds clear bilaterally. Possible transfer back to rehab/floors later today.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593622, "text": "Neuro: responds to pain. opens eyes spontaneously. moves extremities on bed. Not following commands.pupils slightly unequal responding to light.\ncv/resp vss nsr no ectopy. trach mask with mod secretions thick/yellow sx. twice. o2 sats 100% on 40% trach collar.\ngi/gu remains without tube feeds. ?plan to resume today. foley replaced with #14fr 5cc balloon. urine u/a c+s sent. no stools.\ninteg blister noted on right flank intact. left flank blisters some have burst.cleansed and covered with opsite. coccyx rash noted cleansed and zinc cream applied..\nplan : ? return to rehab or transfer out to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2193-09-13 00:00:00.000", "description": "Report", "row_id": 1593623, "text": "Resp Care\n\npt was suctioned for small amts of thick yellow. Airway is paatent\n" }, { "category": "Radiology", "chartdate": "2193-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834096, "text": " 7:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman SAH s/o craniectomy, clipping. S/p right IJ\n CVL.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 57-year-old woman with subarachnoid hemorrhage status post\n clipping. Evaluate for infiltrate.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: The film is rotated. Tracheostomy tube in stable\n position. There is a large band like density in the right base, most likely\n representing atelectasis. There is also some patchy increased density in the\n region of the right cardiophrenic angle, which could reflect atelectasis\n versus pneumonia. There is poor definition of the left hemidiaphragm, without\n significant chagne from prior films. The pulmonary vascularity is normal in\n appearance without redistribution. No pneumothorax.\n\n IMPRESSION: Atelectasis right base; cannot rule out superimposed pneumonia\n here.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-09-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 834536, "text": " 11:15 AM\n CHEST (PA & LAT) Clip # \n Reason: rule out pneumonia\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with right lower lobe consolidation\n\n REASON FOR THIS EXAMINATION:\n rule out pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right lower lobe consolidation, evaluate for pneumonia.\n\n PA AND LATERAL CHEST: AP single view portable exam has been obtained with the\n patient in supine position. Tracheal cannula is in place. No pneumothorax is\n noted. The heart appears to be within normal limits as far as can be judged on\n portable examination. There are parenchymal densities in the left lower lung\n in retrocardiac position obliterating partially the diaphragmatic contour as\n well as that of the descending aorta. The remaining portions of the left lung\n are free and there is no evidence of pulmonary vascular congestion. The right\n lung a plate atelectasis is seen probably involving the right middle lobe\n area. Available for comparison is a previous chest examination obtained on\n . Tracheal cannula was in place already at that time. The right sided\n plate atelectasis appears rather unchanged. The left base retrocardiac area\n was already obscured at that time but is now better visualized with improved\n penetration. Parenchymal densities in the left lower lobe exists could\n represent aspiration pneumonitis. Followup is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-12 00:00:00.000", "description": "PERCU PLCT IVC FILTER S&I", "row_id": 834171, "text": " 2:39 PM\n OR VASCULAR A-GRAM Clip # \n Reason: IVC FILTER, DVT\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ********************************* CPT Codes ********************************\n * PERCU PLCT IVC FILTER S&I VENOGRAPHY IVC S&I *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb Clinical Lookup.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-13 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 834319, "text": " 9:54 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with epidural fluid collection, persistant fevers and\n postive pseudomonas cultures of sputum despite ABx therapy, dvt s/p ivc\n filter placement\n REASON FOR THIS EXAMINATION:\n assess pulmonary parenchyma for pneumonia, rule out PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fevers, positive blood cultures despite antibiotic\n therapy. Status post IVC filter placement. Evaluate for pulmonary embolism\n and pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Helically aquired contiguous axial images were obtained from the\n lung apices to the lung bases before and after the administration of 100 cc of\n IV Optiray. Nonionic contrast was used secondary to the rapid bolus\n requirement needed per protocol. Multiplanar reconstructions were performed.\n\n CT CHEST W/O&W IV CONTRAST: The pulmonary arterial vasculature is well\n visualized down to the segmental branches. No intraluminal filling defects\n are identified. Heart, pericardium, and remaining great vessels are otherwise\n unremarkable. There is no pleural or pericardial effusion identified. Again\n seen are prominent lymph nodes within the prevascular and precarinal regions,\n which are slightly decreased in size since the prior study, and none of which\n meet CT criteria for pathologic enlargement. No new axillary, hilar or\n mediastinal lymphadenopathy is identified.\n\n A tracheostomy tube is seen within the trachea, in stable position. There\n continues to be left lower lobe consolidation, which appears slightly improved\n since the prior study. Within the right lower lobe, there has been interval\n development of new consolidation with air bronchograms present. No other\n parenchymal consolidation or pulmonary nodules are seen. The airways are\n patent to the level of segmental bronchi bilaterally.\n\n In the imaged portion of the upper abdomen, again identified are hepatic\n cysts, stable since the prior study. Tiny punctate calcification is noted\n within the pancreas, unchanged since the prior exam. The visualized portion\n of the spleen, kidneys, adrenal glands, and stomach appear within normal\n limits.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the absence of a pulmonary embolism.\n\n (Over)\n\n 9:54 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ASSESS PULMONARY PARENCHYMA FOR PNEUMONIA, EVAL FOR PE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) No CT evidence of pulmonary embolism.\n\n 2) Interval improvement in consolidation within the left lower lobe. New\n devlopment of right lower lobe consolidation. These findings may be\n suggestive of aspiration or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2193-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834450, "text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with right lower lobe consolidation\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 2:20 PM.\n\n INDICATION: Follow-up pneumonia.\n\n There is slight improvement in the atelectatic changes at the right base since\n . The lungs are otherwise clear. Increased density at the left base\n with loss of visualization of the left diaphragm raising the question of an\n underlying effusion and/or consolidation in the left lower lobe. A\n tracheostomy is again noted.\n\n IMPRESSION: Improved atelectasis at the right base.\n\n Increased density at the left base for which follow-up PA and lateral views of\n the chest are suggested.\n\n\n" } ]

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105,391

69 yo male with PMHX of HTN, Hyperlipidemia, and negative cardiac history who presented with chest pain on exertion. Stress test performed on was positive and cath on revealed three vessel disease with left main stem involvement. Hemaology was consulted preoperatively for elevated PTT(150)and ACT(360) with questionable etiology/anticoagulation management. The decision was made to proceed with off-pump coronary artery bypass grafting to avoid possible anticoagulation issues with the cardiopulmonary bypass. He was taken to the operating room on where he underwent an urgent off-pump coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft obtuse marginal and right coronary arteries. See operative note for full details. He was transferred to the CVICU in stable condition. POD1 the patient was extubated and weaned off all vasoactive medications. Chest tubes and pacing wires were removed per cardiac surgery protocol. He was transferred to step down unit in stable condition on POD1. Hematology had various coagulopathy studies pending at the time of discharge and plts were 261 PTT 82.6 adn Factor V; Factor IX; Factor ; Factor XII were pending. These will be followed up at clinic appointment. He is to be on Plavix for 3 months for Off pump CABG. He was working with physical therapy for strength and mobility. At the time of discharge on POD 4 he was ambulating without assistance, tolerating a full oral diet and his incisions were healing well. It was felt that he was safe for discharge home with VNA services and all appropriate follow up appointments were arranged.

A right IJ line extending to the low SVC, bilateral chest tubes, and a mediastinal drain are in unchanged position. Trivial MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Right internal jugular line ends at low SVC. Compared to the previoustracing of the patient no longer has ventricular premature beats.The slight non-specific T wave changes noted at that time have largelyregressed. Mild wave-like opacities in bilateral lungs signify mild pleural effusion, decreased since . Two chest tubes and a mediastinal drain are present and unchanged in position. The cardiac silhouette and mediastinum is normal. The patient is status post median sternotomy and mildly enlarged heart and sternal sutures are intact. PATIENT/TEST INFORMATION:Indication: Off-pump CABGStatus: InpatientDate/Time: at 11:24Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Low normal LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Trivial mitral regurgitationis seen.There is no pericardial effusion.Post-procedure:The patient is in sinus rhythm, on no inotropes.Preserved biventricular systolic fxn.Trace AI. Simple atheroma in descending .AORTIC VALVE: Normal aortic valve leaflets (3). Hilar and cardiomediastinal contours are stable. : Normal ascending diameter. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 79/24,100/24, and 100/32 cm/sec. Mild vascular congestion is unchanged. Normal sinus rhythm. Mediastinal and hilar contours are stable. Mediastinal surgical clips and sternotomy wires are in unchanged alignment. PA AND LATERAL CHEST: A right IJ line has been removed. FINDINGS: In comparison with earlier in this date, there has been removal of chest tubes. FINDINGS: Intact midline sternal wires are seen. There are new moderate bilateral pleural effusions and associated basilar atelectasis. Trace aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Very faint lucency at left lung apex is most likely a tiny pneumothorax. Very faint lucency at left lung apex is most likely a tiny pneumothorax. No TEE related complications.Conclusions:Pre-procedure:No spontaneous echo contrast is seen in the left atrial appendage.Overall left ventricular systolic function is low normal (LVEF 50-55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic .The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis. There are small bilateral pleural effusions which persist. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 74/21, 89/26, and 103/31 cm/sec. Mild bibasilar atelectasis is also noted. The ICA/CCA ratio is 1.6 These findings are consistent with less than 40% stenosis. Right IJ catheter extends to the lower portion of the SVC. ECA peak systolic velocity is 111 cm/sec. Chest tubes and mediastinal drains remain in stable position. Compared to the previous tracingof there is no change. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is antegrade left vertebral artery flow. Bony structures are within normal limits. IMPRESSION: Since minimal bilateral pleural effusions are smaller and bibasal atelectases, left side more than right have improved. Atelectatic changes are seen at the bases and there is mild engorgement of pulmonary vessels. These findings are consistent with less than 40% stenosis. SEMI-ERECT PORTABLE AP CHEST: The patient has been intubated, and an orogastric tube has been removed. Tracing is within normal limits. There is antegrade right vertebral artery flow. On the right there is moderate heterogenous calcified plaque seen in the ICA. Sinus rhythm with ventricular trigeminy. ECA peak systolic velocity is 120 cm/sec. On the left there is moderate heterogenous calcified plaque seen in the ICA. Intraventricular conduction delay.Occasional ventricular premature beats. Left ICA less than 40% stenosis. Impression: Right ICA less than 40% stenosis. Preop chest radiograph. Findings: Duplex evaluation was performed of bilateral carotid arteries. Sinus rhythm. The patient was undergeneral anesthesia throughout the procedure. IMPRESSION: Improved aeration with overall increased lung volumes, though some basal atelectasis and small bilateral effusions persist. Evaluate for pleural effusion. Left chest tube is in place and there is no evidence of pneumothorax. IMPRESSION: Interval extubation and removal of orogastric tube. CCA peak systolic velocity is 64 cm/sec. No definite pneumothorax is appreciated. There is no new focal opacity to suggest pneumonia. Lungs are clear. Bilateral bibasal atelectases, left side more than right have improved. 6:21 AM CHEST (PORTABLE AP) Clip # Reason: decreased hct Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED ** MEDICAL CONDITION: 69 year old man with POD 2 s/p CABG REASON FOR THIS EXAMINATION: decreased hct FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Single erect portable radiograph of chest was compared to prior radiographs through to . There is increased veiled opacity over the lung bases bilaterally, implying new effusions, moderate in size. CCA peak systolic velocity is 66 cm/sec. A-V conduction delay. Prolonged P-R interval. The tip of the endotracheal tube lies at the clavicular level, approximately 8.5 cm above the carina. The ICA/CCA ratio is 1.6. There is no pneumothorax. There is no pneumothorax. There is no focal opacity to suggest pneumonia. However, overall aeration of the lungs is improved compared to two days prior. Continued enlargement of the cardiac silhouette with retrocardiac opacification consistent with atelectasis and possible effusion. I certifyI was present in compliance with HCFA regulations.

11

[ { "category": "Radiology", "chartdate": "2102-12-22 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1215405, "text": " 7:40 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op for CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with HTN/HLD found to have 3VD on cath today awaiting CABG\n monday\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n CLINICAL HISTORY: 69-year-old man with hypertension, found to have\n three-vessel disease on cardiac catheterization. Awaiting CABG. Preop chest\n radiograph.\n\n FINDINGS: No previous studies for comparison.\n\n The cardiac silhouette and mediastinum is normal. Lungs are clear. There is\n no focal consolidation, pleural effusions or signs of pulmonary edema. No\n pneumothoraces are identified. Bony structures are within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1215656, "text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED **\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD s/p Off-Pump CABG. Please at \n with abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PRX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: Intact midline sternal wires are seen. The tip of the endotracheal\n tube lies at the clavicular level, approximately 8.5 cm above the carina.\n Right IJ catheter extends to the lower portion of the SVC. Nasogastric tube\n extends to the stomach. Left chest tube is in place and there is no evidence\n of pneumothorax. Atelectatic changes are seen at the bases and there is mild\n engorgement of pulmonary vessels.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215998, "text": " 2:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED **\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 2 s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative with chest tube removal.\n\n FINDINGS: In comparison with earlier in this date, there has been removal of\n chest tubes. No definite pneumothorax is appreciated. Continued enlargement\n of the cardiac silhouette with retrocardiac opacification consistent with\n atelectasis and possible effusion. Atelectatic changes are also seen at the\n right base.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215752, "text": " 1:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: bleeding\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED **\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABGx3\n REASON FOR THIS EXAMINATION:\n bleeding\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male status post CABG.\n\n COMPARISON: .\n\n SEMI-ERECT PORTABLE AP CHEST:\n\n The patient has been intubated, and an orogastric tube has been removed. A\n right IJ line extending to the low SVC, bilateral chest tubes, and a\n mediastinal drain are in unchanged position. There is increased veiled\n opacity over the lung bases bilaterally, implying new effusions, moderate in\n size. There is no pneumothorax. Mild vascular congestion is unchanged.\n There is no new focal opacity to suggest pneumonia. Hilar and\n cardiomediastinal contours are stable.\n\n IMPRESSION: Interval extubation and removal of orogastric tube. Chest tubes\n and mediastinal drains remain in stable position. There are new moderate\n bilateral pleural effusions and associated basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2102-12-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1216280, "text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED **\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 4 s/p CABG off pump\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male postop day #4 status post CABG. Evaluate for\n pleural effusion.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST:\n\n A right IJ line has been removed. There is no pneumothorax. Mediastinal\n surgical clips and sternotomy wires are in unchanged alignment. There is no\n focal opacity to suggest pneumonia. There are small bilateral pleural\n effusions which persist. Mild bibasilar atelectasis is also noted. However,\n overall aeration of the lungs is improved compared to two days prior.\n\n IMPRESSION: Improved aeration with overall increased lung volumes, though\n some basal atelectasis and small bilateral effusions persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1215935, "text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: decreased hct\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT ** NO ASSESSMENT NEEDED **\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with POD 2 s/p CABG\n REASON FOR THIS EXAMINATION:\n decreased hct\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Single erect portable radiograph of chest was compared to prior\n radiographs through to .\n\n Right internal jugular line ends at low SVC. Two chest tubes and a\n mediastinal drain are present and unchanged in position. Mild wave-like\n opacities in bilateral lungs signify mild pleural effusion, decreased since\n . Bilateral bibasal atelectases, left side more than right\n have improved. The patient is status post median sternotomy and mildly\n enlarged heart and sternal sutures are intact. Mediastinal and hilar contours\n are stable. Very faint lucency at left lung apex is most likely a tiny\n pneumothorax.\n\n IMPRESSION: Since minimal bilateral pleural effusions are\n smaller and bibasal atelectases, left side more than right have improved. Very\n faint lucency at left lung apex is most likely a tiny pneumothorax.\n\n" }, { "category": "Echo", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 93771, "text": "PATIENT/TEST INFORMATION:\nIndication: Off-pump CABG\nStatus: Inpatient\nDate/Time: at 11:24\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\n: Normal ascending diameter. Simple atheroma in descending .\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPre-procedure:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic .\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\nThere is no pericardial effusion.\n\nPost-procedure:\nThe patient is in sinus rhythm, on no inotropes.\nPreserved biventricular systolic fxn.\nTrace AI. No MR. .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-12-22 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1215367, "text": " 2:27 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op for CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with 3 vessel CAE awaiting CABG on monday.\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason: 69 year old man with 3 vessel CAE waiting CABG.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is moderate heterogenous calcified plaque seen in the ICA. On\n the left there is moderate heterogenous calcified plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 79/24,100/24, and 100/32 cm/sec. CCA peak systolic\n velocity is 66\n cm/sec. ECA peak systolic velocity is 120 cm/sec. The ICA/CCA ratio is 1.6\n These findings are consistent with less than 40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 74/21, 89/26, and 103/31 cm/sec. CCA peak systolic\n velocity is 64 cm/sec. ECA peak systolic velocity is 111 cm/sec. The ICA/CCA\n ratio is 1.6. These findings are consistent with less than 40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA less than 40% stenosis.\n Left ICA less than 40% stenosis.\n\n" }, { "category": "ECG", "chartdate": "2102-12-22 00:00:00.000", "description": "Report", "row_id": 249131, "text": "Sinus rhythm with ventricular trigeminy. A-V conduction delay. No previous\ntracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 249129, "text": "Normal sinus rhythm. Tracing is within normal limits. Compared to the previous\ntracing of the patient no longer has ventricular premature beats.\nThe slight non-specific T wave changes noted at that time have largely\nregressed.\n\n" }, { "category": "ECG", "chartdate": "2102-12-25 00:00:00.000", "description": "Report", "row_id": 249130, "text": "Sinus rhythm. Prolonged P-R interval. Intraventricular conduction delay.\nOccasional ventricular premature beats. Compared to the previous tracing\nof there is no change.\n\n" } ]

17,122

176,368

82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. . 1. Hypotension/Hypertension: Developed hypotension the ED, requiring admission to CCU,likely secondary to overaggressive preload inhibition in setting of moderate AS and increased atenolol levels in setting of ARF. Pt required inotrop/pressor support for ~24 hours with dop gtt at 4-5. She was easily weaned off pressors. No evidence of CNS or cardiac ischemia. No evidence of distributive shock. Blood cultures neg. Does have UTI, but not uroseptic. Lactate improved from 3.3 to 1.3. Antihypertensives were held in the setting of hypotension; they were continued to be held on transfer to the floor. Within 24 hours of being on the floor, pt developed hypertension to 200s systolic, during which she developed flash pulmonary edema. See next issue for details. Pt was started on nitro drip and restarted on po lopressor w/ improved blood pressure. Hydralazine was subsequently added and nitro drip was titrated down. Pt was subsequently restarted on imdur and valsartan; nitro drip and hydralazine were discontinued. Pt's home antihypertensive regimen of lopressor, valsartan, and imdur were titrated for optimal bp control. . 2. Pump: 82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. Possible etiologies include high output failure in setting of UTI/fever, hypertension in setting of diastolic dysfunction. Pt was admitted cold and wet in class IV HF, secondary to recent fluid boluses in the form of heparin bolus and IVF bolus. She diuresed very well with IV lasix. She was transiently on dopamine drip in the CCU for blood pressure support, which helped with diuresis. Pt was hypoxic on admission and required positive pressure vent with BiPAP for ~24 hours. She was continued on CPAP at night. On floor day 1, pt developed flash pulmonary edema in the setting of severe hypertension off antihypertensives. She was noted to be hypoxic to 70s on 4L, with increase to mid 90s on 100% NRB. She was started on nitro gtt, lopressor, and hydralazine for BP control. CXR confirmed worsened pulmonary edema. She was given lasix for diuresis. After adequate diuresis and BP control, pt was able to be weaned down on her oxygen requirement. Pt was restarted on heart failure regimen of lopressor, valsartan, imdur; nitro gtt was weaned and hydralazine discontinued. Pt was diuresed with IV lasix daily for goal 1L daily, with signficant respiratory improvement. Pt should continue to be diuresed w/ IV lasix for 48 hours for goal negative 500cc daily prior to being switched to a po lasix regimen. . 3. CAD: Pt is s/p NTSEMI last month and is s/p PTCA to prox and mid LAD . Pt was continued on asa, plavix, and statin. On admission was noted to have a slight troponin bump likely from demand ischemia and decompensated heart failue. She was restarted on bb, , and imdur, which were titrated. . 4. Rhythm: S/P sucessful DCCV . Pt remained in sinus. Dopamine drip did not cause reversion to AF. Amiodarone was held initially in the setting of bradycardia, but was restarted. She recieved oral and IV vit K at Rehab for INR of 10. Subsequently had suptherapeutic INR. She was restarted on heparin gtt and restarted coumadin 5mg daily for goal INR 2.0-3.0. Pt is being discharged on lovenox bridge . 5. Resp: Initially presented with large Aa gradient, attributed to pulmonary edema. She was hypoxic on admission, requiring BiPAP for ~24 hours. With diuresis, she had decreasing O2 requirements. Supplemental oxygen should continue to be weaned down, with further diuresis. . 6. ID: Pt was febrile to 101 in ED. Pt was noted to have UTI by UA. On day of last discharge she was noted to have >100,000 Staph aureus, which was attributed to contamination and not treated. Admission urine culture once again grew out >100,000 Staph aureus, found to be MRSA sensitive to vanco, gent, tetracyclin, and nitrofurantoin. Pt initially received emperic ceftriaxone and vancomycin. Ceftriaxone was subsequently discontinued. Pt was continued on vancomycin (renally dosed, q48h dosing) to complete a 10 day course. Vanco trough levels should be checked 30 minutes prior to 3rd dose of vanco. She should get a trough level on . Pt's blood cultures remained negative. Repeat UA on the day before discharge is negative, with a urine culture that is negative to date. . 7. Renal: Pt has had ARF since , secondary to contrast nephropathy vs. CHF (poor forward flow). Baseline is 1.0 to 1.3. She received 240mL contrast at time of cath. Creatinine improved with dopamine drip and treatment of heart failure. . 8. Anemia: She has a severe iron deficency anemia without evidence of acute bleed. Last C-scope 3-4 years ago, by report. Received 1U PRBC for goal hct >30. Hct remained stable. . 9. Gout: Stable. Continued on allopurinool . 10. OSA: CPAP at night at outpt settings. Pt was seen by pulmonary consult service who stated that pt has secondary pulmonary hypertension in the setting of left heart failure. Pt should follow up with Dr. for outpatient sleep study. . 11. Cerumen impaction: Pt was noted to have bilateral cerumen impaction preventing her from inserting her hearing aides. She was started on hydrogen peroxide.

CXR SHOWS PULM EDEMA. Moderate(2+) mitral regurgitation is seen. W/CHF, and was treated with NIPV untill adaquatly diureased. Moderate PA systolic hypertension.PERICARDIUM: Trivial/physiologic pericardial effusion. There isa trivial/physiologic pericardial effusion. Heparin gtt adjusted per nomogram.Arterial line dc'd.Afebrile. S/p PCI w/ hypotension.Height: (in) 60Weight (lb): 200BSA (m2): 1.87 m2BP (mm Hg): 79/44HR (bpm): 75Status: InpatientDate/Time: at 09:52Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is perivascular haze and diffuse bilateral interstitial and alveolar opacities consistent with CHF. Trace aortic regurgitation is seen. Mild mitralannular calcification. AREAS CLEANSED AND DSD WITH NON ADH DSG APPLIED. afebrileLungs: BS clear in upper lobes some rales in bases. MD NOTIFED OF ABD WOUNDS AND IN TO ASSESS.ID: AFEBRILE. STARTED ON VANCO AND CEFTRIAXONE FOR ELEVATED TEMP IN EW. BP 160/ and was rx with 2MSO4 and IV NTG. The tricuspid valve leaflets are mildlythickened. LOW BP AFTER NTG IV. D/CD FROM ON TO REHAB. COMPARISON: Radiograph dated . Pt placed on CPAP and a foley was placed. replete lytes as indicated. IMPRESSION: CHF. REASON FOR THIS EXAMINATION: eval for chf FINAL REPORT INDICATION: Increased lower extremity edema. No echocardiographicsigns of tamponade.Conclusions:The left atrium is moderately dilated. There is mild to moderateaortic valve stenosis. TOL WELL BY PT. Moderate (2+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. AT THAT TIME R/I NSTEMI. There is persistent left midzone discoid atelectasis. MAP > 60 after one unit PRBC MAP consistantly > 65. post transfusion hct is 31. palp DP . BS CL/ RALES IN ABSES. BP subsequently down to 90/ and was placed on Dopa 2.5mcgs/kg. on 6l NC initially, on home bipap tolerating well .GI: ABD obese. Possible left ventricular hypertrophy.Non-specific ST-T wave changes. There is moderate pulmonary artery systolic hypertension. There is a probable right-sided pleural effusion and possible small left-sided effusion. TraceAR.MITRAL VALVE: Mildly thickened mitral valve leaflets. DRAINING SM AMTS SEROSANG. TOL PO'S AND MEDS. WOUND CLEASER AND DSD APPLIED. Segmental atelectasis at the right lung base is noted. Baseline artifactSinus rhythm be Normal ECG but baseline artifact makes assessment difficultSince previous tracing of , prolonged Q-Tc interval and T wave changesabsent No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Normal aortic arch diameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. Sinus rhythm. soft with BS. Nasal cannula or face mask when awake. Since the prior study, there has been placement of a left subclavian line, the tip is in the mid superior vena cava. HR 68-74 NSR. RECEIVED 1 UNIT PRBC WITH LASIX GIVEN BETWEEN. Breathsounds are with rales at bases other wise clear. PER NSG JUDGEMENT. SOURCE WHICH HAS SCABING AND DRIED CLOTT. NON PRODUCTIVE COUGH NOTED.GI: APPETITE EXCELLENT. Mild to moderate[+] TR. Moderate AS. Interval improvement in the magnitude of bilateral pulmonary vascular congestion. IMPRESSION: Worsened CHF. There is mild symmetric leftventricular hypertrophy with normal cavity size and systolic function(LVEF>55%). Urine and Blood clutures done for WBC of 17.Tx to CCU -CV - HR 60-70's nsr with rare pvc. IMPRESSION: Interval placement of the left subclavian CVP line. Dopamine slowly weaned to off.NSR/SB with no ectopy. Small brown formed stool guiac negative.GU: foley to gravity. CURRENT SBP 110-120 WITH MAP'S 66-75. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are moderately thickened. SINGLE FRONTAL VIEW OF THE CHEST: There is stable cardiac enlargement. output low initially with unit of PRBC output improved. There are low lung volumes. DNEIES SOB. NOW PRESENTS ON DOPAMINE.. CON'T ATTEMPTS TO WEAN DOAPMINE, FOLLOW HCT. pt has rt shoulder pain, when touch pain is > 5 if not disturbed pt has no pain in arm.CV: sinus brady. + BSGU: U/O EXCELLENT. PT APPEARS WITH LOW SATS. ECHO done at bedside this AM. Baseline artifactSinus rhythmBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific andmay be within normal limits but clinical correlation is suggestedSince previous tracing of , Q-Tc interval appears longer but baselineartifact makes comparison difficult Late transition. NO ABVIOUS S/S OF BLD. LUQ ABD HAS WOUND AREA? ABG'S ON CPAP THIS AM WNL. Sinus rhythmConsider left ventricular hypertrophy by voltageLateral ST-T wave abnormalities - cannot exclude in part ischemia - clinicalcorrelation is suggestedSince previous tracing of , rate faster and further ST-T wave changespresent Compared to the previous tracing no significantchange. AM BUN CREAT PENDINGSKIN: LOWER ABD HAS 3 AREAS OF TAPE ABRASION. K+/MG WNL DESPITE DIURESIS.SOCIAL: DAUGHTER IN ON EVES AND UPDATED ON POC. cre and BUN still high.Skin : intact some redness in coccyx area skin prep applied.A pt has sleep apnea tolerated bipap well.P: turn frequently. MAE.Pain: pt denies chest pain or pain with deep breath. 2841 CURRENTLY -546. The lung apices are partially obscured by the patient's head. Cardiac and mediastinal contours are stable. K+ WNL.RESP: PT ON OWN CPAP @ 6L. AM HCT PENDING. Just had an A-line placed to monitor and obtain ABG's. Cont on Dopamine 4.5mcgs/kg/min. BP is labile 90-140/50. MAELABS/ HEME: HCT 27.6 HOUSE STAFF NOTIFED. PATIENT/TEST INFORMATION:Indication: Left ventricular function. DENIES SOB OR CP. Slight SOB at rest-speaking in word sentences. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Attempted to wean to 4ln/p but O2 sat dropped to 88%.GI - abd is obese with +bs.GU - Diuresing well after Lasix in EW approx 1000cc clear yellow urine.Heme - Hct 31.6 PT 14.1 PTT 53.2 INR 1.3Neuro - Alert and oriented x3.A: 85yof with diastolic dysfunction and tenuous fluid status and labile bp.P: At present, HO placing TLC, cont montitor HR and BP and attempt to wean Dopamine, Cont aggressive diruesis weaning cpap as able monitor coags, Turn and position for comfort, keep pt and family informed per multidisciplinary rounds.

14

[ { "category": "Echo", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 66610, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p PCI w/ hypotension.\nHeight: (in) 60\nWeight (lb): 200\nBSA (m2): 1.87 m2\nBP (mm Hg): 79/44\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 09:52\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS. Trace\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are moderately thickened. There is mild to moderate\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate\n(2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\na trivial/physiologic pericardial effusion. There are no echocardiographic\nsigns of tamponade.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865498, "text": " 1:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with increased LE edema.\n\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increased lower extremity edema.\n\n COMPARISON: Radiograph dated .\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is stable cardiac enlargement. There\n are low lung volumes. There is perivascular haze and diffuse bilateral\n interstitial and alveolar opacities consistent with CHF. There is persistent\n left midzone discoid atelectasis. The lung apices are partially obscured by\n the patient's head. There is a probable right-sided pleural effusion and\n possible small left-sided effusion.\n\n IMPRESSION: CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865796, "text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for flash pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF w/acute SOB\n REASON FOR THIS EXAMINATION:\n evaluate for flash pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF with increasing shortness of breath.\n\n Portable upright frontal radiograph. Comparison is made to two studies\n performed on . There has been an increase in the amount of perihilar\n haziness and mild upper zone vascular redistribution compared to the study of\n 8:45 p.m. on . In addition, there has been an increase in small\n bilateral pleural effusions. No focal consolidation is seen. There is no\n pneumothorax. Cardiac and mediastinal contours are stable.\n\n IMPRESSION: Worsened CHF.\n\n" }, { "category": "Radiology", "chartdate": "2134-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865520, "text": " 7:32 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line placement, r/o pneumothorax, evaluate for inte\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF, hypotension s/p L subclavian line placement\n REASON FOR THIS EXAMINATION:\n evaluate line placement, r/o pneumothorax, evaluate for interval change in\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old with CHF and hypotension, status post subclavian line\n placement, evaluate the line placement.\n\n FINDINGS: AP portable study of the chest was obtained at 20:46 hours and is\n compared to prior study of earlier the same day. Since the prior study, there\n has been placement of a left subclavian line, the tip is in the mid superior\n vena cava. There has been some improvement in the degree of bilateral\n pulmonary vascular congestion since the prior study. Cardiomegaly is\n unchanged. No significant pleural effusion or pneumothoraces are noted.\n\n IMPRESSION: Interval placement of the left subclavian CVP line. Interval\n improvement in the magnitude of bilateral pulmonary vascular congestion.\n\n Segmental atelectasis at the right lung base is noted.\n\n" }, { "category": "ECG", "chartdate": "2134-05-06 00:00:00.000", "description": "Report", "row_id": 139079, "text": "Sinus rhythm. Late transition. Possible left ventricular hypertrophy.\nNon-specific ST-T wave changes. Compared to the previous tracing no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2134-05-04 00:00:00.000", "description": "Report", "row_id": 139080, "text": "Sinus rhythm\nConsider left ventricular hypertrophy by voltage\nLateral ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , rate faster and further ST-T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 139081, "text": "Baseline artifact\nSinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific and\nmay be within normal limits but clinical correlation is suggested\nSince previous tracing of , Q-Tc interval appears longer but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 139082, "text": "Baseline artifact\nSinus rhythm\n be Normal ECG but baseline artifact makes assessment difficult\nSince previous tracing of , prolonged Q-Tc interval and T wave changes\nabsent\n\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486666, "text": "NSG NOTE\n\nCV: CON'T ON DOPAMINE @ 5 MCG/KG/MIN SEVERAL ATTEMPTS MADE TO WEAN,BUT MAP'S DROPPED TO 57-58. HR 68-74 NSR. CK 38. DENIES SOB OR CP. CURRENT SBP 110-120 WITH MAP'S 66-75. K+ CHECKED SEVERAL TIMES OVERNOC IN LIGHT OF AGGRESSIVE DIURESIS. K+ WNL.\n\nRESP: PT ON OWN CPAP @ 6L. TOL WELL ( DID NOT TOL UNIT BIPAP) O2 SATS 98% WHILE AWAKE,BUT SATS DROPPED TO 90% WITH SLEEP. RR STAYED 17. PT APPEARS WITH LOW SATS. ABG'S ON CPAP THIS AM WNL. DNEIES SOB. BS CL/ RALES IN ABSES. NON PRODUCTIVE COUGH NOTED.\n\nGI: APPETITE EXCELLENT. TOL PO'S AND MEDS. ABD SOFT NON TENDER. + BS\n\nGU: U/O EXCELLENT. > 100CC/HR RECEIVED LASIX 20 MG DURING BLD TRANSFUSION. 2841 CURRENTLY -546. AM BUN CREAT PENDING\n\nSKIN: LOWER ABD HAS 3 AREAS OF TAPE ABRASION. DRAINING SM AMTS SEROSANG. AREAS CLEANSED AND DSD WITH NON ADH DSG APPLIED. LUQ ABD HAS WOUND AREA? SOURCE WHICH HAS SCABING AND DRIED CLOTT. WOUND CLEASER AND DSD APPLIED. MICOSTATIN POWDER ORDERED AND APPLIED TO ALL SKIN FOLDS. MD NOTIFED OF ABD WOUNDS AND IN TO ASSESS.\n\nID: AFEBRILE. STARTED ON VANCO AND CEFTRIAXONE FOR ELEVATED TEMP IN EW. CULT PENDING.\n\nNEURO: A/O X3 FOLLOWS COMMANDS. MAE\n\nLABS/ HEME: HCT 27.6 HOUSE STAFF NOTIFED. NO ABVIOUS S/S OF BLD. NO STOOL TO GUIAC. RECEIVED 1 UNIT PRBC WITH LASIX GIVEN BETWEEN. TOL WELL BY PT. AM HCT PENDING. K+/MG WNL DESPITE DIURESIS.\n\nSOCIAL: DAUGHTER IN ON EVES AND UPDATED ON POC. SHE IS CONTACT PERSON FOR PT.\n\nA/P; 82 YR OLD ADM TO ON CAD, S/P 2 STENTS TO LAD X2 WEEKS AGO AT . AT THAT TIME R/I NSTEMI. D/CD FROM ON TO REHAB. DEVELOPED SOB WHILE AT REHAB. CXR SHOWS PULM EDEMA. LOW BP AFTER NTG IV. NOW PRESENTS ON DOPAMINE.. CON'T ATTEMPTS TO WEAN DOAPMINE, FOLLOW HCT. PER NSG JUDGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486667, "text": "Respiratory care:\nPatient received on mask ventilation. 50%. Patient uncomfortable on vent. Patient placed on her own Cpap machine (12cm) with 6 L bleed in. Patient looks more comfortable on her own machine. Sats in mid to high 90's when awake but then fall to 88-90% when asleep. Patient easily arousable allowing sats to increase. ? need of a new sleep study. Breathsounds are with rales at bases other wise clear. Please see respiratory section of carevue for further data.\nPlan: Continue on her own cpap machine as tolerated. Change over to ? Nasal cannula or face mask when awake.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-03 00:00:00.000", "description": "Report", "row_id": 1486668, "text": "See carevue for objective data.\n\nAwake and alert anxious at times. Dopamine slowly weaned to off.\nNSR/SB with no ectopy. Crackles at bases. Slight SOB at rest-speaking in word sentences. Maintaining sat on 6L NC. ECHO done at bedside this AM. No diuresis ordered as of yet today. Urine output 40-50cc's an hour. CVP: .\nTaking diet well. Heparin gtt adjusted per nomogram.\nArterial line dc'd.\nAfebrile. Receiving ceftriaxone/vanco as ordered.\n\nContinue to monitor and support hemodynamics,emotional support,\nmonitor PTT and other lab data, and continue to support pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2134-05-04 00:00:00.000", "description": "Report", "row_id": 1486669, "text": "Neuro: oob in chair at start of shift . chair to commode x2 . walked a few steps. chair to bed. pt is able to walk but is week. MAE.\n\nPain: pt denies chest pain or pain with deep breath. pt has rt shoulder pain, when touch pain is > 5 if not disturbed pt has no pain in arm.\n\nCV: sinus brady. MAP > 60 after one unit PRBC MAP consistantly > 65. post transfusion hct is 31. palp DP . afebrile\n\nLungs: BS clear in upper lobes some rales in bases. on 6l NC initially, on home bipap tolerating well .\n\nGI: ABD obese. soft with BS. no N/V. Small brown formed stool guiac negative.\n\nGU: foley to gravity. output low initially with unit of PRBC output improved. cre and BUN still high.\n\nSkin : intact some redness in coccyx area skin prep applied.\n\nA pt has sleep apnea tolerated bipap well.\n\nP: turn frequently. BIPAP at bed timed. replete lytes as indicated. Kexalate not given K is 4.8 at present.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 1486664, "text": "Respiratory Care:\nPt admit via ambulance from Rehab. W/CHF, and was treated with NIPV untill adaquatly diureased. Then she will be able to go onto her OWN CPAP equipt that she uses daily some time later. Just had an A-line placed to monitor and obtain ABG's. See CareVue for more Info.\n" }, { "category": "Nursing/other", "chartdate": "2134-05-02 00:00:00.000", "description": "Report", "row_id": 1486665, "text": "CCU Nursing Progress Note\nS: I just wasn't feeling well this morning when I woke up.\n\nO: 85yof with extensive PMH admitted to CCU with chief c/o epigastric pain with chest pressure and SOB. Report from Rehab reports that pt recieved a 20,000unit bolus of heparin last night followed by an increase in the Heparin drip by 200units each hour over night. Heparin stopped at 8am and PTT was >200. Vitamin K was administered. At 11:30am, pt c/o being sick BP reported 88/40, rx with 150cc ivf. AT 12noon, pt reports chest pressure, epigastric pain and sob, with a BP 160/100 and rales noted. Rx with 20mg IV Lasix, iisl ntg and cp resolved.\nEMT's called for Tx to \nIn EW - rx with 80mg IV Lasix for rales and O2 sat 88% on RA. Pt placed on CPAP and a foley was placed. BP 160/ and was rx with 2MSO4 and IV NTG. BP subsequently down to 90/ and was placed on Dopa 2.5mcgs/kg. Urine and Blood clutures done for WBC of 17.\n\nTx to CCU -\nCV - HR 60-70's nsr with rare pvc. BP is labile 90-140/50. Cont on Dopamine 4.5mcgs/kg/min. Attempting to wean Dopa, but BP will drop to 90/ Aline placed and is equal to ausc.\n\nResp - On cpap 50% with rales l base maintaining O2 sat 95-100%. Attempted to wean to 4ln/p but O2 sat dropped to 88%.\n\nGI - abd is obese with +bs.\n\nGU - Diuresing well after Lasix in EW approx 1000cc clear yellow urine.\n\nHeme - Hct 31.6 PT 14.1 PTT 53.2 INR 1.3\n\nNeuro - Alert and oriented x3.\n\nA: 85yof with diastolic dysfunction and tenuous fluid status and labile bp.\n\nP: At present, HO placing TLC, cont montitor HR and BP and attempt to wean Dopamine, Cont aggressive diruesis weaning cpap as able monitor coags, Turn and position for comfort, keep pt and family informed per multidisciplinary rounds.\n" } ]

30,158

109,420

On arrival into our intensive care unit the patient was found to be profoundly hypothermic with a core body temperature of 88 degree Fahrenheit. He was profusely bleeding from the abdomen, the nares and the orogastric tube. An arterial blood gas showed a pH of 6.8. He as aggressively resuscitated with fluids, packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate and many attempts at warming using a Bair Hugger device, that and room heating were performed. The patient's core temperature eventually reached 34.9 degrees, but he became progressively more difficult to ventilate. CXR done on admission was unremarkable, however, when the patient had increased difficulty ventilating, bilateral tube thoracotomies were performed. From the right chest tube, the patient had sanguinous discharge. He had continued difficulty with ventilation, and at this point his abdomen was quickly prepped and the retention sutures from his prior surgery were removed and patient was eviscerated. Next, the patient became somewhat easier to ventilate, however, his oxygen saturation continued to deteriorate and the patient became bradycardic, eventually displaying only agonal complexes with no blood pressure. The patient had bilateral chest tubes that had been placed previously, but there was blood clotted in the right chest tube. The team was concerned that the patient had a right hemothorax or a right tension pneumothorax or perhaps cardiac tamponade since the path of the knife was largely unknown. Preparation of the patient's chest from neck to distal abdomen was very rapidly prepped with Betadine. Using a scalpel an incision was made in the 5th intercostal space on the right side from mid axilla to sternum. This incision was carried down through intercostal space into the right pleura. Upon entering right pleura, a small amount of blood was noted, but there was no evidence of a gross right hemothorax or a right tension pneumothorax. The patient continued to be in cardiopulmonary arrest and therefore the incision was carried across the midline into the left and a formal clamshell thoracotomy was performed involving both the right and left hemithoraces. The chest wall was elevated and quickly both hemithoraces quickly examined. There was no evidence of hemothorax on the right or the left side. The pericardium was quickly opened and opened cardiac massage was performed. There was no evidence of hemopericardium or cardiac tamponade. The patient responded with reasonable blood pressure tracings upon open cardiac massage. While there was no spontaneous electrical activity noted, nor was there spontaneous cardiac contraction noted. The open cardiac massage and full code was performed for an additional 15 minutes. Multiple ampules of epinephrine, bicarbonate, calcium and atropine were administered, none of which resulted in resumption of a cardiac rhythm or adequate perfusion. At 7:35 p.m. the code was called and the operation was terminated.

Resuscitated w/ multiple UPRBC, FFP, platelets, cryoprecipitate, warmed LR/NS. The patient is intubated with the tip of the ET tube is approximately 1 cm above the carina and could be withdrawn approximately 2 cm. Respiratory decompensation repeatedly w/ pH remaining <7.0 despite aggressive resusciation w/ bicarb, fluids, 100% FiO2/increased PEEP. Esophageal temp 28.9 upon arrival, bleeding freely from abdominal wound, nares, OGT. A single AP view of the chest is obtained supine on at 05:41 hours. The tip of the vascular sheath is just included in the film above the medial portion of the right clavicle. ET tube tip approximately 1 cm above carina. CT x 2 placed w/ return of frothy red fluid bilaterally. Nasogastric tube is present with its tip below the diaphragm. Mild increase is seen in the interstitial markings bilaterally, which may represent fluid overload or early interstitial edema. Tmax reached 34.9. There is likely a small left pleural effusion. Several clips are noted in the skin in the midline. This could be withdrawn approximately 2 cm. Increased interstitial markings bilaterally may represent fluid overload or interstitial edema. Vigorous attempt to re-warm using Level one for all fluids, Hugger, OR heating pad. INDICATION: Possible retained sponge. Bowel gas pattern is unremarkable. Abdomen opened at bedside in attempt tamponade of bleeding and assess for further trauma. Dr , Dr. at bedside for entirety of effort. Single AP view of the abdomen which does not include the areas of the diaphragms shows no radiopaque foreign material. Received directly from their PACU via ground ambulance transport to TSICU, intubated. IMPRESSION: 1. 5:28 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for infiltrate, effusion, lap sponge packing Admitting Diagnosis: S/P STAB WOUND MEDICAL CONDITION: 30 year old man s/p stabbing transfer in from OSH REASON FOR THIS EXAMINATION: Please evaluate for infiltrate, effusion, lap sponge packing, ETT placement FINAL REPORT EXAMINATION: AP chest. 5:28 AM PORTABLE ABDOMEN Clip # Reason: Please evaluate for lap sponge packing Admitting Diagnosis: S/P STAB WOUND MEDICAL CONDITION: 30 year old man s/p stabbing transfer in from OSH REASON FOR THIS EXAMINATION: Please evaluate for lap sponge packing FINAL REPORT EXAMINATION: Supine abdomen. Increased retrocardiac density on the left side, likely represents atelectasis or airspace disease. INDICATION: Stabbing. Dr. was paged at 13:35 hours without response . NPN, 1900-070030 y/o male stabbing victim transferred from 0450.Single stab wound to right abdomen, taken to OR at for ex lap, repair of liver lac. Priest and family in after pt pronounced @ 0735 PEA cardiac arrest following sudden desat to 40's, unresponsive to all resuscitative measures. No large pneumothorax is seen in this projection. Bony structures are unremarkable. No prior films are available for comparison. 2.

3

[ { "category": "Radiology", "chartdate": "2191-04-30 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1007830, "text": " 5:28 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for lap sponge packing\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p stabbing transfer in from OSH\n REASON FOR THIS EXAMINATION:\n Please evaluate for lap sponge packing\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Supine abdomen.\n\n INDICATION: Possible retained sponge.\n\n Single AP view of the abdomen which does not include the areas of the\n diaphragms shows no radiopaque foreign material. Bowel gas pattern is\n unremarkable. Several clips are noted in the skin in the midline. Bony\n structures are unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007829, "text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate, effusion, lap sponge packing\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p stabbing transfer in from OSH\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate, effusion, lap sponge packing, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Stabbing.\n\n A single AP view of the chest is obtained supine on at 05:41 hours. No\n prior films are available for comparison. The heart is not enlarged. The\n patient is intubated with the tip of the ET tube is approximately 1 cm above\n the carina and could be withdrawn approximately 2 cm. Mild increase is seen\n in the interstitial markings bilaterally, which may represent fluid overload\n or early interstitial edema. Increased retrocardiac density on the left side,\n likely represents atelectasis or airspace disease. There is likely a small\n left pleural effusion. No large pneumothorax is seen in this projection. The\n tip of the vascular sheath is just included in the film above the medial\n portion of the right clavicle. Nasogastric tube is present with its tip below\n the diaphragm.\n\n IMPRESSION:\n\n 1. ET tube tip approximately 1 cm above carina. This could be withdrawn\n approximately 2 cm.\n 2. Increased interstitial markings bilaterally may represent fluid overload\n or interstitial edema.\n\n Dr. was paged at 13:35 hours without response .\n\n" }, { "category": "Nursing/other", "chartdate": "2191-04-30 00:00:00.000", "description": "Report", "row_id": 1651318, "text": "NPN, 1900-0700\n30 y/o male stabbing victim transferred from 0450.\nSingle stab wound to right abdomen, taken to OR at for ex lap, repair of liver lac. Received directly from their PACU via ground ambulance transport to TSICU, intubated. Esophageal temp 28.9 upon arrival, bleeding freely from abdominal wound, nares, OGT. Vigorous attempt to re-warm using Level one for all fluids, Hugger, OR heating pad. Tmax reached 34.9. Resuscitated w/ multiple UPRBC, FFP, platelets, cryoprecipitate, warmed LR/NS. CT x 2 placed w/ return of frothy red fluid bilaterally. Respiratory decompensation repeatedly w/ pH remaining <7.0 despite aggressive resusciation w/ bicarb, fluids, 100% FiO2/increased PEEP. PEA cardiac arrest following sudden desat to 40's, unresponsive to all resuscitative measures. Abdomen opened at bedside in attempt tamponade of bleeding and assess for further trauma. Dr , Dr. at bedside for entirety of effort. Priest and family in after pt pronounced @ 0735\n" } ]

197

129,890

Patient presents with nearly a 1 week course of nausea, vomiting and worsening abdominal pain, and presented to the ED. He had copious amounts of NG output, and a CAT scan consistent with a high-grade small bowel obstruction. The patient preoperatively underwent aggressive resuscitation with IV fluids and electrolyte corrections with potassium and magnesium. Patient's creatinine improved from a creatinine of 3 to 1.7, and the potassium also corrected from 2.7 to 3.1. Central line was placed for resuscitation. The patient consented for exploratory laparotomy, possible bowel resection, possible ostomy. The patient understood risks of procedure. Following the procedure the pt was transfered to the SICU. POD#1 Pt stayed in the SICU with NGT in place. He continued to receive fluids which helped lower his cr value from 3.0 -> 1.7. This value continued to improve during his hospital course. Cardiology was consulted due to TWI/ST depression with borderline long QT. This was most likely due to low K value of 2.6 and low calcium. No ischemic causes were identified or suspected. Aggressive repletion of electrolytes was continued. Pt was NPO, sedated and intubated, was on Kefzol and flagyl. Pt was extubated later in the day on POD #1. POD#2 extubated, NGT with no flatus, UE u/s showed no DVT POD#3 NPO, d/c beta blockers, started ambulating, started course of kefzol due to erythema present at abdominal wound, no systemic signs of sepsis, no fevers POD#4 ABX changed to levo and flagyl, NPO, less erythema at wound site POD#5 NPO, NGT until flatus, levo/flagyl stopped, changed back to kefzol, less erythema at wound site POD#6 NGT d/c, +flatus, Abx continued, erythema at wound resolved, diet advanced to sips/clears POD#7 +flatus, experienced loose stools later that evening POD #8, diet continued to advance

CT ABDOMEN WITHOUT IV CONTRAST: Small focus of ground glass opacity at the right base likely reflects subsegmental atelectasis. creat 1.7 and bun 49.gI abd softly distended. CT PELVIS WITHOUT IV CONTRAST: The bladder, prostate, seminal vesicles appear within normal limits. IMPRESSION: No left upper extremity DVT identified. obstruction No contraindications for IV contrast WET READ: BTCa TUE 4:18 PM Small bowel obstruction with gastric and proximal small bowel distension. Sinus rhythmNonspecific T wave abnormalities - cannot exclude in part ischemia - clinicalcorrelation is suggestedSince previous tracing of , T wave changes slightly less prominent Placed on A/C overnoc. Resp Care,Pt. Productive cough.NEURO: A&Ox3. Sinus rhythmDiffuse nonspecific T wave abnormalities - cannot exclude in part ischemia -clinical correlation is suggestedNo previous tracing available for comparison FINDINGS: The gallbladder is normal in appearance without intraluminal stones. venodynes.respnse: monitor closely post op. protonix as ordered. focus hemodymicsneuro: admitted to the sicu from the or. pneumo FINAL REPORT SINGLE AP PORTABLE VIEW CHEST TO ASSESS LINE PLACEMENT. Findings worrisome for small bowel obstruction versus ileus. NURSING NOTE*PLEASE SEE CAREVUE FOR SPECIFICS*CV: BP stable, systolic 130-150s. 3:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ? Sub segmental atelectasis at the right base. Decompressed loops of sigmoid colon and pelvic small bowel are mostly unremarkable. Sinus arrhythmia. ast 44 and alt 95.action: post op q15min-q1hr vital signs. ngt to lcws. FINDINGS: Right internal jugular vein catheter tip is at cavoatrial junction. There is normal compressibility, respiratory variation, and response to augmentation of the left axillary, paired brachial veins, basilic and cephalic veins. neuro signs q2hrs. The visualized heart and pericardium are unremarkable. 11:03 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: L. PALM SWELLING, ? There are small mesenteric and retroperitoneal lymph nodes, which do not meet CT size criteria for pathologic enlargement. vented and attempt to extubate today. The unopacified liver, gallbladder, pancreas, spleen, and adrenal glands are normal. Compared to the previous tracingof no change. + BS. High-grade small-bowel obstruction with transition point identified in the right lower abdominal quadrant. Pt remains NPO. A transition point is identified in the right lower quadrant (series 2, image 56), with fecalization of small bowel contents with proximal and decompressed loops of small bowel and colon seen distally. There are low lung volumes with bibasilar discoid atelectasis. TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis were obtained following the administration of oral but not intravenous contrast . expressing he has abd pain and fentanyl gtt started and very comfortable.resp breath sounds clear. There is normal compressibility of the left internal jugular vein with normal waveforms and response to augmentation. IMPRESSION: 1. IMPRESSION: 1. Evaluation of the visceral organs is limited secondary to lack of intravenous contrast. iv flagyl and iv cefazolin given. K 4.0. Right nare NGT to lcws putting out small amount light brown liquid drainage. Pt using pump appropriately and cough pillow as needed.GI/ENDO: Abdomen soft, slightly distended. bp 110-130's. intubated with 7.5 et tube. intubated and on iv propofol gtt. Recieving Sodium Phos for Phos of 2.4. No breakdown on backside noted. In the patient's left palm, there is a 3 x 5 x 5 mm hypoechoic nodule without vascularity present. k repleted. RSBI 66 this am. LCTAB, slightly coarse at times. to wean and extubated this am when more awake. NSR HR 70-90s. obstruction FINAL REPORT (Cont) urgent attention. There are no sizable pleural effusions. BONE WINDOWS: A nonspecific sclerotic focus with nonaggressive features is noted in the right ischium, likely a bone island. LINE PLACEMENT Clip # Reason: ? o2sats 99-100%.cardiac: in nsr. No intra- or extra-hepatic biliary duct dilatation identified. No intraluminal filling defects are seen. Plan to cont. Allowing for this factor, there are multiple dilated fluid-filled loops of small bowel with moderate distention of the stomach and proximal bowel loops. NG tube tip is in the stomach. PEERLA 3mm. admitted from OR intubated #7.5 ET taped at 22@lip. Monitor pain, temp, skin integrity. Multiplanar reconstructions were performed. No BM. The right kidney measures 9.7 cm. The liver is mildly echogenic consistent with fatty liver. Pt c/o cramping abdominal pain (), fentanyl drip discontinued and started on Dilaudid PCA, dose 0.12mg with hour total 1.2mg. No osseous findings suspicious for malignancy are identified. Mild echogenic appearance of the liver consistent with fatty liver. no ectopy seen. No ectopy noted.RESP: Pt extubated well today with no problems, maintaining sat's 98-100%. FINDINGS: Both grayscale and color Doppler ultrasound examination was performed. goal is to extubate today. Currently on 1L NC sat'ing 97-99%. The pancreas is not well visualized secondary to overlying bowel gas. The left kidney measures 11.1 cm. 10:03 PM CHEST PORT. Findings were discussed with Dr. at the time of dictation. Findings were relayed to the ED dashboard at time of dictation and marked for (Over) 3:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ?

10

[ { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 950657, "text": " 3:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with Abd Pain\n REASON FOR THIS EXAMINATION:\n ? obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa TUE 4:18 PM\n Small bowel obstruction with gastric and proximal small bowel distension.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old male with abdominal pain.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis\n were obtained following the administration of oral but not intravenous\n contrast . Multiplanar reconstructions were performed.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Small focus of ground glass opacity at the\n right base likely reflects subsegmental atelectasis. The visualized heart and\n pericardium are unremarkable. Evaluation of the visceral organs is limited\n secondary to lack of intravenous contrast. Allowing for this factor, there\n are multiple dilated fluid-filled loops of small bowel with moderate\n distention of the stomach and proximal bowel loops. A transition point is\n identified in the right lower quadrant (series 2, image 56), with fecalization\n of small bowel contents with proximal and decompressed loops of small bowel\n and colon seen distally. There is no evidence of bowel wall thickening, free\n intraperitoneal air or fluid. The unopacified liver, gallbladder, pancreas,\n spleen, and adrenal glands are normal. No calculi or evidence of\n hydronephrosis is seen within either kidney. There are small mesenteric and\n retroperitoneal lymph nodes, which do not meet CT size criteria for pathologic\n enlargement.\n\n CT PELVIS WITHOUT IV CONTRAST: The bladder, prostate, seminal vesicles appear\n within normal limits. Decompressed loops of sigmoid colon and pelvic small\n bowel are mostly unremarkable. There is no free pelvic fluid and no inguinal\n or pelvic lymphadenopathy.\n\n BONE WINDOWS: A nonspecific sclerotic focus with nonaggressive features is\n noted in the right ischium, likely a bone island. No osseous findings\n suspicious for malignancy are identified.\n\n IMPRESSION:\n 1. High-grade small-bowel obstruction with transition point identified in the\n right lower abdominal quadrant. No evidence of bowel wall thickening, free\n intraperitoneal air or fluid.\n 2. Sub segmental atelectasis at the right base.\n\n Findings were relayed to the ED dashboard at time of dictation and marked for\n (Over)\n\n 3:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n urgent attention.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-24 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 950950, "text": " 11:03 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: L. PALM SWELLING, ? ARM CLOT\n Admitting Diagnosis: EXPLORATORY LAPAROTOMY FOR SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with unilateral swelling\n REASON FOR THIS EXAMINATION:\n ? clot\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old man with unilateral left upper extremity swelling,\n evaluate for DVT.\n\n FINDINGS: Both grayscale and color Doppler ultrasound examination was\n performed. There is normal compressibility of the left internal jugular vein\n with normal waveforms and response to augmentation. There are normal\n waveforms and response to augmentation of the left subclavian vein as well.\n There is normal compressibility, respiratory variation, and response to\n augmentation of the left axillary, paired brachial veins, basilic and cephalic\n veins. No intraluminal filling defects are seen.\n\n In the patient's left palm, there is a 3 x 5 x 5 mm hypoechoic nodule without\n vascularity present.\n\n IMPRESSION: No left upper extremity DVT identified.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 950588, "text": " 9:27 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: r/o acute pancreatitis/cholecystitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with n/v for 6 days, abnormal LFT's and hi lipase\n REASON FOR THIS EXAMINATION:\n r/o acute pancreatitis/cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Complete abdominal ultrasound.\n\n INDICATION: 45-year-old male with nausea and vomiting times six days and\n abnormal LFTs.\n\n COMPARISON: There are no studies available for comparison.\n\n FINDINGS: The gallbladder is normal in appearance without intraluminal\n stones. The liver is mildly echogenic consistent with fatty liver. However,\n other forms of liver disease and more advanced liver disease, including\n significant hepatic fibrosis/cirrhosis cannot be excluded on this study. No\n intra- or extra-hepatic biliary duct dilatation identified. The pancreas is\n not well visualized secondary to overlying bowel gas. The left kidney\n measures 11.1 cm. The right kidney measures 9.7 cm. There are no masses,\n stones, or hydronephrosis present within the kidneys.\n\n Of note, there are multiple diffuse dilated small bowel loops throughout the\n entire abdomen which display peristaltic activity.\n\n There is no free fluid identified within the abdomen.\n\n IMPRESSION:\n 1. Multiple dilated small bowel loops within the abdomen displaying\n peristaltic activity. Findings worrisome for small bowel obstruction versus\n ileus. Recommend CT scan for further evaluation.\n\n 2. Mild echogenic appearance of the liver consistent with fatty liver.\n However, other forms of liver disease and more advanced liver disease,\n including significant hepatic fibrosis/cirrhosis cannot be fully excluded on\n this study.\n\n Findings were discussed with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-03-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 950692, "text": " 10:03 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? pneumo\n Admitting Diagnosis: EXPLORATORY LAPAROTOMY FOR SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with RIJ\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST TO ASSESS LINE PLACEMENT.\n\n COMPARISON: None.\n\n FINDINGS: Right internal jugular vein catheter tip is at cavoatrial junction.\n There is no pneumothorax or pleural effusion. There are low lung volumes with\n bibasilar discoid atelectasis. There are no sizable pleural effusions. NG\n tube tip is in the stomach.\n\n" }, { "category": "ECG", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 115890, "text": "Sinus rhythm\nNonspecific T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , T wave changes slightly less prominent\n\n" }, { "category": "ECG", "chartdate": "2174-03-22 00:00:00.000", "description": "Report", "row_id": 115891, "text": "Sinus rhythm\nDiffuse nonspecific T wave abnormalities - cannot exclude in part ischemia -\nclinical correlation is suggested\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2174-03-24 00:00:00.000", "description": "Report", "row_id": 115841, "text": "Sinus arrhythmia. Otherwise, normal. Compared to the previous tracing\nof no change.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262971, "text": "focus hemodymics\nneuro: admitted to the sicu from the or. intubated and on iv propofol gtt. pupils #3 and reacts briskly. moves all extremities on the bed. mouthing words but difficult to understand. attempting to write in the air. expressing he has abd pain and fentanyl gtt started and very comfortable.\n\nresp breath sounds clear. intubated with 7.5 et tube. goal is to extubate today. suctioned for thick yellow sputum. o2sats 99-100%.\n\ncardiac: in nsr. no ectopy seen. bp 110-130's. when coughing bp elevates to the 150's. hct 43.6, k 3.3 and repleted with 40meq kcl iv.\nmagnesium 2.2. iv d5lr with 40meq kcl iv at 125cc/hr.\n\ngu : foley patent and draiing yellow cloudy urine. creat 1.7 and bun 49.\n\ngI abd softly distended. ngt to lcws and draining bilius drainage. no bowel sounds. protonix as ordered. ast 44 and alt 95.\n\naction: post op q15min-q1hr vital signs. fentanyl gtt infusing and propofol gtt. neuro signs q2hrs. iv flagyl and iv cefazolin given. ngt to lcws. vented and attempt to extubate today. k repleted. venodynes.\n\nrespnse: monitor closely post op.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262972, "text": "Resp Care,\nPt. admitted from OR intubated #7.5 ET taped at 22@lip. Placed on A/C overnoc. More awake this am, placed on IPS10/5. RSBI 66 this am. Plan to cont. to wean and extubated this am when more awake.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-23 00:00:00.000", "description": "Report", "row_id": 1262973, "text": "NURSING NOTE\n*PLEASE SEE CAREVUE FOR SPECIFICS*\n\nCV: BP stable, systolic 130-150s. Episode of SBP >160 for about an hour, Dr. aware and started pt on 5mg Lopressor IV, given with effect. EKGx2 done today, cards in to see pt, will correct all electrolytes and monitor EKGs. K 4.0. Recieving Sodium Phos for Phos of 2.4. NSR HR 70-90s. No ectopy noted.\n\nRESP: Pt extubated well today with no problems, maintaining sat's 98-100%. Currently on 1L NC sat'ing 97-99%. LCTAB, slightly coarse at times. Productive cough.\n\nNEURO: A&Ox3. Pleasant and cooperative. PEERLA 3mm. Follows commands, lifts and holds all extremities. Pt c/o cramping abdominal pain (), fentanyl drip discontinued and started on Dilaudid PCA, dose 0.12mg with hour total 1.2mg. Pt using pump appropriately and cough pillow as needed.\n\nGI/ENDO: Abdomen soft, slightly distended. + BS. No BM. Pt remains NPO. Right nare NGT to lcws putting out small amount light brown liquid drainage. No insulin coverage required, no blood sugar checks.\n\nGU: Foley patent draining adequate amount of clear/cloudy dark yellow urine.\n\nSKIN: Intact. No breakdown on backside noted. Original dressing from OR intact on midline abdomen, clean and dry, no drainage.\n\nSOCIAL: Pts wife and friend into visit.\n\nPLAN OF CARE: Continue to check and replace electrolytes as needed. Monitor pain, temp, skin integrity. Pt called out, will transfer to floor with tele when bed available. HO aware of above, will call with any changes.\n" } ]

30,855

179,092

19 yo female with hx of question of asthma with many exacerbations, vocal cord dysfunction, depression, and conversion disorder presents with stridor and tachypnea. . # dyspnea and stridor: this is typical of her previous ? asthma exacerbations, for which she does not appear to have a definitive diagnosis. She received ativan, heliox, and nebs in the ED with some resolution of symptoms. Although she has a question of airway disease and a diagnosis of vocal cord dysfuction, this is most likely a manifestation of her conversion disorder. CXR appears normal and unchanged. Most recent admission reported good response to ativan. She continues to sat well in the upper 90s. She will likely benefit most from consistent social and outpatient medical support to help her more effectively deal with anxieties and avoid the ED/ICU where iatrogenic harm may come to her. She has seen ENT before. She was given ativan prn, reassurance, and her inhalers were continued. A coordinated attempt improve her support structure was already in development, but further impetus was placed by emails and phone calls to her major sources of health care support - her PCP, and . Will discuss with PCP, , and : coordination of care. Follow up appointments are set up health services on at 9 am. They agreed to set up support services necessary to her after the visit tomorrow. Will encourage her to follow up with speech/swallow/behavioral therapy as outpatient . # conversion disorder: previously diagnosed at . As above, this is likely the root cause of her exacerbations and would benefit from greater outpatient and social support. . # depression: previously treated with lamotrigine, though not currently treated. Possible or psychiatric referal after appointments at and/or PCP. . # FEN: regular diet, replete lytes prn . # PPx: ambulation, cont outpatient PPI . # Code: full

CXR CLEAR. RESPONDED WELL TO ATIVAN. ARRIVED WITH NOTABLE STRIDOR. PT. PT. PT. BREATH SOUNDS CTA. BREATH SOUNDS CTA. IN PT. BS+. HEMODYNAMICALLY STABLE.GI: ABD. MEDICATE WITH ATIVAN PRN. Lungs clear. AFEBRILE. + PULSES. EMOTIONAL SUPPORT TO PT. COMPARISON: . MAE. The cardiomediastinal silhouette is normal. ALERT AND ORIENTED X3. NO C/O PAIN. PUPILS EQUAL AND REACTIVE. FINDINGS: AP view of the chest in upright position. PROBABLE C/O TO FLOOR THIS AM. Sats 100%. THE THIRD ADMISSION, PT. The lungs are clear. WHEN WE LEFT ROOM, STRIDOR RETURNED. SOFT. VERY PLEASANT AND COOPERATIVE.RESP: PT. HER SATS REMAINED 98-100%. NO ECTOPY NOTED. NO BM. The pulmonary vasculature is normal. INHALERS ORDERED.CV: NSR/ST WITH HR 90'S TO LOW 110'S. NO EDEMA. AM LABS PENDING. IMPRESSION: No acute cardiopulmonary process. WHEN TALKING TO THIS RN AND MD'S THE STRIDOR WENT AWAY. ORDERED FOR REGULAR DIET.GU: PT. TRANSFERRED HERE TO MSICU FOR CLSER MONITORING.NEURO: PT. There is no pneumothorax or pleural effusion. NO STRIDOR WITH SLEEPING. The osseous structures are unremarkable. FELL ASLEEP SHORTLY AFTER TRANSFER. REASON FOR THIS EXAMINATION: please eval for acute cardiopulmonary process FINAL REPORT INDICATION: Vocal cord dysfunction with stridor and feeling of tightness status post exercise. VOIDING IN COMMODE CLEAR YELLOW URINESKIN: INTACTACCESS: R FA 20G PIV - INTACTPLAN: CONTINUE WITH CONTINUOUS PULSE OX MONITORING. 11:16 PM CHEST (PORTABLE AP) Clip # Reason: please eval for acute cardiopulmonary process MEDICAL CONDITION: F w/known vocal cord dysfunction presents w/stridor and feeling of tightness s/p exercise. GIVEN 3 MG OF ATIVAN AND PUT ON HELIOX. NPN 7P-7ATHIS IS A 19YO FEMALE WITH PMH: MULTIPLE ADMISSIONS WITH INTUBATION FOR PRESUMED ASTHMA EXACERBATIONS, PAROXYSMAL VOCAL CHORD DYSFUNCTION, DEPRESSION AND CONVERSION D/O WHO PRESENTED TO EW WITH DYSPNEA AND STRIDOR. ON 40% AEROSOL FACE MASK WITH SATS 98-100%.

2

[ { "category": "Radiology", "chartdate": "2150-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986602, "text": " 11:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F w/known vocal cord dysfunction presents w/stridor and feeling of tightness\n s/p exercise. Sats 100%. Lungs clear.\n REASON FOR THIS EXAMINATION:\n please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Vocal cord dysfunction with stridor and feeling of tightness\n status post exercise.\n\n COMPARISON: .\n\n FINDINGS: AP view of the chest in upright position. The cardiomediastinal\n silhouette is normal. The lungs are clear. There is no pneumothorax or\n pleural effusion. The pulmonary vasculature is normal. The osseous\n structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-12-30 00:00:00.000", "description": "Report", "row_id": 1658219, "text": "NPN 7P-7A\nTHIS IS A 19YO FEMALE WITH PMH: MULTIPLE ADMISSIONS WITH INTUBATION FOR PRESUMED ASTHMA EXACERBATIONS, PAROXYSMAL VOCAL CHORD DYSFUNCTION, DEPRESSION AND CONVERSION D/O WHO PRESENTED TO EW WITH DYSPNEA AND STRIDOR. OF NOTE, SHE HAS HAD 3 RECENT ADMISSIONS (, AND ) FOR HER VOCAL CHORD D/O VS. ASTHMA FLARE REQUIRING 2 INTUBATIONS. THE THIRD ADMISSION, PT. RESPONDED WELL TO ATIVAN. IN PT. GIVEN 3 MG OF ATIVAN AND PUT ON HELIOX. CXR CLEAR. BREATH SOUNDS CTA. HER SATS REMAINED 98-100%. TRANSFERRED HERE TO MSICU FOR CLSER MONITORING.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. PUPILS EQUAL AND REACTIVE. NO C/O PAIN. VERY PLEASANT AND COOPERATIVE.\n\nRESP: PT. ON 40% AEROSOL FACE MASK WITH SATS 98-100%. BREATH SOUNDS CTA. PT. ARRIVED WITH NOTABLE STRIDOR. WHEN TALKING TO THIS RN AND MD'S THE STRIDOR WENT AWAY. WHEN WE LEFT ROOM, STRIDOR RETURNED. PT. FELL ASLEEP SHORTLY AFTER TRANSFER. NO STRIDOR WITH SLEEPING. INHALERS ORDERED.\n\nCV: NSR/ST WITH HR 90'S TO LOW 110'S. NO ECTOPY NOTED. + PULSES. NO EDEMA. AFEBRILE. HEMODYNAMICALLY STABLE.\n\nGI: ABD. SOFT. BS+. NO BM. PT. ORDERED FOR REGULAR DIET.\n\nGU: PT. VOIDING IN COMMODE CLEAR YELLOW URINE\n\nSKIN: INTACT\n\nACCESS: R FA 20G PIV - INTACT\n\nPLAN: CONTINUE WITH CONTINUOUS PULSE OX MONITORING. MEDICATE WITH ATIVAN PRN. EMOTIONAL SUPPORT TO PT. AM LABS PENDING. PROBABLE C/O TO FLOOR THIS AM.\n" } ]

24,963

126,722

Pt is a 82 yo female R CHF, Afib on coumadin, DM, non-healing vascular ulcers, and CRI who is transferred to MICU for sepsis. She was intubated in the ED. It was felt that the hypotension was secondary to sepsis based on exam, with a possible cellulitis as a source. Blood cultures grew out GNR on HD #1. She was convered broadly with zosyn and vancomycin as well as flagyl for potential gut sources. We continued levophed. Given her low SVO2s, dobutamine was tried with resultant decrease in blood pressure; dopamine was then added. Over the course of the day, pt was anuric despite many fluid boluses. It was thought that her severe right sided heart failure and 4+ TR were leading to a cardiac component to the shock. Given her extremely grave prognosis, several family meetings were held. It was decided on the night of to make patient CMO. She passed away at 11:26 pm on with her entire family present.

Diffuse osteopenia is noted. The aorta is diffusely atherosclerotic and calcified. Mild (1+) aortic regurgitation is seen. EXHIBITS GROSS JVD, AND HISTORY OF SEVERE TRICUSPID REGURG.PT. DOBUTAMINE WAS DC'D. PT'S LACTATE 6.9, INR 6.0. Again noted is diverticulosis of the sigmoid colon. TTE DONE SHOWING LARG RIGHT SIDE OF HEART. WAS HYPOTENSIVE UPON ARRIVAL TO THE E.D. HAS BEEN SUCTIONED FOR SCANT CLEAR SECRETIONS. There is atrivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , the estimatedpulmonary arterty systolic pressure and severity of tricuspoid regurgitationare lower. SHOWS COMPRESSION OF LEFT SIDE OF HEART BY RIGHT.GI- ABD SOFT DISTENDED WITH ABSENT BS. B/P REMAINS SUPPORTED BY LEVOPHED PRESENTLY AT 0.1MCG/KG/MIN. IS INTUBATED WITH A 7.5/21 RIGHT LIP LINE. The common iliac arteries are noted to be diffusely calcified. RIGHT SIDE 75/40, AND LEFT 86/46. Aside from a probable right adrenal hematoma, the abdominal and pelvic organs appear grossly within normal limits. Mildaortic valve stenosis is present. REMAINS NPO, WITH OGT PLACED IN E.D. THIS IS A RE OCCURING WOUND THAT PT. LACTATE 6.9. Abnormal diastolic septalmotion/position consistent with RV volume overload.AORTA: Normal aortic diameter at the sinus level. DRESSING REMAINS D&I. THIS IS SLIGHTLY INPROVED WITH FLUID BOLUSES. GRIMACED TO CARE. Right ventricular function.Height: (in) 61Weight (lb): 159BSA (m2): 1.72 m2BP (mm Hg): 94/45HR (bpm): 65Status: InpatientDate/Time: at 12:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. CONTINUES ON FLAGYL, AND UNASYN. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. VAP PROTOCOL FOLLOWED.PT. PRECEPT CATHETER HAS BEEN REPOSITIONED, STILL WAVEFORM IS QUESTIONABLE, BUT PT. IS DRAINING APPROX. Moderate PA systolichypertension.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left and right atria are moderately dilatedThe estimated right atrialpressure is >20 mmHg. CONT ON FLAGYL. The ascending aorta ismildly dilated. There is abnormal diastolic septal motion/positionconsistent with right ventricular volume overload. WAS INTUBATED AND PLACED ON SEPSIS PROTOCOL. ABG WAS 7.29/20/92/10. There is trivial mitralregurgitaiton. The origins of the celiac and SMA are noted to be calcified as well. REMAINS SEDATED ON BOTH FENTANYL 12.5MCG, AND VERSED 1.5MG/HR. Mild AS (AoVA1.2-1.9cm2). The tip of this catheter is in the expected location of the cavoatrial junction or possibly just inside the right atrium. The right ventricular cavity is moderately dilated withgood free wall motion. WILL RESPOND AFTER GTT IS SHUT OFF FOR APPROX. Degenerative changes of the hips bilaterally, right greater than left, are relatively unchanged compared to the CT from . There is diffuse anasarca of the subcutaneous tissues. Good oxygenation when FiO2 1.0. REMAINS ON SEPSIS PROTOCOL AT THIS TIME. There is a small left pleural effusion. STARTED ON LEVO. Focal calcifications inaortic root. 5:24 PM FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT Clip # Reason: Subcutaneous air. DR AWARE. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. Normal regional LV systolic function.RIGHT VENTRICLE: Moderately dilated RV cavity. Dilated IVC (>2.5cm) with nochange with respiration (estimated RAP >20 mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). MONITOR UO. Thereis moderate pulmonary artery systolic hypertension. IMPRESSION: Diffuse ascites and the presence of anasarca suggest so-called "third-spacing" of fluid. TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases to the feet. Trivial MR.TRICUSPID VALVE: Moderate to severe [3+] TR. IS NOTED PRIOR TO THIS ADMISSION TO HAVE +MRSA CULTURE TO THIS WOUND SITE. A comparison was made to prior radiographs dated . Heart size remains enlarged and there is a stable position to endotracheal tube which now appears approximately 4 cm from the carina, orogastric tube, and a single lead left-sided pacemaker device. Mildly dilated ascending aorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. she was sx'd for minimal secretions. SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: A right-sided internal jugular central venous catheter has been pulled back with tip now within the distal SVC. CT OF THE LOWER EXTREMITIES WITHOUT CONTRAST: There is diffuse stranding within the subcutaneous tissues. Moderate to severe [3+] tricuspid regurgitation is seen. Right ventricular cavity size and free wall motioin are similar.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. IMPRESSION: Findings consistent with mild congestive heart failure. Compared to the previous tracing of no change.TRACING #1 PRESENTLY THIS IS TO LOW INTERMITTENT WALL SUCTION FOR SCANT AMT'S OF TAN/CLEAR DRAINAGE. Just superior to the right kidney, there is a 4.1 x 3.9 cm collection with multiple punctate foci (series 2, image 28), which could represent an adrenal hemorrhage. Tip of a right-sided central venous catheter within distal SVC. SVO2 IN THE MID TO UPPER 60'S. BOWEL SOUNDS ARE ABSENT AT PRESENT.FOLEY CATHETER REMAINS IN PLACE WITH URINARY OUTPUT NIL. There is minimal associated atelectasis secondary to pleural effusions. The femoral artery, popliteal arteries, and their respective branches are noted to be calcified bilaterally. IMPRESSION: 1. IMPRESSION: 1. Additionally, a mild interstitial edema appears improved. A single AP view of the chest was obtained on at 1759 hours but is presented on for interpretation. Themitral valve leaflets are mildly thickened. THIS DRESSING HAS BEEN CLEANSED WITH N/S AND DSD APPLIED. The abdominal organs, including the bowel, appear grossly within normal limits otherwise on this noncontrast, limited evaluation. Ventricular pacemaker. Ventricular pacemaker. COMPARISONS: CT pelvis from . Regional systolicfunction is normal. PRESENTLY PT. SON IN WHO IS HER HCP. There is bilateral perinephric stranding and diffuse mesenteric stranding which could be related to the ascites. WITH THIS HER HR WENT UP INTO THE 70'S AFIB WITH RARE PVC. There are multilevel degenerative changes of the lumbar and lower thoracic spine. Improvement to mild interstitial pulmonary edema. COMPARISONS: . UO SINCE HAS BEEN 2-12CC/HR. ON THIS SHE WITHDREW TO PAIN.

17

[ { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 960572, "text": " 5:42 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new R IJ line\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Line placement.\n\n A single AP view of the chest was obtained on at 1759 hours but is\n presented on for interpretation. It is compared with a radiograph\n performed approximately one hour previously and shows insertion of a\n right-sided IJ line. The tip of this catheter is in the expected location of\n the cavoatrial junction or possibly just inside the right atrium. No other\n acute change is noted from the prior radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960596, "text": " 9:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tlc line placement\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p intubation\n\n REASON FOR THIS EXAMINATION:\n tlc line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Reevaluation of line.\n\n Comparison is made to multiple prior films dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n A right-sided internal jugular central venous catheter has been pulled back\n with tip now within the distal SVC. Additionally, a mild interstitial edema\n appears improved. Heart size remains enlarged and there is a stable position\n to endotracheal tube which now appears approximately 4 cm from the carina,\n orogastric tube, and a single lead left-sided pacemaker device.\n\n The lungs are otherwise clear.\n\n IMPRESSION:\n\n 1. Tip of a right-sided central venous catheter within distal SVC. No\n evidence of pneumothorax.\n\n 2. Improvement to mild interstitial pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "LP FEMUR (AP & LAT) LEFT PORT", "row_id": 960570, "text": " 5:24 PM\n FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT Clip # \n Reason: Subcutaneous air. Please do the whole left leg. Thanks.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with non-healing ulcers concern for nec fas\n REASON FOR THIS EXAMINATION:\n Subcutaneous air. Please do the whole left leg. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with non-healing ulcers concerning for\n necrotizing fasciitis.\n\n COMPARISON: .\n\n FINDINGS: Four views of the left thigh and lower extremity. There is a large\n soft tissue defect in the posterior aspect of the mid left lower extremity.\n There is a 1.6 cm density in the superior and medial aspect of the soft tissue\n defect which could represent foreign body or overlying bandage material.\n Bandage material is seen overlying the soft tissue defect. Hardware from\n previous bimalleolar fracture is again noted, not completely assessed in this\n lateral view. Diffuse osteopenia is noted. No evidence of gas within the soft\n tissues. No evidence of acute fracture. No evidence of knee joint effusion.\n The left femoral head is obscured by overlying soft tissues.\n Vascular calcifications.\n\n IMPRESSION:\n 1. Large soft tissue defect in the posterior aspect of the mid left lower\n extremity with a 1.6 cm density in the superior and medial aspect which could\n represent foreign body or overlying bandage material.\n 2. No evidence of gas within the soft tissues.\n 3. Limited evaluation of the left femoral head due to overlying soft tissues.\n 4. Vascular calcifications.\n\n Findings discussed with Dr. at 10:30 PM on .\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960578, "text": " 6:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n assess ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female status post intubation.\n\n A comparison was made to prior radiographs dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS\n\n Endotracheal tube terminates approximately 3 cm from the carina and orogastric\n tube projects below the diaphragm, however distal tip is not visualized but\n likely terminates within the stomach. Appearance of radiograph is otherwise\n unchanged from film taken approximately one hour prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 960583, "text": " 7:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT LOW EXT W/O C BILAT\n Reason: evalaute for source of infection, sepsis\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with renal failure, sepsis\n REASON FOR THIS EXAMINATION:\n evalaute for source of infection, sepsis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen to the feet.\n\n INDICATION: 82-year-old female with renal failure, sepsis. Assess for source\n of infection.\n\n COMPARISONS: CT pelvis from .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases\n to the feet.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral pleural effusions,\n right greater than left. Limited views of the lung bases are unremarkable.\n There is minimal associated atelectasis secondary to pleural effusions. There\n is a significant amount of perihepatic and perisplenic fluid, which extends\n throughout the abdomen and into the pelvis. Just superior to the right\n kidney, there is a 4.1 x 3.9 cm collection with multiple punctate foci (series\n 2, image 28), which could represent an adrenal hemorrhage. This area measures\n approximately 35 Hounsfield units. There is bilateral perinephric stranding\n and diffuse mesenteric stranding which could be related to the ascites. The\n abdominal organs, including the bowel, appear grossly within normal limits\n otherwise on this noncontrast, limited evaluation. The aorta is diffusely\n atherosclerotic and calcified. The origins of the celiac and SMA are noted to\n be calcified as well. There is diffuse anasarca of the subcutaneous tissues.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Extensive diverticulosis of the sigmoid\n and distal descending colon is present and high-density material is seen\n within multiple diverticula, which could be residual barium, but there are no\n reports of recent studies at this institution. There is pelvic fluid\n surrounding the uterus and bladder. A Foley balloon is present within the\n bladder. The common iliac arteries are noted to be diffusely calcified.\n\n CT OF THE LOWER EXTREMITIES WITHOUT CONTRAST: There is diffuse stranding\n within the subcutaneous tissues. At the level of the mid tibia, there is a\n prominent defect within the subcutaneous tissues extending to the deep tissue\n planes along the posterior medial surface of the left lower extremity which\n correlates to a known nonhealing ulcer. There is no associated subcutaneous\n air in this area. The femoral artery, popliteal arteries, and their respective\n branches are noted to be calcified bilaterally.\n\n (Over)\n\n 7:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT LOW EXT W/O C BILAT\n Reason: evalaute for source of infection, sepsis\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n Degenerative changes of the hips bilaterally, right greater than left, are\n relatively unchanged compared to the CT from . There are multilevel\n degenerative changes of the lumbar and lower thoracic spine.\n\n IMPRESSION: Diffuse ascites and the presence of anasarca suggest so-called\n \"third-spacing\" of fluid. Without IV or oral contrast, this examination is\n limited. Aside from a probable right adrenal hematoma, the abdominal and\n pelvic organs appear grossly within normal limits. A left lower extremity\n subcutaneous defect is present but there is no evidence of subcutaneous air in\n the soft tissues. Again noted is diverticulosis of the sigmoid colon.\n\n Findings were discussed with Vascular Surgery service and Dr. from\n General Surgery at 10:00 p.m. on by Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 960562, "text": " 4:45 PM\n CHEST (PA & LAT) Clip # \n Reason: evalaute for volume overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with h/o CHF now with SOB, wt gain\n REASON FOR THIS EXAMINATION:\n evalaute for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray with AP and lateral views.\n\n INDICATION: 82-year-old female with history of CHF, now presenting with\n shortness of breath and weight gain. Assess volume overload.\n\n COMPARISONS: .\n\n FINDINGS: A single-lead pacemaker projects over the left chest. The cardiac\n silhouette is enlarged and the pulmonary vascular markings are prominent. The\n interstitial markings are prominent as well. There is a small left pleural\n effusion. The aorta remains calcified and tortuous without focal dilatation.\n No focal infiltrate within the lungs is present. The soft tissues and osseous\n structures are unremarkable aside from mild degenerative changes of the\n thoracic spine.\n\n IMPRESSION: Findings consistent with mild congestive heart failure.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587772, "text": "PT. BROUGHT FROM HOME WITH C/O WORSENING SOB, AND LEG SWELLING. PT'S MED REGIME WAS CHANGED TWO WEEKS AGO, DUE TO RISING CREATININE. PT. EXPERIENCED A 17 POUND WEIGHT GAIN, ALONG WITH SOB, AND WORSENING LEG EDEMA. PT. WAS HYPOTENSIVE UPON ARRIVAL TO THE E.D. RIGHT SIDE 75/40, AND LEFT 86/46. PT. IS KNOWN TO HAVE RIGHT SIDED HEART FAILURE AND SEVERE TRICUSPID VALVE REGURG . SOB, AND WORSENING LABS PREEMPTED INTUBATION. PT'S LACTATE 6.9, INR 6.0. PT. TAKEN TO CAT SCAN WITH SURGICAL CONSULT ORDERED FOR POSSIBLE ISCHEMIC BOWEL. PT. PLACED ON LEVOPHED, GIVEN 2 LITERS OF N/S AND 2 UNITS OF FFP, AND VITAMIN K.\n\nALLERGIES: ZAROXOLYN\n\nPT. IS A FULL CODE, AND REMAINS ON CONTACT PRECAUTIONS FOR MRSA IN HER WOUND.\n\nPT. REMAINS SEDATED ON BOTH FENTANYL 12.5MCG, AND VERSED 1.5MG/HR. PT. WILL RESPOND AFTER GTT IS SHUT OFF FOR APPROX. 15-20MINS, AND WILL OPEN EYES SPONTANEOUSLY, AND MAE'S. PT. DOES NOT FOLLOW COMMANDS, OR TRACK. PUPILS ARE BILAT EQUAL AND REACTIVE. PT. REMAINS ON BAIR HUGGER DUE TO LOW TEMPS. PRESENTLY PT. IS 95.7 DOWN FROM 96.2 AFTER BEING ON BAIR HUGGER FOR PAST FEW HOURS.\n\nPT. HAS REMAINED 100% V PACED AT RATE OF 65. NO NOTED ECTOPY THROUGHOUT THIS SHIFT. B/P REMAINS SUPPORTED BY LEVOPHED PRESENTLY AT 0.1MCG/KG/MIN. REFER TO CAREVUE FOR LATEST SETTINGS. PT. HAS ALSO RECEIVED OVER 4LITERS OF N/S BOLUSES. PULSES REMAIN DOPPLED AND LOWER LEGS HAVE DARKENED DURING THIS SHIFT. VASCULAR TEAM HAS BEEN AROUND AND, IS AWARE OF THIS. B/P HAS BEEN 88-115/50-60'S. SVO2 MONITORED AND RANGES 64-66. CVP MONITORED AT 30-36. PRECEPT CATHETER HAS BEEN REPOSITIONED, STILL WAVEFORM IS QUESTIONABLE, BUT PT. EXHIBITS GROSS JVD, AND HISTORY OF SEVERE TRICUSPID REGURG.\n\nPT. IS INTUBATED WITH A 7.5/21 RIGHT LIP LINE. VENT SETTINGS ARE CMV TV 500, 60%, RATE 24, AND 5 OF PEEP. PT. HAS BEEN SUCTIONED FOR SCANT CLEAR SECRETIONS. PT. CONTINUES TO BREATH ABOVE VENT, BY 2-4BPM. THIS IS DUE TO HER METABLIC ACIDOSID. VAP PROTOCOL FOLLOWED.\n\nPT. REMAINS NPO, WITH OGT PLACED IN E.D. THIS WAS TRAUMATIC WITH ORALL BLEEDING NOTED FOR 2HRS POST PLACEMENT OG THIS TUBE. PRESENTLY THIS IS TO LOW INTERMITTENT WALL SUCTION FOR SCANT AMT'S OF TAN/CLEAR DRAINAGE. ABD. IS LARGE AND ROUND WITH DOCUMENTED ASCITIES FOUND ON CT SCAN. BOWEL SOUNDS ARE ABSENT AT PRESENT.\nFOLEY CATHETER REMAINS IN PLACE WITH URINARY OUTPUT NIL. PT. IS DRAINING APPROX. 4CC/HR OS CLEAR AMBER URINE. THIS IS SLIGHTLY INPROVED WITH FLUID BOLUSES. CREATININE HAS ALSO RESPONED TO FLUID BOLUSES. 2.7 DOWN FROM 3.2.\n\nSKIN EXHIBITS FIST SIZE ULCER TO LEFT LOWER CALF. THIS IS A RE OCCURING WOUND THAT PT. HAD PLANS FOR A SURGICAL DEBRIDEMENT SCHEDULED FOR NEXT WEEK. THIS DRESSING HAS BEEN CLEANSED WITH N/S AND DSD APPLIED. PT. IS NOTED PRIOR TO THIS ADMISSION TO HAVE +MRSA CULTURE TO THIS WOUND SITE. BOTH LOWER EXT'S REMAIN DUSKY AND DARK, LEFT WORSE THAN RIGHT. LEFT LEG ALSO HAS A REDDENED CELLULITIS WHICH WAS MARKED AT THE BEGINNING OF THIS SHIFT. THIS HAS NOT EXTENDED AT ALL. ALL TEAMS, SURGICAL, VASCULAR, AND MI\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587773, "text": "Respiratory Care\nPt admitted to unit from ED intubated on ventilatory support. Initial ABG demonstrates significant respiratory compensated metabolic acidosis with high minute ventilation requirements. Good oxygenation when FiO2 1.0. No AM RSBI due to FiO2 requirements. BS clear anteriorly and equal. Xray reports satisfactory placement of ETT. No plans for vent wean at this time.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587774, "text": "(Continued)\nCU ARE AWARE. RIGHT I.J PRECEPT CATHETER REMAINS INTACT, AND AFTER BLEEDING AT THIS SITE FOR FIRST FEW HOURS AFTER INSERTION. DRESSING REMAINS D&I. RIGHT PIV TO HAND REMAINS INTACT AND PATENT.\n\nPLAN: PT. REMAINS A FULL CODE. PT. CONTINUES ON FLAGYL, AND UNASYN. PT. WILL RECEIVE AN ALINE, AND WILL WEAN PRESSORS TO SUPPORT B/P. PT. REMAINS ON SEPSIS PROTOCOL AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587775, "text": "FOCUS; NURING PROGRESS NOTE\n82 YEAR OLD FEMALE ADMITTED TO ED LAST PM WITH SOB, INCREASED LEG SWELLING AND HYPOTENSION. WAS INTUBATED AND PLACED ON SEPSIS PROTOCOL. LACTATE 6.9. STARTED ON LEVO. RECEIVED A TOTAL OF 1L IVF OVERNIGHT.\nREVEIW OF SYSTEMS-\nNEURO- SHE WAS SEDATED ON 1.5MG/HR OF VERSED AND 12.5MCG/HR OF OF FENTANYL. ON THIS SHE WITHDREW TO PAIN. PEARL 2MM. GRIMACED TO CARE. THESE WERE SHUT OFF FOR DAILY WAKEUP. SHE IS SLIGHTLY LIGHTER AS SHE WITHDRAWS ALL EXT TO PAIN. AND GRIMACES MORE FREQUENTLY TO CARE. IS CALM WHEN NO CARE BEING DONE. SHE HAS MAE WITH TURNING. HAS COUGH AND GAG.\nRESP- SHE REMAINS INTUBATED AND VENTED. WAS ON 60% FIO2 TV OF 500CC AND A/C RATE OF 24 OVERBREATHING BY UP TO 4 BREATHS. PEEP 5. ABG WAS 7.29/20/92/10. SHE HAD INCREASED WOB AND WAS SWITCHED TO PS OF 15 &0% FIO2 AS SATS WERE ONLY 92% AND 5 PEEP. ON THIS RESP HAVE BEEN IN THE MID 20'S AND SATS HAVE BEEN 93-96%. BS CLEAR. SUCTIONED FOR ALMOST NOTHING THIS SHIFT Q 4 HOURS.\nCARDIAC- HR THIS AM WAS 65 V PACED. MAP WAS MAINTAINED AT 60 WITH LEVOPHED AT UP TO .322MCGS/KG/MIN. ON ROUNDS TEAM DECIDED TO SLOWLY ADD DOBUTAMINE DUE TO HER HX OF RIGHT SIDED HEART FAILURE WITH SVO2 IN HIGH 50'S TO LOW 60'S. DOBUTAMINE WAS STARTED AT .5MCGS/KG/MIN AND TITRATED UP TO 2.5 MCGS/KG/MIN. ON 2.5 MCGS/KG/MIN SHE DROPPED HER SBP TO THE MID 80'S AND HER SVO2 TO 40'S. DOBUTAMINE WAS DC'D. DECISION WAS MADE TO START DOPA AND SHE HAS BEEN ON 5-7MCGS/KG/MIN TO MAINTAIN MAP OF 60 OR GREATER. SVO2 IN THE MID TO UPPER 60'S. CVP 25-35. WITH THIS HER HR WENT UP INTO THE 70'S AFIB WITH RARE PVC. K THIS AM 5.2. REPEAT PENDING FROM 1500. TTE DONE SHOWING LARG RIGHT SIDE OF HEART. SHOWS COMPRESSION OF LEFT SIDE OF HEART BY RIGHT.\nGI- ABD SOFT DISTENDED WITH ABSENT BS. OGT TO LIS DRAINING SMALL AMOUNTS BROWN GASTRO POS DRAINAGE. NO STOOL TODAY. TEAM WANTED TO KEEP HER NPO AS ? OF BOWEL ISHCEMIA BUT UNABLE TO DO CONTRAST CT TO R/O THIS AS SHE CANNOT GET DYE WITH INCREASED CREAT SHE HAS. ALSO GENERAL SURGERY STATES SHE IS NOT A SURGICAL CANIDATE SHOULD SHE HAVE ISCHEMIC BOWEL.\nGU/RENAL- UO 60CC FOR 2 HOURS THIS AM. UO SINCE HAS BEEN 2-12CC/HR. DR AWARE. WILL CONT TO WATCH. FEEL THIS IS DUE TO HER HEART FAILURE AND THAT WE CAN DO NO MORE THAN WE ALREADY ARE. CREAT 2.7 THIS AM WHICH IS WORSE THAN HER BASELINE BUT SLIGHTLY BETTER THAN LAST PM.\nHEME- HCT 41.1. INR UP TO 4.4.\nENDO- BS AT NOON 127. NO NEED FOR SS INSULIN.\nID- TEMP 96.5-98.8. DOSED WITH VANCO FOR LEVEL OF 12.9 TODAY. CONT ON FLAGYL. AMPICILLIN CHANGED TO ZOSYN AS HAD ONE BC FROM YESTERDAY WITH GRAM NEG RODS. PUT IN FOR BC IN AM.\n SON IN WHO IS HER HCP. PULM FELLOW AND DR AND THIS NURSE MET WITH HIM. HE WAS UPDATED ON THE GRIM PROGNOSIS. HE SEEMS TO UNDERSTAND HOW ILL HIS MOTHER IS BUT HAS HOPE THINGS COULD CHANGE. OF NOTE TODAY IS THE ANNIVERSARY OF THE HUSBANDS DEATH FROM RENAL CELL CA. PATIENT REMAINS A FULL CODE.\nPLAN- DOPA 5-10MCGS/KG/MIN TO MAINTAIN MAP >60.\n MONITOR UO.\n MONITOR SVO2.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587776, "text": "FOCUS; NURING PROGRESS NOTE\n(Continued)\n CALL SON IF CONDITION DETERIORATES.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587777, "text": "focus; addendum\nCARDIAC- SPOKE WITH DR AT 1720. AT THIS TIME PATIENT IS ON 10MCGS/KG/MIN OF DOPA AND HAS MAPS OF 59 WITH SVO2 OF HIGH 50'S. NOT ANYMORE TO DO AS SHE WILL NOT TOLERATE PRESSORS WITH HER RIGHT HEART FAILURE. FLUIDS WILL ALSO NOT DO WELL FOR HER AND DOBUTAMINE HAS FAILED. IF HER CONDITION WORSENS WILL INFORM SON.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587778, "text": "pt weaned to PSV successfully early in shift which improved pt's BP. she was sx'd for minimal secretions. plan uncertain at this time.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 1587779, "text": "focus; addendum\ncardiac- patient on 20mcgs/kg/min of dopa and not responding . svo2 in the mid 40's. hr 65 and paced and map 64. spoke with son and told him that things were looking poorly. Dr paged to discuss code status with family. Priest paged and will be up to give the patient the last rights.\n" }, { "category": "Echo", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 69195, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Congestive heart failure. Right ventricular function.\nHeight: (in) 61\nWeight (lb): 159\nBSA (m2): 1.72 m2\nBP (mm Hg): 94/45\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 12:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Dilated IVC (>2.5cm) with no\nchange with respiration (estimated RAP >20 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Abnormal diastolic septal\nmotion/position consistent with RV volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA systolic\nhypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left and right atria are moderately dilatedThe estimated right atrial\npressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy\nwith normal cavity size and systolic function (LVEF>55%). Regional systolic\nfunction is normal. The right ventricular cavity is moderately dilated with\ngood free wall motion. There is abnormal diastolic septal motion/position\nconsistent with right ventricular volume overload. The ascending aorta is\nmildly dilated. The aortic valve leaflets are moderately thickened. Mild\naortic valve stenosis is present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is trivial mitral\nregurgitaiton. Moderate to severe [3+] tricuspid regurgitation is seen. There\nis moderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the estimated\npulmonary arterty systolic pressure and severity of tricuspoid regurgitation\nare lower. Right ventricular cavity size and free wall motioin are similar.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2121-05-30 00:00:00.000", "description": "Report", "row_id": 154789, "text": "Ventricular pacemaker. No change from the previous tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2121-05-29 00:00:00.000", "description": "Report", "row_id": 154790, "text": "Ventricular pacemaker. Compared to the previous tracing of no change.\nTRACING #1\n\n" } ]

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Patient was taken to the operating room and underwent an orthotopic liver transplant; the patient only required 1 unit of packed cells, 2 units of platelets, 500-cc of albumin, and 1 unit of cryo intraop. He was taken to the APCU intubated and in stable condition. Patient did extremely well and was therefore extubated later that day (ahead of the pathway). He stayed in the ICU for monitoring for another 24hours, and was then transferred to the floor late on POD1. From here he made a remarkabel recovery. He continued to make good urine and LFTs went downward for the first few days. He ambulated with assitance and tolerated good po pretty early. Some hampering to his recovery was the fact that he is blind and somewhat deaf - he was continually claiming to be depressed because of boredom and lonliness. Duplex on POD1 was normal, and CXRs continued to be normal. His CVL was removed before he left the ICU. On POD5 his LFTs bumped up slightly, so he recieved 2 boluses of steroids as a precautionary measure and a repeat US was performed which showed a mural thrombus in the donor IVC. Biopsy was done which was normal and without signs of rejection. After that, LFTs started to decline again and patient continued to do extremely well.

A new 2.9 x 1.1 x 1.4 cm echogenic nodule is seen within the region of the excluded donor IVC most consistent with thrombus. The main, right, and left hepatic arteries demonstrate normal systolic upstroke with resistive indices measuring 0.83, 0.72, and 0.83, respectively. UO 40-180cc/hr.Integ: Abdominal "" incision w/ primary dsg intact; small amount of serosang drainage noted on dsg. IMPRESSION: PA and lateral chest compared to : Normal heart, lungs, hila, mediastinum and pleural surfaces. Abdominal dsg w/ small amount serosang drainage; dsg changed by transplant team. acute process / baseline FINAL REPORT PA AND LATERAL CHEST . Normal liver Doppler study. vs remain stable.resp: intubated ac at 28%fio2x 650x 10x peep5, ls clear, sats 98%, overbreathing 1 to 2 breaths. FINDINGS: The previously seen Swan-Ganz catheter has been exchanged for a right internal jugular central venous line with the tip appearing to terminate high within the right atrium. Pt w/ trace generalized edema. IMPRESSION: Normal liver transplant ultrasound. pt has oral thrushgi: ogt to ilws, +bs, abd drsg d&I, tolerated transplant surgery well md's. With the patient in end-expiration, the skin was marked over the right lobe of the liver. 2:52 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: please do duplex? UpdateSee careview for details....Neuro: Pt off propofol for extubation, post extubation pt 3, MAE, calm and cooperative, denies pain, MAE, very HOH and legally blindCV: Hemodynamics stable, PA line d/c'd and changed to TLC, NSR 80's, + periph pulses, post op EKG done this AM as orderedResp: Pt extubated this afternoon, tol 35% OFM, sats 97-98%, denies SOB, encouraging to C&DB, lungs clear after extubationGI: Abd soft, hypoactive BS, no BM, NGT d/c'd per transplant team, tol sips, no N/VGU: fair UO via foley, transplant team awareSkin: Abd dsg D&I with sm amt serosang dng to dsg, JP x2 with min dng, #1 straw colored dng, #2 serosang dngEndocrine: BS's elevated this AM, Spoke with Dr , MD prfers that insulin gtt not exceed 10 units/hr, ordered to bolus instead, blood sugars remain high, IVF's changed from D5 .45NS to .45 NS, BS's decreased to 90's, insulin gtt down to 4units/hrPlan: Monitor labs, UO, pain Incentive spirometry teaching performed; inspiratory volume 250-750mL.GI: Abdomen softly distended w/ hypoactive BS. The right, middle, and left hepatic veins demonstrate normal direction of flow and respiratory variation. LIVER TRANSPLANT ULTRASOUND: FINDINGS: The portal vein is patent and has normal direction of flow. NPO except meds. Labs drawn q8hr; stable. 3rd (last) dose of Unasyn given. LFTs decreasing.Pulm: Lungs clear, diminished at bases. New thrombus within excluded donor IVC. 4:08 AM CHEST (PORTABLE AP) Clip # Reason: ? Right internal jugular central venous catheter tip remains within the proximal right atrium. The right jugular Swan-Ganz catheter terminates in the right main PA. A nasogastric tube terminates in the gastric fundus. COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and compared with previous study of yesterday. Sinus rhythm.Rightward axis - is nonspecific and may be within normal limitsSince previous tracing of , no significant change The tip of the endotracheal tube is identified at the thoracic inlet. SUPINE AP VIEW OF THE CHEST: Patient has been extubated and the nasogastric tube removed. FINAL REPORT INDICATION: Status post liver transplantation and extubation. No BM this shift.Endo: Insulin gtt titrated per CSRU protocol. Continue 0.45% NS @ 100cc/hr and D5W @ 10cc/hr. CT scan showed 2x1.8sm enhancing mass in r lobe of live, biopsy demonstrated HCC and cirrhosis, pt denies and extrahepatic manifestations of his HCV. Start methylprednisolone on POD#1. Continue ICU care and treatment. underwent RFA of lesion , currently prior to surgery pt states he is feeeling well and has no complaints. The hepatic veins are patent. Superior extension to the recipient IVC anastomosis is not clearly identified, and follow-up imaging is recommended. The main, posterior right, anterior right, and left portal veins are patent, with appropriate direction of flow. BS checked q1hr.GU: Foley intact w/ clear, yellow urine. HR 70-90s (NSR). LIVER ULTRASOUND WITH DOPPLER EXAMINATION: The liver parenchyma is normal in echogenicity, without focal nodules or masses. The endotracheal tube and NG tube are in stable position. Diet changed to clear liquid. The hepatic artery and its branches are patent. JP#1 w/ small amount serous drainage and JP#2 w/ small amount serosang drainage. Addendum to NPN:Hct 27.1; WBC elevated 16.9 (Dr. and transplant team aware; see CareVue for all labs). source of hep c)he has been tx with pegIFN/RBV x3 without SVR, summer pt had noted rise in AFP on screening. HISTORY: Preop liver transplant. 10:06 AM CHEST PORT. DP/PT pulses palpable. COMPARISON: Chest x-ray obtained earlier on the same day. Pt w/ nonproductive cough. Insulin gtt d/c'd at 0600; continue to monitor BS. 2:11 PM CHEST PORT. Sinus rhythmRightward axis - is nonspecific and may be within normal limitsSince previous tracing of , no significant change ABP 120-140/50-60s. Monitor JP output and empty frequently. O2 sat >/= 97% on 3LNC. JPX2 to bulb suction. Patchy atelectasis is seen at the lung bases. Offer pain med as needed. Please mark spot for liver biopsy. Update pt and family w/ plan of care. No c/o nausea. IMPRESSION: 1. FINDINGS: Limited study of the liver was performed for localization.

14

[ { "category": "ECG", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 204563, "text": "Sinus rhythm\nRightward axis - is nonspecific and may be within normal limits\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2175-07-11 00:00:00.000", "description": "Report", "row_id": 204564, "text": "Sinus rhythm.\nRightward axis - is nonspecific and may be within normal limits\nSince previous tracing of , no significant change\n\n" }, { "category": "Radiology", "chartdate": "2175-07-11 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 915761, "text": " 12:15 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE LIVER DISEASE\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with HCV/HCC pre-op for liver transplant\n REASON FOR THIS EXAMINATION:\n ? acute process / baseline\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST .\n\n HISTORY: Preop liver transplant.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Normal heart, lungs, hila, mediastinum and pleural surfaces.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915926, "text": " 2:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PA line change over wire to CVL, check placement\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n PA line change over wire to CVL, check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, PA line changed over wire.\n\n COMPARISON: Chest x-ray obtained earlier on the same day.\n\n FINDINGS: The previously seen Swan-Ganz catheter has been exchanged for a\n right internal jugular central venous line with the tip appearing to terminate\n high within the right atrium. Note is made of relatively low lung volumes.\n There is increased atelectatic changes in the left retrocardiac region. The\n endotracheal tube and NG tube are in stable position. The remainder of the\n lungs are clear. No pneumothorax or effusions are identified. Surgical\n changes in the upper abdomen are also noted.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-17 00:00:00.000", "description": "P GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT", "row_id": 916516, "text": " 7:57 AM\n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT Clip # \n Reason: ONLY NEED BEDSIDE US MARKING FOR LIVER BIOSPY BY HEPATOLOGYP\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man S/P LIVER TRANSPLANT\n REASON FOR THIS EXAMINATION:\n ONLY NEED BEDSIDE US MARKING FOR LIVER BIOSPY BY HEPATOLOGYPLEASE DO IN AM\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY\n\n HISTORY: 66-year-old man S/P liver transplant. Please mark spot for liver\n biopsy.\n\n FINDINGS: Limited study of the liver was performed for localization. With\n the patient in end-expiration, the skin was marked over the right lobe of the\n liver. Biopsy to be performed by the clinical staff.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 915897, "text": " 10:27 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: S/P LIVER TRANSPLANT ,EVAL FOR VASCULATURE FLOW AND PATENCY\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant day 0\n REASON FOR THIS EXAMINATION:\n DUPLEX - please evaluate vasculature flow and patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male status post liver transplant.\n\n TECHNIQUE: The liver transplant was performed.\n\n LIVER TRANSPLANT ULTRASOUND:\n\n FINDINGS: The portal vein is patent and has normal direction of flow. The\n hepatic artery and its branches are patent. The hepatic veins are patent. No\n obvious fluid collections or free fluid is seen.\n\n IMPRESSION: Normal liver transplant ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2175-07-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915893, "text": " 10:06 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line position\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess line position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE\n\n INDICATION: 66-year-old man status post liver transplant.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with previous study of yesterday.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right jugular Swan-Ganz catheter terminates in the right main PA. A\n nasogastric tube terminates in the gastric fundus. No pneumothorax is\n identified.\n\n Patchy atelectasis is seen at the lung bases. The lungs are clear otherwise.\n The heart is normal in size.\n\n IMPRESSION: No pneumothorax. No active lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-16 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 916432, "text": " 2:52 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: please do duplex? rejection ?thrombus/clot\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant with increasing lfts\n REASON FOR THIS EXAMINATION:\n please do duplex? rejection ?thrombus/clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man status post liver transplant with increasing\n liver function tests. Evaluate.\n\n COMPARISON: .\n\n LIVER ULTRASOUND WITH DOPPLER EXAMINATION: The liver parenchyma is normal in\n echogenicity, without focal nodules or masses. A new 2.9 x 1.1 x 1.4 cm\n echogenic nodule is seen within the region of the excluded donor IVC most\n consistent with thrombus. Superior extension to the recipient IVC anastomosis\n is not clearly identified, and follow-up imaging is recommended. The adjacent\n recipient IVC is patent. The right, middle, and left hepatic veins\n demonstrate normal direction of flow and respiratory variation. The main,\n posterior right, anterior right, and left portal veins are patent, with\n appropriate direction of flow. The main, right, and left hepatic arteries\n demonstrate normal systolic upstroke with resistive indices measuring 0.83,\n 0.72, and 0.83, respectively.\n\n IMPRESSION:\n 1. Normal liver Doppler study.\n\n 2. New thrombus within excluded donor IVC. Proximal extension into the\n recipient IVC is not clearly defined, and follow-up imaging is recommended for\n further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915992, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p liver transplant and extubation\n\n REASON FOR THIS EXAMINATION:\n ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplantation and extubation.\n\n COMPARISON: and .\n\n SUPINE AP VIEW OF THE CHEST: Patient has been extubated and the nasogastric\n tube removed. Right internal jugular central venous catheter tip remains\n within the proximal right atrium. Two drains project over the upper abdomen.\n Heart is normal size. Slight widening of the mediastinum and new mild\n pulmonary edema may be secondary to the patient's recent extubation or\n reflect volume overload. Heterogeneous opacity in left lower lobe is likely\n atelectasis. No effusions or pneumothorax are present.\n DFDdp\n\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413131, "text": "admission note\npt is 65 yo male with hx of testicular CA tx with l orchiectomy and chemo( received blood products ? source of hep c)he has been tx with pegIFN/RBV x3 without SVR, summer pt had noted rise in AFP on screening. CT scan showed 2x1.8sm enhancing mass in r lobe of live, biopsy demonstrated HCC and cirrhosis, pt denies and extrahepatic manifestations of his HCV. underwent RFA of lesion , currently prior to surgery pt states he is feeeling well and has no complaints. please see hx for extensive animal and plant ownership by pt\n** pt is functionally blind and ahs neurological deafness ( can hear using bilat hearing aids)\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413132, "text": "admission note\npt admitted from OR at 5am,\nneuro: sedated on propofol at 40mcg, perrla at 2mm, pt's wife took home his hearing aid.\n\npain: none sedated.\n\ncad hr 94 to no ectopy noted, abp 97/58 to 130/51 neo off shortly after admission. vs remain stable.\n\nresp: intubated ac at 28%fio2x 650x 10x peep5, ls clear, sats 98%, overbreathing 1 to 2 breaths. pt has oral thrush\n\ngi: ogt to ilws, +bs, abd drsg d&I, tolerated transplant surgery well md's. no bm, no flatus noted. jp's patent, draining ss fluid #1 3.2 cc #2 17.5cc total since admission\n\ngu: foley patent draining clear yellow urine 130 to 200cc/hr.\n\nid: temp 99.2, next dose of unasyn due at 10am,\n\nendo: insulin gtt started at 630am at 10u/hr\n\nplan: continue transplant clinical pathway, monitor vs, i&o, resp status as ordered. unasyn at 10am, labs due at 1300.\n" }, { "category": "Nursing/other", "chartdate": "2175-07-12 00:00:00.000", "description": "Report", "row_id": 1413133, "text": "Update\nSee careview for details....\nNeuro: Pt off propofol for extubation, post extubation pt 3, MAE, calm and cooperative, denies pain, MAE, very HOH and legally blind\n\nCV: Hemodynamics stable, PA line d/c'd and changed to TLC, NSR 80's, + periph pulses, post op EKG done this AM as ordered\n\nResp: Pt extubated this afternoon, tol 35% OFM, sats 97-98%, denies SOB, encouraging to C&DB, lungs clear after extubation\n\nGI: Abd soft, hypoactive BS, no BM, NGT d/c'd per transplant team, tol sips, no N/V\n\nGU: fair UO via foley, transplant team aware\n\nSkin: Abd dsg D&I with sm amt serosang dng to dsg, JP x2 with min dng, #1 straw colored dng, #2 serosang dng\n\nEndocrine: BS's elevated this AM, Spoke with Dr , MD prfers that insulin gtt not exceed 10 units/hr, ordered to bolus instead, blood sugars remain high, IVF's changed from D5 .45NS to .45 NS, BS's decreased to 90's, insulin gtt down to 4units/hr\n\nPlan: Monitor labs, UO, pain\n" }, { "category": "Nursing/other", "chartdate": "2175-07-13 00:00:00.000", "description": "Report", "row_id": 1413134, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Pt slept most of the night. Easily arousable to voice. Pupils not equal; left is 4mm and right pupil is 3mm (Dr. and Dr. aware). Bilat pupils are sluggish. Pt is blind. Pt moves all extremities; follows commands. Very hard of hearing; pt's wife took home his hearing aids, but will bring them in tomorrow. Clear speech. Aks appropriate questions. Morphine 2mg IV given for back pain w/ +effect.\nCV: Afebrile. HR 70-90s (NSR). ABP 120-140/50-60s. MAP 83-90. CVP 2-8. Pt w/ trace generalized edema. DP/PT pulses palpable. 24hr net I&O balance was approx +6,355cc. Pt's weight is up 3kg from yesterday (weight today: 69.7kg). Start methylprednisolone on POD#1. 3rd (last) dose of Unasyn given. Continue 0.45% NS @ 100cc/hr and D5W @ 10cc/hr. Labs drawn q8hr; stable. LFTs decreasing.\nPulm: Lungs clear, diminished at bases. O2 sat >/= 97% on 3LNC. RR 18-24. Cough/deep breathing encouraged. Pt w/ nonproductive cough. Incentive spirometry teaching performed; inspiratory volume 250-750mL.\nGI: Abdomen softly distended w/ hypoactive BS. NPO except meds. Pt swallowed pills without difficulty. No c/o nausea. No BM this shift.\nEndo: Insulin gtt titrated per CSRU protocol. BS checked q1hr.\nGU: Foley intact w/ clear, yellow urine. UO 40-180cc/hr.\nInteg: Abdominal \"\" incision w/ primary dsg intact; small amount of serosang drainage noted on dsg. JPX2 to bulb suction. JP#1 w/ small amount serous drainage and JP#2 w/ small amount serosang drainage. Both JPs stripped and emptied q2hr. Pt turned and repositioned frequently to maintain skin integrity. No pressure ulcers noted. T&R also helps relieve back pain.\nSocial: wife called x1; updated by RN on plan of care and on pt's condition. Wife will visit in the afternoon.\nPlan: Monitor VS, I's and O's, labs. Check tacrolimus trough in the morning at 0700. Monitor JP output and empty frequently. Titrate insulin gtt per CSRU protocol; check BS q1hr while on insulin gtt. Offer pain med as needed. ?transfer to 10 today. Update pt and family w/ plan of care. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2175-07-13 00:00:00.000", "description": "Report", "row_id": 1413135, "text": "Addendum to NPN:\nHct 27.1; WBC elevated 16.9 (Dr. and transplant team aware; see CareVue for all labs). Abdominal dsg w/ small amount serosang drainage; dsg changed by transplant team. Insulin gtt d/c'd at 0600; continue to monitor BS. Diet changed to clear liquid. OOB to chair today. ?transfer to 10 later today.\n" } ]

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1. Respiratory: This baby required oxygen for the first few hours after admission to the Neonatal Intensive Care Unit. He then weaned to room air and remained in room air through the remainder of his course. He has had no episodes of spontaneous apnea or bradycardia. 2. Cardiovascular: maintained normal heart rates and blood pressures. No murmurs have been noted. 3. Fluids, electrolytes and nutrition: Enteral feeds were started on day of life one and gradually advanced to full volume. He required some gavage feeds during the first two days of admission but then has been all bottle since that time. He has been taking between 150 and 200 cc per kg per day of breast milk or Enfamil 20. His weight on the day of discharge is 2.58 kg. 4. Infectious disease: Due to his prematurity and oxygen requirement, this baby was evaluated for sepsis. A white blood cell count was 9,700, 30% polys, 0% bands. Blood culture was obtained and was no growth in 48 hours. He was not treated with antibiotics. 5. Hematology: Hematocrit at birth was 52.5%. This baby has not required any transfusions of blood products. His bllod type and ccombs was O+, coombs negative. 6. Gastrointestinal: required treatment for unconjugated hyperbilirubinemia with phototherapy. His peak serum bilirubin occurred on day of life five with a total of 14.5/0.3 mg per dL direct. He was treated with phototherapy for three days. His rebound bilirubin on was 10/0.3 direct for an indirect of 9.7 mg per dL. 7. Neurology: has maintained a normal neurological examination during admission and there are no concerns at the time of discharge. 8. Orthopedic: Polydactyly of the hands and feet were discussed with Dr. , orthopedic surgeon from . He will follow up with the patient after discharge. He has an appointment on . 9. Sensory/audiology: Hearing screening was performed with automated auditory brainstem responses. passed in both ears.

Was d/ctoday. Neonatology-NNP Physical ExamInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. Dev remains in OAC, Temp stable, swaddled with hat.Active with cares. Vigorousnon-nutritive suck. Rebound biliobtained and values in careview. Abd benign. BMZ given on and . Continue tomonitor.4. c/=. AFOSF, PFOSF, MAE, AGA. RRR, without murmur, pulses 2+ and symmetrical. Extra digits PWWP. Mild S/Cretractions noted. Resp remains in RA. Will cont to educateand prepare for discharge.REVISIONS TO PATHWAY: 1 RESP; resolved Cl and = BS. V/S.Continueto monitor and support FN. Circ healing. NPN 7p7a#2 Wt 2580 (+60). Active BS. Neonatology Attending NoteDay 1RA. RESP: Pt remains in RA with RR 30-60's. Girth stable.Continue to encourage PO feeds.3. Will cont to keep informed andsupported. Vigorous non-nutritivesuck. Signed consent s for PKU and Hep B. Pedi choosenbut no appointment yet. Continue tomonitor.2. Made aware of possible DCtomorrow. Lites DC . Neonatology Attending NoteDay 2CGA 33 RA. Nospells or desats noted.2. AGA. Given BBO2 only. PO/PG. Continue tomonitor and support developmental mile stones.4. A/A with cares. Returned to floor. Refer to RR inflowsheet. MAES. FOS&F. Active and alert with cares.#4 No parental contact thus far this shift. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. All POs, BM/E20. Needed some direction re BF andbottling and when to burp. Monitor DS, start IVF with D10W. NPNI have examined this infant. Lungs clear, equal and well aerated.#2 Weight down 45gms to 2395 on full enteral feeds of PE20at 80cc/k/d po/pg. Abd soft,round. TF 80 cc/k/day PE20. TF 80 cc/k/day all pg. Nl voiding and stooling. PE 20. d/s 84.Under radiant warmer.A/P: - Monitor for the development of PDA - Maintain current TF - Transition to isolette Polydactyly noted onboth hands and on right foot. Continue to encourage PO's.3. Baby remains in RA, color pink, BBS equal, clear,very mild sc retractions, RR40-50, no spells A: stable in RA P: continue to monitor.2. Continue to monitor.2. Abd soft,nt/nd, no loops. Tolerates well with nospits. Nobleeding. Active, alert in an open warmer, AFOF, sutures split, good tone. If increased WOB or increasing O2 req may need CXR, ABG. Active bowel sounds, without loops, without HSM, tolerating feeds well. Refer toflowsheet for temps. No murmur, pulses +2, pink, RRR. No murmur, pulses +2, pink, RRR. No murmur,pulses +2, pink, RRR. TF 80cc/k PE20 33cc q4h, all pg except took 18cc po atlast feeding, abd soft, active bowel sounds, no loops, nospits, minimal aspirates, voiding, no stool A: toleratingfeedings P: continue present care, check bili at 24h.3. Temps remain stable in open cribdressed, hatted and swaddled. Neonatology Attending NoteDay 3CGA 34RA. 1. FN TF 120cc/kg/d of PE/BM 20 q4h. TF min 100cc/k/day. Refer to flowsheet for RR. Sleepy duringPO's however able to surpass min. Without rashes. Feeding well. Belly is soft with active bowelsounds, stable girths, no spits and no residuals. HR 130-150s. Tolerates wellwith no spits, and surpasses min. Obtinradiographic studies of extra digits. Remains in RA sats >95%, no drifts, spells, desats. P. Check bili this am. P: CHECK BILIIN AM. P: CHECK BILI IN AM. Nursed well then PC 60cc Bm. Check bili in am, TEMP STABLE. Reviewed d/cteaching. Hep B given and PKUdone. BFWx30minutes. P: A.M. bili pending. Voiding qs, Passing lgstools.A: Adequate intake for wt gainP: Cont per plan.#3 Dev: O: Temps stable in heated isolette. Neonatology-NNP Physical ExamInfant remains in RA. Fontanelssoft/flat. NPN:RECEIVED INFANT @ 0100:2. O: Infant remains on min TF's of 120cc/k/d of BM20. BABY IS NOWNESTED IN HIS ISOLETTE. Cl and = BS. A: AGA. Mom in at .. (TFI: 178). (TFI: 178). Infant sl. INFANT SL. Abd soft and round with active bowelsounds. This R,N. 0700- NPN AddendumHYPERBILI: Bili drawn this AM was 9.4-0.2-9.2. Pt is currentlydressed/swaddled. MAEW. Cl and =. Cl and =. Bottles well. Tol well. EYESCLEAN AND COVERED. A: IMPROVING BILI. Am bilisent-pending. continue with current plan.#4 S. O. Nl voiding and stooling.Under single phototherapy. Neonatology Attending NoteDay 6CGA 34 3RA. Min 80 cc/k/day PO ad lib BM20 (TFI: 171). Both Mom and baby did verywell. Active, in an isolette, AFOF, sutures opposed, good tone. Neonatology Attending NoteDay 7RA. Nospits. CONT TO MONITOR. CONT TOMONITOR.3. A: Tolerating po feeds. O: Infant remains under single phototherapy. TF 120 cc/k/day BM/E20. Discharge teaching.#5 Hyperbili:O: under single phototx. NPN#2 S. O. belly benign. A. A. BABY FEEDSWITH BM20. ABDOMEN BENIGN,VOIDING AND STOOLING. MAE, /active with cares, wakesindependently for feeds. INFANT WOKE @ 0300 AND BOTTLED100CCS OF BM20. TF 120 cc/k/day BM20 all po. A. Jaundiced. A: FEEDING WELL. Neonatology Attending NoteDay 8CGA 34 5RA. Infant continues on adlib demand feeding schedule. Bili mask in place.Color jaundiced.A/P; Cont. Nursing Progress Note#2. TF REMAIN @ MIN 80CC/KG/D. A: Involved Mom. P: CONTINUE TO KEEP INFORMED.#5 O: CHANGED FROM BILIBLANKET TO PHOTOTHERAPY AS BILIINCREASED SLIGHTLY TODAY. A: APPROPRIATE FOR AGE. A: APPROPRIATE FOR AGE. A: APPROPRIATE FOR AGE. A:APPROPRIATE FOR AGE. TF 145 +BF-BM/E20 all po. Sweetand active with cares. HR 130-160s. A:WAKING TO DEMAND FEED. Appropriate activity for age. Nl voiding and stooling.In open crib.A/P: - Progressing well. Eye shieldsin place. To home today. RR30-60s. RR40-70s. Invested mom.P.Support and keep updated.#5 S. O. Singlephototherapy was d/c'd at 1030 as ordered. CONT TO DEV NEEDS.4. A: feeding wellP: Follow weight#3 Temps stable in air isolette under phototherapy. Abdomen benign. AFOF, and activewith feeds , MAE. with phototx. Infant doing wellwith feeds.P. Askinglots of appropriate questions. Mom needing assistance with positioning.Otherwise po fed well. Neonatology Attending NoteDOL 5CGA 34 RA. BABY MOVED TO ISOLETTEFOR CHANGE TO PHOTOTHERAPY FROM BILIBLANKET. jaundiced. benign, soft, active BS, noloops. Nursing Discharge NoteF&N: TF min 120cc/kg/day BM/E20. Pt is voiding, trace stool x 1.G&D: Received pt in air-controlled isolette that was turnedoff at 1030, temps have remained stable. Infant received145cc/k/d +BFW x1 yesterday. WAKING FOR FEEDS, SUCKINGVIOGURSLY ON PACIFIER. Rebound bili tobe checked tomorrow AM. Voiding and stooling. Voiding and stooling. Voiding and stooling. Bottling/ Nursing well.A: AGAP: Cont to support dev.#4 :o: Mom in to visit, Handling infant well.A/P: Cont to suuport and inform.

36

[ { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725557, "text": "NPN 1900-0730\n\n\n#1 Stable in RA, no drifts or spells, problem resolved.\n\n#2 Weight up 25gms to 2420 on full enteral feeds of BM/PE20\nat 100cc/k/d po. Taking po feeds well except for \nfeeding after long afternoon of visitors. Ngt dropped after\ninfant bottled 10cc. Now awake and acting interested. Belly\nis soft with no spits or loops, voiding and stooling well.\nWill cont to offer all po's and d/c feeding tube if able.\n\n#3 Waking for feeds every four hours. Temps remain stable in\nopen crib dressed, hatted and swaddled. Vigorous\nnon-nutritive suck. Sleeps quietly when undisturbed.\n\n#4 Mom up at to visit, bringing breast milk. No new\nquestions or concerns voiced. States feeling much better\nthan this afternoon. Will cont to keep informed and\nsupported.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725558, "text": "Neonatology Attending Note\nDay 3\nCGA 34\n\nRA. RR40s. No murmur.\n\nWt 2420, up 25 gms. TF min 100cc/k/day. all PO.\n\nIn open crib.\n\nA/P:\n - TF to 120 cc/k/day\n - If continues to feed well, with no CVR issues, will be ready to go home soon\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725559, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOf, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur,pulses +2, pink, RRR. Abdomen soft,non-distended with active bowel sounds, no HSM, tolerating feeds. Extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725548, "text": "Nursing Admission Note\n\n\nPt admitted to NICU at from L&D. Please see Attending\nMD/NNP note for maternal history and pt's physical exam.\n\n1. RESP: Pt remains in RA with RR 30-60's. Mild S/C\nretractions noted. Sats >93%. Lung sounds are clear. No\nspells or desats noted.\n\n2. F&N: Pt is workign up on feeds. Pt initiall received\n20cc/k of PE20 and was then advanced by 20cc/k/d Q 4 hours.\nGoal TF is 80cc/k/d. Initial D/S 84. Feeds gavaged in via\nNG tube. BS were initially hypoactive, but increasing\nactive during this shift. No spits and no aspirates noted\nso far this shift. Voiding small amounts. No stool noted.\n\n3. DEV: Pt was placed upon sheepskin on radiant warmer.\nTemp stable. Baby meds were given. Polydactyly noted on\nboth hands and on right foot. Mongolian spot noted.\nFontanels are soft and flat.\n\n4. PAR: Maternal grandmother in to visit. Mom has not\nbeen in to visit because she is still in L&D.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725549, "text": "Neonatology Attending Note\nDay 1\n\nRA. RR30-60s. Cl and = BS. No A&Bs. No murmur. HR 120-150. Mean BPs 41-57.\n\nWt 2440. TF 80 cc/k/day all pg. PE 20. d/s 84.\n\nUnder radiant warmer.\n\nA/P:\n - Monitor for the development of PDA\n - Maintain current TF\n - Transition to isolette\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725550, "text": "1. Baby remains in RA, color pink, BBS equal, clear,\nvery mild sc retractions, RR40-50, no spells A: stable in RA\n P: continue to monitor.\n2. TF 80cc/k PE20 33cc q4h, all pg except took 18cc po at\nlast feeding, abd soft, active bowel sounds, no loops, no\nspits, minimal aspirates, voiding, no stool A: tolerating\nfeedings P: continue present care, check bili at 24h.\n3. temps stable on servo warmer, now swaddled on off warmer,\non sheepskin with boundaries, quiet alert and active with\ncares, brings hands to mouth and sucks well on pacifier P:\ncontinue to support needs for growth and development.\n4. Mom in briefly on her way to floor, continue to update\nand offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1725551, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open warmer, AFOF, sutures split, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725552, "text": "NPN 1900-0730\n\n\n#1 No resp issues this shift, minimal to absent WOB with\nsats >96% in RA. Lungs clear, equal and well aerated.\n\n#2 Weight down 45gms to 2395 on full enteral feeds of PE20\nat 80cc/k/d po/pg. Able to take all feeds po thus far\ntonight with little effort. Belly is soft with active bowel\nsounds, stable girths, no spits and no residuals. Voiding\nwell, no stool thus far, but infant noted to be passing\nflatus. Will cont to monitor and advance feeds. TBili wnl\nat this time.\n\n#3 Temps remain stable in open crib with infant dressed,\nhatted and swaddled. Waking for feeds every four hours and\nsleeping quietly when undisturbed. Vigorous non-nutritive\nsuck. Active and alert with cares.\n\n#4 No parental contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-26 00:00:00.000", "description": "Report", "row_id": 1725547, "text": "Newborn Med Attending Admit\n\n2440g, 33 4/7 weeks EGA male infant born by pit augmented vaginal delivery to a 27 yo G4 p1->2. Unremarkable preganancy until mother seen in clinic on and noted to have high BP. BMZ given on and . Induction today for worsening PIH.\n\nDR: Infant emerged with good cry. Given BBO2 only. APgars .\n\nPNS: O-/AB-/HBSAg-/RPRNR/GBS?\n\nexam: intial exam only notable for extra digits (see newborn exam sheet). Subsequently developed mild supplemental O2 req with mild G/F/Ring, still good air entry.\n\nA: Preterm male infant presents with mild resp distress. Most likley retained fetal lung fluid but can't r/o RDS at this time. No sepsis risk factors except prematurity and possibly GBS (mother's status unknown).\n\nP: Place in BBO2. Monitor sats and WOB. If increased WOB or increasing O2 req may need CXR, ABG. Obtain CBC and blood cx. Hold abx uness clinical exam worsens or supplemental O2 req persisits beyond a few hours. Monitor DS, start IVF with D10W. Obtinradiographic studies of extra digits. If no structures will tie off at base of pedicle. Keep family informed of plans and progress.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1725560, "text": "CoWorker Progress Note\n\n\n1. Remains in RA sats >95%, no drifts, spells, desats. C/=\nno worker breathing. Refer to flowsheet for RR. Continue to\nmonitor.\n\n2. FN TF 120cc/kg/d of PE/BM 20 q4h. Tolerates well with no\nspits. PO/PG. Refer to flowsheet for volumes. Abd soft,\nnt/nd, no loops. V/ no stool as of yet. Girth stable.\nContinue to encourage PO feeds.\n\n3. GD Temp stable in OAC, swaddled with hat. Refer to\nflowsheet for temps. A/A with cares. Wakes for feeeds.\nSleeps well between. AFOSF, PFOSF, MAE, AGA. Continue to\nmonitor and support developmental mile stones.\n\n4. Parent Mom in this afternoon with grandmother. Asking\nappropriate questions. Will return possibly tonight. Was d/c\ntoday. Excited to go home. Anxious for d/c of baby. \ncontinue to update, educate, and support mom.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725561, "text": "NPN 1900-0730\n\n1 RESP\n\n#2 Cont to grow and gain weight well on full enteral feeds\nof BM20 po ad lib with a min of 120cc/k/d. Weight up 35gms\nto 2455, surpassing birth weight. Po feeding very well, ngt\npulled. Waking every 3-3.5hrs to eat. Belly is soft with\nactive bowel sounds, voiding and stooling very well. No\nspits.\n\n#3 As above, waking for feeds. Active and alert with cares,\nMAEW. Extra digits PWWP. Vigorous non-nutritive suck,\nenjoys snug boundaries. Temps remain stable in open crib\ndressed, hatted and swaddled. Hearing screen completed.\nCirc is red with some bloody staining on gauze with diaper\nchanges. Sat monitor d/c'd.\n\n#4 Mom in with MGM, discharge teaching completed except CPR\nand car seat training. Mom to bring in seat tonight for\ntesting. Is aware of infants impending discharge and is\nexcited to take him home. No new questions or concerns.\nShe does have a pediatrician lined up. Will cont to educate\nand prepare for discharge.\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725562, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Circed male, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725563, "text": "Neonatology Attending\n\nDOL 4 CGA 34 1/7 weeks\n\nStable in RA. No A/B\n\nBP 70/50 mean 57\n\nOn min of 120 cc/kg/d BM/E 20. Taking 55-60 cc q 3, took 124 cc/kg yest. Voiding. Stooling. Wt 2455 grams (up 35)\n\nBili 14.4/0.3\n\nCircumcision done.\n\nDr. following re polydactyly.\n\nTemp stable in crib.\n\nFamily visiting and up to date.\n\nA: Doing very well. Never had A/B. Feeding well. Hyperbili requires treatment.\n\nP: Monitor\n Feed ad lib\n Start wallaby\n Follow bili\n Car seat test, hearing screen and PKU before discharge\n If he continues to do well, can go home early next week once off phototherapy\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725553, "text": "Neonatology Attending Note\nDay 2\nCGA 33 \n\nRA. RR40-50s. No rtxns. No murmur. HR 130-150s. BP 83/53, 71.\n\nBili 6.1/0.2.\n\nWt 2395, down 45 gms. TF 80 cc/k/day PE20. All po. Nl voiding and stooling. d/s 90.\n\nIn open crib.\n\nA/P:\n - Adv TF to 100c/k/day\n - Dr. consulted for polydactyly. He would like to meet the family 1 week post discharge.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725554, "text": "NICU CoWorker Note\n\n\n1. Resp remains in RA. Sats > 93%. c/=. Refer to RR in\nflowsheet. no drifts, no spells. Continue to monitor.\n\n2. FN TF increased to 100cc/kg/d of PE/BM20. Tolerates well\nwith no spits, and surpasses min. Abd benign. V/S.Continue\nto monitor and support FN. Continue to encourage PO's.\n\n3. Dev remains in OAC, Temp stable, swaddled with hat.\nActive with cares. does not wake for feeds. Sleepy during\nPO's however able to surpass min. MAE, AFOSF, PFOSF, AGA.\n6th digit on both hands and one lower extremity. Continue to\nmonitor.\n\n4. Mom in for 12 feed. Unable to stay because of\nN/V. Returned to floor. Unable to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725555, "text": "NPN\nI have examined this infant. I agree with this co-worker's note for this shift.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1725556, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feed. Extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725580, "text": "NPN 7p7a\n\n\n#2 Wt 2580 (+60). All POs, BM/E20. Active BS. Abd soft,\nround. Voiding and stooling. No spits. Tolerating TF PO.\nMonitor weight and exam.\n#3 In OAC since evening . Stable temps. A/A with cares.\nWakes on own q 3-4 hrs for feeding. FOS&F. MAES. Appointment\nset with Dr. for consult re extra digits on hands and\nfoot. Circ healing. Some swelling and red glans. No\nbleeding. Covered with gauze and petrolium. AGA. Support\nG/D.\n#4 Mother in this evening. Participated in cares.\nEnthusiastic to participate. Needed some direction re BF and\nbottling and when to burp. Made aware of possible DC\ntomorrow. Signed consent s for PKU and Hep B. Pedi choosen\nbut no appointment yet. Involved and caring mother. Support\nand educate.\n#5 Infant slightly jaundice. Lites DC . Rebound bili\nobtained and values in careview. Active, feeding and\nstooling. Infant with hyperbilirubinemia. Monitor activity\nand labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725581, "text": "Neonatology Attending Note\nDay 8\nCGA 34 5\n\nRA. RR30-50s. No A&Bs. Cl and = BS. No murmur. HR 130-160s. BP 86/56, 62.\n\nRebound bili 10/0.3 (9.4 yest).\n\nWt 2580, up 60 gms. TF 120 cc/k/day BM/E20. (TFI: 178). Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\n - Progressing well. To home today. Please see dictated summary and bedside chart for further details\n\nd/c t>30'.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-03 00:00:00.000", "description": "Report", "row_id": 1725582, "text": "Nursing Discharge Note\n\n\nF&N: TF min 120cc/kg/day BM/E20. Baby taking over minimum.\nHas bottled 75cc, 55cc, and 45cc so far this shift. No\nspits. belly benign. Stool heme -.\nDev: Temp stable in open crib. Awake and with cares.\nWaking q3-4hrs to eat. Appropriate activity for age.\n: Mom and grandma in to d/c baby. Reviewed d/c\nteaching. Pedi appt made for Friday. Hep B given and PKU\ndone. Will have Caregroup VNA visit within the next couple\nof days.\nHyperbili: Resolved.\nBaby dc'd home with mom.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725574, "text": "NPN\n\n\n#2 FEN:\n O: Wt 2.520 (+ 55 gms) Abd. benign, soft, active BS, no\nloops. Nursed well then PC 60cc Bm. Voiding qs, Passing lg\nstools.\nA: Adequate intake for wt gain\nP: Cont per plan.\n\n#3 Dev:\n O: Temps stable in heated isolette. AFOF, and active\nwith feeds , MAE. Bottling/ Nursing well.\nA: AGA\nP: Cont to support dev.\n\n#4 :\no: Mom in to visit, Handling infant well.\nA/P: Cont to suuport and inform. Discharge teaching.\n\n#5 Hyperbili:\nO: under single phototx. Bili mask in place.Color jaundiced.\nA/P; Cont. with phototx. Check bili in am,\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725575, "text": "#2 TF min 120cc/k=50cc of BM20 q 4hrs. Took in 178cc/k yest.\nBottled 70cc each feed overnight easily. Abdominal exam\nbenign. Voiding and stooling. Weight ^ 55g. A: feeding well\nP: Follow weight\n\n#3 Temps stable in air isolette under phototherapy. Sweet\nand active with cares. Bottles well. A: AGA P: Support\ndevelopment\n\n#4 No contact overnight.\n\n#% Beneath single spotlight phototherapy. Am bili\nsent-pending. Eye shields in place. A: ^ bili P: Follow labs\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725576, "text": "Neonatology Attending Note\nDay 7\n\nRA. RR30-60s. No rtxns. No A&Bs. HR 130-160s.\n\nUnder single photo --> 9.4/0.2\n\nWt 2520, up 55 gms. TF 120 cc/k/day BM20 all po. (TFI: 178). Tol well. Nl voiding and stooling.\n\nIn isolette (for photo).\n\nA/P:\n - Approaching d/c readiness\n - d/c photo - check bili in am\n - Transition to open crib\n - If rebound bili ok and temps ok in open crib will d/c to home tomorrow\n - d/c planning including car seat, hepatitis\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725577, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, extra digits on hands and right foot. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725578, "text": "0700- NPN\n\n\nFEN: TF= min 140cc/kg/d of BM20 (50cc Q4hr). Pt currently\ntaking all feeds PO, and took 80cc at each feed this shift.\nNo spits. Abdomen benign. Pt is voiding, trace stool x 1.\n\n\nG&D: Received pt in air-controlled isolette that was turned\noff at 1030, temps have remained stable. Pt is currently\ndressed/swaddled. MAE, /active with cares, wakes\nindependently for feeds. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. Pt passed car seat test this shift. AGA.\n\nPARENTING: Mom called x 1 for update, asking appropriate\nquestions. Mom plans to visit sometime this afternoon or\nevening.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-02 00:00:00.000", "description": "Report", "row_id": 1725579, "text": "0700- NPN Addendum\n\n\nHYPERBILI: Bili drawn this AM was 9.4-0.2-9.2. Single\nphototherapy was d/c'd at 1030 as ordered. Rebound bili to\nbe checked tomorrow AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725570, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY CONTINUES TO FEED AD LIB DEMAND. BABY WOKE\nEVERY 4 HOURS TODAY AND FED WELL. ABDOMEN BENIGN, VOIDING\nAND STOOLING, NO SPITS. DESITIN APPLIED TO DIAPER RASH\nWHICH WAS BLEEDING THIS MORNING, IMPROVED THIS AFTERNOON.\nCIRC IMPROVING. VASELINE APPLIED. A: FEEDING WELL TODAY.\nP: CONTINUE TO FEED AD LIB DEMAND WITH BREASTFEEDING WHEN\nMOM VISITS.\n#3 O:TEMP WAS STABLE IN AN OPEN CRIB. BABY MOVED TO ISOLETTE\nFOR CHANGE TO PHOTOTHERAPY FROM BILIBLANKET. BABY IS NOW\nNESTED IN HIS ISOLETTE. TEMP STABLE. BABY WAKES TO DEMAND\nFEEDS AND FEEDS WELL. BABY SLEEPS WELL BETWEEN FEEDS. A:\nAPPROPRIATE FOR AGE. P: CONTINUE TO SUPPORT DEVELOPMENT.\n#4 O: MOTHER CALLED FOR AN UPDATE THIS AFTERNOON AND PLANS\nTO VISIT THIS EVENING. P: CONTINUE TO KEEP INFORMED.\n#5 O: CHANGED FROM BILIBLANKET TO PHOTOTHERAPY AS BILI\nINCREASED SLIGHTLY TODAY. BABY REMAINS JAUNDICED. EYES\nCLEAN AND COVERED. A: APPROPRIATE FOR AGE. P: CHECK BILI\nIN AM.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-30 00:00:00.000", "description": "Report", "row_id": 1725564, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY IS WAKING TO FEED EVERY 3 TO 4 HOURS TODAY.\n55 TO 90CC TAKEN. LAST FEEDING GIVEN AT 1800. BABY FEEDS\nWITH BM20. MOTHER WAS ENCOURAGED TO BREASTFEED AT HER NEXT\nVISIT. ABDOMEN BENIGN, VOIDING AND STOOLING, NO SPITS. A:\nWAKING TO DEMAND FEED. P: CONTINUE AD LIB FEEDS AND\nBREASTFEEDING.\n#3 O: TEMP STABLE IN OPEN CRIB. BABY IS AND ACTIVE\nWITH CARES AND WAKES TO DEMAND FEED. BABY SLEEPS WELL\nBETWEEN FEEDS. A: APPROPRIATE FOR AGE. P: CONTINUE TO\nSUPPORT DEVELOPMENT.\n#4 O: MOTHER CALLED AND PLANS TO VISIT LATER THIS EVENING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725571, "text": "Nursing Progress Note\n\n\n#2. O: Infant remains on min TF's of 120cc/k/d of BM20. Mom\nin to BF this evening for first time. Infant latched. BFW\nx30minutes. Mom needing assistance with positioning.\nOtherwise po fed well. Abd soft and round with active bowel\nsounds. No loops. Voiding and stooling. Infant received\n145cc/k/d +BFW x1 yesterday. Wgt is down 15gms tonight to\n2465gms. A: Tolerating po feeds. P: Encourage Mom to BF\nwhile visiting.\n\n#3. O: Infant remains in low heat isolette with stable temp.\nHe is and active with cares. MAEW. A: AGA. P: Continue\nto assess and support developmental needs.\n\n#4. O: Mom in this evening. First time breastfeeding. Asking\nlots of appropriate questions. Both Mom and baby did very\nwell. A: Involved Mom. P: Continue to inform and support.\n\n#5. O: Infant remains under single phototherapy. Eye shields\nin place. A: Hyperbilirubinemia. P: A.M. bili pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725572, "text": "Neonatology Attending Note\nDay 6\nCGA 34 3\n\nRA. RR 40-50s. Cl and =. HR 140-150s. No murmur. Mean BP 51. No A&Bs.\n\nWt 2465, down 15 gms. TF 145 +BF-BM/E20 all po. Nl voiding and stooling.\n\nUnder single phototherapy. Bili 13/0.3.\n\nReceiving nystatin for dipaer rash.\n\nNeeds hep B vaccine.\n\nA/P:\n - Mature feeding skills and cardioresp control\n - Still being treated for hyperbilirubinemia\n - Appraoching discharge readiness once increased bili resolves\n" }, { "category": "Nursing/other", "chartdate": "2120-04-01 00:00:00.000", "description": "Report", "row_id": 1725573, "text": "NURSING PROGRESS NOTES.\n\n\n#2 O: TOTAL FLUID MIN 120CC/KG/DAY OF BM20. FEEDS OFFERED\nON DEMAND AND WERE TAKEN WELL. NO SPITS. ABDOMEN BENIGN,\nVOIDING AND STOOLING. A: FEEDING WELL. P: CONTINUE AD LIB\nFEEDS AND BREASTFEEDING WHEN MOM VISITS.\n#3 O: TEMP STABLE IN ISOLETTE ON AIR MODE. BABY WAKES FOR\nFEEDS AND SLEEPS WELL NESTED IN ISOLETTE AND UNDER\nPHOTOTHERAPY. A: APPROPRIATE FOR AGE. P: CONTINUE TO\nSUPPORT DEVELOPMENT.\n#4 O: NO CONTACT FROM TO TIME OF REPORT.\n#5 O: BABY REMAINS UNDER SINGLE PHOTOTERAPY. EYES CLEAN AND\nCOVERED. A: IMPROVING BILI. P: CHECK BILI IN AM.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725565, "text": "NPN\n\n#2 S. O. Weight up 25 grams. Voiding and stooling. Circ\nsite red. Vaseline applied to area. Infant continues on ad\nlib demand feeding schedule. Infant woke at 5 hours and\ntook 80cc po of breast milk 20 cal. A. Infant doing well\nwith feeds.P. continue with current plan.\n\n#4 S. O. Mom in at .. This R,N. explained to mom about\ninfant requiring bili blanket. (Infant ate at 1800 and was\nsleeping. ) Mom pumped and will return tomorrow. Mom aware\nthat we should have car seat tomorrow. A. Invested mom.P.\nSupport and keep updated.\n\n#5 S. O. Infant sl. jaundiced. Infant on bili blanket. A.\n Jaundiced. P. Check bili this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725566, "text": "5 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 5 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725567, "text": "NPN:\n\n\nRECEIVED INFANT @ 0100:\n\n2. TF REMAIN @ MIN 80CC/KG/D. INFANT WOKE @ 0300 AND BOTTLED\n100CCS OF BM20. INFANT WAKING Q4-5HRS TO BOTTLE. VDG AND\nSTOOLING ADAQUATE AMTS, ABD BENIGN, NO SPITS. CONT TO\nMONITOR.\n\n3. INFANT REMAINS SWADDLED IN AN OAC, TEMPS REMAIN STABLE.\n AND ACTIVE WITH CARES. WAKING FOR FEEDS, SUCKING\nVIOGURSLY ON PACIFIER. FONTANELS REMAIN SOFT AND FLAT. CIRC\nRED, NO OZZING AT SITE. APPLIED VASELINE WITH EACH DIAPER\nCHANGE. CONT TO DEV NEEDS.\n\n4. NO CONTACT FROM THUS FAR, UNABLE TO ASSESS FAMILY\nDYNAMICS AT THE PRESENT TIME.\n\n5. INFANT SL. JAUNDICE, REMAINS UNDER PHOTOTHERAPY BLANKET.\nBILI DRAWN THIS AM WAS GROSSLY HEMOLYZED, PLAN TO REDRAW\nBILI @ NEXT CARE. CONT TO MONITOR.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725568, "text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOf, breath sounds clear/equal with easy WOB, no murmur, abd soft, + bowel sounds, circ clean/equal no drainage, perianal red slighlty excoriated diaper rash, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-31 00:00:00.000", "description": "Report", "row_id": 1725569, "text": "Neonatology Attending Note\nDOL 5\nCGA 34 \n\nRA. RR40-70s. Cl and =. No A&Bs. No murmur. HR 140-150s.\n\nBili 14.5/.0.3 --> bili blanket\n\nWt 2480, up 25 gms. Min 80 cc/k/day PO ad lib BM20 (TFI: 171). Nl voiding and stooling.\n\ns/p circ.\n\nDesitin to diaper dermaitis.\n\nIn open crib.\n\nA/P:\n - Will change to photo light to facilitate reduction in bili\n - Good po intakes\n - Approaching discharge readiness\n" } ]

30,984

138,822

Patient came into the ED and midline shift had increased from 5mm to 2cm since prior CT obtained at the OSH. Attempts were made to reverse anticoagulation in the patient, but due to the extent of the lesion and evidence early transtentorial and tonsillar herniation with entrapment the ventricle, a poor prognosis was discussed with her husband . explained that prior discussions with his wife led him to believe that she would not want any heroic interventions, and this surgical intervention was deferred. He did leave his wife intubated so that other family members could come by to see her and say their good-byes. On PM, she was extubated and subsequently expired shortly thereafter.

Nsurg HO and SICU HO notified. Afebrile.+ BS x4 abd soft nt/nd. Foley draining adeq amounts cyu. Stable on vent. Pboots on. BP stable. Skin wdi. BLBS clear. LSCTA. +bs. IVFs. Pt in afib with occasional PVCs. Leftward subfalcine, uncal, early downward transtentorial and tonsillar herniation, and entrapment of the contralateral lateral ventricle. See careview for further details. See Careview for further details. NPNPlease see carevue for further details.Family at bedside. We are sxtn for scant secretions. Bs are bil clear. Bs are bil clear. Continues on A/C w/ PIP/Pplat = 22/18; not initiating over set vent rate of 16. Plan: keep confortable. IMPRESSION: 1. Effacement of basal cistern, suggestive of uncal herniation. We asxtn for scant amt of thick yel secretions from ETT. Abd soft/nd. RSBI done ~77. See resp flowsheet for specific vent settings/data.Plan: maintain support LS clear throughout. SpO2 90s. Respiratory TherapyPt remains orally intubated on full mechanical support. Dilatation of contralateral ventricle. Afib 90s. Morphine titrated for pt comfort. Respiratory Care:Pt remain orally intubated on full ventilatory support. NPnPlease see carevue for further details.Extubated on day shift. Respiratory Care:Pt rremain orally intubated on full ventilatory support. There is significant mass effect with obliteration of the right frontal , entrapment of the contralateral lateral ventricular temporal , leftward subfalcine herniation of 2 cm, and uncal, early downward transtentorial and tonsillar herniation. Pt withdraws to nailbed pressure, at times posturing in BUE. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. Made comfort measures only. SBP 130-140s. Nursing NotePlease see carevue for detailsPt admitted from ED with large IPH. Continue to provide comfort and support. Visualized paranasal sinuses and mastoid air cells are clear. Family at bedside. Family at bedside. Family at bedside. 2. sats 98-100. transfer to morgue. pt appears comfortable. Consult SW. Continue to provide comfort and support to pt and family. addendumPt passed at 0520. Hypodensity within the left basal ganglia may reflect a prior lacunar infarct. This may be secondary to anticoagulation (of which there is reportedly, a history), amyloid angiopathy - though ventricular extension is rare, or an underlying mass. STATUSD: NEURO STATUS UNCHANGED..AWAITING FAMILY(HUSBAND) TO EXTUBATE PTA: FAMILY HERE PT ..STARTED ON MSO4 GTT & EXTUBATED @ 1700 WITH FAMILY & HUSBAND AT BEDSIDER: P: COMFORT MEASURES (Over) 5:53 PM CT HEAD W/O CONTRAST Clip # Reason: eval ICH FINAL REPORT (Cont) Unresponsive, not opening eyes, + corneal reflexes, PERRL, UE posturing to painful stimuli bilat, LE withdraw to nail bed pressure bilat. No vent changes. No vent changes. Plan: awaiting husband & priest in AM and will elective extuabted, maded . Intraventricular hemorrhage in lateral ventricles bilaterally, and in 4th ventricle. Continue to closely monitor and provide comfort and support to the family. PERRL 2- 3 mm brisk. No vent changes made this shift. FINDINGS: There is a large right frontal lobar parenchymal hemorrhage, with associated vasogenic edema. No gag or cough. Intubated on AC 50%/16/500. Osseous structures are unremarkable. Large right frontal lobar parenchymal hemorrhage with transependymal dissection and intraventricular extension. The hemorrhage extends into the ventricular system, with hemorrhage seen within the lateral, third, and fourth ventricles, and also into the foramen of Luschka. Awaiting husband and priest in the morning. No prior studies for comparison. Findings were entered into the ED dashboard at the time of interpretation, and reviewed with Dr. (Neurology) in-person. FOCUS: CONDITION UPDATED: SEE CAREVUE FOR DETAILS.81 Y/O WOMEN S/P LARGE HEAD BLEED.FAMILY VERY SUPPORTIVE OF PATIENT'S WISHES, AND WAITING FOR ALL FAMILY TO BE HERE BEFORE EXTUBATING PATIENT AND PROVIDING COMFORT MEASURES ONLY.ON A/C NOW ON VENT, BUT WILL BREATH WHEN PLACED ON CPAP.WILL PROVIDE SUPPORT TO FAMILY/PATIENT.EXTUBATE AND STARTS MSO4 GTT FOR COMFORT WHEN ALL FAMILY HERE.SOCIAL SERVICES CONSULTED--SUPPORT GIVEN. suctioning mod amounts of thick yellow sputum. Family meeting with , NP - pt made DNR, end of life decisions discussed, but not finalized - waiting for pt's brother and sister today.Plan: Monitor neuro status. Per husband, awaiting to speak to pt's priest in the a.m and then will proceed making pt and extubate in the morning. FINAL REPORT HISTORY: 81-year-old female with large intracranial hemorrhage, evaluate intracranial hemorrhage. Morphine gtt at 20 mg/hr.

10

[ { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659154, "text": "Nursing Note\nPlease see carevue for details\n\nPt admitted from ED with large IPH. Unresponsive, not opening eyes, + corneal reflexes, PERRL, UE posturing to painful stimuli bilat, LE withdraw to nail bed pressure bilat. Pt in afib with occasional PVCs. BP stable. Stable on vent. LSCTA. Abd soft/nd. +bs. Foley draining adeq amounts cyu. Skin wdi. Family meeting with , NP - pt made DNR, end of life decisions discussed, but not finalized - waiting for pt's brother and sister today.\n\nPlan: Monitor neuro status. Consult SW. Continue to provide comfort and support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659155, "text": "Respiratory Care:\n\nPt rremain orally intubated on full ventilatory support. No vent changes. Bs are bil clear. We are sxtn for scant secretions. Plan: keep confortable. See careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659156, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on A/C w/ PIP/Pplat = 22/18; not initiating over set vent rate of 16. SpO2 90s. BLBS clear. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2133-04-22 00:00:00.000", "description": "Report", "row_id": 1659157, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR DETAILS.\n81 Y/O WOMEN S/P LARGE HEAD BLEED.\nFAMILY VERY SUPPORTIVE OF PATIENT'S WISHES, AND WAITING FOR ALL FAMILY TO BE HERE BEFORE EXTUBATING PATIENT AND PROVIDING COMFORT MEASURES ONLY.\nON A/C NOW ON VENT, BUT WILL BREATH WHEN PLACED ON CPAP.\nWILL PROVIDE SUPPORT TO FAMILY/PATIENT.\nEXTUBATE AND STARTS MSO4 GTT FOR COMFORT WHEN ALL FAMILY HERE.\nSOCIAL SERVICES CONSULTED--SUPPORT GIVEN.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659158, "text": "NPN\nPlease see carevue for further details.\nFamily at bedside. Per husband, awaiting to speak to pt's priest in the a.m and then will proceed making pt and extubate in the morning. Pt withdraws to nailbed pressure, at times posturing in BUE. PERRL 2- 3 mm brisk. Intubated on AC 50%/16/500. No gag or cough. suctioning mod amounts of thick yellow sputum. LS clear throughout. sats 98-100. Afib 90s. SBP 130-140s. Pboots on. Afebrile.\n+ BS x4 abd soft nt/nd. IVFs. Family at bedside. Awaiting husband and priest in the morning. Continue to provide comfort and support.\n" }, { "category": "Radiology", "chartdate": "2133-04-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1014209, "text": " 5:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with large ICH, transfer\n REASON FOR THIS EXAMINATION:\n eval ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 7:10 PM\n Right large intraparenchymal hemorrhage with edema, significant mass effect\n with subfalcine herniation of 2.3 cm. Effacement of basal cistern,\n suggestive of uncal herniation. Dilatation of contralateral ventricle.\n Intraventricular hemorrhage in lateral ventricles bilaterally, and in 4th\n ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with large intracranial hemorrhage, evaluate\n intracranial hemorrhage.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is a large right frontal lobar parenchymal hemorrhage, with\n associated vasogenic edema. There is significant mass effect with\n obliteration of the right frontal , entrapment of the contralateral\n lateral ventricular temporal , leftward subfalcine herniation of 2 cm,\n and uncal, early downward transtentorial and tonsillar herniation. The\n hemorrhage extends into the ventricular system, with hemorrhage seen within\n the lateral, third, and fourth ventricles, and also into the foramen of\n Luschka. Hypodensity within the left basal ganglia may reflect a prior lacunar\n infarct. Visualized paranasal sinuses and mastoid air cells are clear. Osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1. Large right frontal lobar parenchymal hemorrhage with\n transependymal dissection and intraventricular extension. This may be\n secondary to anticoagulation (of which there is reportedly, a history),\n amyloid angiopathy - though ventricular extension is rare, or an underlying\n mass.\n 2. Leftward subfalcine, uncal, early downward transtentorial and\n tonsillar herniation, and entrapment of the contralateral lateral ventricle.\n\n Findings were entered into the ED dashboard at the time of interpretation,\n and reviewed with Dr. (Neurology) in-person.\n (Over)\n\n 5:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659159, "text": "Respiratory Care:\n\nPt remain orally intubated on full ventilatory support. No vent changes. RSBI done ~77. Bs are bil clear. We asxtn for scant amt of thick yel secretions from ETT. Plan: awaiting husband & priest in AM and will elective extuabted, maded . See Careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-23 00:00:00.000", "description": "Report", "row_id": 1659160, "text": "STATUS\nD: NEURO STATUS UNCHANGED..AWAITING FAMILY(HUSBAND) TO EXTUBATE PT\nA: FAMILY HERE PT ..STARTED ON MSO4 GTT & EXTUBATED @ 1700 WITH FAMILY & HUSBAND AT BEDSIDE\nR: \nP: COMFORT MEASURES\n" }, { "category": "Nursing/other", "chartdate": "2133-04-24 00:00:00.000", "description": "Report", "row_id": 1659161, "text": "NPn\nPlease see carevue for further details.\nExtubated on day shift. Made comfort measures only. Morphine gtt at 20 mg/hr. pt appears comfortable. Family at bedside. Morphine titrated for pt comfort. Continue to closely monitor and provide comfort and support to the family.\n" }, { "category": "Nursing/other", "chartdate": "2133-04-24 00:00:00.000", "description": "Report", "row_id": 1659162, "text": "addendum\nPt passed at 0520. Nsurg HO and SICU HO notified. Family at bedside. transfer to morgue.\n" } ]

1,620

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A/P 30 year old woman with AML s/p allo with relapse, GVHD, hematochezia p/w progressing gait impairment and sensory deficit . 1.) Gait impairment: The patient's symptoms and exam were concerning for cord compression from either an infectious or neoplastic process in the L5 region. High dose steroids were started with dexamethasone 10 mg iv x1 and 4mg q6 hours thereafter. An emergent MRI was attempted. A neurology consult was obtained. However, due to patient pain and involuntary movement despite mild sedation, initial imaging was inadequate. The patient was electively intubated with general anesthesia to allow for adequate imaging. An epidural mass in the L4-L5 region was identified. A neurosurgical consult was obtained who recommended CT guided biopsy. A CT guided biopsy was not performed as it was thought that the lesion was not safely approachable. She was empirically treated for a chloroma with radiation therapy. She underwent XRT treatment planning to receive 10 fractions treating to a total of 20 Gy. She tolerated the XRT well except for some mild nausea. She received 4 treatments while inpatient. Her leg strength did not appreciably improve during her hospital course. She was able to walk adequately with a walker. She was evaluated by physical therapy and was witnessed walking stairs safely prior to discharge. She will receive PT services as an outpatient. . 2.) AML with GVHD: There was no evidence of peripheral blood relapse. She continued to receive her home regimen of cellcept. While she received dexamethasone for her neurologic condition, her home prednisone for GVHD was held. A bone marrow biopsy was not not performed while an inpatient, however, this could be considered as an outpatient. . 3.) Hx of GIB: The patient was recently admitted for a upper GI bleed with subsequent clipping of a visible vessel. She had trace guaiac positive stools, but there was no evidence of significant bleeding. She continued to receive her home PPI, sucralfate . 4.) Bradycardia: Following transfer back to the BMT service from the ICU, the patient developed transient asymptomatic bradycardia with heart rate in the upper 30's. Her blood pressure was normal. The rhythm was sinus. She underwent a TTE which revealed normal LV function and estimated filling pressures. By time of discharge, her heart rate had normalized. The most likely causes of the bradycardia was sedating medications, high dose steroids, or physiologic causes for a young patient. . 5.) UTI: The patient developed dysuria without vaginal symptoms. She had a UA that was remarkable for elevated WBC. She received 3 days of ciprofloxacin. A urine culture was pending at the time of discharge. . 6.) CMV viremia: On the patient had surveillance CMV viral load drawn. The result was less than 600 copies, but not "non-detected." She was started on empiric treatment with valganciclovir with concern for rapid viral replication while on high dose steroids. A repeat CMV viral load was ~800. She will complete a 21 day course of valganciclovir. 7.) Prophy: fluc, acyclovir, bactrim, PPI . 8.) CODE: FULL . 9.) Dispo: home to have outpatient PT and to return to to complete XRT course. f/u appointment with hematology clinic scheduled prior to discharge. Medications on Admission: Mycophenolate Mofetil 500 mg PO TID Acyclovir 400 mg PO Q8H Pantoprazole 40 mg PO Q12H Fluconazole 400 mg PO Q24H Prednisone 25 mg PO DAILY Sucralfate 1 gm PO QID Hydromorphone 2 mg PO ONCE Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:*56 Tablet(s)* Refills:*0* 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Line Care Midline line care per protocol 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:*21 Tablet(s)* Refills:*0* 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 9. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Primary: Epidural mass Leukemia . Secondary: Chronic graft versus host disease Cytomegalovirus viremia Discharge Condition: good. ambulating with walker. climbing stairs without incident. tolerating oral nutrition and medications. Discharge Instructions: You have been evaluated and treated for your leg weakness and difficulty walking. These symptoms were attributed to a mass in your low back that was pressing on your nerves. You received steroids and radiation therapy to treat this mass. Your radiation therapy will continue after you leave the hospital as was discussed while you were here. . While you were in the hospital you were found to have a urinary tract infection. Please take the antibiotic (ciprofloxacin) as directed and contact your doctor if the pain returns. . Please attend your physical therapy and radiation treatments. . Please take your medications as prescribed. . If you develop any concerning symptoms particularly worsening leg strength, inability to urinate, fevers to greater than 100.3F, or shortness of breath, please seek medical attention. Followup Instructions: You have your next radiation treatment on Monday . The radiation therapists will give you the appointment time. . Please arrange for physical therapy near your home to start on Monday. . You have an appointment to see Dr. on next Thursday at 12:30pm

Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting bradycardic (HR<60bpm).Conclusions:The left atrium is elongated. Normal ascending aorta diameter. IMPRESSION: Left PICC catheter positioned as described, unchanged from . The estimated pulmonary artery systolic pressure is normal.There is no pericardial effusion.Compared with the report of the prior study (images unavailable for review) of, tricuspid regurgitation is now less prominent. PATIENT/TEST INFORMATION:Indication: bradycardiaHeight: (in) 63Weight (lb): 182BSA (m2): 1.86 m2BP (mm Hg): 110/83HR (bpm): 48Status: OutpatientDate/Time: at 09:28Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. IMPRESSION: No abnormal enhancement identified in the cervical or thoracic region. REASON FOR THIS EXAMINATION: evidence of cord compression No contraindications for IV contrast FINAL REPORT EXAM: MRI of the cervical and thoracic spine. Supraventricular bradycardiaShort P-R intervalNormal ECG except for rateSince previous tracing, no significant change No resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Pt in NARD on current vent settings; no vent changes required overnoc. Taken to MRI x 2 without incident for seperate scans. FINDINGS: No abnormal intraspinal enhancement is seen in the cervical or thoracic region. CHEST, SINGLE AP VIEW CENTERED AT THE LEVEL OF THE DIAPHRAGMS: An NG tube is present. TECHNIQUE: T1 sagittal and axial images of the lumbar spine were obtained following gadolinium administration. The indication states confirm right PICC placement, though discussion with the ordering physician, . THORACIC SPINE: TECHNIQUE: T1 and T2 sagittal images acquired. FINAL REPORT EXAM: Thoracic spine. Mildlydilated aortic arch.AORTIC VALVE: Normal aortic valve leaflets (3). THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic spine were acquired. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation. ADEQUATE U/O'S.CV: HEMODYNAMICALLY STABLE.ENDOC: K+ 3.4-REPLETED WITH 40MEQ KCL.HEM: HCT AND PLTS STABLE. TECHNIQUE: T1 sagittal images of the cervical and thoracic spine were obtained following gadolinium administration. The mediastinal and hilar contours are normal. FINDINGS: The previously noted mass at the anterior epidural space at L4 and L5 level does not demonstrate enhancement. There is mild symmetric left ventricularhypertrophy. IMPRESSION: No significant abnormalities on the MRI of the cervical spine. The mass appears to be epidural in location with compression of the thecal sac and cauda equina. The distal spinal cord shows normal signal intensities. The distal spinal cord shows normal signal intensities. MED X1 FOR PAIN IN THE RIGHT LOWER LEG, OTHERWISE NO DISCOMFORT NOTED. Tissue velocity imagingdemonstrates an E/e' <8 suggesting a normal left ventricular filling pressure(<12mmHg). FINDINGS: No cord compression or intrinsic spinal cord signal abnormalities. REASON FOR THIS EXAMINATION: evidence of brain lesions No contraindications for IV contrast FINAL REPORT EXAM: MRI of the brain. Neuro: patient off propofol sedation @ 1100, alert and oriented, denies pain in lower extremeties, slightly weak but was able to move them without difficulty. FINDINGS: The ventricles and extra-axial spaces are normal in size. still on MRSA and VRE precaution. Following gadolinium, no evidence of abnormal parenchymal, vascular, or meningeal enhancement seen. IMPRESSION: No significant abnormalities detected on the MRI of the brain with and without gadolinium. The left ventricular cavity size is normal. IMPRESSION: The previously noted epidural mass does not demonstrate enhancement and is less likely due to a neoplastic lesion. The sideport lies at the level of the lower esophagus and has not passed beyond the GE junction. Respiratory CarePt remains on full ventilatory support as noted in Carevue. REMAINS INTUBATED. Resp care Note:Pt cont intub with OETT and on mech vent as per Carevue. Right ventricular chamber size and free wall motion are normal. It is most likely due to hematoma. Correlation was made with the earlier lumbar spine MRI examination of . IMPRESSION: No cord compression or intraspinal mass in thoracic region. Comparison was made with the previous thoracic spine MRI of the same day of . 12:01 PM MR SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST Clip # -52 REDUCED SERVICES Reason: PLEASE USE GADO. Vascular flow voids are maintained. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were acquired. OF HEMATOMA. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal images of the lumbar spine were obtained. CLINICAL INFORMATION: Patient with AML status post allograft with gait impairment and sensory deficit evidence of cord compression. A left-sided PICC line is present, the tip appears to lie in the left brachiocephalic vessel, immediately proximal to its junction with the SVC. O2 SATS 99-100%.NEURO: REMAINS ON PROPOFOL. There is a left-sided PICC catheter in place, with the tip overlying the distal left brachiocephalic vein. Please evaluate epidural mass. Please evaluate epidural mass. Normal LV cavity size. There is enhancement at the superior aspect which appears to be secondary to venous enhancement. Theaortic arch is mildly dilated. The mass appears to be extending bilaterally into the neural foramina but no enhancement is seen. Gadolinium-enhanced MRI recommended for further evaluation. SUCTIONED FOR SCANT AMT OF TAN SECRETIOS.

20

[ { "category": "Echo", "chartdate": "2106-09-23 00:00:00.000", "description": "Report", "row_id": 78320, "text": "PATIENT/TEST INFORMATION:\nIndication: bradycardia\nHeight: (in) 63\nWeight (lb): 182\nBSA (m2): 1.86 m2\nBP (mm Hg): 110/83\nHR (bpm): 48\nStatus: Outpatient\nDate/Time: at 09:28\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). TVI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardic (HR<60bpm).\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue velocity imaging\ndemonstrates an E/e' <8 suggesting a normal left ventricular filling pressure\n(<12mmHg). Right ventricular chamber size and free wall motion are normal. The\naortic arch is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, tricuspid regurgitation is now less prominent.\n\n\n" }, { "category": "ECG", "chartdate": "2106-09-22 00:00:00.000", "description": "Report", "row_id": 191482, "text": "Supraventricular bradycardia\nShort P-R interval\nNormal ECG except for rate\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283038, "text": "RESP: BS'S CLEAR. REMAINS INTUBATED. SUCTIONED FOR SCANT AMT OF TAN SECRETIOS. NO VENT CHANGES. O2 SATS 99-100%.\nNEURO: REMAINS ON PROPOFOL. GIVEN FREQUENT BOLUSES WHILE IN MRI. PT. REQUIRED 2ND MRI WITH CONTRAST. EPIDURAL MASS SEEN. ? OF HEMATOMA. CT SCAN WITH BIOPSY SCHEDULED FOR TOMORROW AM ON THE ? .. PT CRYING WHEN PROPOFOL HALVED FOR NEURO CONSULT. I ASSURED HER THAT THE TUBE WOULD BE REMOVED AFTER HER PROCEDURES.\nGI: OGT PLACED FOR ORAL MEDS. PASSING FLATUS.\nRENAL: IVF'S AT 100CC/HR. ADEQUATE U/O'S.\nCV: HEMODYNAMICALLY STABLE.\nENDOC: K+ 3.4-REPLETED WITH 40MEQ KCL.\nHEM: HCT AND PLTS STABLE. ELEVATED LFT'S.\nID: + for MRSA, VRE, C-DIFF.\nsocial: HUSBAND INTO BY THE RESIDENT.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283039, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\n30 yo, married, w/ 21 months child, hx AML s/p allo BMT from sister; relaps then tx MEC and DLI ; has chronic GVHD skin and liver--bili stable; UGIB;\n\nc/c: 2 weeks hx bilat motor, sensory, and urinary symptoms, progressive gait instability (though symptoms (numbness) in Rt leg started one month ago); found to have L3-4 to L5-S1 mass; CT guided bx recommended; XRT likely recommended if mass is tumor, possibly chemo;\n\nthis night;\npt remains intubated on same settings, with hope of CT Sun. ;\ntan return when suctioned;\n\nno new findings neuro exam; remains on propofol without change; pt able to awaken and respond w/ nods, also writes on tablet;\n\nvss; remains on IVF of D5 at 100 ml/hr; urine output adequate, amber;\n\nreceiving prn oxycodone for pain, as had been taking at home for leg pain d/t develping recent LE symptoms;\n\nteam did not desire serum K+ or lytes in the eve, stated to wait for morning labs and to maybe send abit early;\n\n2 sisters, pt's mother, and another relative in to visit last eve;\n\nPLAN:\n1) ?CT Sun \n2) a.m. labs sent at 02:15, check results\n3) oxycodone prn for pain, avoid over sedation\n4) emotional support to pt and family\n5) pt wrote on tablet last eve \"no students\"\n" }, { "category": "Nursing/other", "chartdate": "2106-09-20 00:00:00.000", "description": "Report", "row_id": 1283044, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 109/65-162/98. SB/SR WITH HR RANGING FROM 50-88, NO ECTOPY NOTED. PPP BILAT.\n\nNEURO: A&OX3. MED X1 FOR PAIN IN THE RIGHT LOWER LEG, OTHERWISE NO DISCOMFORT NOTED. FOLLOWS COMMANDS. NO DEFICTS NOTED.\n\nRESP: PT WAS EXTUBATED YESTERDAY AT 1100 WITH NO DIFFICULTY. LUNGS HAVE REMAINED CLEAR THROUGHOUT. SAO2 HAS RANGED FROM96-100% ON RA. RR 10-21.\n\nGU: FOLEY CATH PATENT AND DRAINING ADEQUATE AMTS OF CLEAR YELLOW URINE.\n\nGI: ABD SOFT WITH +BS, PASSING FLATUS. WAS EATING SM AMTS FROM WHICH FAMILY BROUGHT IN.\n\nPLAN: NO BX TO THE MASS FOUND IN LOWER SPINE. PLAN IS FOR PT TO HAVE XRT ON MASS. PT DOES NOT WANT STUDENTS TO DO PROCEEDURES ON HER. PT IS A CALL OUT WAITING FOR HER BED ON 7F.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283036, "text": "MICU ADMISSION NOTE\nPATIENT IS A 30 Y/O WITH H/O GASTRIC BYPASS, MRSA BACTEREMIA, GIB WITH ULCER, HTN. H/O AML WITH ALLOGENIC TRANSPLANT , RELAPSED IN , RECEIVED CHEMO THEN A DONOR LYMPHOCYTE INFUSION FROM HER SISTER.\n\nPRESENTED FROM CLINIC YESTERDAY WITH BILATERAL LE PAJN AND NUMBNESS WITH UNSTABLE GAIT. ALSO EXPERIENCING URINARY HESITENTANCY. ? CORD COMPRESSION. HAD MRI YESTERDAY IN WHICH SHE RECEIVED ATIVAN AND DILAUDID BUT WAS UNABLE TO TOLERATE MRI FOR MORE THAH 1/2 HOUR AND IMAGING WAS UNINTERPRETABLE. BEING ADMITTED TO INTUBATION AND MRI.\n\nARRIVED @0430. HD STABLE. UNDERSTOOD THAT SHE WAS TO BE INTUBATED. TUBED BY ANESTHESIA AND SEDATED ON PROPOFOL. FOLEY PLACED. TRANSPORTED TO MRI FOR SCAN OF NECK AND SPINE WITH CONTRAST TO R/O CORD CMPRESSION.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-18 00:00:00.000", "description": "Report", "row_id": 1283037, "text": "Respiratory Care\nPt remains on full ventilatory support as noted in Carevue. Taken to MRI x 2 without incident for seperate scans. All vent settings noted in Carevue as well.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283040, "text": "Resp care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283041, "text": "npn 7a addendum:\n\nre a.m. labs:\nsome LFT's slightly higher than yesterday morning, ?change from Propofol for sedation to another sedative?\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283042, "text": "Neuro: patient off propofol sedation @ 1100, alert and oriented, denies pain in lower extremeties, slightly weak but was able to move them without difficulty. pupils 2mm reactive to light, patient stated \"I don't want any students\" Patient was crying most of the time while intubated, post extubation, in a happy mood, conversing with family members and staff.\n\nRespi: extubated @ 1100, no shortness of breath or respiratory distress, lung sounds clear, diminished @ bases. sats >95% @ room air.\n\nCV: episodes of asymptomatic SB, BP 130-140's; PICC line within normal limits, denies any chest pain.\n\nGI/GU: on regular diet, ate lunch with good appetite. OGT pulled out 1100, no BM today. passing out gas.Bowel sounds present, soft and non-tender. adequate amount of amber urine.\n\nEndo: on RISS, FS 1200 = 190, 2 units coverage given\n\nSocial: family in and stayed @ bedside, takled with team on plan of care.\n\nPlan:\n\npossible transfer out to floor, possible radiation therapy in the morning, monitor patient for weakness of extremeties, support to patient and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-09-19 00:00:00.000", "description": "Report", "row_id": 1283043, "text": "addendum:\n\npatient called out of ICU, waiting for availability of room. still on MRSA and VRE precaution.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR L SPINE WITH CONTRAST", "row_id": 928104, "text": " 12:01 PM\n MR L SPINE WITH CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: r/o cord compression by mass or abscess\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p alloBMT with chronic GVDH, now with left leg\n pain, urinary retention, unsteady gait\n REASON FOR THIS EXAMINATION:\n r/o cord compression by mass or abscess\n ______________________________________________________________________________\n FINAL REPORT\n MRI LUMBAR SPINE\n\n CLINICAL INFORMATION: Patient with AML and left leg pain and urinary\n retention and unsteady gait. Rule out cord compression.\n\n TECHNIQUE: T1 sagittal and axial images of the lumbar spine were obtained\n following gadolinium administration. Fat suppression was utilized to detect\n enhancement. Comparison was made with the previous lumbar spine MRI obtained\n on the same day earlier on .\n\n FINDINGS: The previously noted mass at the anterior epidural space at L4 and\n L5 level does not demonstrate enhancement. There is enhancement at the\n superior aspect which appears to be secondary to venous enhancement. The mass\n appears to be extending bilaterally into the neural foramina but no\n enhancement is seen. There are no paraspinal abnormalities seen.\n\n IMPRESSION: The previously noted epidural mass does not demonstrate\n enhancement and is less likely due to a neoplastic lesion. It is most likely\n due to hematoma. Clinical correlation with patient's laboratory bleeding\n functions is recommended. In absence of an involvement of the vertebral\n bodies or disc infection or abscess is not considered likely.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR T SPINE SCAN WITH CONTRAST", "row_id": 928105, "text": " 12:01 PM\n MR SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: PLEASE USE GADO. Please evaluate epidural mass.\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p BMT, with gait instability.\n REASON FOR THIS EXAMINATION:\n PLEASE USE GADO. Please evaluate epidural mass.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Thoracic spine.\n\n CLINICAL INFORMATION: Patient with leukemia and mass in the lumbar spine, for\n further evaluation of thoracic spine for abnormal enhancement.\n\n TECHNIQUE: T1 sagittal images of the cervical and thoracic spine were\n obtained following gadolinium administration. Comparison was made with the\n previous thoracic spine MRI of the same day of .\n\n FINDINGS: No abnormal intraspinal enhancement is seen in the cervical or\n thoracic region. There is no evidence of discitis or osteomyelitis in the\n lumbar or thoracic region.\n\n IMPRESSION: No abnormal enhancement identified in the cervical or thoracic\n region.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 928065, "text": " 5:37 AM\n MR L SPINE W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evidence of cord compression\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of cord compression\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI lumbar spine.\n\n CLINICAL INFORMATION: Patient with AML status post allograft with gait\n impairment and sensory deficit evidence of cord compression.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were acquired. Correlation was made with the earlier lumbar\n spine MRI examination of .\n\n FINDINGS: As seen on the previous study, there is an epidural mass identified\n extending from L3-4 to L5-S1 level within the anterior epidural space with\n high-grade compression of the thecal sac and cauda equina. The mass also\n extends to both neural foramina at L4-5 level. No paraspinal mass is\n identified. There is no evidence of abnormal signal seen within the vertebral\n bodies or discs in the lumbar region. The distal spinal cord shows normal\n signal intensities.\n\n IMPRESSION: Epidural mass from L3-4 to L5-S1 level with high-grade thecal sac\n compression. The mass extends to both neural foramina at L4-5 level. This\n finding could be secondary to an epidural hematoma or due to leukemic\n infiltrates. Gadolinium-enhanced images would help for further assessment.\n Findings were discussed with BMT attending at the time of interpretation of\n this study on .\n\n" }, { "category": "Radiology", "chartdate": "2106-09-17 00:00:00.000", "description": "MR THORACIC SPINE W/O CONTRAST", "row_id": 928041, "text": " 8:29 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/n\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with\n REASON FOR THIS EXAMINATION:\n 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/numbness/weakness to\n right leg x 1 week\n ______________________________________________________________________________\n WET READ: DDH SAT 3:01 AM\n very limited exams secondary to motion artifact; no obvious cord\n compression seen. may consider repeating with appropriate sedation\n if indicated.\n\n\n , MD\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic and lumbar spine.\n\n CLINICAL INFORMATION: Patient with AML, status post ablation and bone marrow\n transplant with back pain and numbness in the lower extremities one week, for\n further evaluation.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1 and T2 sagittal images acquired.\n\n FINDINGS: The examination is somewhat limited by motion. There is no\n evidence of spinal cord compression or intraspinal mass identified. There is\n no abnormal signal seen within the spinal cord. There is no evidence of\n abnormal signal seen within the vertebral bodies on limited evaluation.\n\n IMPRESSION: Limited study due to motion. No evidence of cord compression.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal images of the lumbar spine\n were obtained.\n\n FINDINGS: There is a mass identified within the spinal canal extending from\n L3-4 disc to L5-S1 disc level. The mass appears to be epidural in location\n with compression of the thecal sac and cauda equina. On T1-weighted images,\n the mass is isointense to the distal spinal cord and on T2 images it is low\n signal. The differential diagnosis includes an epidural hematoma versus\n leukemic infiltrates in the epidural space.\n\n There is no evidence of other abnormality in the lumbar spine. The distal\n spinal cord shows normal signal intensities.\n\n (Over)\n\n 8:29 PM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n -52 REDUCED SERVICES\n Reason: 29 yr old s/p ablative bmt, s/p chemo, many bmbx with pain/n\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Epidural mass extending from L3-4 to L5-S1 level with low T2 and\n isointense T1 signal could be due to an epidural hematoma or due to leukemic\n infiltrates. Gadolinium-enhanced MRI recommended for further evaluation.\n Findings discussed with BMT attending on-call at the time of interpretation of\n this study on at 9 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928123, "text": " 4:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG placement\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC, s/p elective intubation now\n with ng tube.\n REASON FOR THIS EXAMINATION:\n NG placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AML status post BMT, assess NG tube placement.\n\n CHEST, SINGLE AP VIEW CENTERED AT THE LEVEL OF THE DIAPHRAGMS:\n\n An NG tube is present. The tip overlies the expected site of the GE junction.\n The sideport lies at the level of the lower esophagus and has not passed\n beyond the GE junction. As a result, the NG tube should be advanced prior to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 928063, "text": " 5:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evidence of brain lesions\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of brain lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with AML and status post allograft with gait\n impairment and sensory deficit, to rule out evidence for brain lesions.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were obtained. Following gadolinium, T1 axial and\n coronal images of the brain were acquired. There are no prior similar\n examinations for comparison.\n\n FINDINGS: The ventricles and extra-axial spaces are normal in size. No\n evidence of midline shift, mass effect, or hydrocephalus seen. There are no\n focal signal abnormalities seen within the brain. Vascular flow voids are\n maintained. Following gadolinium, no evidence of abnormal parenchymal,\n vascular, or meningeal enhancement seen.\n\n IMPRESSION: No significant abnormalities detected on the MRI of the brain\n with and without gadolinium.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928062, "text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of ETT\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC, s/p elective intubation\n\n REASON FOR THIS EXAMINATION:\n eval placement of ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate ET tube.\n\n CHEST, SINGLE AP PORTABLE SUPINE VIEW\n\n There are low inspiratory volumes. An ET tube is present, tip approximately\n 2.2 cm above the carina, in satisfactory position. A left-sided PICC line is\n present, the tip appears to lie in the left brachiocephalic vessel,\n immediately proximal to its junction with the SVC. No pneumothorax is\n identified. Prominence of vascular markings is likely accentuated by low\n inspiratory volumes. No focal infiltrate or effusion is identified. No\n pneumothorax is seen.\n\n IMPRESSION:\n\n ET tube satisfactory position 2.2 cm above the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-09-17 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 928031, "text": " 6:32 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: confirm R PICC placement\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p bmt with PICC\n REASON FOR THIS EXAMINATION:\n confirm R PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with AML status post bone marrow transplant with PICC.\n The indication states confirm right PICC placement, though discussion with the\n ordering physician, . , the patient's PICC is on the left side.\n No right-sided PICC was placed.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The heart size is normal. The mediastinal and hilar\n contours are normal. There is a left-sided PICC catheter in place, with the\n tip overlying the distal left brachiocephalic vein. It is unchanged compared\n to . There is no consolidation or vascular congestion within\n the lungs. A tiny (sub 3-mm) rounded opacities in the lower portions of the\n lungs likely represent vessels on end. No pleural effusion or pneumothorax.\n\n IMPRESSION: Left PICC catheter positioned as described, unchanged from \n .\n\n Findings were discussed with Dr. at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2106-09-18 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 928064, "text": " 5:35 AM\n MR CERVICAL SPINE; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MR THORACIC SPINE W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: evidence of cord compression\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with AML s/p allo with gait impairment and sensory deficit.\n REASON FOR THIS EXAMINATION:\n evidence of cord compression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical and thoracic spine.\n\n CLINICAL INFORMATION: Patient with bone marrow transplant and lower extremity\n weakness and sensory deficit and gait impairment for further evaluation.\n\n CERVICAL SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient echo and T2\n axial images of the cervical spine were obtained.\n\n FINDINGS: From the skull base to T3 level, there is no evidence of cord\n compression or abnormal signal within the cord. There is no significant disc\n bulge, disc herniation or spinal stenosis seen. There is increased signal\n seen in the nasopharynx and oropharynx which could be related to retained\n fluid.\n\n IMPRESSION: No significant abnormalities on the MRI of the cervical spine. No\n evidence of cord compression seen. No abnormal signal within the cord.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were acquired.\n\n\n FINDINGS: No cord compression or intrinsic spinal cord signal abnormalities.\n No evidence of discitis or osteomyelitis. No intraspinal mass.\n\n IMPRESSION: No cord compression or intraspinal mass in thoracic region.\n\n" } ]

10,247

168,051

64 yo male with a PMH significant for morbid obesity, DMII, GERD, HTN, yperlipidemia, and prior ventilatory dependency (felt to be multifactorial in the setting of obesity, OSA, and ?COPD) s/p trach removal for plugged trach, presents with hypotension and hypercarbic respiratory failure, now resolved and extubated. . # Hypercarbic Respiratory Failure: Quickly weaned from , have been caused by infection, ie UTI, with poor pulmonary reserve, or mucus plugging, given quick recovery. Now extubated and sats in mid 90s on room air. Continue with alb/atro, chest PT, to prevent future mucus plugging. . # Genital abnormality: divided ventral surface of penis, congenital hypospadias vs possibly secondary to chronic indwelling foley catheter, appears chronic with well-healed skin and no signs of infection. Recommend outpatient follow-up with urology if patient desires reconstructive surgery. . # Acute renal failure: Pts BL Cr is 0.9 to 1.1, with Cr peak 1.6, now 1.0. Peripheral diff shows 10% eos, down from 12, likely resolving AIN. Recent new medications have included bactrim, imipenem, and levofloxacin. Possible causes of AIN include the bactrim and levofloxacin. - received vanc and cefepime for UA with mod leuk est, neg nitr, + WBCs, but culture negative, so will D/C abx . # Eosinophilia: Suspect AIN given ARF. --trend diff now that off abx and Cr normalized . # Diastolic dysfunction: From TTE in , the pt had a nl EF with hyperdynamic function. Restart lasix on discharge. . # HTN: Restarted lisinopril 20, metoprolol 75 tid, amlodipine 10mg since BP stable after extubation. . # CAD risk equivalent: on , home statin . # DM: continue SSI and NPH; had been on NPH 35 , reduced to 14 qam and 10 qpm with good control of FSBS. need to increase again if diet changes. . # Psych: Continue on Wellbutrin and Effexor; restarted remeron after it had been on hold for concern of contributing to decreased MS. . # PPX: SC Heparin, colace, reglan, PPI # FEN: Diabetic diet. # Access: R IJ placed in ICU; D/C'd RIJ since has working peripherals # FULL CODE

Generalized + edema. +PP, mild peripheral edema. Note is made of stable appearance of elevated left hemidiaphragm. Left atrial abnormality. Foley patent drng minimal u/o HO aware pt started on Maint IVF.Endo: RISSID: On Vanco/cepPlan: cont to monitor resp status. BS remain slightly coarse bilaterally with increased aeration. Bs initially with expiratory wheezes bilaterally. SVO2 monitoring d/c'd.GI - Abd obese, +BS. Unchanged appearance of elevated left hemidiaphragm and atelectatic changes of left lung. Antibx. Pt tolerating extubation well. Wean to MDI's as tolerated. + Obese abd soft NT. Nebs. Lungs clear to coarse diminished at the bases.GI/GU: Currently NPO except meds. Afebrile. Afebrile. There is a small rounded hypodensity of the left basal ganglia, which is consistent with a small lacune or enlarged perivascular space. 1 suture visible, MICU team unable to d/c. Sinus rhythm. FINAL REPORT INDICATION: Altered mental status. IMPRESSION: 1. Pt. Pt. Pt. Wheezes clearing over course of shift. The endotracheal tube has been removed. Respiratory Care:Patient given Albuterol/Atrovent nebs Q4hr. SR w/occ PVCs. Vanco and cefapime for UTI, ? RLL PNA.Skin - W->D dsg on coccyx, positioned side->side. + BS +BM today. Cont to monitor resp status. +BS, abdomen soft, obese. Left lower lobe atelectasis, elevation of the left hemidiaphragm and distention of the splenic flexure of the colon are unchanged. Stage II to coccyx reddened, serosang drainage. Crit stable. There is mild-to-moderate mucosal thickening within the ethmoid air cells. The heart, mediastinal and hilar contours are otherwise unremarkable. SBP 130s. The right IJ line with tip in the right atrium is unchanged. FINDINGS: There is bilateral lower lobe volume loss. AM CXR pending. Atelectatic changes of the left lung base is unchanged. ET tube tip terminates 2.4 cm above the carina. ABP 113-140/48-55. Ill-defined opacity in the right lower lung field is consistent with right middle lobe atelectasis. cont with current Plan of care Denies pian. HR 80-110's with occ PVC's. Lung sounds clear, healing old trach site w/DSD to cover, no drainage. Lacune vs. enlarged perivascular space of the left basal ganglia. CVP 5-10. FINAL REPORT REASON FOR EXAM: Shortness of breath, altered mental status, assess ET tube placement. ETT tip terminates 2 cm above the carina. Denies pain. CVP 6-8 Pre-cep cath SV02 70-73. MAE and follows commands.CV: Pt currently off levo. Lacune versus enlarged perivascular space of the left basal ganglia. Deconditioned d/t prolonged illness. Comparison is made to the recent CT of the trachea on . W-D applied this am, wound care RN to assess. ? ? ? Pt given 2 1Liter fluid bolus's early in am for hypotension. The remainder of the lungs are unremarkable. Otherwise, no diagnostic interim change. Good cuff leak present prior to extubation with difficult airway cart on standby. Will cont to monitor for s/s fatigue. Pt enc to cough and deep breathe. Tolerated well with mask. Urine is tea colored.UD - Afebrile. FSBS covered by HISS, to restart NPH today-? 2. SINGLE AP PORTABLE VIEW OF THE CHEST. Alert and oriented X3. Otherwise, the osseous and soft tissue structures are unremarkable. ABG 7.31/48/113/26.CV - ABP 170s/60s, HR 100s ST last night, restarted on lopressor with HR decreasing NSR 80s, occ PACs, PVCs. Atrialectopy is no longer recorded. SINGLE AP PORTABLE VIEW CHEST. Pt able to clear secretions and protect airway. Glucose stable on NPH/SSRI. No resp distress. NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by patient movement. 2:55 AM CHEST (PORTABLE AP) Clip # Reason: ett placement? Lungs are essentially clear throughout, RR teens. There is a small osteoma the left maxillary antrum. 8:52 PM CT HEAD W/O CONTRAST Clip # Reason: MS CHANGES. Nursing Progress NOTePlease see carvue for specifics:Neuro: Pt very pleasant. Pt maintaining MAP >65 w/o medical intervention. c/o to floor tomorrow if remains stable. HR 80's with RR mid teens. able to easily assist w/turning and repositioning. O2 sats 99%.Improved with bronchodilators. restart diet today. The ventricles and cisterns are normal. 3:56 AM CHEST PORT. Otherwise, the density values of the brain parenchyma are normal, with preservation of the -white matter differentiation. extubated yesterday and continues to do well.Plan: Will continue to follow with Nebs Q4hr. able to clear secretions without difficulty. Meds crushed in custard. BLOOD / MASS. There are no other acute interval changes. Other visualized paranasal sinuses and mastoid air cells are clear. Nursing note: A/Ox2-3, at times forgets he isn't in NH. Skin care consult to be done.Plan - Monitor resp care, Nebs, O2. Very pleasant and cooperative w/care. Tolerating diabetic diet, good appetite, no dysphagia. Foley patent amber urine in adequate amounts, >30cc/hr. Now normotensiveResp: Extubated this PM around 1700. Foley irrigated, balloon deflated, advanced, with large UOP. Family in to visit.A/P:Stable for c/o to floor. Intraventricular conduction delay.Compared to the previous tracing of the rate has increased. IMPRESSION: No evidence of acute intracranial hemorrhage. Productive cough of thick yellow secretions. No evidence of acute cardiopulmonary process. 40% cool mist in use via face tent. There is no pneumothorax. Note is also made of tortuous course of the trachea. Sats 97-100%, desatted to 85% when asleep. No stool. Comparison is made with prior study performed 1 hour before. MAE on bed, assists with turns. There are no prior studies for comparison. Resp CarePt extubated this afternoon to 40% cool aerosol well with spo2 100% RR 18-20.

11

[ { "category": "Radiology", "chartdate": "2110-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954842, "text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusion\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB, COPD\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Altered mental status.\n\n FINDINGS: There is bilateral lower lobe volume loss. It is unclear if any of\n the opacity represents an underlying infectious infiltrate. The endotracheal\n tube has been removed. The right IJ line with tip in the right atrium is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 954700, "text": " 3:56 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for line placement\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB s/p intubation\n\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Evaluate ETT placement.\n\n Comparison is made with prior study performed 1 hour before.\n\n SINGLE AP PORTABLE VIEW CHEST. ETT tip terminates 2 cm above the carina. There\n are no other acute interval changes.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954671, "text": " 7:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with altered mental status and shortness of\n breath.\n\n Comparison is made to the recent CT of the trachea on .\n\n Note is made of stable appearance of elevated left hemidiaphragm. The heart,\n mediastinal and hilar contours are otherwise unremarkable. Note is also made\n of tortuous course of the trachea. Atelectatic changes of the left lung base\n is unchanged. The remainder of the lungs are unremarkable.\n\n IMPRESSION:\n\n 1. Unchanged appearance of elevated left hemidiaphragm and atelectatic\n changes of left lung.\n\n 2. No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-04-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 954679, "text": " 8:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS CHANGES. ? BLOOD / MASS.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for bleed, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:14 PM\n No evidence of acute hemorrhage. Lacune vs. enlarged perivascular space of the\n left basal ganglia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n There are no prior studies for comparison.\n\n NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by patient\n movement. There is no evidence of acute intracranial hemorrhage or shift of\n normally midline structures. The ventricles and cisterns are normal. There\n is a small rounded hypodensity of the left basal ganglia, which is consistent\n with a small lacune or enlarged perivascular space. Otherwise, the density\n values of the brain parenchyma are normal, with preservation of the -white\n matter differentiation. There is mild-to-moderate mucosal thickening within\n the ethmoid air cells. Other visualized paranasal sinuses and mastoid air\n cells are clear. There is a small osteoma the left maxillary antrum.\n Otherwise, the osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. Lacune versus\n enlarged perivascular space of the left basal ganglia.\n\n" }, { "category": "Radiology", "chartdate": "2110-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954697, "text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement?\n Admitting Diagnosis: URINARY TRACT INFECTION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with altered mental status, SOB s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ett placement?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Shortness of breath, altered mental status, assess ET tube\n placement.\n\n Comparison is made with prior study performed seven hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST. ET tube tip terminates 2.4 cm above the\n carina. Ill-defined opacity in the right lower lung field is consistent with\n right middle lobe atelectasis. Left lower lobe atelectasis, elevation of the\n left hemidiaphragm and distention of the splenic flexure of the colon are\n unchanged. There is no pneumothorax.\n\n" }, { "category": "Nursing/other", "chartdate": "2110-04-25 00:00:00.000", "description": "Report", "row_id": 1397645, "text": "Resp Care\n\nPt extubated this afternoon to 40% cool aerosol well with spo2 100% RR 18-20. Good cuff leak present prior to extubation with difficult airway cart on standby. Will cont to monitor for s/s fatigue.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-25 00:00:00.000", "description": "Report", "row_id": 1397646, "text": "Nursing Progress NOTe\nPlease see carvue for specifics:\nNeuro: Pt very pleasant. Alert and oriented X3. MAE and follows commands.\nCV: Pt currently off levo. Pt maintaining MAP >65 w/o medical intervention. CVP 6-8 Pre-cep cath SV02 70-73. HR 80-110's with occ PVC's. Crit stable. Afebrile. Pt given 2 1Liter fluid bolus's early in am for hypotension. Now normotensive\nResp: Extubated this PM around 1700. Pt tolerating extubation well. Pt enc to cough and deep breathe. Pt able to clear secretions and protect airway. Lungs clear to coarse diminished at the bases.\nGI/GU: Currently NPO except meds. + Obese abd soft NT. + BS +BM today. Foley patent drng minimal u/o HO aware pt started on Maint IVF.\nEndo: RISS\nID: On Vanco/cep\nPlan: cont to monitor resp status. Cont to monitor resp status. ? c/o to floor tomorrow if remains stable. cont with current Plan of care\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397647, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs Q4hr. Tolerated well with mask. Bs initially with expiratory wheezes bilaterally. HR 80's with RR mid teens. Productive cough of thick yellow secretions. Pt. able to clear secretions without difficulty. 40% cool mist in use via face tent. O2 sats 99%.\nImproved with bronchodilators. Wheezes clearing over course of shift. BS remain slightly coarse bilaterally with increased aeration. No resp distress. Pt. extubated yesterday and continues to do well.\nPlan: Will continue to follow with Nebs Q4hr. Wean to MDI's as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397648, "text": "MICU nursing progress note 7P-7A\nNeuro - A&O x 3, awake most of night, watching TV. Slept in naps. MAE on bed, assists with turns. Deconditioned d/t prolonged illness. Denies pain. Takes pills crushed in custard, drinking PO fluids without difficulty.\n\nResp - No resp distress, doing well on 40& cool neb via face tent. Nebs. + strong cough, expectorating thick yellow secretions, using yankeur. Lungs are essentially clear throughout, RR teens. Sats 97-100%, desatted to 85% when asleep. AM CXR pending. ABG 7.31/48/113/26.\n\nCV - ABP 170s/60s, HR 100s ST last night, restarted on lopressor with HR decreasing NSR 80s, occ PACs, PVCs. ABP 113-140/48-55. Generalized + edema. CVP 5-10. SVO2 monitoring d/c'd.\n\nGI - Abd obese, +BS. No stool. FSBS covered by HISS, to restart NPH today-? restart diet.\n\nGU - UOP increased 90-200cc/hr after fluid bolus last night then tapered off again. Foley irrigated, balloon deflated, advanced, with large UOP. Urine is tea colored.\n\nUD - Afebrile. Vanco and cefapime for UTI, ? RLL PNA.\n\nSkin - W->D dsg on coccyx, positioned side->side. Skin care consult to be done.\n\nPlan - Monitor resp care, Nebs, O2. ? restart diet today. Meds crushed in custard. Antibx.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-26 00:00:00.000", "description": "Report", "row_id": 1397649, "text": "Nursing note:\n A/Ox2-3, at times forgets he isn't in NH. Very pleasant and cooperative w/care. Denies pian. Afebrile. SR w/occ PVCs. SBP 130s. +PP, mild peripheral edema. Lung sounds clear, healing old trach site w/DSD to cover, no drainage. 1 suture visible, MICU team unable to d/c. +BS, abdomen soft, obese. Tolerating diabetic diet, good appetite, no dysphagia. Foley patent amber urine in adequate amounts, >30cc/hr. Glucose stable on NPH/SSRI. Stage II to coccyx reddened, serosang drainage. W-D applied this am, wound care RN to assess. Pt. able to easily assist w/turning and repositioning. Family in to visit.\nA/P:Stable for c/o to floor.\n\n" }, { "category": "ECG", "chartdate": "2110-04-24 00:00:00.000", "description": "Report", "row_id": 209252, "text": "Sinus rhythm. Left atrial abnormality. Intraventricular conduction delay.\nCompared to the previous tracing of the rate has increased. Atrial\nectopy is no longer recorded. Otherwise, no diagnostic interim change.\n\n" } ]

15,929

171,608

Post catheterization Integrilin was held secondary to the recent surgery, but aspirin and Plavix was continued. He remained chest pain free in the hospital and had no more events on telemetry. His episode of ventricular fibrillation in the catheterization laboratory was likely due to the ventricular irritation. His cardiac enzymes trended downward in the hospital with a peak CK of 1301. His echocardiogram showed an ejection fraction of 50% with 2+ MR was evaluated by physical therapy on the day of discharge and deemed stable to go home.

Site wnl, no hematoma, dopplerable pulses.GI: NPO except for sips clears with meds in anticipation of sheath removals. Theleft ventricular inflow pattern suggests impaired relaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. Discussed anti-hypertensives/rate control drug dose changes -> maintained doses at current level as HR decreases to 60-70's when asleep and is 80's when awake and OOB, and captopril was held at mid-night dose.Pulses strong, HRR, NSR.RESP: LS clear, no issues, no distress.GI: BS present. Moderate (2+) mitral regurgitation is seen. PT DENIES SOB, LS CLEAR.CV: HR NSR 70-90'S, NO ECTOPY. Overall leftventricular systolic function is mildly depressed.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Bedrest maintained with RLE flat MD order. RIGHT FEM ANGIO SITE D&I. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 70Weight (lb): 200BSA (m2): 2.09 m2BP (mm Hg): 99/49Status: InpatientDate/Time: at 13:56Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. BS clear bilat.CV: HR 60's-80's SR with occasional unifocal PVC's. There is mildmitral annular calcification. Frequent v/s per order, stable. NSR without ectopics, blood pressure stable. Tolerating Metoprolol, Captopril doses. Moderate (2+) mitralregurgitation is seen. +BIL PULSES.GI/GU: ABD SOFT, +BS, NO BM. R groin arterial and venous cath sheath and pacing wires dc'd by Dr. , no swelling, hematoma, + distal pulses. Sinus rhythm- borderline first degree A-V blockLong QTc intervalLeft axis deviationInferior infarct - probably acute/recentAnterolateral ST-T changes are nonspecific but consider posterolateral wallinvolvementNo previous tracing for comparison Passed hard stool and lg amt of flatus. PT TOLERATING . Neurologically intact, prn-mild disorientation, easily redirects, anxious to move out of unit. Slept in short naps.Resp: Stable, sats > 97% on 3l NP. GU: diuresing well.GI: abd soft, no stools today. Rt fem art sheath capped off, venous sheath with NS @ KVO. Nursing Progress Note-0700-Generally good day. NURSING MICU NOTE 7P-7ANEURO: PT 2, MAE, FOLLOWS COMMANDS. Tolerating po's. The left ventricular cavity size is normal. Pt agreed to tx.SKIN: Intact. BP stable. PT WANTED TO SPEAK W/ MD. Inferior hypokinesis is present.3. Stool guaiac negative.GU: Voiding qs, urine has strong malaodorous scent.HAEM: Spoke with intern re: risks/benefits of Plavix and aspirin s/p stents and with history of macular degeneration. Overall left ventricularsystolic function is mildly depressed. CVstable. CCU INTER AWARE.RESP: PT ON RA, O2 SATS 97-99%. PT DENIES ANY PAIN. ATIVAN PRN WAS ORDERED, NONE GIVEN AT THIS TIME. Received Percocet 1 PO for c/o back discomfort, Ambien 5mg PO at 2300 for sleep. Nursing Progress Note-1900S/ONEURO: Alert, oriented. The left atrium is moderately dilated.2. PT WAS THEN PLACED BACK IN BED AND GIVEN TIME TO COOL DOWN. No stool overnight, + bowel sounds.GU: Voiding qs clear yellow urine.Social: Full code. Irregular sinus tachycardia - premature ventricular contractionsInferior infarct - age undetermined - may be acute/recentAnterolateral ST-T changes may be due to myocardial ischemia - in part toposterolateral wall involvementClinical correlation is suggestedSince previous tracing of : spresentinus tachycardia SBP 90-110;S. PT DID HAVE SBP 140 THIS AM WHEN AGITATED. Resp: lung fields clear to auscultation, all fields, 02 weaned to off, spo2>95%. Had stent placed in lab, episode VT/VF shocked x1 w/200j, episode of symptomatic bradycardia Rx w/ 0.5mg Atropine IV, transvenous pacing wire left in overnight.Neuro: Awake, alert, oriented x3. At 1800, sat up, dangled for 10min, weak, mildly shaky, tol x10min, became tired. VOIDING IN URINAL CLEAR AMBER URINE.DISPO: PT HAS BEEN CALLED OUT TO MEDICAL BED, AWAITING A TELE BED. Nursing Progress Note85 yr old gentleman with PMH per FHP/Adm History sheet is admitted to MICU-B from CCL as CCU boarder. PT . PT IS A FULL CODE. Transfers self from chair to bed and bed to chair with supervision due to ARMD and inability to see wires.CV: HR increased with activity. Vent pacing wire in place, attached to pacer box mA2/sens2, rate 50, no pacing overnight. The aortic valve leaflets (3) are mildly thickened.4. PT STATED HE WANT TO LEAVE THE HOSPITAL NOW AND THAT WE WERE KEEPING HIM HERE PRISIONER. Bleeds at puncture sites, stops with pressure held x 5 minutes and pressure dressing applied.O/P:Continue current care.Support pt through his frustration during hospitalization by explaining all care options. The mitral valve leaflets are mildly thickened. Quiet day, awaiting bed on step-down . PT DENIES ANY CP. Pleasant and cooperative with care. PT WAS PLACED IN CHAIR, CCU INTERN UP TO SPEAK W/ PT. AT 0430 PT AWAKE, ANGRY AND AGITATED. PT REFUSING TO HAAVE BP CUFF ON AND LABS DRAWN THIS AM. Social: wife called in and spoke w/ twice. A FEW TIMES OVERNIGHT PT HAD ATTEMPTED TO GET OOB, NOT KNOWING WHERE HE WAS.

7

[ { "category": "Echo", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 73809, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 99/49\nStatus: Inpatient\nDate/Time: at 13:56\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate (2+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed. Inferior hypokinesis is present.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 172019, "text": "Irregular sinus tachycardia\n - premature ventricular contractions\nInferior infarct - age undetermined - may be acute/recent\nAnterolateral ST-T changes may be due to myocardial ischemia - in part to\nposterolateral wall involvement\nClinical correlation is suggested\nSince previous tracing of : spresentinus tachycardia\n\n" }, { "category": "ECG", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 172020, "text": "Sinus rhythm\n- borderline first degree A-V block\nLong QTc interval\nLeft axis deviation\nInferior infarct - probably acute/recent\nAnterolateral ST-T changes are nonspecific but consider posterolateral wall\ninvolvement\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 1469781, "text": "Nursing Progress Note\n85 yr old gentleman with PMH per FHP/Adm History sheet is admitted to MICU-B from CCL as CCU boarder. Had stent placed in lab, episode VT/VF shocked x1 w/200j, episode of symptomatic bradycardia Rx w/ 0.5mg Atropine IV, transvenous pacing wire left in overnight.\nNeuro: Awake, alert, oriented x3. Pleasant and cooperative with care. Received Percocet 1 PO for c/o back discomfort, Ambien 5mg PO at 2300 for sleep. Slept in short naps.\nResp: Stable, sats > 97% on 3l NP. BS clear bilat.\nCV: HR 60's-80's SR with occasional unifocal PVC's. BP stable. Tolerating Metoprolol, Captopril doses. Vent pacing wire in place, attached to pacer box mA2/sens2, rate 50, no pacing overnight. Rt fem art sheath capped off, venous sheath with NS @ KVO. Site wnl, no hematoma, dopplerable pulses.\nGI: NPO except for sips clears with meds in anticipation of sheath removals. No stool overnight, + bowel sounds.\nGU: Voiding qs clear yellow urine.\nSocial: Full code. Pt's family in to visit during evening, updated by Nursing and CCU resident.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 1469784, "text": "Nursing Progress Note\n-1900\n\nS/O\nNEURO: Alert, oriented. Transfers self from chair to bed and bed to chair with supervision due to ARMD and inability to see wires.\n\nCV: HR increased with activity. Discussed anti-hypertensives/rate control drug dose changes -> maintained doses at current level as HR decreases to 60-70's when asleep and is 80's when awake and OOB, and captopril was held at mid-night dose.\n\nPulses strong, HRR, NSR.\n\nRESP: LS clear, no issues, no distress.\n\nGI: BS present. Tolerating po's. Passed hard stool and lg amt of flatus. Stool guaiac negative.\n\nGU: Voiding qs, urine has strong malaodorous scent.\n\nHAEM: Spoke with intern re: risks/benefits of Plavix and aspirin s/p stents and with history of macular degeneration. Pt agreed to tx.\n\nSKIN: Intact. Bleeds at puncture sites, stops with pressure held x 5 minutes and pressure dressing applied.\n\nO/P:\nContinue current care.\nSupport pt through his frustration during hospitalization by explaining all care options.\n" }, { "category": "Nursing/other", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 1469782, "text": "Nursing Progress Note-0700-\nGenerally good day. Neurologically intact, prn-mild disorientation, easily redirects, anxious to move out of unit. CV_stable. NSR without ectopics, blood pressure stable. R groin arterial and venous cath sheath and pacing wires dc'd by Dr. , no swelling, hematoma, + distal pulses. Bedrest maintained with RLE flat MD order. Frequent v/s per order, stable. Resp: lung fields clear to auscultation, all fields, 02 weaned to off, spo2>95%. GU: diuresing well.GI: abd soft, no stools today. Social: wife called in and spoke w/ twice. At 1800, sat up, dangled for 10min, weak, mildly shaky, tol x10min, became tired. Quiet day, awaiting bed on step-down . \n" }, { "category": "Nursing/other", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 1469783, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT 2, MAE, FOLLOWS COMMANDS. PT DENIES ANY PAIN. A FEW TIMES OVERNIGHT PT HAD ATTEMPTED TO GET OOB, NOT KNOWING WHERE HE WAS. PT . AT 0430 PT AWAKE, ANGRY AND AGITATED. PT STATED HE WANT TO LEAVE THE HOSPITAL NOW AND THAT WE WERE KEEPING HIM HERE PRISIONER. PT WANTED TO SPEAK W/ MD. PT WAS PLACED IN CHAIR, CCU INTERN UP TO SPEAK W/ PT. PT WAS THEN PLACED BACK IN BED AND GIVEN TIME TO COOL DOWN. ATIVAN PRN WAS ORDERED, NONE GIVEN AT THIS TIME. PT REFUSING TO HAAVE BP CUFF ON AND LABS DRAWN THIS AM. CCU INTER AWARE.\n\nRESP: PT ON RA, O2 SATS 97-99%. PT DENIES SOB, LS CLEAR.\n\nCV: HR NSR 70-90'S, NO ECTOPY. SBP 90-110;S. PT DID HAVE SBP 140 THIS AM WHEN AGITATED. PT DENIES ANY CP. RIGHT FEM ANGIO SITE D&I. +BIL PULSES.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT TOLERATING . VOIDING IN URINAL CLEAR AMBER URINE.\n\nDISPO: PT HAS BEEN CALLED OUT TO MEDICAL BED, AWAITING A TELE BED. PT IS A FULL CODE.\n" } ]

89,936

136,208

# CORONARIES: The patient had an inferior STEMI with occlusion of left circumflex. The patient received two bare metal stents in the left circumflex. She was then medically managed initially with ASA 325 mg daily, Clopidogrel 75 mg daily, Metoprolol 12.5 mg , Atorvastatin 80 mg daily. Her lipid panel showed a total cholesterol of 157, triglycerides of 65, HDL of 56, and LDL of 88. Her echocardiogram showed mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function (LVEF > 55%). Mild mitral regurgitation. Increased PCWP. Lisinopril was also added to help control her hypertension. She was returned to her home dose of atenolol. . # PUMP: Patient's PCWP was 28. JVD was . Patient denied symptoms of right-sided heart failure. On the morning of , the patient awoke to a coughing fit and some dyspnea. Due to the hydration given and concerns for heart failure, she was administered Lasix 10mg IV. Her dyspnea improved, but given the lack of other symptoms of heart failure, her cough may have been the result of a chronic post-nasal drip, as the patient reports cough for many months. . # HYPERTENSION: Given the STEMI, the patient's anti-hypertensive regimen was changed. She was kept on atenolol, since she was already on and toerated that beta-blocker. The patient's HCTZ was stopped, adn lisinopril started at a low dose. . # COUGH, LIKELY SECONDARY TO POST-NASAL DRIP: During the patient's hospitalization, she demonstrated a regular cough. The patient ascribed the cough to post-nasal drip. She was prescribed Flonase.

Mild symmetric left ventricularhypertrophy with preserved global biventricular systolic function. Left pleuraleffusion.Conclusions:The left atrium is mildly dilated. Moderate mitral annularcalcification. Mild (1+) mitral regurgitation is seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Consider lateral myocardialinfarction. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Inferior wall myocardial infarction, age undetermined.Q waves in the lateral precordial leads. Since the previous tracing of ventricular ectopy is nowpresent. Mild mitralregurgitation. Inferior Q waves suggestive of old inferior myocardialinfarction. Sinus rhythm with ventricular premature beat. Coronary artery disease.Height: (in) 60Weight (lb): 170BSA (m2): 1.74 m2BP (mm Hg): 133/55HR (bpm): 58Status: InpatientDate/Time: at 15:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). Since the previous tracing of ST segment elevationin lead V6 is less prominent. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are mildly thickened (?#). Inferoposterolateral myocardial infarction. There is no pericardial effusion.IMPRESSION: Suboptimal image quality. Estimated cardiac index is normal(>=2.5L/min/m2). No resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Increased PCWP.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Compared to the previous tracing of ST segment elevations haveresolved.TRACING #2 There is mild symmetric left ventricularhypertrophy with normal cavity size and global systolic function (LVEF>55%).Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Inferior Q waves persist compared to the previous tracing.TRACING #3 Inferolateral myocardialinfarction with ST-T wave configuration suggesting acute/recent/in evolutionprocess. TissueDoppler imaging suggests an increased left ventricular filling pressure(PCWP>18mmHg). No AS. There is no aortic valvestenosis. The pulmonary arterysystolic pressure could not be determined. No previous tracingavailable for comparison.TRACING #1 No aortic regurgitation is seen. TDI E/e' >15, suggesting PCWP>18mmHg. The mitral valve leaflets aremildly thickened.

6

[ { "category": "Echo", "chartdate": "2126-11-04 00:00:00.000", "description": "Report", "row_id": 77207, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Coronary artery disease.\nHeight: (in) 60\nWeight (lb): 170\nBSA (m2): 1.74 m2\nBP (mm Hg): 133/55\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 15:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Estimated cardiac index is normal\n(>=2.5L/min/m2). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global biventricular systolic function. Mild mitral\nregurgitation. Increased PCWP.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2126-11-02 00:00:00.000", "description": "Report", "row_id": 182178, "text": "Sinus rhythm. Inferior Q waves suggestive of old inferior myocardial\ninfarction. Compared to the previous tracing of ST segment elevations have\nresolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-11-02 00:00:00.000", "description": "Report", "row_id": 182179, "text": "Sinus rhythm. Inferoposterolateral myocardial infarction. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2126-11-05 00:00:00.000", "description": "Report", "row_id": 182175, "text": "Sinus rhythm. Inferior wall myocardial infarction, age undetermined.\nQ waves in the lateral precordial leads. Consider lateral myocardial\ninfarction. Since the previous tracing of ST segment elevation\nin lead V6 is less prominent.\n\n" }, { "category": "ECG", "chartdate": "2126-11-04 00:00:00.000", "description": "Report", "row_id": 182176, "text": "Sinus rhythm with ventricular premature beat. Inferolateral myocardial\ninfarction with ST-T wave configuration suggesting acute/recent/in evolution\nprocess. Since the previous tracing of ventricular ectopy is now\npresent.\n\n" }, { "category": "ECG", "chartdate": "2126-11-03 00:00:00.000", "description": "Report", "row_id": 182177, "text": "Sinus rhythm. Inferior Q waves persist compared to the previous tracing.\nTRACING #3\n\n" } ]

3,023

106,157

He was referred to Dr. of cardiac surgery and was seen and evaluated. The plan was discussed with CMI attending, and it was determined that his benefits would be far greater with bypass grafting. The following morning, on , he underwent coronary artery bypass grafting x 3 with a LIMA to the LAD, a vein graft to the PDA, and a left radial artery to the OM. He was transferred to the cardiothoracic ICU in stable condition on a propofol drip at 40 mcg/kg/min, and Neo-Synephrine drip at 0.5 mcg/kg/min, and a nitroglycerin drip at 0.5 mcg/kg/min for coverage of is radial artery. On postoperative day 1, the patient removed on a Neo- Synephrine drip at 1.5 and nitroglycerin drip at 0.8. He was started on aspirin therapy. He was hemodynamically stable with a postoperative hematocrit of 31.2 and a creatinine of 0.8. He had some sinus tachycardia and some ectopy, but these both normalized by the end of the day. The patient was successfully extubated. He had been started briefly on Levophed, and this was weaned off on postoperative day 2. He began beta blockade with Lopressor and Lasix diuresis. On postoperative day 2, he was transferred out to the floor. He had some sinus tachycardia to 114 with a stable blood pressure. He continued on Lasix diuresis. His beta blockade was increased to 75 p.o. twice a day and then switched over to Toprol XL 100 later that day. His creatinine remained stable. He was saturating 94 percent on room air. He began to work with the nurses and physical therapist. His chest tubes were removed later on postoperative day 3. On postoperative day 4, he had a low-grade temperature overnight. It was 101.2 in the morning. His Toprol was increased to 125 p.o. once a day. He continued to ambulate. Percocet was switched over to Dilaudid, and repeat labs were drawn. He did complain of some pain with movement, and he was instructed on splinting and continued to receive p.o. pain medications. He was alert and oriented, and he was strongly encouraged to use in incentive spirometer and work on pulmonary toilet. His incisions were clean, dry, and intact. On postoperative day 5, he was restarted on his Lipitor. He continued to progress very well and did a level 5 later in the day and was discharged to home with VNA services. He was also seen and evaluated by case management prior to his discharge to VNA services.

MAE SPONT AND TO COMMAND.ID--FEBRILE TO 101. BY THIS AM NOTED W/ EXERTIONAL EXP WHEEZES. PA LINE D/CED.GI--NGT D/CED WITH REMOVAL OF ETT. NTG WEANED OFF AFTER RECEIVING PO IMDUR. REMAINS TACHY AT 110'S. WEANED OFF. PERCOCET GIVEN W/ EFFECT. GIVEN 4U SQ AND GTT OFF. WBC FLAT THIS AM.ASSESS: SEDATE. TITRATE . REMAINS SINUS TACHY TO LOW 100'S (PT FEBRILE EARLY IN SHIFT).RESP: LUNGS INITIALLY CLEAR W/ DIM BASES BILAT. RECEIVED VANCO. PCT/TORADOL/PUL HYGIENE W/ GOOD EFFECT.WBC FLAT.ASSESS: STABLE PM. TO RECHECK BS AT 1600.NEURO--WEANED OFF VENT WITH . TOL PO LIQUIDS THUS FAR. FEBRILE . USING IS TO 1L. LOW DOSE RESUMED FOR BP. SINUS TACH LOW 100'S MUCH OF PM. PERL. TORADOL ADDED TO MED REGIME W/ EFFECT.ID: T MAX 102.3. DENIES NAUSEA. RELIEF OBTAINED.SKIN--CONSTANTLY DIAPHORETIC WITH DECREASE IN BODY TEMP. CTGI/GU: ABD SOFT. CARAFATE/PROTONIX CONT.ID: T MAX TO 38.5->TYLENOL GIVEN, REMAINS 38.1. DID NOT FOLLOW.CV: VS/HEMOS AS PER FLOWSHEET. MUCH PULM TOILET GIVEN WITH USE OF IS. PRESENTLY ON .08MCG/KG/MIN. ALSO C/O OF MOD BACK PAIN, NO RELIEF DESPITE REPOSITION, OOB TO CH. FEBRILE.PLAN: WEAN , DELINE, PULM TOILET, ?TRANSFER 2. PATIENT 'S U/O DRIFITNG DOWN NEED VOLUME VS. ATIVAN 1MG IV AS WELL. CRACKLES RT BASE. WILL LET SERVICE MADE AWARE ON PM ROUNDS. NO DEFICITS.CV: VS AS PER FLOWSHEET. LUE CSM INTACT. Non-specific inferolateral repolarization changes.Non-diagnostic inferior Q waves. PT IS X3. ?D/C SWAN. ABD SOFT. UP FOR BP. NO ISSUES W/ CO. A/V WIRES FUNCTIONING, CHECKED LATE IN SHIFT R/T TACHY.RESP: GOOD ABG THIS. Resp Care: pt continues intubated overnoc and on ventilatory support with simv to abg; bs clear, sxn small amts tan secretions, will wean when awake. DECREASE IN TEMP, MUCH PULM TOILET NEEDED.P--CON'T PULM TOILET. LASIX BEGAN W/ GOOD RESULTS. PULSES INTACT. ATTEMPTING TO WEAN . TEMP DOWN TO 99.0 WITH PULM TOILET.PAIN--MEDICATED X2 WITH 4MG MSO4 SC. SBP 84-120/50'S. USING IS TO 1000CC INDEPENDENTLY. UOP QS W/ GOOD RESPONCE FROM LASIX.PAIN: C/O INCISIONAL PAIN. PATIENT SHAVED/NEW DSD TO CL PLACED.. PT STATES HE IS NOT HUNGRY. DENIES HUNGER. CON'T WITH POST OP PLAN. O2 4L N/C W/ O2 SATS HIGH 90'S. Sinus tachycardia, rate 104. CSRU NURSING PROGRESS NOTE 0700-1500RESP--WEANED AND EXTUBATED. .PLAN: WEAN TO EXTUBATION AS QUICKLY AS POSSIBLE IN AM. csru upadteNEURO: ALERT, ORIENTED. CSRU UPDATENEURO: PT HAS REMAINED SEDATED ON PROPOFOL THROUGHOUT SHHIFT. NTG CONT FOR RAD ART GRAFT. SX FOR MOD THICK TAN SECRETIONS, OCCAS SM, OLD BLD NOTED. SOME COFFEE GRND DNG EARLIER THOUGH APPEARS TO BE CLEARING TO CLEARISH DNG. INTACT. CT TO SX FOR MOD (~40CC/H)SANG DNG, NO AIR LEAKGI/GU: UOP QS VIA FOLEY. BETA BLOCKER. BS WNL NO TREATMENT. MAP >65. O2 SATS 95-99%. WEARING O2 VIA FACE TENT AND ITITIALLY SAO2 90-91%. BILATERAL BREATH SOUNDS ARE COARSE IN ALL FIELDS.CARDIAC-- WEANED OFF. TEAM AWARE. BP UP/DOWN DOES NOT APPEAR TO CORRELATE W/ LEVEL OF SEDATION. PT DOES REMAIN ON FULL VENT SETTINGS AS NOTED, NO CHANGES THIS SHIFT AS OF YET. NO SIGNS OF ETOH WITHDRAWEL. SAO2 NOW 96-97%.PT HAS PRODUCTIVE STRONG COUGH OF TAN/BROWN SPUTUM. ALL INCISIONS WITH DSD INTACT.COPING--FAMILY MEMBERS HAVE PHONED AND HAVE BEEN UPDATED REGARDING CONDITION.A--TOL WEAN. PATIENT EASILY WEANED OFF , ST IN THE 120'S GIVEN TOTAL OF 15MG IV GIVEN WITH TEMPORARILY RESPONSETO 108 -110, TOTAL OF 25MG LOPRESSOR PO GIVEN OVER 2HRS. OFFER SUPPORT TO PT AND FAMILY. TOL SIPS WATER. 500CC LR MD. CHECK RESULT OF LABS. No previous tracing available for comparison. NEURO CONTINUES TO WAKE WITH EXTREME AGITATION THRASHING IN BED PULLING AT LINE MOVING ALL EXTREMETIES DOES FOLLOW SOME COMMANDS BUT REMAINS AGITATED DESPITE AT .6MCGS AND PROPOFOL AT 30MCGS MS FOR POSSIBLE PAIN AS SOURCE OF AGITATION WITH NO EFFECTC/V SR TO ST WITH NO FURTHER ECT HR DROP FOR 90S TO 60S WITH MD OFF PROPOFOL MAINTAINED FOR SEDATION B/P STABLE LOW DOSE NEO NITRO MAINTAINEDRESP VENT UNCHANGED SATS 97% 40% FIO2 LUNGS CLEAR CHEST TUBES SMALL AMTS SANG DRAINAGEGU/GI ABD SOFT CARAFATE AND PROTONIX FOR COFFEE GROUND MATERIAL VIA O/G ADEQUATE URINES VOLUMES REPLACEDPLAN MAINTAIN SEDATION TONOC WITH VERY GRADUAL DECREASE TO EXTUBATE IN AM PLEASANT, COOPERATIVE,INQUISITIVE AND ASKING QUESTIONS. HYPOACTIVE BS.GU--FOLEY CATH PATENT DRAINING >50 CC HR OF CLEAR YELLOW URINE.ENDO--INSULIN GTT WEANED OFF FROM 2U HR. DID BECOME RESTLESS ON 60MCQ/K OF PROPOFOL, NOTED TO MAE IN BED. STRONG COUGH PRODUCTIVE OF THICK YELLOW SECRETIONS. HE STATES THAT HE HAD BROWN PHLEGM BEFORE THE SURGERY AND TOLD INTAKE RN HE HAD THIS.

8

[ { "category": "ECG", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 193257, "text": "Sinus tachycardia, rate 104. Non-specific inferolateral repolarization changes.\nNon-diagnostic inferior Q waves. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 1301203, "text": "47 Y/O PMH HTN HIGH CHOLESTEROL ETOH/SMOKES 6/DAY ADMITTED FROM OR POST CABG X3 WITH L RADIAL ARTERY HARVEST PATIENT ALLERGIC TO SHELLFISH\n\nNEURO SEDATED ON PROPOFOL WEANED TO SEDATION ATTEMPTS TO WEAN OFF PROPOFOL WITH DIFFICULTY PATIENT WAKES THRASHING IN BED MOVES ALL EXTREMETIES BUT NOT TO COMMANDS PULLING ON LINES AND TUBES LIFTING SELF UP OFF BED MS FOR PAIN WITH LITTLE EFFECT PRECEDEX STARTED AT .4MCG AND PROPOFOL DECREASED TO 40MCGS WITH WAKING WITH CONTINUED AGITATION LIFTING UP OFF BED PRECEDEX INCREASED TO .5MCG WITH NO EFFECT PRECEDEX CURRENTLY AT .6MCGS WITH PROPOFOL DOWN TO 25MCGS TOL WELL\n\nC/V ST WITH FREQ PVCS COUPLETS SOME 3 BEAT RUNS ON ARRIVAL TO CSRU MAG INFUSING K REPLACED INCREASED VOLUME GIVEN WITH GOOD RESULTS HR DECREASED TO 92-106 NO FURTHER ECT CVP 12-15 B/P MAINTAINED WITH NEO TITRATED AS NEEDED NITRO MAINTAINED AT .5MCGS FOR RADIAL ARTERY GRAFT\nEPI WIRES INTACT FUNCTIONAL AWIRES CI > 2 PALP PULSES\n\nRESP VENT MAINTAINED ABG WITH PH 7.33 TO REASSESS RESP INCREASED RR TO 10 SUCTIONED FOR SMALL AMT THICK LUNGS SOME COARSE SOUNDS UPPER CHEST TUBES WITH MOD AMTS SANG DRAINAGE INCREASED WITH AGITATION SATS 98-100%\n\nGU/GI ABD SOFT UNABLE TO HEAR BOWEL SOUNDS OG DRAINAGE MOD AMTS COFFEE GROUND MATERIAL CARAFATE GIVEN PROTONIX STARTED LARGE AMTS URINE OUT REPLACED WITH VOLUME\n\nPLAN ATTEMPT TO ACHIEVE CONTROL OF AGITATION WITH PRECEDEX AND WEAN TO EXTUBATE\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301207, "text": "CSRU NURSING PROGRESS NOTE 0700-1500\nRESP--WEANED AND EXTUBATED. WEARING O2 VIA FACE TENT AND ITITIALLY SAO2 90-91%. MUCH PULM TOILET GIVEN WITH USE OF IS. SAO2 NOW 96-97%.PT HAS PRODUCTIVE STRONG COUGH OF TAN/BROWN SPUTUM. HE STATES THAT HE HAD BROWN PHLEGM BEFORE THE SURGERY AND TOLD INTAKE RN HE HAD THIS. USING IS TO 1L. BILATERAL BREATH SOUNDS ARE COARSE IN ALL FIELDS.\n\nCARDIAC-- WEANED OFF. NTG WEANED OFF AFTER RECEIVING PO IMDUR. REMAINS TACHY AT 110'S. SBP 84-120/50'S. ATTEMPTING TO WEAN . PRESENTLY ON .08MCG/KG/MIN. MAP >65. PA LINE D/CED.\n\nGI--NGT D/CED WITH REMOVAL OF ETT. TOL SIPS WATER. PT STATES HE IS NOT HUNGRY. HYPOACTIVE BS.\n\nGU--FOLEY CATH PATENT DRAINING >50 CC HR OF CLEAR YELLOW URINE.\n\nENDO--INSULIN GTT WEANED OFF FROM 2U HR. GIVEN 4U SQ AND GTT OFF. TO RECHECK BS AT 1600.\n\nNEURO--WEANED OFF VENT WITH . WEANED OFF. PT IS X3. PLEASANT, COOPERATIVE,INQUISITIVE AND ASKING QUESTIONS. NO SIGNS OF ETOH WITHDRAWEL. MAE SPONT AND TO COMMAND.\n\nID--FEBRILE TO 101. RECEIVED VANCO. TEMP DOWN TO 99.0 WITH PULM TOILET.\n\nPAIN--MEDICATED X2 WITH 4MG MSO4 SC. RELIEF OBTAINED.\n\nSKIN--CONSTANTLY DIAPHORETIC WITH DECREASE IN BODY TEMP. INTACT. PULSES INTACT. ALL INCISIONS WITH DSD INTACT.\n\nCOPING--FAMILY MEMBERS HAVE PHONED AND HAVE BEEN UPDATED REGARDING CONDITION.\n\nA--TOL WEAN. DECREASE IN TEMP, MUCH PULM TOILET NEEDED.\n\nP--CON'T PULM TOILET. CHECK RESULT OF LABS. OFFER SUPPORT TO PT AND FAMILY. CON'T WITH POST OP PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301208, "text": "PATIENT EASILY WEANED OFF , ST IN THE 120'S GIVEN TOTAL OF 15MG IV GIVEN WITH TEMPORARILY RESPONSETO 108 -110, TOTAL OF 25MG LOPRESSOR PO GIVEN OVER 2HRS. ATIVAN 1MG IV AS WELL. PATIENT 'S U/O DRIFITNG DOWN NEED VOLUME VS. BETA BLOCKER. WILL LET SERVICE MADE AWARE ON PM ROUNDS. BS WNL NO TREATMENT. PATIENT SHAVED/NEW DSD TO CL PLACED..\n" }, { "category": "Nursing/other", "chartdate": "2132-02-16 00:00:00.000", "description": "Report", "row_id": 1301209, "text": "csru upadte\nNEURO: ALERT, ORIENTED. NO DEFICITS.\n\nCV: VS AS PER FLOWSHEET. LOW DOSE RESUMED FOR BP. LASIX BEGAN W/ GOOD RESULTS. REMAINS SINUS TACHY TO LOW 100'S (PT FEBRILE EARLY IN SHIFT).\n\nRESP: LUNGS INITIALLY CLEAR W/ DIM BASES BILAT. BY THIS AM NOTED W/ EXERTIONAL EXP WHEEZES. CRACKLES RT BASE. STRONG COUGH PRODUCTIVE OF THICK YELLOW SECRETIONS. USING IS TO 1000CC INDEPENDENTLY. O2 4L N/C W/ O2 SATS HIGH 90'S. CT\n\nGI/GU: ABD SOFT. DENIES NAUSEA. TOL PO LIQUIDS THUS FAR. DENIES HUNGER. UOP QS W/ GOOD RESPONCE FROM LASIX.\n\nPAIN: C/O INCISIONAL PAIN. PERCOCET GIVEN W/ EFFECT. ALSO C/O OF MOD BACK PAIN, NO RELIEF DESPITE REPOSITION, OOB TO CH. TORADOL ADDED TO MED REGIME W/ EFFECT.\n\nID: T MAX 102.3. TEAM AWARE. PCT/TORADOL/PUL HYGIENE W/ GOOD EFFECT.\nWBC FLAT.\n\nASSESS: STABLE PM. FEBRILE.\n\nPLAN: WEAN , DELINE, PULM TOILET, ?TRANSFER 2.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-02-14 00:00:00.000", "description": "Report", "row_id": 1301204, "text": "NEURO CONTINUES TO WAKE WITH EXTREME AGITATION THRASHING IN BED PULLING AT LINE MOVING ALL EXTREMETIES DOES FOLLOW SOME COMMANDS BUT REMAINS AGITATED DESPITE AT .6MCGS AND PROPOFOL AT 30MCGS MS FOR POSSIBLE PAIN AS SOURCE OF AGITATION WITH NO EFFECT\n\nC/V SR TO ST WITH NO FURTHER ECT HR DROP FOR 90S TO 60S WITH MD OFF PROPOFOL MAINTAINED FOR SEDATION B/P STABLE LOW DOSE NEO NITRO MAINTAINED\n\nRESP VENT UNCHANGED SATS 97% 40% FIO2 LUNGS CLEAR CHEST TUBES SMALL AMTS SANG DRAINAGE\n\nGU/GI ABD SOFT CARAFATE AND PROTONIX FOR COFFEE GROUND MATERIAL VIA O/G ADEQUATE URINES VOLUMES REPLACED\n\nPLAN MAINTAIN SEDATION TONOC WITH VERY GRADUAL DECREASE TO EXTUBATE IN AM\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301205, "text": "CSRU UPDATE\nNEURO: PT HAS REMAINED SEDATED ON PROPOFOL THROUGHOUT SHHIFT. PERL. DID BECOME RESTLESS ON 60MCQ/K OF PROPOFOL, NOTED TO MAE IN BED. DID NOT FOLLOW.\n\nCV: VS/HEMOS AS PER FLOWSHEET. SINUS TACH LOW 100'S MUCH OF PM. 500CC LR MD. UP FOR BP. BP UP/DOWN DOES NOT APPEAR TO CORRELATE W/ LEVEL OF SEDATION. NTG CONT FOR RAD ART GRAFT. LUE CSM INTACT. NO ISSUES W/ CO. A/V WIRES FUNCTIONING, CHECKED LATE IN SHIFT R/T TACHY.\n\nRESP: GOOD ABG THIS. PT DOES REMAIN ON FULL VENT SETTINGS AS NOTED, NO CHANGES THIS SHIFT AS OF YET. O2 SATS 95-99%. SX FOR MOD THICK TAN SECRETIONS, OCCAS SM, OLD BLD NOTED. CT TO SX FOR MOD (~40CC/H)SANG DNG, NO AIR LEAK\n\nGI/GU: UOP QS VIA FOLEY. ABD SOFT. SOME COFFEE GRND DNG EARLIER THOUGH APPEARS TO BE CLEARING TO CLEARISH DNG. CARAFATE/PROTONIX CONT.\n\nID: T MAX TO 38.5->TYLENOL GIVEN, REMAINS 38.1. WBC FLAT THIS AM.\n\nASSESS: SEDATE. FEBRILE . .\n\nPLAN: WEAN TO EXTUBATION AS QUICKLY AS POSSIBLE IN AM. TITRATE . ?D/C SWAN.\n" }, { "category": "Nursing/other", "chartdate": "2132-02-15 00:00:00.000", "description": "Report", "row_id": 1301206, "text": "Resp Care: pt continues intubated overnoc and on ventilatory support with simv to abg; bs clear, sxn small amts tan secretions, will wean when awake.\n" } ]

26,702

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While on floor, pt experienced hypercarbic respiratory failure of unknown etiology, was intubated and transferred to the -ICU on . hospital course: 1.) Respiratory Failure: Initially thought to flash pulmonary edema of ?etiology (no hx of CHF) and pt was treated initially for ?CHF with diuresis with ethacrynic acid (distant hx of sulfa allergy - therefore intially lasix was not used), also treated for ?COPD with steroids. Immediate complications included excessive bloody secretions, thought likely traumatic intubation, which was managed with holding anticoagulation and frequent suctioning. During this time CXR was showing improvement and differential diagnosis included 1.) flash pulmonary edema norpace for AFib (therefore norpace d/ced) or MR (ECHO had demonstrated 1+ MR) - attempted treatment of pulmonary edema included diuresis without improvement 2.) Chemical pneumonitis 2/2 blood from traumatic intubation, although did not clear with time 3.) Viral pneumonia 4.) Pulmonary/Renal process - thought of as a possibility bloody secretions (although more likely contributed bloody secretions to traumatic intubation) - r/o w/ negative ANCA, negative U/A for blood. Pulmonary embolism was ruled out on with negative CTA. Respiratory status complicated by worseing lung exam/CXR/oxygenation/fever spike on with sputum cultures sent that grew MRSA - therefore patient experience VAP +MRSA. Was treated with 14 day course of Vancomycin. Subsequent sputum culture was + for pseudomonas and patient was treated w/ Genatmicin x 2 days, switched to Merapenem after sensitivities returned. Further complication of patients respiratory status was fluid overload, as patient remained >10L positive throughout length of stay. Fluid removal with diuresis (ethacrynic acid and later lasix) was not effective due to patient's developed ARF during hospital stay. CVVH was started with gentle fluid removal as patient's blood pressure tolerated (as patient was on levophed pressors for BP support). Attempts made at vent weaning were met with decrease paO2 or respiratory acidosis on ABG - therefore, patient was maintained with as low FiO2 and PEEP as ABG would tolerate. Patient's breathing became completely ventilator-dependent, and decision was made by family to not withdraw care but to keep patient comfortable. 2.) ID: As mentioned above, patient suffered from VAP +MRSA from sputum cx and treated with 14 day course of Vancomycin. Also with subsequent sputum cx +pseudomonas and treated with gentamicin->merapenem. Other infections include repeatedly +urine cx for yeast = albicans, treated with 7 day course fluconizole. Also C. Diff+ and treated with flagyl. Blood cxs remained negative throughout hospital course. Maintnance LFTs sent in ICU to r/o obstruction and were negative. Sacral Decub ulcer was checked daily without signs of infection. Patient defervesced and antibiotics were withdrawn when course was completed. Once patient became completely ventilator-dependent and it was realized that all medical efforts would be futile, no further antibiotics were administered, and patient was kept comfortable on ventilator per wish of family. 3.) Hypotension: Pt with hypotension on initial presentation to ICU, initially responsive to fluid boluses. With fever spike/septic picture on hypotension returned requiring pressor support. Initially started on dopamine (as patient was bradycardic), but then became tachycardic w/ afib/flutter - therefore pressor was changed to levophed with good HR control. Wean was attempted, but was not successful, especially after starting CVVH with fluid removal, and patient remained on levophed pressor for BP support. Due to hypotension, patient received significant amount of fluids. Pressors were discontinued along with all non-essential medications once family decision was made to keep patient comfortable but not withdraw mechanical ventilation. 4.) AFlutter: Pt with history of AFlutter s/p ablation - returned to Aflutter on floor w/ HR into 90's. Initially placed on Procainimide gtt then to standing dose Procainimide - however, pt experienced hypotension, and among other interventions, procainimide d/ced and amiodarone started. During this time, pt became bradycardic and was becoming septic - therefore, all anti-arrythmics were held throughout rest of hospital course, and pt remained in AFib/Flutter, but with good HR control (80's-100). 5.) Acute Renal Failure: Pt developed acute renal failure, likely contrast induced ATN after CTA/Abd CT on . Creatinine increased (max=2.4) and she became oliguric. CVVH was eventually started fluid overload and unresponsiveness to lasix, and levophed was titrated up to allow more fluid removal from CVVH. Creatinine and urine output slightly improved on CVVH. After 3-5 days on CVVH, machine clotted and Lasix gtt was tried instead for fluid removal - successful in increasing UOP to 30-110cc/hr, but pt w/ net positive fluid balance over 24 hours, and after 24 hours on Lasix gtt, experienced increased Cr (0.9->->1.4) and decreased response to lasix even w/ titrating up drip (UOP=30-40cc/hr) - therefore switched back to CVVH. CVVH was discontinued, and patient continued to remain hypotensive. Within this time period, decision was made to remove all non-essential and non-comfrot medications/procedures, CVVH being one of them. 6.) Anemia: Pt with repeatedly decreased HCt requiring blood transfusions (average units pRBC/week) throughout hospital course. Thought to be acute illness + blood loss from traumatic intubation w/ continued bloody secretions + frequent blood draws for labs. More acute bleed (such as abd/retroperitoneal bleed) r/0 with negative Abdominal CT . No other signs of blood collection/hemorrhage noted (no gross GI bleed, no large hematomas, etc.). HCt monitored throughout stay until patient's status was changed to comfort care with mechanical ventilation. 7.) Abdominal distension: Pt with stable abdominal distension throughout stay. Likely constipation from the sedation medication (fentanyl and versed) - treated with Lactulose PRN. Subsequently likely C. Diff treated with flagyl. Abd hemorrhage r/o w/ negative abd CT . Exam monitored without significant change, though patient was heavily sedated and comatose during the last several weeks of her hospital course. 8.) DM: Patient maintained on Insulin gtt throughout initial ICU stay for goal BS control 80-110 in setting of acute illness. Changed to ISS and standing dose long insulin with poor BS control - therefore changed back to Insulin gtt along w/ standing dose of long-acting insulin with good BS control. Once decision was made to withdraw non-essential medications and keep patient comfortable, insulin gtt was discontinued. 9.) FEN: Pt maintained on tube feeds per NG tube -> changed to OG tube per nutrition recommendations. Patient was having high residuals once comfort measures were instituted, tube feeds were then discontinued. 10.) Prophylaxis: Pt maintained on PPI, SC heparin until comfort only with mechanical ventilation measures instituted. 11.) Communication: With husband and 2 sons throughout hospital course. 12.) Numerous conversations concerning prognosis, code status were discussed throughout stay, and family was updated on patient's condition daily. Family discussion w/ husband and rabbi to explain medical condition of patient. Family decision = full intervention. Ethics involved as medical condition without change and still with poor prognosis per ICU team x past 3-4wks. At family meeting on Monday, with Dr. , pt's husband, 2 sons on phone, the futility of further intervention was discussed. Patient's family had extensive discussions with home rabbi and hospital rabbi, and eventually decision was reached to not withdraw care (i.e. ventilator) but to only institute measures that would keep patient comfortable. Patient was maintained on mechanical ventilation and sedation for several more weeks, with further discussions with the family and ethics. It was felt by the ICU team that maintaining patient on ventilator without any improvement, and rather, decline, was harming the patient. Ethics was re-consulted, and a family meeting had been planned. However, prior to the meeting, patient's BP began to decline further and oxygen saturation dropped, and patient expired on .

ABGS CONSISTENT WITH SLIGHT RESP. pt tolerating CVVHD. with A-fib with HR 70-120. Resp CarePt. softly distended with hypoactive BS.GU: Foley cath in place. Latest ABG's pH 7.42, PCO2 33, PaO2 91. on Levophed gtt at 0.015mcg/kr/min maintaining ABP 100-130/50-60. resp. Administering Albuterol and Atrovent MDI's in line with vent ~Q2hrs. NPNNEURO: Pt. Abd soft distended, BS hypoactive. remains DNR. sacral decub still with duoderm in place. made DNR this PM. Generalized edema and weaping.GU: Lasix gtt at 7cc/hr. Followup abg 7.34/47/140/26. remains on IV sedation Versed 9mg/hr and Fentanyl 300mcg/hr. BUN 52, creat 1.5 this AM.GI: Abd distended and firm. will continue with present vent settings.gi: pt still not receiving tube fdgs b/cause of high residuals. slight weeping from upper extremities.resp: remains on same vent settings- see events. T-Max 99-100.Resp: Remains intubated. Resp Care Note:Pt intub with OETT and on vent as per Carevue. abd remains distended with absent bowel sounds on asucultation.gu: foley cath in place with minimal up throughout the day- <30cc's this shift. remains DNR/DNI. BS hypoactive and TF on hold after Pt. Settles out when left alone.UO 0-10 cc hr. Remains on CVVHD,vent changed order so Ric can PM it.Poor prognosis,hypoxemic,sensitive to FI02 changes.BS coarse withR>L,on MDI Albuterol/Atrovent. Sons & also phoned & were updatedPt remains CPR not indicatedA/P: Stable on above vent settings. Smicu nsg progress noteS/O- essentually unresponsive on fent/versed gtt. No VEA noted.Cont on CVVH. Smicu nsg progress noteS/O- to be unresponsive on fent/versed gtts. (Do not increase levo to maintain hrly neg balance)Apears adequately sedated on fent & versed.Support to family distended and soft, BS hypoactive.GU: Pt. last glu 199 at 1230 and covered.ID: afebrile with fluconozole added to regimen. course bs with exp wheezes throughout. RESPIRATORY CARE: PT W/ A 7.0 ORAL ETT IN PLACE.REMAINS ON PCV AS PER CV. No spontaneous movement noted.CV: Tmax 100.0 axillary. ABD FIRMLY DISTENDED WITH ABSENT BS. Cardiac: HR 90-100's afib, rare PVC's cont on levo, titrated to keep SBP>90/ range tonight has been 0.808mcg/kg/min to 0.55. presently on 0.55mcg/kg/min. progress note:Neuro: remains sedated on fent 75 mcg and midaz 2 mg with PERL sluggish. Albuterol/Atrovent MDI's given Q4hr. MD aware.Gi/GU: PT remains oliguric. ALBUTEROL AND ATROVENT MDI'S GIVEN.WILL C/W VENTILATORY SUPPORT. Tolerating PO2 of >60.ID: Hypothermic at 96 axillary. sacral decub with douderm in place. sacral decub with douderm . mdi's given q4h and prn. repeat ABG pnd. remains edeamtous, LOS is still + ll liters. anascara, oozing from prevous puctures. Resp CarePt. Respiratory CarePt weaned today changed mode to A/C 450/22/peep14/40% last abg734/34/96/19/-6 pt bld. Administering Albuterol and Atrovent MDI's in line w/ vent, see flowsheet for rx times. 7cc urine output noted.Skin: Duoderm remains on . sedated on Versed 1mg/hr and fentanyl 50,cg/hr. LS COURSE AND DIMINSHED BILAT.GI/GU: TF ON HOLD SECONDARY GROSS AMOUNTS OF RESIDUAL. Douderm over sacral decub. FOLEY CATH WITH NO OUT-PUT.SKIN: DUODERM CHANGED TODAY. BS ansent. remains NPO d/t increased residuals. RESP CARE:Pt remains intubated with 7.0ETT/on vent on settings per carevue. Albuterol and Atrovent MDI given Q vent check. Changed .Access: R IJ Dialysis cath / L IJ TL Central line.Plan: Pt. NPNNeuro: Pt. GU: foley in place and draining. Albuterol/Atrovent MDI's given Q4hr. BS insp/expri wheezes on the right. Hypoactive bowels sds. Albuterol/ Atrovent MDI Q vent check. r/t fluid status. LEFT BRISK.GU: FOLEY CATH PATENT, HAD BEEN REPLACED DURING SHIFT, THE FOLEY PT ARRIVED WITH WAS NOTED TO BE OUT. Sacral decub with duoderm dsg c/d/i. Cardiac: remains on Levophed to maintain SBP>90 attempted to wean to off and SBP dropped to low of 82/ back on levophed at the original dose...0.03mcg/kg/min. HSV vs trauma.Continues on Levophed. Able to wean levo from .07mcg/kg to .03mcg/kg. GI: abd distended. MSICU NPN 0700-1900Please see flowsheet for further details...Remains sedated on Fentanyl and versed gtt. 1 interruption in therapy d/t clotted filter. remains DNR/. Otherwise .Access: R IJ Dialysis cath, L IJ central line.Plan: Pt. remains sedated with versed/fentanyl. ABG=7.39/28/94/-. Foley cath w/ << u/o - 0-30cc/hr. Miscellaneous (not measured) output of mod-lg amt of PO secretions as well as mod-lg amt of serosanguinous drainage from around L SC. Is now being ultrafiltrated only. Hypoactive bowel sds. remains NPO.GU: Pt. A-line dc'd..following with NBP More tachycardic..?d/t fever.. ID: Febrile..given tylenol GI: TF continue..no stool.. GU: Poor u/o..<10cc hr. opens eyes to suctioning and repositioning, otherwise no movement noted.cv: hr ranging 70s-low 100s afib with occas pvcs in pm. Levophed gtt weaned off. Will hold on gtt and cover with s/s and fixed dose glargine in pm. Smicu nsg progress noteNeuro- Well sedated on 170mcg/hr fent and 5mg/hr versed. Pt has become hypotensive in past when levo d/c'd.Resp- Intub/vented. Weaned off Levophed.ROS:NEURO: Pt remains sedated on Fentanyl and Versed gtts; rates increased d/t pt appearing uncomfortable. Remains in afib with occasional PVC's. secreations minimal this shift.abgs:ess. wheezes tx'd with mdis as ordered. GI: abd distend, +BS sounds, stool x 1 mod amount. Remains on .03mcg/kg/min levofed with BP 110's-120's/40's. Suctioned for minimal clear secretions.GI: Abd firm with edema, +BS's. remains NPO d/t absent BS and increased residuals. Responds fairly to some supplemental bolusing.CV: HR 70's-90's, Afib with occassional PAC. is now CPRNI. settings titrated per abgs, again with worsened oxygenation although stable on vent today d/t incr.sedation level. Resp CarePt. Resp CarePt. Turned and repositioned as tolerated. Stable left groin bowel containing hernia. There is a minimally increased gradient consistentwith minimal aortic valve stenosis. Normal ascending aorta diameter.AORTIC VALVE: Aortic valve not well seen. Trivial MR.TRICUSPID VALVE: Mild [1+] TR. Bilateral patchy infiltration involving both lungs and left pleural effusion are again noted, unchanged. Extremities stiff.Cont on CVVH. Trivial mitral regurgitationis seen. Stable mild intrahepatic biliary ductal prominence. Cont with very little uo 0-10cc/hr. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. There is aminimally increased gradient consistent with minimal aortic valve stenosis.Mild (1+) aortic regurgitation is seen. Mild mitral annularcalcification. There is mild pulmonary artery systolichypertension. Mild pulmonary hypertension is now detected. IMPRESSION: 1) Endotracheal tube and nasogastric tube in stable position. Right ventricular chamber size and free wall motion arenormal. Sinus bradycardiaBorderline first degree A-V blockPoor R wave progression - probable normal variantSince previous tracing of , no significant change MildPA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated.

237

[ { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611730, "text": "NPN 0700-1900\n\nNeuro: Remains on same dose of sedation: fent/versed 50/1. Opens eyes spontaneously, moving L arm up to face, other extremities are stiff; ocassionally answers yes or no questions by nodding or shaking head; denies having pain; PERRL.\nCV: ABP 111-155/43-57 with maps 57-82, no pressors required, BP increases with any stimulation; HR 69-95, NSR, no ectopy; CVP 10-14; 3+ generalized body edema, L leg is bigger than R.\nResp: Vent settings unchanged, 500X20X.5X8; suctioned q 1-2hrs for large amts brownish red sputum; has a good cough; lung sounds are coarse throughout; O2sats 97-100%.\nGI/FEN: Abdomen obese, slightly firm; TF thru NGT nepro at 40/hr tolerated well with no residuals; no stools during the night.\nGU: Foley catheter draining 20-35cc/hr yellow urine with sediment; fluid status is presently +68.5, LOS +8816.\nEndo: FSBG 102-135; insulin gtt has been at 2.5 units/hr continuously.\nID: Tmax 99.3; wbc 15.4; remains on aztreonam.\nAccess: A-line L radial; multi-lumen L subclavian; R subclavian dialysis catheter.\nSkin: Duoderm on remains ; no other breakdown.\nPlan: Continue to monitor resp status, wean vent and sedation as tolerated, aggressive pulmonary toilet; monitor hemodynamic status, administer pressors as needed; monitor fluid/electrolyte status, replete prn; skin care as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611731, "text": "Respiratory Care Note:\n Patient remains intubated and ventilated. Suctioned for moderate amounts of thick blood tinged, tan sputum. BS are coarse t/o. WBC >15. She remains >+9Kg up in volume. See Carevue flowsheet for specifics. FIO2 weaned with SaO2>97%. Patient has #7.0 ET tube with cuff pressure 28cm for minimal occlussive pressure. Mouth with lots of ulcerations and patient does not like to have her mouth suctioned. Plan to maintain supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611732, "text": "MSICU NPN 0700-1900\n\n\nplease see flowsheet for further details...\n\nNo change in sedation. Easily arousable. Does not follow commands.Grimaces with turning and becomes hypertensive which resolves with cessation of activity.\n\nFiO2 decreased to 40%. No other changes. Sputum less bloody today. ABG unchanged.\n\nAfebrile. UO remains ~20cc/hr. Foley changed d/t yeast in urine. Currently leaking mod amt and balloon filled more.\n\n dsd changed by skin care RN.\n\nTol TFs at goal of 35cc/hr. No stool.\n\nHusband in most of day. Both sons called.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611789, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnoc. Sxing thick pale yellow secretions. BS's diminished, no wheezing heard. Administering Albuterol and Atrovent MDI's in line with vent. See flowsheet for data and rx times. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611790, "text": "Respiratory Care Note\nPt received on AC as noted. BS diminished throughout; Pt suctioned for mod amts thick secretions; MDI's given; BS increased aeration with expiratory wheezes bilat. IMV weaned and PEEP increased according to ABG's. Pt vomited and aspirated RN who suctioned tube feeding from ETT. Plan to remain on current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611747, "text": "RESP CARE: PT REMAINS INTUBATED WITH 7.0ETT/ON VENT ON SETTINGS PER CAREVUE. NO CHANGES OVERNIGHT. LUNGS COARSE BILAT. SXD THICK BLD TINGED SPUTUM. PT BITING ON TUBE AT TIMES. MDIS GIVEN WITH GOOD EFFECT. NO RSBI DUE TO HEMODYNAMIC STATUS. ABGS CONSISTENT WITH SLIGHT RESP. ACIDOSIS. CONTINUE FULL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611748, "text": "Reps Care\n\nPt remains intubated but mode ov ventilation was changed to CPAP/PSV. Pt settings 20/8/50%. Followup abg 7.34/47/140/26. BS remain coarse and suctioning thick blood tinged sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611749, "text": "MICU/SICU NPN ICU day #15\nNo events\nFull code\n\nS/O:\n\nNeuro: pt remains sedated with fentanyl/midazolam, no independednt movement of extremities noted, pupil fixed and nonreactive\n\nPulm: pt remains intubated in PSV 13+5/0.5, last ABG 7.34/47/140, SpO2 100%, LS coarse, dim at bases, Vt 470's, Ve 6.7-9.5\n\nCV: 77-102 AF without notable ectopy, BP 92-131/42-55, CVP 14-15, please see flowsheet for data\n\nInteg: remains anasarcic most notably in extremities, sacral decub dressed with Duoderm, dsg change next due on Tues., old healed venous stasis ulcer on RLE, multiple areas of eccymosis on abdomen and thorax\n\nGI/GU: and is firm and distended, BS present, tolerating Nepro with Promod at goa rate of 35cc/h, LBM , Foley is patent for small amts clear yellow urine\n\nLines: left SC QLCL day #11, left radial art line day #15, right IJ Quenin cath day #9\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT and indwelling catheter\naltered breathing r/t volume overload\nhigh risk for injury cebro/cardiovascular r/t hypotension, pressor requirement\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contniue to wean resp support as tolerated, contninue to wean hemodynamic support as tolerated, schedule family meeting at earliest convenience\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611750, "text": "RESPIRATORY CARE:\n\nPt remains intubated, switched back to AC at 10pm this shift, for worsening acidosis. Pt has been significantly bronchospastic, I:E wheezing noted throughout all lung fields. Administering Albuterol and Atrovent MDI's in line with vent ~Q2hrs. Continue to sx thick brown/bloody secretions. See flowsheet for rx times, further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-25 00:00:00.000", "description": "Report", "row_id": 1611809, "text": "NPN\n\nNeuro: Pt remains on fent and versed, she is very sedated today and rarely opens her eyes to stimulation.Her versed was decrease to 9 mg/hr and her fent to 300 mcg/hr and she remains somulent.\n\nCV: Remains in afib 70s-120s, SBP started to drop this afternoon to to 70s and 80s though she conts to urinate.\n\nResp: Remains on A/C, no changes were made on the vent, sx for thick tan secreations.\n\nGI: Tolerating her TF, no stool today, conts on bowel meds.\n\nGU: U/O 10-20cc/hr\n\nSoc: Husband was in today as was their rabbi, though two along with their son discussed where to head with her care - they will discuss this with us tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611761, "text": "S/MICU Nursing Progress Note\n Respiratory: difficult night sedating pt, biting on ETT, PIP of 40-50's with dropping TV, requiring increasing her sedation... a number of bolused throughout the night. presently is on 170mcg/hr of fentanyl and 5mg/hr of versed. still will bite and PIP's up t50's with any type of stimulation. Have had difficulty with vent, rising CO2 and droping pH. have adjusted her vent accordingly. settings are 500cc/30/60%/12 .... only showing TV of 380cc during the night. suctioning for thick tan to yellow sputum.\n Cardiac: HR 80-90's Afib, rare PVC's, rare couplet. BP 140-170/'s on levo at 0.06mcg/kg/min. have not try to titrate as pt is on CVVHD\n Renal: BUN 96 creat 1.9 restarted CVVHD last evening at 1845. goal is to be -100cc/hr. have slowly increased PFR. pt tolerating CVVHD. temp low was 96 ax. blanket placed on temp now up to 98. have had a number of problems with access pressures. reversed the ports. Pt will still stop the machine with coughing,\n ID: temp max 99 ax. cont on vanco( will need levels before tonight's dose) D7, aztreonam D11( increased the dose last night from 500mg to 1000mg) and po flaygly for +c-diff. WBC this am 18.7\n Skin: oozing from everywhere esp arms. elevated on pillows, bleeding from dialysis cath site and now from triple site. numberous eccymotic areas. hepatic lesions on lips and inner lips, bleeding from those sites. with biting on ETT ...bite block was neccessary. causing more bleeding. sacral decub still with duoderm in place.\n GI: cont on TF of deliver with promod, rate 35cc/hr at goal rate. mushroom catheter in place min stool output.\n Plan: sedation requirements increased but may also be related to dialysis. cont CVVHD with goal to be -100/hr. monitor VS closely.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611829, "text": "NPN:\nNeuro: Pt. remains on IV sedation with Fentanyl and versed. No dose increase this shift.\n\nCV: BP remains low at 50-60's systolic with MAP 30-40's.\n\nResp: LS coarse. Suctioned x2 this shift for moderate amount of thick tan sputum. Unable to do mouth care, Pt. clamping down her teeth. Pt. vented with A/C 450x16 peep of 5 and FiO2 50%.\n\nGI: Tube feeding held again for high residual of bile liquid. MD aware of high residuals and decision made to keep tube feedings off. Residuals greater than amount fed for the past 24 hr. Abd. softly distended with hypoactive BS.\n\nGU: Foley cath in place. Urine output remains low at 5-10cc every 2 hr. Positive for anasarca.\n\nSocial: Pt. remains DNR. Awaiting visit from son who is ariving from in AM. Plan to make Pt. .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611830, "text": "Resp Care\nPt. remains intubated/sedated with no changes overnight.\nBS: coarse bilat. 'd for mod. amts. of thick tan.\nPlan: family meeting once son arrives, to make pt. >\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611831, "text": "Resp Care\n\nP tremains intubated and on full vent support. NO changes made during the shift. BS coarse and suctioning thick tan sputum. Spo2 100%\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611791, "text": "NPN\n\nNeuro: Pt remains on fent and versed, the rates have not been increased but I have given her versed boluses (5-10 mg) for aggitation. She is lighter than she was yesterday but mostly appears comfortable.\n\nCV: Remains on levo, SBP has been 110-130s, HR 70s-80s afib\n\nResp: LS coarse, she vomited TF this morning and TF appearing material was suctioned from her ETT. A CXR showed that her pedi tube is at the GE junction - to be replaced by the team. ABG was 7.50/32/66, the alkolosis is felt to be due to the lasix gtt, her rate was decreased to 16 and PEEP was increased to 12.\n\nGI: Vomited TF as above, pedi tube to be replaced because it is in the GE junction. Her ABD remains firm and distended, reglan and lactulose are now q6hrs, to start on PO narcan to decrease the GI effects of the fent - this should not effect her systemically.\n\nGU: U/O 30-80cc/hr, her lasix rate is now 7mg/hr, K to be checked this afternoon, CVVHD is on hold because of we are able to get fluid off with the lasix.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611792, "text": "NPN\nNeuro; Pt. sedated on Fentanyl 300mcg/hr and Versed 10 mg/hr. Pt. cont. to reuired additional sedation boluses when being turned.\n\nResp: Pt. remains on a Vent A/C 450x16 with FiO2 of 50 and PEEP of 12. Latest ABG's pH 7.42, PCO2 33, PaO2 91. Ls remain coarse but unable to suction any secretions.\n\nCV: Pt. cont. on Levophed gtt at 0.015mcg/kr/min maintaining ABP 100-130/50-60. Cont. with A-fib with HR 70-120. Pt. also on Lasix gtt at 7cc/hr. H/H this AM 9.7/28.8 and stable. MD aware and no new orders at this time. Generalized edema and weaping.\n\nGU: Lasix gtt at 7cc/hr. Urine output anywhere from 27-85cc/hr of clear yellow urine. BUN 67, creat 1.4 this AM and MD aware. Cont. with Lasix gtt. Fluid balance +0.23L for 24hr and +13.7L LOS.\n\nGI: OGT insterted on day shift . Placement checked with CXR and by ascultation. Probalance tube feed restarted at at 10cc/hr. Rate slowely titrated up to 30cc/hr with last increase in dose at 0400. Residual 10cc each time. Goal to increase tube feeding to 35cc/hr. Pt. on insulin gtt at 5units/hr. BS at 97. Insulin rate decreased and then stoppped for BS 84. Lantus insuline held on for BS of 80-90's. Insulin gtt restarted and infusing at 4 units/hr. Cont. to monitor BS q 1 hr. Mushroom cath in placce with no significant BM noted. Pt. on Lactulose q 6 hr till BM.\n\nSocial: Pt. remins full code. Spoke with son who called from . Will update family on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611894, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 40%, and Peep 5. Bs decreased and slightly coarse bilaterally. Sx'd for sm amounts of thick yellow secretions. O2 sats 97-100%. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611895, "text": "resp. care\npt. remains intubated/vented. no vent changes today.\nplan continue support. family meeting tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611896, "text": " ICU nursing progress note:\n Remains intubated and vented.no changes mad. Pt was turned with left side down to clean backside..noted decreased sat and hr..pt was cyanotic..placed on back..hr and sat slowly returned to baseline.\n BP running 50-60/..remains in af.\nTo have family meeting tomorrow at 1400 with ICU team,sons,husband,rabbi,ethics and social service.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611810, "text": "NPN\nNEURO: Pt. remains on IV sedation Versed 9mg/hr and Fentanyl 300mcg/hr. Pt. sedated and does not seem to be in pain.\n\nCV: Pt. remains off levophed gtt. ABP 80's-115/60-80. HR 80's-100's. Pt. remains with anasarca with weeping skin. No labs this AM.\n\nResp: Pt. intubated on vent with A/C 450x16 peep 10 and FIO2 50%. O2 sat 100%. LS coars. Pt. suctioned x2 this shift for moderate amount of thick yellow secretions.\n\nGI: Pt. remains on tube feeding at 35cc/hr. Residuals 10-20cc. Abd soft distended, BS hypoactive. No BM this shift. Mushroom cath in place.\n\nGU; Foley cath in place and draining clear yellow urine 10-15cc/hr. Fluid balance +13.8L LOS and 0.389L 24 hr.\n\nSocial: Pt. made DNR this PM. Will update family on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611811, "text": " 4icu npn 0700-1900\nAt present pt's husband wants to continue vent support and continue \"hydration\". Cont on TF\nNo labs drawn\nCont on fent and versed gtts. All other medications except tylenol d/c'd.\nOpens eyes when turned. otherwise no spont movement. extrem stiff.\nNo vent changes. Scant to small amts white to ligh yellow secretions.\nSBP >90's most of the day with transient drops to low of 76. Bp improves with stimulation\noliguric.\nHusband in to visit most of the shift\nA/P; No sig change in status.\nAppears comfortable on fentanyl & versed gtts.\nCont vent support and TF at present with comfort proirity.\nSupport to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 1611812, "text": "Respiratory Care:\nPt remains fully ventilated but occasionally adds 1 or 2 extra breaths. The respiratory Meds have all been D/C'd. Still significantly fluid overloaded. The meds that are continuing are for BP support.\nPlease see CareVue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-01 00:00:00.000", "description": "Report", "row_id": 1611832, "text": "S/MICU Nursing Progress Note\n Neuro: sedated on fentanyl and versed. not moving still at times biting on ETT unable to do mouth care.... drooling creamy like substance similar to tube feeding( though has not been fed for over 24hours)\n Respiratory: vented, no changes in settings 450/16/50/5. O2 sat 100% suctioning q3-4 hr for thick creamy tan/green sputum\n Cardiac: HR 80-110 afib BP had been 50-60's/ during most of day... after trying to do mouth care, BP up to 100/ and HR up to 115's received bolus of fentanyl 200mcg and 3mg of versed.... then able to do mouth care.\n GI no stool. no BS, abd still distended. aspirates remain high.\n Social: husband and two sons at bedside most of the day... aware of poor hemodynamic. are with DNR/DNI. to the family means still provide hydration/feeding(unable to fed due to high gastric residuals.)\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611833, "text": "Progress Note 7p-7a\nEvents: No change from previous shift.\n\nNeuro: Pt remains sedated with versed and fentanyl. Pupils equal and reactive.\n\nCVS: Pt remained A-Fib throughout shift with HR 80's to low 100's. SBP 60's to 80's. 4+ pitting edema noted. Weeping from extremities. Pulses difficult to palpate. T-Max 99-100.\n\nResp: Remains intubated. Vent settings unchanged at: 450/16/50/5. Coarse breath sounds bilat. Thick tan secretions from mouth. Thick yellow/green secretions from lungs.\n\nGI: OGT in place. Feedings remain on hold d/t absent BS. No BM last night.\n\nGU: Foley cath in place. Minimal urine output.\n\nSkin: decub. ulcer on covered with duoderm. R IJ dialysis cath. L ij TL central line.\n\nPlan: Pt. remains DNR/DNI. Pt.'s family did not agree to . They want nothing withdrawn. Pt. is an Orthodox Jew, therefore if possible the family would like her fed and hydrated as well. Pt. is not having any more blood draws (including blood sugar checks).\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611834, "text": "RESP CARE\nPt. remains intubated on AC mode with no changes made.\nBs: coarse bilat.'d thick yellow x2.\nPlan: DNR/I . to support as is.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611835, "text": "multisystem failure\nd: pt sedated on fentanyl gtt at 375 mcg/hr and versed gtt at 14 mg/hr. pupilsequally reactive to light but sluggish in response. no spontaneous movements to her extremities.\n\ncardiac: hr has been in the 90's without ectopy and sbp 50-60's pt is a dnr but because of the families' religious beliefs they do not want to withdraw care. both pt's husband and 2 sons were at the bedsdie this afternoon and were updated on pt's condition. no labs are being drawn.\n\nresp: pt orally intubated with vent settings of 50%/450/ac 16 with 5 peep and pt not overbreathing the vent. coarse bs bil on auscultation. suctioned orally for thick tan secretions and via ett for sm to mod amts of thick yellow sputum. will continue with present vent settings.\n\ngi: pt still not receiving tube fdgs b/cause of high residuals. abd remains distended with absent bowel sounds on asucultation.\n\ngu: foley cath in place with minimal up throughout the day- <30cc's this shift. pt with 4 + pitting edema and leaking serous fluid from upper extremities. pt not receiving maintenance ivf b/cause of her total body fluid overload and kidney failure. fluid balance pos 17.2 liters fpr los.\n\nid: max temp=99 and not on any antibiotics.\n\nintegumentary: pt turned form side to side throughout htis shift. pt on kinair air mattress. duoderm to decub at site and q 3 day drsg for tomorrow. pt with r ij quintan cath and l ij triple lumen in place.\n\nsocial: pt is dnr/dni but family would like pt to receive nutrition and iv hydration but aware that this is not being done at present time because of high residuals form tube fdg and total boly fluid overload. pt's son and his wife have returned to this afternoon but voiced that they would like to be called if his mother was passing. they were informed that we would place a call to them that they may not make it back to the hospital in time. will continue with present level of care and keep family well informed on pt's status. will offer emotional support to family .\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611726, "text": "MICU/SICU NURSING NOTE 7p-7a:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNEURO: PT remains sedated on Fentanyl/versed. Pt opens eyes to painful stimuli. non-purposeful movement of upper ext. NOt following commands. PT with decreased cough/gag.\n\nCV: PT weaned off Dopamine. BP 105-160/40-70. (Goal MAP > 60). HR 50-80 SB-SR no ectopy. afebrile. Repeat HCT 29.0 after 2 unit PRBC on dayshift for HCt 23.4. + 3 anasarca + pedal pulses bilat. L sub TLC WNL. WHIte port clotted off and tpa administered. Currently infusing without difficulty with good blood return. L rad A-line WNL + waveforem/+blood return. R IJ dialysis cath dsg c/d/i.\n\nPULM: Pt's vent weaned aggressively yesterday. Peep increased from 5 to 8 secondary to paO2 = 65. Pt currently on AC-20 50% TV 500 Peep 8 last abg 7.42/40/107/27. Sats 96-100% lungs reamin coarse t/o suctioning mod amount thick bloody/clots from ETT. MD aware. PT= 13.3 INR= 1.2 ptt= 32.4 Fibrinogen = 351.\n\nGI/GU: Abd soft, NT + BS X 4. no BM overnight. NGT placement confirmed via air bolus. TF increased this morning to 30 cc/hour (GOAL = 40 cc/hour). PT tolerating feedings, minimal residuals noted. Foley draining yellow/cloudy urine with sediment. UO decreased ~ 10-15 cc/hour overnight. Md aware. NO talks of restarting CVVHD. Last creat 1.7.\n\nENDOCRINE: Insulin gtt @ 2.5 units/hour. glucose stable, will cont to follow insulin protocol as ordered.\n\nSKIN: Sacral stage III decub with duoderm c/d/i. Groin/thigh rash red, no open areas noted, miconazole powder applied. R leg ulcer healing/OTA no drainage observed.\nPT bathed. Turned side-to-side as tolerated.\n\nPLAN: Wean vent as tolerated, ANtibiotics, Keep MAPS > 60, Cont TF advance as tolerated to goal rate 40cc/hour, cont to check BS q 2 hours titrate insulin as needed, wound care, monitor labs replete as needed. Will cont to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611727, "text": "Respiratory Care\nPt's 1100 and 1400 data recorded on careview after system became up and running. Paper flow sheet kept unti that time.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-18 00:00:00.000", "description": "Report", "row_id": 1611897, "text": "micu/sicu nsg note: 19:00-7:00\nevents: remains intubated and vented with no change in vent settings. appears comfortable on fent. and versed gtts. desats to the high 80s on fi02 40%, tidal volume 450, rr 16, peep 5 with audible cuff leak and ? hole in tubing of cuff. tegaderm noted to be on part of the tubing of the cuff- ? there was a hole with air leaking. air replaced into cuff by resp but pt continues with intermittent air leaks. continues to have moderate green thick secretions suctioned from her ett. sp02 up to 93% after air inserted into the cuff by resp.\n\nneuro: remains unresponsive with no grimacing noted. appears comfortable on 500mg/hr fentanyl and 15mg/hr versed. no movement noted.\n\ncv: hr ranging 90s-100s afib, bp 30s-60s/20s-40s. generalized anasarca. slight weeping from upper extremities.\n\nresp: remains on same vent settings- see events. 'd moderate amts green thick sputum. mouth care given.\n\ngi/gu: abd obese, remains npo, no bowel sounds. rectal tube remains in with lbm . no bm overnight. foley patent with minimal urine- only 5cc the whole shift of brown thick colored urine.\n\nskin: stage 2 5x4cm unchanged. area cleansed with soap and water. left ota as all dsgs do not stay on area. aloe vesta applied to site.\n\nsocial: has 2 sons and husband involved in care. pt's husband is \"not ready to let go\" per sw note. family meeting is planned for today with and ethics team involved.\n\nlines: l ij patent- dsg changed as the other dsg was peeling off. r ij dialysis catheter .\n\nplan: continue vent settings as ordered. maintain comfort for pt with fent and versed gtt. family meeting today to discuss pt's plan.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-18 00:00:00.000", "description": "Report", "row_id": 1611898, "text": "micu/sicu nsg note: 19:00-6:15am addendum\npt having runs of vtach progressing in length and having low minute ventilations with low tidal volumes with audible cuff leak despite air inserted. md aware. comfort maintained with 5cc fentanyl bolus given x2 when pt appeared to have a slight grimace. at 6:05am pt found pulseless and breathless with no obtainable 02 sat. md notified and pronounced pt at 6:15am. md notified pt's 2 sons and sons to notify pt's husband. rn remained and remains at bedside with pt. family to come in to see pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611728, "text": "MSICU NPN 0700-1900\n\nplease see flowsheet (careview and paper flowsheet) for further details....\n\n\nRemains on Fentanyl and Versed gtts. No changes made. Opens eyes to stimuli. Does not follow commands. Grimaces when mouth care attempted (will not open mouth). Sleeps when undisturbed.\n\nDopamine gtt at 2mcg/kg/hr. Weaned to 1mcg but MAP dropped to 50s and UO dropped (from ~35-20). Increased to 2mcg for most of day with no improvement in UO. Weaned off at 1730. HR 60-70s NSR. CVP 13.\n\nSame vent settings. PEEP decreased to 5cm from 8cm but PaO2 dropped to 66 and PEEP inc to 8cm. Suctioned q 2h-3hrs for tenacious bloody sputum. Sputum appears more brown this afternoon. Min spont RR.\n\nAfebrile.\n\n dsd dry and . Skin RN to come back tomorrow. Plan to change dsd then. Supplies ordered. Mouth w/multiple sores. Frequent lip care given including area above ETT. Scabs beginning to fall off.\n\nCreat up to 1.9. Renal team in. CRRT remains on hold for now.\n\nHusband in. Spoke with Dr. and Social Worker.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1611729, "text": "Resp Care\nPt. remains intubated/sedated overnight with no vent changes or abgs.\nBs: coarse bilat. with scattered exp. wheezes. Sxn'd for copious amts. of thick blood q4.\nPlan:continue current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611785, "text": "NPN\n\nNeuro: Conts on 300mcg/hr of fent and 10 mg/hr of versed, she is less sedated than Sun when I last took care of her on Sunday. She opens her eyes with turning, suctioning, moving the ETT, she requires ~ 10 mg of versed and sometimes 150-300 mcg of fent to resedate her. She does not move any of her extremities, her body conts to be very stiff.\n\nCV: She conts of levo at .03 mcg/kg/min, her BP droped to the 90s-100s this morning after the CVVHDF clotted off - this has not been restarted do to her lower BP. Given K this morning for a K of 3.6.\n\nResp: Remains on A/C 450x18/ .5/10 PEEP with an 7.45/37/66, sx for min amount of yellow/tan colored sputum, LS diminished, conts to bleed from her mouth/lips.\n\nGI: ABD remains firm and distended, she was given lactulose, no stool out today, conts on TF at her goal rate of 35cc/hr.\n\nGU: Her CVVHDF clotted off this morning, her BP has since been 90s-100s and she has not been restarted, the team would like to try a lasix gtt before putting her back on CVVHD. Her u/o has increased since the CVVHD stopped but she conts to be positive by.\n\nEndo: She is back on an insulin gtt to maintain a blood sugar of 80-120 - she conts to receive lantus in the evening.\n\nHeme: HCT was 27 this morning - she is receiving a unit of PRBC.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611786, "text": "Patient transfered from to today.Transfused due to low Hct.Hypokalemia treated,ABG shown hypoxemia with acceptable PH and paco2.BP fluctuated during CVVHD. Mild temp,BS coarse,treated with Albuterol/Atrovent with vent check.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611787, "text": "NPN Addendum\n\nPt vomited tube feeding like material, her TF are no on hold, ABD remains firm and distended, she does not have any residuals from her pedi tube, I can oscultate her fedding tube in her ABD, I did not suction out TF from her ETT. She was given half of her lantus dose (17 units), she conts on an insulin gtt. The lasix gtt remains on hold until her BP increases.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-20 00:00:00.000", "description": "Report", "row_id": 1611788, "text": "Neuro: Pt. intubated and sadeted with Fentanyl 300mcg/hr and Versed 10mg/hr. Pt. aroused to painful stimuli.\n\nResp: Pt. intubated on vent A/C 450x18 with 50% FiO2 and 10 of PEEP. LS coarse, requiering to be suctioned x2 for thick tan secretions.\n\nCardiovascular: Pt.on Levophed 0.03mcg/kg/min for low BP. ABP 120-140/70's and Levophed gtt off. ABP down to 90's systolic when off the gtt. Levophed gtt restarted at 0.015 mcg/kg/min and BP remain stableat SBP 130-140's. Pt. also started on Lasix gtt at 5mg/hr. H/H 10.2/30.3 after transfusion. Pt. cont with anasarca, skin weaping. electrolytes WNL as per careview.\n\nGU: Pt. with foley cath in place and draining clear yellow urine, small amount of sediment noted. Urine output 30-100cc/hr after lasix gtt initiated. BUN 52, creat 1.5 this AM.\n\nGI: Abd distended and firm. BS hypoactive and TF on hold after Pt. vomited. Lactulose given to promote BM. Mashroom cath in place. Pt. was incontinent of large amount of liquid stool this AM. Tube feeding on hold. Abd. remains firm, BS positive. Mashroom cath remains in place.\n\nSkin: Pt. with large decube ulcer to . wound cleansed and new duoderm applied.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611883, "text": "MICU/SICU NPN\nPt remains sedated with fentanyl & midazolam, unresponsive to all stimuli. Remains intubated on AC 16x450x0.50/+5, please see flowsheet for assessment data. Plan to continue comfort focus of care without initiating new therapies, DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611884, "text": "ADDENDUM NPN:\nPT IS STILL SAME CONDITION, SEDATED NOT RESPONDING, ON SAME MECHANICAL VENTILATOR SETTING, SUCTIONED WITH MODERATE THICK YELLOWISH SECRETIONS. B.P 50-55/15-16, T 32.5 AX. ANURIC, DR. INFORMED, SUGGESTED NOTHING TO BE DONE.\nPLAN: CONTINUE SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611885, "text": "Respiratory Care\nPt remains on current vent settings, suctioning moderate amounts of thick green/yellow secreations. No spontaneous inspiratory efforts noted.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611886, "text": "Resp Care Note:\n\nPt intub with OETT and on vent as per Carevue. Lung sounds coarse rhonchi improve somewhat with suct sm=>mod th yellow sput. Pt in NARD on current settings; no vent changes required overnoc. vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611887, "text": "NPN 0700-1500\nPt remains sedated on fentanyl 500mcg/hr and midazolam 15mg/hr. Pupils unreactive bilaterally and is unresponsive to all stimuli. Remains intubated on CMV at 17x 450-560x.40x5, SPo2 89-93. Lungs course bilaterally. HR 93-105, AFib, no ectopy, MAPs 27-35. Bowel sounds absent. Rabbi in to speak with Attending, patient's husband and nursing staff regarding current treatment status and will be in Thursday, 25th to speak with team and patient's husband again. Please page him then. Continue comfort care, DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-15 00:00:00.000", "description": "Report", "row_id": 1611888, "text": "Respiratory Care\nPt remains on current vent settings as per carevue. Suction for moderate amounts of thick green/yellow secreations. No chnages made in current settings.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611889, "text": "Smicu nsg progress note\nS/O- to be unresponsive on fent/versed gtts. Bp marginal 40-60s with no urine output. on vent. No changes made. Suctioned for copious amts thick yellow foul smelling secretions.\nA- Unchanged\nP- . Family Support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611723, "text": "NPN\n\nNeuro: Remains on fent and versed, her fent was increased to 50 mcg/hr from 25 because she was easily arrousible and often coughing and fighting with the vent. SHe appears to be more comfortable with the increased sedation.\n\nCV: Hypotensive to the 60s this morning, CVP was 8, she was given 1000cc NS which brought her SBP up to the 70s, CVP to 10. She was started on levophed and has needed a max of .05 and is now .02 mcg.kg.min, we are still unable to wean her off of this even after 2 units of PRBC - she dropped her BP to 90/40s and a MAP in the low 50s. Her Sputum has MRSA in it, to continue on vanco and aztreonam.\n\nResp: Remains on A/C 500x20/.5, able to wean the PEEP down to 8 with an ABG of 7.42/38/100, to go down to 5 of PEEP. She has MRSA in her sputum, she conts to have bloody secreationes from her ETT and from her mouth, she conts on vanco and aztreonam.\n\nGI: ABD is now soft, tolerating her TF, had a formed BM today.\n\nGU: Her U/O is low 5-13cc/hr, there are no plans to restart to the CVVHDF due to her sepsis - this will be readdressed in the furture.\n\nEndo: Able to keep her BS under fairly good control with the insulin gtt\n\nSoc: Her husband was in for most of the day, told that she was not doing well, he spoke with his sons and the attending about the choices of care, her husband and sons want to talk with their rabbi.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611724, "text": "Addendum\n\nLevo changed to dopa due to bradycardia - she now has a HR in the 60s\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1611725, "text": "Respiratory Care\nPt. remains intubated/sedated on ventilator. PEEP was weaned aggressively yesterday, resulting in moderate hypoxia via abg. PEEP increased back to 8CMh20.\nBs: coarse bilat with scattered rhonchi, and diffuse exp. wheezes. Sxn'd q3-4 for mod-copious thick bloody clots.\nPlan: continue current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611782, "text": " 4 ICU NPN 0700-1900\nWeaned to 50% X 400 X 24, PEEP 15. ABG 7.47/35/75/26/1. BS coarse. Small amts thick, yellow secretions.\nBP/MAP maintained on levophed 0.031.HR 70-8's AF. No VEA noted.\nCont on CVVH. Negative fld balance 1.5L since MN. Goal 100 cc(-) hr. Prisma filter clotted. System changed. treatment resumed.\nFent 300 mcg hr & versed 10 mg hr. Occas opens eyes when she is turned in bed with transient htpertension. Settles out when left alone.\nUO 0-10 cc hr. BUN 51, creat 1.0\nAfeb. Cont on meropenum & flagyl. Fluconazole d/c'd.\nTf at goal. Mod amt brown diarrhea. Abd firm with good BS.\nDuoderm on sacral skin break down\nReceived glargine 35u at 1800\n husband in to visit throughout the day. He was updated on pt's condition. Husband also spoke with dr. & Social worker . Sons & also phoned & were updated\nPt remains CPR not indicated\n\nA/P: Stable on above vent settings. Cont CVVH for fld removal. Wean as tol. ? trach if PEEP can be weaned.\nTOL CVVH with good effect on small amt levo. Cont to remove fld with goal 100 cc negative Q hr. Decrease hrly negative goal if MAP falls <60. (Do not increase levo to maintain hrly neg balance)\nApears adequately sedated on fent & versed.\nSupport to family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611890, "text": "Resp Care Note:\n\nPt intub with OETT and on vent as per Carevue. Lung sounds coarse rhonchi improve somewhat with suct for sm=>mod th yellow sput. Pt in NARD on present vent settings; no vent changes made overnoc. vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611891, "text": "MICU NPN\nNO CHANGES IN PT'S CONDITION, NO VENT CHANGES, HUSBAND AT BEDSIDE THIS AFTERNOON, FAMILY MEETING PLANNED FOR THIS COMING FRIDAY WITH HUSBAND AND CHILDREN AND RABBI AND TEAM TO DISCUSS A DECISION THAT NEEDS TO MADE RE: CARE FOR PT. FENT/VERSED GTTS. UNCHANGED.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-16 00:00:00.000", "description": "Report", "row_id": 1611892, "text": "resp care\nremains intub/full vent support in ac mode,.no changes made today. cuff appears to be sealed adequately. scant to small dk yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-17 00:00:00.000", "description": "Report", "row_id": 1611893, "text": "Smicu nsg progress note\nS/O- essentually unresponsive on fent/versed gtt. Marginal bp with no uo. No changes made in ventilation.\nA- No change\nP- . Family meeting for friday.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611693, "text": "Micu Nursing Progress Notes\nEvents: Sent for CTA scan of chest and abd, continuing to suction blood from ETT, disimpacted for a large amount of very hard stool.\n\nResp: Vent settings unchanged, PCV driving pressure 25, Peep 10, FIO2 50%. Suctioning large amounts of very thick bloody secretions that require lavage to remove. Pt went for CTA of chest and abd. Results pending.\n\nCardiac: B/P 130-140/50's, HR 60's, When she had any ADL's or suctioning her B/P increases to 160-170/'s. Procainamide stopped at 1700 as ordered.\n\nGI: She remains NPO due to a distended firm abd. A dulcolax supp was given at 11 am with no results by 1600. She placing the supp it was felt that the rectal vault was filled with hard stool. So when no results were obtained from the supp, she was dis-impacted for a very large amount of hard stool. She did have some bleeding following the dis-impaction.\n\nEndo: Insulin gtt at 0.5u/hr with blood sugars 148-147. However at 1100 her BS increased to 161 so the insulin gtt was increased to 1u/hr and her BS hav e dropped to 114-127.\n\nGU: Her foley was drainiing clear yellow urine. U/O 30-50cc/hr. No leakage seen from her foley.\n\nNeuro: Fentanyl maintained at 100mcg/hr and the versed was 4mg/hr. She did require several boluses of versed 1mg, to help with routine care. Her BP would increase to 160-170/ and then fall following the boluses back to 130-140/.\n\nSkin: Sacral decub cleaned and deodurm. Decub is through dermis layer, clean and without digns of infection.\n\nSocial: Her husband in to visit most of the day and both of her sons called to inquire. Husband asked many questions and they were answered was well as possible.\n\nPlan: suciton PRN, monitor resp status, monitor cardiac status for possiblilty of arrhythmias, support husband and family\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611694, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient continues on PCV with Pinsp. 35 Peep 10, RR: 26 with I:E 1:1.9. Breathsounds are coarse. Suctioned multiple times for bloody secretions and one bloody plug. Albuterol/atrovent given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611783, "text": "Remains on CVVHD,vent changed order so Ric can PM it.Poor prognosis,hypoxemic,sensitive to FI02 changes.BS coarse withR>L,on MDI Albuterol/Atrovent.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-19 00:00:00.000", "description": "Report", "row_id": 1611784, "text": "Smicu nsg progress note\nNeuro- Remains sedated on 300mcg fent and 10mg midaz. Does open eyes and grimise with turning/suctioning but easily settles. Not requiring additional boluses. No spontaneous movement of extremities noted.\nResp- Intub/sedated initially on ac 450x24 50% 15peep. Resp rate decreased to 22 and then 20. Cont with good abg's 121/36/7.48. Ventilation and oxygenation appear to be improving with fluid removal. ?decrease peep to 10 as pt will need decrease peep before ?trach.\nCardiac/fluids- Pt cont on chhv initially able to maintain goal of 100cc neg/hr with stable bp/hr on .03 mcg levo. Pt 2000cc neg at 12m. Then becoming more tacycardiac with hr 110-120af Bp down to 88-94s. Removal rate initially decreased to keep pt even and then decreased to removal rate of 0 (see flow sheet). Bp and hr improving. Cont on levo at .03 mcg.\nGi- Cont on goal tube feeds. Bs/fs more elevated today. ? need to add ss insulin.\nId- Remains afebrile on current antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611870, "text": "Resp: Pt remains intubated and vented on a/c 16/450/+5/50%. Bs are coarse bilaterally. Suctioning for moderate amounts of thick yellow/greenish secretions. Slight leak noted, but maintaining adequate Vt's. Pt remains unresponsive. No vent changes noc. No abg's. Pt is dnr.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611871, "text": "Respiratory Care\nPt remains on same A/c settings without change, continues to have balloon leak, suctioning thick green secrections from et tube.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611872, "text": "S/MICU Nursing Progress NOte\n Pt remains the same, no changes in the vent. on fentanyl 400mcg/hr and versed at 14mg/hr. husband and son at bedside during the afternoon. with comfort care\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611873, "text": "PT WITHOUT CHANGE. NO CHANGE IN VENT SETTINGS.PT ON FENTANYL 400MG/HR & VERSED 14MG/HR. SHE REMAINS ON .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611874, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nUnable to measure RSBI due to lack of spontaneous respiration.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-12 00:00:00.000", "description": "Report", "row_id": 1611875, "text": "S/MICU Nursing Progress Note\n Pt remains unchanged on the same vent settings 450/16/.50/5 suctioning q3-4hr for thick yellow sputum. BS remain coarse throughout. remains no urine output. +++ pitting edema, oozing from arms. saturating the pads. Fentanyl increased to 500mcg/hr and versed increased to 15mg/hr as pt out of phase with the vent... comfort care remains a priority. Son in contact via phone.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611876, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no changes made to any parameters throughout the night. SX'd for moderate amounts of green, thick sputum.\n\nNo RSBI determined due to lack of spontaneous respiration.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611877, "text": "NPN 7P-7A:\n\nPT WITHOUT CHANGE NOTED. NO CHANGE IN VENT SETTINGS. SHE ON FENT/VERSED.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-12 00:00:00.000", "description": "Report", "row_id": 1611758, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains vented with settings of A/C 500cc/20/. suctioning q2-3 for thick tan sputum BS cont to be insp/expir wheezes throughout all fields. BS diminished on the right. cont to maintain O2 sat 98-100%.\n Cardiac: HR 90-100's afib, rare PVC's cont on levo, titrated to keep SBP>90/ range tonight has been 0.808mcg/kg/min to 0.55. presently on 0.55mcg/kg/min. given lasix 40mg x2 with only sm response. pt is presently 17 liters LOS +, very edematous .... weeping from the arms.\n ID: presently on vanco(day 7) aztreonam (day 10) po flaygl(day 2) pt has MSRA in sputum, c-diff+, yeast in urine(did receive po fluconzole), rash in groin area improved. less reddened. still with ulcers/lesions on lips and inner lip region. new culture to be sent this am.\n SKin: still with a number of eccymotic ares, though nothing new... still eccymotic around right shoulder,chin,near dialysis line, under right breast, right calf, and right lower abd. duoderm over the sacral area due to be changed in three days..(22)\n GI: cont on TF of nepro with promod at 35cc/hr. at goal rate. mushroom catheter in place. sm amt of output. abd soft. BS+ Pt had received 2 units of RBC overnight and post transfusion hct was 34.\n GU: foley in place and draining. urine yellow, less sedimented from prevous. BUN 89 with creat 1.9\n Social: no contact tonight.\n : goal to get fluid off pt .... will not be able to wean given her BS ... really wheezy. monitor I&O's closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-12 00:00:00.000", "description": "Report", "row_id": 1611759, "text": "progress note:\nNeuro: remains sedated on fent 75 mcg and midaz 2 mg with PERL sluggish. pt alert to noxious stim during mouth care but doesn\"t follow commsnds.\n\ncard: afib rate 70-80's, sys bp >100 on .08 mcg/kg /min levophed. decreased levo at 1500 and sys in 90-100 range.\n\nresp: current vent settings CMV at 8 peep rate 20 02=50% with set tv 500 and actula 370. no changes made in vent. course bs with exp wheezes throughout. CXR this am indicates inc in fluid and will start CVVH this evening. per team suggestion pt needs freq lavage and suction to mobilize secretions. thick tan green speciman sent for cult.\n\nrenal: will start cvvh this eve. solutions ordered and requested from pharmacy. hope to remaove fluid and decision made with son and husband to cont to offer all support available to pt.\n\ngi: approx 25 cc in fecal bag and no inc in output noted. gave lactulose at 0800. pos bs and cont tf at 35 cc/hr\n\nendo: swithched pt to SSI and eve dose glargine. last glu 199 at 1230 and covered.\n\nID: afebrile with fluconozole added to regimen. herpes cult of mouth lesion sent.\n\nplan: start cvvh and remove fluid as tolerated, per family meeting, will head toward peg and trach asap, cont to wean levo if poss\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611878, "text": "NPN 7P-7A:\n\nPT WITHOUT CHANGE NOTED. VENT SETTINGS UNCHANGED. SX FOR THICK YELLOW SPUTUM ON LARGE AMOUNTS. FENTANYL 500MCG/HR & VERSED 15MG/HR.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611879, "text": "S/MICU Nursing Progress Note\n condition remains unchanged... on the vent with setting of A/C 450/16/.50/5 suctioned q3-4 hr for thick yellow sputum. afebrile. no urine output. remains anasarca grossly weeping from arms. frequently changing pads under arms. Husband and in to visit. Continue with DNR.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-13 00:00:00.000", "description": "Report", "row_id": 1611880, "text": "Respiratory Care\nPt remains on a/c vent without changes, suctioning thick green secrections from airway, stopcock at pilot holding vol.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611881, "text": "Respiratory care:\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. No morning abg results and no RSBI determined at this time due to lack of spontaneous respirations.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-14 00:00:00.000", "description": "Report", "row_id": 1611882, "text": "pt.is unchanged. unresponsive and sedated on fentanyl and versed gtts.\nNo vent changes. sbp in the 50's most all night. remains in afib in the 80's.Frequently suctioned for thick copious yellow sputum.\nSkin continues to weep/ full body edema noted.\nno uop or stool.\ndnr/ status\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611745, "text": "MICU/SICU NPN ICU Day #14\nNo events\nFull code\n\nS/O:\n\n\nNeuro: pt remains sedated with fentanyl/midazolam, no independent movement of extremities noted, pupils fixed and non-reactive\n\nPulm: pt remains intubated on AC 20/500x0.5/+8, SpO2 96-100%, LS coarse, occasional I/E wheezes on left, dim at bases, Vt 430-507, Ve 8.8-9.9. PIP 37-41, RR 20-24\n\nCV: HR 82-105 AF/Aflutter, BP 96-132/38-60 on Levophed, CVP 14-15, please see flowsheet for data\n\nInteg: total body anasacra particularly n extremities, sacral decub healing, Aquacel dsg changed today next due on tuesday, right lower leg venous stasis ulcer has nearly healed, pt has multiple areas of eccymosis over abdomen and thorax\n\nGI/GU: abd is firm and distended, BS are present, pt is tolerating Nepro with Promod at goal rate of 35cc/h, pt was incontinent of large amts OB neg loose brown stool, a mushroom catheter is in place and draining small amts loose stool, Foley in place and patent for small amts clear yellow urine\n\nLines: left SC TLCL day #10, left radial art line day #14, right IJ Quentin cath day #8\n\nFEN: remains on insulin gtt at 1.5U/h and FSBS have been 124-164\n\nA:\n\naltered breathing r/t volume overload\nhigh risk for infection r/t invasive lines, ETT indwelling catheter\nhigh risk for injury, cerebro/cardiovascular r/t hypotension and pressor requirement\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contniue to wean respiratory support as tolerated, contniue to wean hemodynamic support as tolerated, consider gentle diuresis while on pressors, resume HD when appropriate, attempt to schedule family meeting with sons and husband at earliest conveneince\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1611746, "text": "NURSING NOTE 7P-7A:\n\nSEE CAREVUE FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS SEDATED ON FENTANYL/VERSED. PUPILS PINPOINT/NONREACTIVE BILAT. PT OPENS EYES TO PAINFUL STIMULI. DECREASED COUGH/GAG + CORNEALS. NO PURPOSEFUL MOVEMENT.\n\nCV: PT TMAX 98.9 (AX). HR 80-100 AFIB/FLUTTER. PT RESTARTED ON LEVOPHED GTT @ 0.06 MCG/KG/MIN TO KEEP MAPS> 60. CVP 9-20. +4 ANASARCA + PULSES.\n\nPULM: PT REMAINS INTUBATED ON AC-20 50% TV 500 PEEP 8. SATS 97-100%. ABG THIS AM 7.33/46/113/25. PIP 30-40 MINUTE VENT= 8.5-9.3 LUNGS COARSE T/O DECREASED @ BASES. SMALL AMOUNT THICK/TAN BLOOD TINGED SECRETIONS SUCTIONED FROM ETT.\n\nGI/GU: ABD LARGE/FIRM + BS X 4. TUBE FEEDS @ 35CC/HOUR (GOAL) INFUSING WITHOUT DIFFICULTY VIA ORAL PEDITUBE. PLACEMENT CONFIRMED WITH AIR BOLUS. NO RESIDUALS NOTED. FOLEY DRAINING AMBER/CLEAR URINE\n~25-35 CC/HOUR. LAST CREAT 1.9 MUSHROOM CATHETER IN PLACE NO STOOL OVERNIGHT.\n\nENDOCRINE: PT REMAINS ON INSULIN GTT @ 1.5 UNIT/HOUR. CONT TO CHECK FINGERSTICKS Q 2 HOURS AND ADJUST GTT PER PROTOCOL.\n\nPLAN: WEAN VENT AS TOLERATED, FOLLOW LABS REPLETE AS NEEDED, ANTIBIOTICS, WOUND CARE, LEVOPHED TO MAINTAIN MAPS > 60, INSULIN GTT PROTOCOL, CONT SEDATION, CONT WITH CURRENT , CONT TO MONITOR.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611690, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 114/48-165/70. SB/SR WITH H/R RANGING FROM 55-71 WITH OCC BLOCKS TO THE 40'S WHEN PT COUGHS AND MIN VOL DECREASES. PPP BIL. PT HAS 3+ EDEMA IN HANDS AND FEET. ON PROCANIMIDE AT 2MG/MIN X24 HOURS, (UNTIL 1700). QTC WAS 368 BY EKG. CVP 19-24 WITH 10 OF PEEP. PT 1 UNIT OF PRBC FOR HCT 28.3. ( 2 UNITS ON PREVIOUS SHIFT FOR HCT OF 23.8 FOR TOTAL OF 3 UNITS).\n\nRESP: ON PCV WITH50% FIO2, RR 26,PEEP 10, INS PRESSURE 35TV 400-460 RANGE. LUNGS COARSE THROUGHOUT WITH SX SEVERAL X FOR MOD AMT OF OLD BLOODY SECRETIONS. AT BEGINING OF SHIFT SX RED SECRETIONS.\n\nNEURO: SEDATED ON VERSED 4MG AND FENTANYL 100MIC/HR. DOES WITHDRAW WHEN TURNED AND GRIMMACES TO PAIN. OPENED EYES ONCE WHEN BEING TURNED. PUPILS EQUAL BUT SLUGGISH. DOES NOT FOLLOW COMMANDS AND NO PURPOSEFUL MOVEMENTS.\n\nENDO: PT HAD BEEN ON INSULIN GTT YESTERDAY AT 0.5UNITS HOUR HAS NOT BEEN RESTARTED BUT WILL BE IF FSBS INCREASES TO > 150.\n\nSKIN: DECUBIDUS ULCER NO COCCYX WITH DUODERM INTACT. PT IS ON CONTACT PRECAUTIONS FOR POSSIBLE MRSA IN WOUND.\n\nGU/GI: FOLEY CATH PATENT. FOLEY DID LEAK A LG AMT OF URINE. ON FOLEY SLIPPED OUT ENTIRELY AND A LARGER FOLEY WAS INSERTED. U/O MINIMAL UNTIL SHE ETHNACRYNIC ACID 100MG AND UNABLE TO MEASURE AS THE URINE LEAKED FOR AN HOUR. URINE LYTES WERE SENT YESTERDAY TO R/O POSSIBLE ATN. ABD FIRMLY DISTENDED WITH ABSENT BS. NGT PLACEMENT VERIFIED. YESTERDAY PT HAD OLD COFFEE GROUND DRAINAGE.\n\nPLAN: CONT TO DIURESE PT FOLLOW CVP. WEAN PT FROM VENT AS APPROPRIATE. MONITOR SECRETIONS TO ENSURE NO FURTHER BLEEDING. STOP PROCANIMIDE AT 1700. PROVIDE UPDATES FOR FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611691, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick bld tinged secretions. MDI'S given. HR occ SB. Sedated with fentanyl and versed.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 1611692, "text": "RESPIRATORY CARE: PT W/ A 7.0 ORAL ETT IN PLACE.\nREMAINS ON PCV AS PER CV. VT ABOUT 400 CC W/ A\nDP OF 25 CM H2O. CT SCAN OF CHEST/ABDOMEN TODAY\nW/OUT INCIDENT. SX FOR BLOOD-TINGED SPUTUM.\nALBUTEROL/ATROVENT MDI'S GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611824, "text": "NPN\nNeuro: Pt. . on IV sedation with Versed 14mg/hr and Fentanyl 350mcg/hr. Pt. remains comfortable did not require extra boluses this shift.\n\nCV: NBP 60-80 systolic with HR 70-90 in A-fib. Pt. afebrale this shift.\n\nResp: LS coarse. Pt. suctioned x2 this shift for moderatr amount of thick tan sputum. Pt. remains intubated on vent A/C 450x16 peep of 5 and FiO2 of 50.\n\nGI: Pt. restarted on tube feedings after gastric contents residual 40cc at 2200. Tube feedings at 10cc/hr. Unable to increase rate due to residual of 90cc 4 hr after tube feedings restarted. Will check residual later this shift and increase rate if Pt. tolerates. Abd. distended and soft, BS hypoactive.\n\nGU: Pt. with no urine output since about midnight today. Pt. has general anasarca and skin weeping.\n\nSocial: Pt. is a DNR/DNI. Will keep family informed on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611825, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 98%; bs coarse, thick tan secretions, will full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611826, "text": "S/MICU NURSING PROGRESS NOTE\n Neuro: on sedation of fentanyl 350mcg/hr and versed 14mg/hr. no grimacing with turning at times will still bite down on ETT/NGt unable to do mouth care. requiring a bolus of meds to get suction in the mouth.\n Respiratory: vent without any changes... A/C 450/16/0.5/5 O2 sat of 98-100% suctioning for thick creamy sputum(very much like TF coloring) BS coarse throughout.\n GI: was on Deliver with promod at 10cc/hr found to have drooling out mouth...same as TF, residuals 60cc. stopped TF at 9am recheck still 50cc remain off. BS hypoactive no stool\n GU: foley in place and no urine output.\n Social: husband and son in today and updated by Dr. .\n Plan: Continued with support. focusing on comfort... family and rabbi believe, feeding, antibx are part of comfort care.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611827, "text": "Resp Care\n\nPt remains intubated and on full vent support. BS coarse and suctioning thick tan sputum. Spo2 in the high 90's\n" }, { "category": "Nursing/other", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 1611828, "text": "MICU NPN:\nNEURO: Sedated on 350mcg/hr of fentanyl and 14mg/hr of versed. Appears comfortable but biting down on tube. No spontaneous movement noted.\nCV: Tmax 100.0 axillary. HR 70s-100s AF, with occasional pacs. SBP 50s-70s. Pt. with anasarca.\nRESP: No vent changes made- continues on ACV 450x16 +5peep and 50% O2 with O2 Sat >95%. LS coarse throughout. Sx'd for moderate amts of thick tan secretions via ETT and mouth.\nGI/GU: Abd. distended with hypoactive bowel sounds. TF restarted but shut off again for high residuals. No BM. Foley with small amts of amber yellow urine.\nSKIN: Duoderm to . Repositioned side to side and on air mattress.\nOTHER: Husband into visit this evening. Son , from , due in tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611707, "text": "MICU/SICU NPN ICU Day #7\nEvents: started on furosemide gtt yesterday, remains oliguric\n\nS/O:\n\nNeuro: remains sedated with fentanyl/midazolam, eyes open to painful stimulation, no independent movement of extremities, pupils pinpoint\n\nPulm: remains intubated on PCV 38+18/0.4/24, last ABG 7.36/31/87, SpO2 98-100%, LS coarse, Ve 10.5-12.1, Vt 405-530, PIP 40\n\nCV: HR 59-77 SR with occasional PVC's and rare PAC's, BP 83-143/35-57, PA 43-74/25-37, PCWP 21-24 (corrects to for PEEP), CVP 14-25 (corrects to for PEEP), CI 3.40-4.17, please see flowsheet for data\n\nInteg: global anasarca particularly in extremities, pt has a healing venous stasis ulcer on right lower leg, 1cm x 1cm, pt has Duoderm over sacral decub due for change today, pt has a rash between thighs, in groin and in flod beneath abd pannus\n\nGI/GU: abd is obese, firm and distended, BS are present, pt tolerating Nepro at goal rate of 35cc/h via NGT in left nare, FOley in place draining scant amts clear yellow urine dispite furosemide gtt, furosemide on hold for now\n\nAccess: left SC intorducer with PAC day #3, left radial art line day #3\n\nFEN: pt remains hyperkalemic, hyperphosphatemic, creatinine continues to rise, daily weight 105 kg\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT, indwelling catheter\naltered breathing r/t acute inflammatory process vs. acure on chronic cardiac process\nimpaired skin integrity r/t chronic altered nutrition, chronic immobility\nhigh risk for injury, cardiopulmonary r/t acute on chronic pulmonary HTN\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contninue to wean resp supports as tolerated, contnieu skin/wound care as reccomended, consider HD vs CVVHDF as pt not responding to diuresis\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611708, "text": "RESP CARE NOTE\n\nPT REMAINS ON PCV 38/18 0N 40%, RR 24. THERE IS AN INCREase IN THE AMT OF SECRETIONS SINCE WEDNESDAY. There has been an improvement in lung dynamics and oxygenation however. Last ABG 7.36, 31,87 showing continued metabolic acidosis with significant respiratory compensation. Pt appears to have peripheral edema but also is still hypotensive at times. CVVH is being considered\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611709, "text": "MICU NURSING NOTE 10:30-1900:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNeuro: PT remains sedated on Fentanyl/Versed. PT opens eyes to painful stimuli. PUpils pinpoint bilat. MD aware. NO spontaneous movement of extremities. Decreased cough/gag.\n\nCV: PT hypotensive this am, Fentanyl gtt decreased and pt received 1 unit PRBCs for HCt 26.9. PT BP responded. BP currently 105-140/40-60. HR 50-80 SR with rare PACs and PVCs. Afebrile. + 4 anasarca + pulses. L subclavian Swanganz catheter d/c this afternoon and triple lumen placed over guide wire. Pt oozing blood from site. MD aware. INR 1.3 and plts = 109. Pt to receive vit K 5 mg sq when returns to floor. CVP 16-20.\n\nPULM: PT switched from PCV to Volume control ventilation and Peep weaned. Current vent settings rate 24 FIO2 40% TV 450 Peep 14 Pt tolerating vent changes Last ABG on current settings was 7.36/31/87/18/96 sats 96-100%. Minute volumes 8.5-10.0. PIP=30-40. SUctioning mod amount of thick bloody secretions. MD aware.\n\nGi/GU: PT remains oliguric. Foley draining 5-15 cc urine/hour. LAsix gtt off since @ 0100. Renal saw patient today and CVVHD to be started this evening. Pt currently in IR for dialysis catheter placement. Creat 2.3, K= 4.9 Abd large, firm distended + BS X 4 quad. PT has not stooled since . Lactulose dose given this am, will repeat as ordered until pt stools. pt also receiving reglan to promote BM. NGT placement confirmed by air bolus Pt tolerating Nepro @35cc/hour (goal). Minimal residuals noted.\n\nSKin: R leg with healing ulcer OTA no drainage noted. Sacral decub Stage III. Wound base yellow small serosang drainage. Duoderm dsg changed today. Cont to turn pt side to side as tolerated. Groin, bilat thighs with yeast/rash, Mitrazol powder applied.\n\nEndocrine: Pt remains on Insulin gtt @ 4 units/ hour. WIll titrate gtt per insulin gtt protocol. BS Q1 hour.\n\nSocial: Family visited and updated on pt status and POC by attending physician. given emotional support.\n\nPLAN: Wean vent as tolerated, Wound care, start CVVHD this evening, INsulin gtt per protocol, cont sedation, monitor labs replete as needed. Will cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611710, "text": "Respiratory Care\nPt weaned today changed mode to A/C 450/22/peep14/40% last abg\n734/34/96/19/-6 pt bld. Pt traveled to IR without incident for cath placement will start cvvhd tonight. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-30 00:00:00.000", "description": "Report", "row_id": 1611711, "text": "NURSING NOTE ADDENDUM:\n\nPT HAD DIALYSIS CATHETER PLACED R IJ SITE WNL. WILL BEGIN CVVHD THIS PM. L SUBCLAVIAN TRIPLE LUMEN SITE CONTINUED TO OOZE BLOOD, SUTURE PLACED BY MD WITH GOOD RESULTS. PT LAST ABG 7.30/40/69/- ON VOLUME CONTROLLED VENT RR= 22 TV 450 FIO2 40% PEEP= 14. VENT CHANGES MADE BY RT, RR INCREASED TO 25, TV INC TO 500 AND FIO2 INCREASED TO 50%. WILL SEND REPEAT ABG @ 1900.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611712, "text": "S/MICU Nursing Progress Note\n Events: weaned sedation on days, dialysis catheter placed in RIJ, multilumen catheter in the left subclavian, CVVHDF started at tonight.\n Neuro: on sedation of fentanyl at 50mcg/hr and versed at 1mg/hr, will open eyes to pain, grimaces with turning and movement. extermites extremely edematous. difficult for spontaneous movement. +gag,+cough.\n Respiratory: cont to suction thick bloody sputum. occasional plugs. BS coarse throughout. able to wean the vent down to a rate of 23. Current settings are A/C 500x 23, spontaneous RR of 4 over the vent. FIO2 50% PEEP of 14cm. repeat ABG pnd.\n Renal: CVVHDF started at last night. slowly increasing PFR up to goal of -100cc. intially tolerating then dropping her SBP to lowest of 80/ decreased flow rate. BP back up to SBP>100. will slowly increase rate. goal is to be -100cc/hr. Did have difficult with access pressures. able to flush catheter and only draw back 3cc with resistance, better flow from venous side. reversed ports. warming blanket placed on the pt. temp now 97-98ax.\n Cardaic: Hr 60-70's NSR , no VEA, BP mostly 90-120/60's as noted above. off pronestyl. hourly intake 50cc/hr.\n GI: TF infusing at 35cc/hr. tolerating well. residuals only 20cc, have not advance rate as needed to turn off TF to lie pt flat with hypotensive episode. Abd remains firm, BS thoughout all quads. +flautus with turning. no stool cont with lactolose.\n SKin: rashes in the folds of abd, placed on nystatin powder. extremely edematous, eccymotic areas on the right calf,right armpit. areas. sacral decub with douderm in place. due to be changed on . +mouth sores.\n Endocrine: was on IVF insulin at a rate of 5units/hr. FS came back at 49,,insulin stopped and amp D50 given, FS onl yup to 69 second amp was given. insulin restrated at 3am for fS 178. now on 3uints/hr.\n Social: spoke with son this evening updated.\n Plan: will cont to try to get goal rate on CVVHDF cont to monitor labs q6hro and q12.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611713, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported on AC overnoc. BS's coarse throughout. Sxing moderate amts thick bloody secretions from ETT. Administering Albuterol and Atrovent MDI's in line w/ vent, see flowsheet for rx times. Pt airway pressures borderline, plateau=30-40 overnoc. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611805, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt cont on the vent with settings of 450/16/.50/10 spont RR 0-5, suctioned Q4hr for thick scant amts of tan sputum. BS coarse upper and diminished at the bases. no wheezes, cont on steroids 40mg Q8hr. Remains sedated on fentanyl 350mcg/hr and versed at 12mg/hr.\n Neuro: as noted above pt is sedated on fentanyl and versed. will open eyes when turning. biting down on ETT and NGT, ocluding both. requiring bolus of meds. no spont movement from pt. impaired gag and cough.\n Cardiac: Hr 80-100's afib with occasional PVC, cont on levophed at 0.03mcg/kg/min BP ranging 100-130/70's unable to titrate. remains edeamtous, LOS is still + ll liters.\n Renal: on CVVHD, was averaging over 100cc neg with an ending balance of -883 cc at midnight. As per Renal fellow CVVHD was stopped at 2300. over the past few hours pt is now +350cc. anascara, oozing from prevous puctures. Restarting will depend on family meeting today..\n ID: cont on antibx, po flaygl and IV merepenum. rash in groin improved, oral ulcer improved. still on internal lips.\n Skin: cont on the air bed. turing frequently. sacral decub with douderm . eccymotic areas on the right calf, upper right neck,\n Plan: family meeting plan for today with the sons being at the meeting via phone. plan is to discuss comfort care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611806, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 50% and Peep 10. Abg's within normal limits with PaO2 103. Bs coarse R lung, decreased L lung. Albuterol/Atrovent MDI's given Q4hr. CVVHD in use. No further changes made. Continue with mechanical support and wean peep as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-24 00:00:00.000", "description": "Report", "row_id": 1611807, "text": "NPN\n\nNeuro: Remains sedated, no changes were made in the rate, she was given a 10mg vent and a 200mcg fent bolus for HTN and tachycardia - good effect with a lowering of both HR and BP.\n\nCV: She is off levo with no plans to restart it, her SBP has been 100-130.\n\nResp: LS coarse, no changes were made on the vent, sx for thick tan secreations.\n\nGI: Her residuals were 210 this morning, they were off until the residuals were <150 - 5 hrs. She has been having liquid stool, conts on bowel meds.\n\nGU: U/O 15-20cc/hr, she remains off of CVVHD with no plans to restart.\n\nEndo: BS have been 80-100s, glargine has been reduced to 25 units.\n\nSoc: There was a family meeting today with the husband, her rabbi, both of her sons were on conferance call. She is CPRNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-25 00:00:00.000", "description": "Report", "row_id": 1611808, "text": "NPN\nNeuro: Pt. remains sedated on Versed 12mg/hr and Fentanyl 350mch/hr. Did not require extra boluses this shift.\n\nCV: Pt. remains off Levophed at this time. ABP 100-120's HR 80-100. Cont. with A-fib. Pt. remains with anasarca and weeping through her skin. Labs pending.\n\nResp: Pt. remains intubated on vent A/C 450x16 with peep of 10 and FiO2 50%. LS remain coarse did not require to be suctioned this shift.\n\nGI: Pt. on tube feeding at 35cc/hr tolerating well with less than 15cc residual. Abd. softly distended, BS+. Pt. cont. with liquid brown stool contained with mushroom cath. Pt. cont. on bowel meds. Lactulose held for liquid stool this shift.\n\nGU: Pt. off CVVH at this time. Foley cath in place draining 8-25cc/hr. MD aware.\n\nSocial: Pt. remains full code with CPR not indicated MD order. Ethics involved in case. Will cont. to update family on plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611754, "text": "NPN 1900-0700\n\nEvents: Levophed gtt weaned off at 0400.\n\nNeuro: Sedation unchanged. Opens eyes slightly to verbal and physical stimuli; grimaces when turned or extremities moved; pupils pinpoint; no spontaneous movement noted.\nCV: ABP 106-134/48-60; levo weaned as above with maps staying above 60; HR 81-100, a-fib with ocassional PVC; gross body edema unchanged.\nResp: Remains on vent in AC mode 500X20X50%X5; repeat ABG's 7.32/44/114/24/-3; RR 20-28, ocassional spontaneous breath; suctioned ET tube 4-5 times for moderate amounts reddish brown sputum; frequent suctioning of mouth required also; sores on lips are healing slowly; O2 sats 99-100%; lung sounds coarse throughout.\nGI/FEN: Abdomen obese; TF at goal of 35/hr tolerated fair; rectal tube in place, drained 200cc golden brown stool, C. diff spec sent; no electrolyte repletion during the night, am labs pendingl\nGU: Foley drained 15-30cc/hr plus leaking moderate amount every 2-3 hrs.\nID: Tmax 99.1 ax; remains on aztreonam and vanco.\nSkin: Duoderm on buttucks , due to be changed today; sores on lips are healing slowly; abdomen is very ecchymotic from heparin shots\nEndo: FSBG 83-107; insulin gtt decreased to 1.5units/hr.\nPlan: Trach/PEG if unable to wean vent; continue antibiotics, monitor temp, wbc's, follow cultures; replete lytes prn; TF, insulin gtt per protocol; maintain good skin care, turn frequently.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611755, "text": "Pt on AC x 20 x 500, 50%, + 5. Pips increased since last evening. Sx for mod amts tk blood streaked. Last ABG better than previous but still a conbined resp and met. acidosis.Continue to support and monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611756, "text": "NPN\n\nNeuro: Pt conts on 75 mcg/hr of fent and 2 mg/hr of versed for sedation, she has been gimicing with some of her care - turning, rotation of the ETT, she does not follow any commands.\n\nCV: She became hypotensive to the upper 70s this morning and was started back on levo, she has been maintaining a SBP of90-100s on .04-.1 mcg.kg/min, her HR has been in the 70s-80s (down from 90s-100s) while on the levo - she has dropped her HR by 20-30 beats/min in the past to levo.\n\nResp: Remains on the vent, she was placed on PS for a very short period of time but dropped her MV to far due to a decrease in her VTs. SATs have been in the upper 90s, suctioning dark blood, LS with exp wheezes.\n\nGI: ABD is firm and distended, positive BS, conts on TF at 35cc/hr. given lactulose - no stool today so far.\n\nGU: U/O 10-20cc/hr, creat 1.8, k 4.4\n\nEndo: Remains on an insulin gtt, she has required increase doses today due to rising BS, she will be started on glargine this evening but cont on the insulin gtt to maintain a BS of 80-120.\n\nSoc: There was a family meeding today with the patients husband and their rabbi, the team went through her case and their questions were answered, no decisions were made.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1611757, "text": "RESPIRATORY CARE: PT W/7.0 ORAL ETT IN PLACE.\nREMAINS ON AC MODE AS PER CV. UNABLE TO STAY\nON PSV DUE COMBINATION OF UNDERLYING METABOLIC\nACIDOSIS AND APNEIC PERIODS. SX FOR YELLOW\nSPUTUM. ALBUTEROL AND ATROVENT MDI'S GIVEN.\nWILL C/W VENTILATORY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611770, "text": "resp care\nremains oett/vented in ac mode. multiple changes today d/t worsening oxygenation, dysynchrony on vent. in a.m. had line change in trendelenburg position...during which above complications started. ?water in exhalation valve...changed with good results. in p.m again with dysynchrony with poor oxygenation...responded to increased sedation. does not tolerate any spont resp efforts...pips incr, desats,etc. mdi's given q4h and prn. sxning brownish to green sputum. c/w passive ventilation, on increased peep level again.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611771, "text": "NPN\n\nDiffucult day; cont need for pressors, worsening oxygenation and venilatory, increased sedation requirements.\n\nNeuro: She has needed increased doses of both fent and versed, more alert this morning, periods of opening her eyes, this afternoon she was fighting the vent causing increased PIPs, decreased VTs and MVs. I have given her doses of 300-500mcg of fent and 10-15 mg of versed in a bolus, her fent is now 300mcg/hr and her versed is 10 mg/hr - she is still requiring boluses with these increased doses.\n\nCV: Remains on the levo, her rate has increase to as high as .2mcg/kg/min and as low as off but mainly she has been ~ .03 mcg/kg/min. She remains in afib, her HR was as high as 120s and her SBP 170s while alert, she presently has a BP of 100-120s/40s, with a mean ~ 60-70s, her CVP is , HR 60s, she conts on levo and CVVHDF. The CVVHDF was restarted this afternoon, the levo will most likely continue to be needed to maintain a MAP of >60 - the goal is to keep the levo at a low level, if her BP drops than decrease the PFR on the CVVHDF.\n\nResp: LS diminished, she needed to have her SC line replaced necessitating that she be in trandelanberg, during the proceedure her PIPs increased to the 40s, her MV dropped to 4-5L/min, VTs were cut in half due to the pressure, her ABG was 7.39/42/58; the PEEP was increased to 15, rate to 26, FI02 to 100%, the MV decreased to 400, and her sedation was increased. A pressure valve was replaced and this initially helped but she again had low MVs, VTs and high PIPs, her present ABG on the 400x26/15/100% was 7.43/37/174; her FI02 was dropped to 80%. Sx for sm to mod amounts of tan/brown secreations.\n\nGI: Her ABD conts to be distended and firm, TF cont, I am not able to pull back any residuals from her pedi tube, she has pos BS, she was given lactulose x2 today.\n\nGU: Poor u/o 0-20cc/hr, she was restarted on CVVHDF and is tolerating it so far, she does cont on the levophed at a low dose of .03 mcg/kg/min.\n\nEndo: She has been hyperglycemic all day - she was restarted on an insulin gtt and is presently at 4 units/hr - the goal of her FS is 80-120.\n\nAccess: Her L SC was leaking and only 2 ports would withdraw blood, when I flushed to the white port with NS it leaked - the other ports did not do this; she now has a new L IJ which is not leaking, her SC was removed.\n\nID: She has been afebrile today ~ 96 ax, her gent and aztreonam were d/ced. meropenum was added.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611772, "text": "M/SICU Nursing Progress Note (1900-0700)\n\nPlease see carevue for all objective data, including q1hr fingersicks and subsequent adjustments in insulin gtt, hemodynamic monitoring and subsequent titration of levophed, q1hr CVVHD documentation and hourly fluid removal.\n\nCNS: Pt. well sedated on fentanyl and versed gtts. They have both been titrated down slightly due to hypotension and are currently running at fentanyl 250mcg/hr, versed at 8mg/hr. Occasional boluses of fentanyl (250-300mcg) given with turning and bathing. Pt. also requires additional boluses when overbreathing due to drop in MV. Pt. does grimace with noxious stim, but settles down when left to rest.\n\nCVS: Heart rate variable at 60-100, AFib, no VEA noted. Levophed weaned off by 0400 and B/P stable at 100-120/syst with MAP>60.\n\nF and E/CVVHD: Unable to remove any fluid (due to hypotension) as of midnight. Pt. ended past 24hr 500cc+. PFR gradually increased and is now at goal of -100cc hourly. -116cc as of 0400 and will continue to ultrafiltrate as tolerated. CVP initially 8, increased to 15 (?accuracy). Electrolytes WNL. Of note, both filter pressure and effulent pressure have increased significantly. No clotting visible in filter.\n\nRESP: Lungs with coarse, diminished breath sounds. Suctioned infrequently for small brown plugs. FIO2 decreased from 80% to 60% with ABG of 7.36 42 63 25 -1. Tolerating PO2 of >60.\n\nID: Hypothermic at 96 axillary. Bair hugger on with only mild improvement.\n\nENDO: Insulin gtt adjusted per hourly fingersticks. Currently at 5U/hr with blood sugars in the 120's.\n\nSKIN: Anasarca. Oral ulcers oozing BRB. Duoderm over , not removed.\n\nGI: Tolerating tube feedings at goal rate. Mushroom catheter, no additional stool overnight.\n\nSOCIAL: Son, , called and was updated on his mother's condition. He seems appropriately concerned and aware of the severity of her condition.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611773, "text": "Resp Care\nPt. remains intubated/sedated on ventilator. Fio2 weaned overnight, otherwise no changes.\nBS:coarse bilat. sxn'd x2 for thick brown plugs.\nabgs:moderately hypoxic, tolerating PaO2>60. Other parameters within acceptable range.\nPlan: cont. to support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611850, "text": "Resp: pt on a/c 16/450/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs auscultated reveal bilateral wheezing noted with coarse sounds. Suctioned for moderate amounts of thick yellow/greenish secretions. Pt biting on ett at times. No changes noc. Will continue with full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611851, "text": "Respiratory Care Note\nPt remains on AC as noted. No vent changes. BS coarse throughout. Pt suctioned for moderate amts thick yellow-green secretions. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611818, "text": "S/MICU Nursing Progress Note\n Pt remains intubated, no vent changes on settings of A/C 450/16/50/5 suctioned for thick sputum. on sedation of versed at 12mg/hr and fentanyl 350mcg/hr. pt comfortable, no grimacing with turning will elevate her HR and BP with activity but then quickly returns to previous level.\n Cardiac: HR 70-100 afib. rare to occasional PVC, BP lowest 68 during the night. now up to 93/33\n GI: on TF at 35cc/hr. sm amt of stool\n Social: son phoned and updated on mother's status. family is planning to come on Sunday ( son should arrive from on Sunday)\n Plan: with present plan, comfort care is the priority.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611819, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 100%; bs coarse, thick tan secretions, rsbi not indicated: , full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-29 00:00:00.000", "description": "Report", "row_id": 1611820, "text": "NPN\n\nPt remains sedated, the versed was increased to 14 mg/hr due to biting on the ETT, she appears comfortable, SBP 60s-90s, HR 70s-80s, her HR will increase to the low 100s with turning or care. Son to visit tomorrow, to come early this coming week.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611821, "text": "NPN\nNeuro: Pt. sedated on IV Fentanyl 350mcg/hr and Versed 14mg/hr. Pt. remains comfortable with no grimace.\n\nCardiovascular: NBP systolic 70-80's over 30's. HR 80-100's . in A-fib.\n\nResp: LS coarse. Pt. suctioned for moderate amount of thick tan secretions. O2 sat 100%. Pt. . on vent A/C 450x16 with PEEP of 5 and FiO2 50%.\n\nGI: Tube feeding on hold for large amounts of brown liquid residual from OG tube.\n\nGU: Foley cath in place draining small amounts of dark yellow urine 5-10cc/hr. Pt. . with anasarca and weeping skin.\n\nSocial: Pt. DNR/DNI. Pt.'s son called about Pt.'s condition. Family awaiting visit from Pt.'s son from possibly sunday. ? comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611822, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 100%; bs coarse, thick tan secretions with lavage, will full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-30 00:00:00.000", "description": "Report", "row_id": 1611823, "text": "NPN\n\nNeuro: Pt remains sedated on versed and fent, she was given boluses of each for biting on the ETT and increased HR to the low 100s, she presently appears comfortable.\n\nCV: Her BP has been 70s-80s for most of the day, her HR has been decreasing through the day, this morning it was in the 90s-100s and now in the 70s-80s.\n\nResp: LS coarse, sx for thick tan secreations, no changes were made on the vent.\n\nGI: She conts to have residuals from her OGT and her TF remain off because of them. ABD firm and distended, hypoactive bowel sounds.\n\nGU: U/O 5-10cc/hr, conts to have anasarca.\n\nID: She had a temp today to 100.8, she was started on levoquin.\n\nSoc: Her husband was in today, he conts to state as he has throughout her hospitalization that he \"doesn't know what he will do without her\", that \"she is all he has\". Her son came today, is making plans to be here on Tuesday.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611701, "text": "S/MICU Nursing Progress Note\n Events: swan ganz placed,ultrasound of right calf/leg,\n Respiratory: cont on the vent with settings of PCV driving pressures of 26 able to decrease to 22cm, PEEP of 18cm, TV ranged from 480cc-600cc suctioning for thick blood tinge sputum, occasional plugs.\n BS coarse throughout. sedated on fentanyl 100mcg/hr and versed 3mg/hr.\n Cardiac: HR 50-60NSR, cont on Pronestyl 250mg po, BP stable today 90-130/70's Swan-ganz catheter place this afternoon. Readings showed a PA 68/38, CVP 20, PCW 28 with fick CO 9.1, will cont to monitor overnight but will consider CCVHD tomorrow.\n GU: foley in place and draining. U/O poor for the day. BUN up to 71 with creat 1.7\n GI: NGt in place, on LCS with output 300cc of coffee grounds abd still firm, +BS, +flatus, no stool today. lactolose given x1.\n Neuro: sedated, will grimace to painful stimuli, no spont movement.\n +gag,+cough.\n Skin: hematoma on the right leg, seen by surgery ? if pt had a lipoma on the calf and has brusing around the area. ultrasound ordered and done, results pnd. Pulses good, foot warm to touch. Douderm over sacral decub. (dsg is aquacel in the wound,douderm overwound and to be changed every 3days....due on the 8th)\n Social: husband in to visit, updated by Dr. , on phone and updated by Dr. . Son calls from .\n Plan:MOnitor swan ganz readings, I&O's ? CVVHD tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611702, "text": "MICU/SICU NPN ICU DAY #6\nEvents: PAC placed last PM, FiO2 weaned to 0.40\n\n\nS/O:\n\nNeruo: pt remains well sedated on fentanyl/midazolam gtt, fentany and midazolam reduced, no independent movement of extremities, pupils pinpoint, initially no response to noxious stimuli, pt now opens eyes to painful stim\n\nPulm: remains intubated on PCV 40+18/0.4/26, last ABG 7.42/27/157, SpO2 97-100%, LS coarse, suctioned x2 for small amts clear thick secretions, it can be difficult to pass suction catheter into ETT at times, Ve 12.3-13.1, Vt 470-510, PIP 41-42, Pplat 36-38\n\nCV: HR 66-86 SR with rare to occasional PVC's, BP 92-141/44-56, MAP 55-83, PAP 43-67/25-37, PCWP 17-22 (corrects to for 18cm H2O of PEEP), CVP 14-25 (corrects to for PEEP), CI 2.9-3.94, episodes of hypotension appear to occur in relation to bradycardic episodes, please see flowsheet for data\n\nInteg: pt has anasarca, particularly in extremities, pt has a healing venous stasis ulcer, 1cm x 1cm, on anterior RLE, it is C/D/I, pt has a Duoderm over a sacral decub that is reported to be dressed with Aquacel\n\nGI/GU: abd is obese, firm and distended, BS are present, pt has a clamped NGT in left nare for meds, it can be difficult to aspirate gastric content at times, last PM ~30cc \"coffee grounds\" were aspirated and found to be OB negative with a pH of 2, Pt has a Foley in place which is draining scant amts of clear yellow urine, pt had no reponse to 60mg IV furosemide\n\nAccess: left radial art line day #2, left SC introducer with VIP+ PAC at 55cm day #2, #20 angio right hand\n\nFEN: pt remains mildly hyperkalemic, daily weight unchanged from 104.0 Kg, nutritional support on hold at this time\n\nA:\n\nhigh risk for infection r/t invasive lines, ETT, indwelling catheter\nrisk for altered nutrition, LBR r/t >72h poor caloric intake\naltered breathing r/t acute inflammatory process vs. acute on chronic cardiac process\nimpaired skin integrity r/t chronic altered nutrition, chronic immobility\nhigh risk for injury, cardiopulmonary r/t acute on chronic pulmonary hypertension\n\nP:\n\ncointinue to monitor hemodynamic/respiratory status, contniue to wean respiratory support as tolerated, consider judicious reduction in PEEP, aggressive pulmonary toilet, gentle diuresis, consider adding small amts free water throughout the day to replete intravascular volume without worsening edema and improve hydration, consider dietitian's reccomendation to start TF even if only at trophic rate, continue skin/wound care as reccomended, consider reanal consult to evaluate need for HD vs. CRRT\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611703, "text": "Resp Care Note\n\nPt is vented on PCV Pi 40, + 18, weaned to 40%, RR 26. Last ABG showing compensated ( severe metabolic ) acidosis presumably due to renal failure. Pt is getting combi vent MDI Q 4-6 hrs. BS are course and diminished, there are few if any wheezes. Due to rebounded pO2, oxygen has been weaned to 40% from 55% @ start of shift. Driving pressure still @ 22, may consider decresing peep later on\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611704, "text": "NPN 0700-1900\n\nNeuro: Remains on fentanyl 75mcg/midazolam 2mg/hr; Opens eyes when turned, suctioned, sometimes to voice; no movement of extremities noted; pupils pinpoint.\n\nCV: HR 60-79, NSR with ocassional PVC; po pronestyl reordered for 500mg tid, 250mg ; ABP 83-134/41-60 with maps 58-120, SBP decreases to 80's when asleep but goes right up with stimulation; PAP 37-69/22-37 with mean 27-48; CVP 14-24; PAWP 20-22; C.O. 6.10-8.83; lasix gtt started at 7mg/hr and titrated to keep uo >30cc/hr, presently gtt is at 15mg with uo only 15cc/hr; ABP stable in low 100's, high 90's; transfused 1U PRBC's for crit 25.1; no active signs of bleeding noted.\n\nResp: Intubated on vent in PSV mode 40x18x.4x26, no changes made on vent; O2sats 96-100%; suctioned 3-4 times for moderate amounts thick dark tan sputum; lung sounds are coarse throughout; solumedrol decreased to 40mg; esophageal balloon d/c'd when tube retaped per Dr. ; oral airway removed due to sores on pt's lips.\n\nGI/FEN: Abdomen firmly distended, slightly less than yesterday per team, +BS, small amt loose brown stool X2; TF of Nepro w/additives started at 10cc/hr thru NGT, goal is 35/hr.\n\nGU: Foley draining 5-22cc/hr; lasix gtt started as above; fluid status is +1L X24hrs, +2351 for LOS. Renal U/S done per renal consult, results pending; plan is likely for ultrafiltration with CVVH\n\nSkin: Sacral decub remains covered with duoderm, due to be changed tomorrow; peri area is red and peeling, ?fungal, mycostatin powder ordered; RLE ecchymosis remains unchanged; pt has sores on L upper lip from ?oral airway vs intubation process.\n\nEndo: FSBG 49-122; insulin gtt off X 2hrs for hypoglycemia and resumed at 2units/hr with BS wnl; pt given 1 amp D50 X1 for BS of 49.\n\nID: Tmax 98.6 core temp. Remains on MRSA precautions; not antibiotics; sputum darker and thicker today.\n\nPlan: Monitor hemodynamic status, diurese with lasix gtt as tolerated, titrate to u.o. > 30cc/hr, continue cardiac meds; monitor resp status, wean sedation and vent as tolerated, suction prn; monitor crit and s/s of bleeding, goal crit >25; monitor fluid/electrolytes, ultrafiltration to decrease anasarca; monitor temp, sputum, cultures; FSBG q 1hr, titrate insulin gtt accordingly; drsg as ordered for sacral decub, turn q 2hrs, ?A& to sores on lips.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611705, "text": "Resp. Care Note\nPt remains intubated and vented on PCV settings as charted on resp flowsheet. With driving pressure of 22, TV's mid 400's with minute vent. of 11-12L. Sats 97-98% and last PaO2 157 this morning. esophageal balloon measurements this morning showed trans. pulm end exp pressure was -5. Esophageal balloon DC'd in afternoon as threaded through oral airway and 2 deep cuts noted on pt's lips from the airway. Sxn for thick tan secretions. Albuterol and Atrovent MDI given Q vent check. Plan to recheck ABG and adjust vent.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 1611706, "text": "Addendum to NPN 0700-1900\n\nRepeat labs K 5.0, Mg 2.1, ABG's 7.45/29/100; vent changes made as follows PSV 38/40%/24/18; will repeat abg's at 1900; FSBG at 1800 76, insulin gtt off.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611852, "text": "NPN 7A-7P:\n\nNEURO: PT INTUBATED AND SEDATED ON FENTANYL 375MCG/HR AND MIDAZOLAM 14MG/HR, WITH GOOD EFFECT NOTED. SHE RAMAINS UNRESPONSIVE WITHOUT PURPOSEFUL MOVEMENT NOTED. PUPILS 2MM AND REACTIVE. SHE DOES BITES DOWN ON THE ET TUBE WITH SX AT TIMES.\n\nRESP: VENT SETTINGS 50%X450/ PEEP5/RR 16. O2 SAT 90-98%. SX FOR THICK WHITE/BROWN PLUGS X2-3 HOURS IN MOD AMOUNTS. LS COURSE AND DIMINSHED BILAT.\n\nGI/GU: TF ON HOLD SECONDARY GROSS AMOUNTS OF RESIDUAL. NO BS. NO BM. FOLEY CATH WITH NO OUT-PUT.\n\nSKIN: DUODERM CHANGED TODAY. WOUND PINK AT BASE. MILD ORDOR NOTED. SCANT YELLOW DRAINAGE. ANASARCA NOTED. 6+ ON RIGHT FOOT.\n\nAXCESS: RIGHT DIALYSIS CATH, AND LEFT IF CENTRAL LINE.\n\nSOCIAL: HUSBAND IN TODAY. TALK TO ICU TEAM. PT REMAINS .\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611853, "text": "Progress Note 7p-7a\nEvents: Pt. unchanged. No significant events throughout shift\n\nNeuro: Pt. remains sedated on fentanyl and versed. Pupils 2mm and brisk bilat. No purposeful movement noted. Gag and cough reflex impaired at this time. Pt. occassionally bites ETT with suctioning.\n\nResp: Pt. remains intubated/on ventilator. No change in settings: 50/450/5/16. Thick yellow/green sputum with suctioning.\n\nCVS: Pt. remains in AFib with rate controlled in 70's-80's. BP 40's to 60's systolic. Pitting/weeping edema in all extremities and trunk. Pulses difficult to palpate. T-max 95.6\n\nGI: Pt. remains NPO d/t increased residuals. BS ansent. OGT remains in place.\n\nGU: Foley cath in place. 7cc urine output noted.\n\nSkin: Duoderm remains on . Changed .\n\nAccess: R IJ Dialysis cath / L IJ TL Central line.\n\nPlan: Pt. remains DNR/ with no meds/lab draws. Family in to visit pt. yesterday and continue to refuse to withdraw life support d/t religious beliefs (Orthodox ). Continue to offer support to family members. pt. comfortable.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611854, "text": "Resp: Rec'd on ac 16/450/+5/40%. Bs are coarse thoughout bilaterally. Suctioned for moderate amounts of thick yellow/green secretions. Ett re-taped and secured. No vent changes noc. Will continue full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611855, "text": "Patient remains on mechanical ventilation with no vent changes.Bit on pilot balloon line during bronchial hygien. One clamp is used to stop the leak until ETT is replaced.Suctioned for minimal to small amount of secretion.Patient vot responding to commands,but visually loks better.Maintaning good saturation,BP labile with good HR;will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611738, "text": "S/MICU Nursing Progress Note\n Respiratory: cont on the vent with settings 500/20/8/.50 suctioned q2-3 hr for thick blood tinged sputum. coarse BS throughout. occasionally biting on ETT, difficult to do mouth care as pt clamping down. sedated on Versed 1mg/hr and fentanyl 50,cg/hr.\n ID: temp max 101.2 rectally, pan cultured Blood cultures x 2 one from triple lumen and one from arterial line. urine and sputum sent. cont on vanco(+MRSA in sputum, and yeast in urine from previous cutures) aztreonam. tyenol given x1\n Cardaic: HR 90-100's afib, BP 94-130/60 cont on levo at 0.05mcg/kg/min attempted to wean to 0.03 however dropped BP to low of 68/ presently levo at 0.109 mcg/kg/min\n GI: cont on TF of 3.4 str nepro with promod, rate at 35cc/hr residuals high 65cc. have not advanced rate.sm oozing of stool, +++flatus, lactolose given at 12am.\n GU: foley in place and urine yellow with sediment.output only averaging 20-30cc/hr.\n Skin: sacral decub with duoderm, numerous eccymotic areas.... increasing in size and location.. right arm pit, lower abd, right calf and left arm.\n Social: no contact tonight with family\n Plan: Pt cont to slowly have a downward course. Will not be able to wean vent. Con discussions of code status. ? need to encourage sons to travel to .\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611739, "text": "RESP CARE:Pt remains intubated with 7.0ETT/on vent on settings per carevue. No changes this shift. Lungs coarse rhonchi/wheezes bilat.Sxd thick bld tinged sputum. MDIs given Q$ with good effect. No RSBI at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611740, "text": "Resp Care\n\nPt remains intubated with a # 7 OETT and is on full vent support. Receiving bronchodilators and BS remain coarse and suctioning thick bloody tinged sputum\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1611741, "text": "MSICU NPN 0700-1900\n\n\nRemains on Fentanyl and Versed gtts. No changes made. Grimaces w/turning and suctioning. Very edematous. Minimal spontaneous mvmt. Sluggish cough and gag. Fights mouth care w/ down.\n\nNo vent changes. Suct ~q4hrs for sm-mod amt thick brown,occ bld-tinged sputum. O2sats gd on 50% FiO2.\n\nT max 99.4 ax. NGT changes to OGT d/t presumed sinusitis. Nasal sprays started. Gentamycin started. Lips remain excoriated. ? HSV vs trauma.\n\nContinues on Levophed. MAPS drop below 60 gtt weaned. Currently on 0.1 mcgs/kg. Remains in Afib.\n\nUO ~ 20cc/hr. No Lasix given d/t hypotention. Renal team following.\n\nNo stool. No change in TFs. Asp 15-120cc. Plan to give Lactulose q2hr until she stools. Send stool for C-diff.\n\nHusband in most of afternoon. Updated by MD.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611742, "text": "S/MICU Nursing Progress Note\n Pt is a 80y/o woman admitted from rehab with abnormal labs,increasingly agitated and poor po intake, intially admitted to medical floor found to be in Aflutter converted to NSR chemically, over 24hrs developed SOB, and respiratory arrested.. intubated and transfer to S/MICU on . course in the ICU has been renal failure, worsening edema now +10liters for LOS, increasely infected,,, yeast in urine, gram +and neg in sputum currently on vanco,aztreonam, renal dose of gent and fluconozole.\n Pmh: see FHPA\n Allergies: Sulfa, Keflex, clindamycin and PCN\n System Review:\n Respiratory: remains intubated on settings of 500/20/. spont rate 0-4 over the vent. sedated on fentanyl 50mcg/hr and versed 1mg/hr. only bolused x2 during the night as pt biting on ETT. suctioning creamy thick bloody to blood tinged sputum. Q2-3 hr. BS insp/expri wheezes on the right. coarse on the left. right BS more diminished.\n Cardiac: HR 80-100\"s afib, BP ranged for low 70(after bolused with meds) to 120's cont on levo at 0.103 unable to titrate.\n GI: on TF on nepro with promod at goal rate of 35cc/hr. was having high residuals, giving lactolose yesterday now having loose stool mushroom catheter in place. c-diff spec sent this am.\n GU: foley in place urine output only 30-40cc/hr was on CVVHD stopped as pt was hypotensive during treatment and unable to get much fluid off. did receive lasix on Wednesday with fair response but need pressors after 8hr.\n ID: spiked sputum gram +, gram - on vanco, aztreonam, yeast in urine , fluconozole, gent x1. groin rash.\n Skin: decub on sacral aquacel and covered with duoderm. numberous areas of eccymotic areas..... right shoulder, right lower abd and right calf.\n Neuro: grimaces with turning and movement, +coughing, biting on ETT, occasionally moves her left arm.\n Social: no contact with family during the night.\n Plan: cont to monitor. unable to wean vent, unable to wean pressors.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611743, "text": "RESP CARE: PT REMAINS INTUBATED/ON VENT PER CAREVUE. NO VENT CHANGES THIS SHIFT. LUNGS COARSE WITH WHEEZES BILAT. SXD THICK BLD TINGED SPUTUM. PT BITING ON TUBE AT TIMES. NO RSBI THIS AM DUE TO HEMODYNAMIC INSTABILITY.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1611744, "text": "Resp Care\n\nPt remains intubated and on full vent support. BS remain coarse and suctioning thick blood tinged sputum. Receiving bronchodilators\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611687, "text": "NARRATIVE NOTE:\n\nRESP: PT ARRIVED FROM FLOOR PRIOR TO SHIFT. INTUBABED. PLEASE SEE CARE VUE FOR VENT CHANGES AND ABGS DRAWN THROUGHOUT SHIFT. PRESENT VENT SETTINGS ARE PCV 50%,RATE 26, PEEP 10, AND ISP PRESSURE 35.LUNGS VERY COARSE THROUGHOUT WITH SX Q 2-3 HR FOR MOD TO LG AMTS OF BRIGHT RED BLOOD. SAO2 HIGH 90'S.\n\nCV: B/P HAS RANGED FROM 116/31-171/74. SB SR WITH HR RANGING 56-84, NO ECTOPY NOTED. PPP. PT HAS + EDEMA IN EXTREMITIES. HCT AT 2100 26.5 DOWN TO 23.8 THIS AM. INTERN NOTIFIED. PT WILL A UNIT OF BLOOD. PT HAS ONE SMALL IV ACCESS AND INTERN AND RESIDENT WILL REPEAT ATTEMPT TO START A TRIPLE LUMEN. K HAS BEEN HIGH, PT 30GM OF EX AND A DOSE OF LACTULOSE THIS AM AS PT HAS HAD NO RESULTS AS OF YET.\n\nNEURO: PT ON VERSED AT 4MG/HR WHICH WAS TITRATED UP FROM 2MG. ALSO ON FENTANYL AT 75MIC/HR. PT NOT FOLLOWING COMMANDS. WITHDRAWS TO PAIN. OPENS EYES TO PAINFUL STIMULI. + GAG AND COUGH. R PUPIL SLUGGISH. LEFT BRISK.\n\nGU: FOLEY CATH PATENT, HAD BEEN REPLACED DURING SHIFT, THE FOLEY PT ARRIVED WITH WAS NOTED TO BE OUT. U/O MARGINAL. PT DID ETHACRYNIC 50MG. UNSURE HOW EFFECTIVE AS FOLEY DISLODGED. BALLOON ONLY SLIGHTLY INFLATED ON OLD FOLEY. NG TUBE PLACED WITHOUT DIFFICULTY. PLACEMENT VERIFIED BY XRAY., AND BY AIR BOLUS AND ASPIRATION. ABD SOFTLY DISTENDED. BS+ X4 QUADS.\n\nSKIN PT HAS STAGE III PRESSURE ULCER ON COCCYX. DUODERM PLACED.\n\nPLAN: PLACE A CENTRAL LINE AND PROVIDE BLOOD PRODUCTS AS NEEDED. PROVIDE RESP SUPPORT AS NEEDED, WITH ABG'S. MONITOR HEMODYNAMICS . PROVIDE SUPPORT TO FAMILY WITH UPDATES AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611688, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated on the vent with settings of PCV driving pressure 26, PEEP 10cm, inspir Pressures 36, maintaining TV 440-500cc with minute ventilations of liters/minute. When pt coughing,or appears to be bearing down will drop her TV 100-200cc and then will block to a HR 38-40SB, slight drop in BP however will resolve with boluses of sedation. Have suctioned to evaluate possible plug, secretions are bloody to old blood no plugging. Secretions are thick not really frothy or thin (as CHFvs pul edema are part of differatal dx.) FIO2 at 50%(tried to wean to 40% and pAO2 down to 69)BS coarse througout. on alb and atrovent\n Cardiac: Hr 60-70 NSR(P waves sometimes difficult to see however confirmed on EKG) will block to 34-40's with drop in her TV/minute ventilation. BP stable 110-130/60's this am after multiple boluses of sedation pt did drop her BP to 84/ due to 2 Units of RBC's transfused each over 2hr, CVP ranged 10-14 this morning after 2uints of RBC then up to 15-16(on 10cm of PEEP) did give 100mg ethnacrynic acid. with good response. u/o 330cc after dose. Norpace dose D/C started on procaimide at 2mg/min over 24hours, levels to be checked in the am. QTC at start of IVF 368(by 12lead).Serum K 5.6 am no change all day. repeat level tonight.\n Renal: poor u/o all day slight improvement after dose of ethnacrynic acid. BUN 68 creat 1.2 urine lytes sent to evalutate possible ATN\n GI: NGT in place, aspirates coffee grounds, clears after 100cc flush ( ?trauma from insertion) hct had been 23 received two units of RBC post tx hct 27.5 will repeat at 1800. no stool today, +flatus, lactose given this am no results. serum K 5.6(no peaked T on EGK)\n Neuro: sedated on Versed 4mg/hr and Fentanyl 100mcg/hr. grimace with pain, slight tremor noted in the left arm. no spont movement. Pupils Pinpoint.\n endocrine: once IV access was obtained started on IV insulin at 12pm low dose 0.5 to 1unit/hr. titrated accordingly. FS qhr.\n IV: quad lumen place in the right IJ after multiple attempts in the subclavian. CXray done post procedures. Perpherial IV in the left hand. Art line left radial.\n Skin: sacral decub, open through epidermis, no drainage, douderm placed 3 & 4 + pitting edema on extremites. right foot skind cracked and started to ooze fluid.\n ID: low grade temp only 99.8 po blood cultures x2 today, sputum x1 sent for culture. urine had been sent yesterday. not on antibx.\n Plan: diursis, follow I&O's closely with CVP, monitor ABG and wean accordingly. still feel event that cause her respiratory arrest was sudden unclear etiology. differital DX, CHF, PE, pneumonia(?inflitrate in right upper lobe) or COPD. pt has hx crushing CP the evening before event. CPK presently flat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611689, "text": "Respiratory Care:\nPt remains on PCV. Bleeding on and off today via lung ??? Occasionally over breaths the vent. ABG @ 13:34 7.32 40 81 22 -5. Develops lo MV's that trigger lo sats but these episodes have spontainously resolved. Look at CareVue for detals.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611766, "text": "NPN\n\nNeuro: Conts on fent and versed, she woke suddenly - eyes open, appeared scared, SBP was in the 170s, I told her where she was and why she was here, she requred a total of 300mcg of fent and 15mg of versed before she was sedated again. She has woken periodically through the day, she again has required fent and versed bolus though not as large, when she cough or fight the vent then the CVVHD shuts off greatly increasing the risk of it clotting.\n\nCV: Pt became hypotensive this morning BP 60/30, CVP OF 6, levo was started. She is currently on .09mcg/kg/min of levo, she conts on CVVHDF with the goal of even for the day. She had one episode of bradycardia to the 30s when the levo was started, she has since had a HR in the 60s-80s, afib, occ PVCs.\n\nResp: Conts on A/C, new settings of 450x22/12/.5, sx for min amounts of reddish sputum. LS diminished.\n\nGI: ABD firm and distended though less this afternoon after she was given lactulose. No today so far. She conts on TF 3/4 strength Deliver with 55 gms Promod at the goal rate of 35cc/hr.\n\nGU: The CVVHDF conts, the pt removal rate was 0 this morning while she was hypotensive, after her BP came up with the levo fluid was again removed with a pt removal rate of 100cc/hr. She is presently ~ 100cc neg since MN, her goal is even for today, when she tolerates being off of the levo than we will again try to make her fluid balance neg each day.\n\nEndo: She conts to have high BS, her long acting insulin will be increased this evening.\n\nID: She has been afebrile, WBC 7, gent is now q24 hrs with peak and trough levels being followed, conts on aztreonam and vanco - she needs a peak vanco at 8 pm. Total body anasarca conts, she is weaping from any open areas including her IV sites.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611767, "text": "Resp. care note - Pt. remaines intubated and vented, fio2 rr and peep weaned pt. tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611768, "text": "Smicu nsg progress note\n Pt initially well sedated on 225mcg/kg fent and 7.5mg versed. Not requiring additional boluses even with turning. At 4am pt becoming suddenly more awake with eyes open increased hr/bp. Given additional boluses fent/versed and pt evenually settling down.\nCardiac- Bp relatively stable. Able to wean levo from .07mcg/kg to .03mcg/kg. Does have intermittent periods with bp down to 90's but increases to 110-120's without intervention. Remains in af with hr 70-110.\nResp- Remains intub/vented. Peep weaned to 10. Abg on ac 450x22 50% 86/41/7.39. Suctioned for mod amts thick tan secretions requiring saline instillation.\nRenal- Cvvhd on hold. Will readdress in am. Cont with minimal urine output(see flow sheet). Also with total body anacarcia- weeping from arms/legs/iv sites. Lytes/bun/creat have been stable.\nGi- Cont on goal tube feeds without problem. Passing sm amt brown stool via mushroom cath.\nId- Remains afebrile. No changes in antibiotics.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-15 00:00:00.000", "description": "Report", "row_id": 1611769, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated this AM. Peep decreased to 10. Sxn for thick blood tinged secretions. BLBS are coarse.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611801, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains intubated with settings of 450/16/.50/10 spont RR 0-3 over the vent. suctioned Q3-4 hr for thick white sputum. BS coarse throughout, with diminished at the bases.\n Cardiac: remains on Levophed to maintain SBP>90 attempted to wean to off and SBP dropped to low of 82/ back on levophed at the original dose...0.03mcg/kg/min. urine output only averaging 10-30cc/hr. still is 12liter LOS + for fluid balance, anascara,\n Renal: off CVVHD during the night to be restarted in the am. ended yesterday -1600cc for 24 hr. urine output only 10-30cc/hr.\n GI: cont on TF of deliver with promod at 35cc/hr tolerating well. low aspirates, receiving lactolose and colace. stool output averaging 200cc for 12hr. period.mushroom catheter in place. NGT orally.\n Neuro: cont on sedation of fentanyl at 350mcg/hr and versed at 12mg/hr. will open eyes to stimuli, not moving exteremites....however they are very edematous and very difficult to move.\n Skin: sarcal decub dsg changed today area size remains unchanged. still 4cm length and 3cm in wideth. healing well.\n Social: no contact with family during the night.\n Plan: CVVHD this am, cont with goal to diuresis 1.6 liters off /day.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611802, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 10. Sx'd for sm amounts of thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr. O2 sats 98-100%. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611803, "text": "SMICU NSG PROGRESS NOTE\nNeuro- Remains essentually unresponsive on 350mcg fent and 15mg midaz. Pt will bite down and grimise with turning but does not follow commands. No spontaneous movement noted. Cont with total body anacarca.\nCardiac- Bp stable on .03 mcg levo. More tachycardiac today with hr 98-112 af. ? r/t fluid status. Lytes stable.\nResp- Intub/vented. No changes made. Cont with minimal et secretions. Lg amts thick tan oral secretions. Cont to bite down with any stimulation. Will need to address need for trach if decision made to cont tx.\nRenal- Cvvh restarted. Able to maintain goal of 100cc neg/hr. Goal is to remove ~ 1-1.5l/day. Of note, filter pressures have been on high side even when cvvh first initiated. Renal notified. If Cvvh cont after discussion with family tommorrow ? consider heparin. Also ? need to change dialysis line. Cont with minimal uo.\nGi- On goal tube feeds. Abdominal appears firmer today. Still with good bowel sounds. Cont to pass mod amts liquid stool. Following fs Q6hrs on s/s and qpm glargine.\nId- Cont afebrile on current antibiotics.\n Pt's husband in to visit most of day. Updated on pt condition. Plans to attend family meeting on Monday to discuss further care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-23 00:00:00.000", "description": "Report", "row_id": 1611804, "text": "Resp Care\n\nPt remains intubated and on full vent support. No changes in ventilation made. BS coarse. Spo3 96%\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611751, "text": "Nursing NOte 7p-7a:\n\nSee carevue flowsheet for full assessment details and labs.\n\nNEURO: Pt remains sedated on fentanyl/versed. gtts increased secondary to biting of tube and not synchronizing with ventilator. Pupils fixed/nonreactive. eyes open to pain. no spontaneous movement of extremities. cough/gag decreased.\n\nCV: PT received 1 unit PRBCs on evening shift for hct 27.2 AM CBC pending. HR 70-90 Afib/no ectopy. Remains on levophed gtt @ 0.08 mcg/kg/min MAPs range from 60-70. Goal MAP > 60. +4 anasarca + pulses.\n\nPULM: Pt switched back to AC-20 50% TV 500 peep 5 after becoming increasingly acidotic. pt extremely bronchospastic, inhalers given by RT q 2hours. Suctioning mod amount thick/tan blood tinged secretions. sats 96-100% last abg 7.34/42/91/24\n\nGI/GU: Abd large, firm distended. + BS X 4. - BM overnight. PT tolerated TF @ 35 cc/hour (goal) infusing via oral peditube. Placement confirmed with air bolus no residuals noted. foley draining amber/clear urine, UO 30cc/hour.\n\nEndocrine: Pt remains on insulin gtt @ 1.5 units/hour. COnt to check glucose q 2 hours. Fingersticks range from 105-130 overnight.\n\nSKin: PT bathed. Sacral decub with duoderm dsg c/d/i. old healed ulcer on right leg OTA, multiple ecchymotic areas will cont to turn side to side as tolerated.\n\nPLAN: antibiotics, wean vent as tolerated and follow abgs, wound care, follow H&H transfuse as needed, titrate levophed to maintain MAP > 60, fingersticks q 2hours adjust insulin gtt per protocol, cont with current , cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611752, "text": "Resp Care\n\nPt remains intubated and in full vent support. Attempted to change mode to psv but abg after 1hr 15 minutes reveal a respiratory acidosis. (7.27/51/81/24) Mode was than returned to A/C. MV on PSV was approx. 6L. On A/C MV is 9L. Lung examine reveals inspired and expired wheezing. Pt receiving bronchodilators. Suctioning thick blood tinged sputum.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1611753, "text": "MSICU NPN 0700-1900\n\n\nPlease see flowsheet for further details...\n\nArousable to pain. Grimaces w/turning and suctioning. Very anasarcic. Appears comfortable when left alone. No changes made in Fentanyl and Versed gtts.\n\nAttempted PSV trial w/20cm PSV and 5cm PEEP. She dropped MV < 7L despite inc RR. ABG w/ Ph 7.27. Returned to A/C mode. Suctioned q3-4hrs for sm-mod amt brownish tan sputum.\n\nLevophed gtt weaned from 0.1 to 0.04. Current MAP 58. Remains in AF.\n\nUO ~ 25cc/hr. Wt continues to climb.\n\nAfebrile.\n\nTol TFs at goal rate. No stools. Hypoactive bowels sds. Lactulose given x2.\n\nHusband in all afternoon. Plan for conference call with sons and medical team this evening.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611697, "text": "Resp. Care Note\nPt received intubated and vented on PCV settings as charted on resp flowsheet. Pt with marginal oxygenation despite peep 10 and 60%. Esophageal balloon placed which showed pt was under-peeped. Peep increased from , with an end exp trans pulm pressure of -5. Peep later increased again to 18 with some improvement in oxygenation. Currently ventilated with a driving pressure of 25 and Tv 450-500 range. Albuterol/ Atrovent MDI Q vent check. Sxn for blood tinged secretions. Cont current support, follow ABG's, adjust vent.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611844, "text": "d: pt's condition unchanged. pt unresponsive on fentanyl and versed gtts at rates/doses documented in careview. no vent changes made. pt wiht rhoncherous bs bil and exp wheezes as well. suctioned ett for mod amts of thick yellow/green sputum. hr afib with rate of 80-100's without ectopy and sbp 40's to low 60's.foley in place with no uo this shift. pt is dnr/ but family will not withdraw ventilator support b/cause of religious beliefs. continue with present medical management. pt's husband and son in to visit at bedside for short period of time today. will continue to support family members,\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611845, "text": "Smicu nsg progress\nS/O- Remains unresponsive with minimal bp. Still with no urine output. Remains on ventilator without change.\nA- No change\nP- . family support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611846, "text": "Resp: Pt remains on intubated and vented on a/c 16/450/50%/+5. ETT #7, 22 lip. BS are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. No abg's or changes noc. Will continue full support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611847, "text": "nursing progress note: pt is DNR comfort measures only\n\nneuro: pt remains unresponsive. only response was biting et tube upon suctioning and inc resp rate with bathing. pupils 1 mm unresponsive to light.\n\ncard: bp 40-60 sys rate 80-100 afib with rare pvcs\n\nresp: remains vented with 16 bpm, 50% o2, 5 peep tv 500 CMV\nsuctioned by resp care.\n\ngi: htpoactive bs, no bm this shift\n\ngu: renal failure, no output this shift. intake is only iv meds infusing\n\nskin: duoderm patch to in place, arms edematus and weeping serous fluid. otherwise no other breakdown areas\n\nmeds: ONLY CHANGE MADE WAS TO CONCENTRATE MIDAZOLAM TO 250 MG IN 125 CC.\n\nFAMILY SUPPORT: SON\n called and asked to be called if death seems immediatly eminent.\nhusband not in due to sabbath.\n\nplan> support to family and maintain measures for pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-05 00:00:00.000", "description": "Report", "row_id": 1611848, "text": "Respiratory Care Note\nPt remains on AC as noted. BS coarse bilaterally. Pt suctioned for moderate amts thick yellow-green secretions. No vent changes. Plan to continue with current rx plan.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-06 00:00:00.000", "description": "Report", "row_id": 1611849, "text": "Progress Note 7p-7a\nNeuro: Pt. remains sedated with versed/fentanyl. Pt. unresponsive. Pupils 1mm and brisk bilat. No purposeful mvmt. noted.\n\nCVS: SBP remains 40's to 60's. HR 70's to 90's - AFIB. 4+ pitting, weeping edema. Pulses difficult to palpate.\n\nResp: Remains intubated. On ventilator: 50%/5/500. Thick green/tan secretions with suctioning. Insp/Exp wheezes present with auscultation of breath sounds.\n\nGI: Bowel sounds remain hypoactive. OGT in place and clamped. No BM noted this shift. Pt. remains NPO.\n\nGU: Pt. in renal failure. No urine output this shift.\n\nSkin: Duoderm remains over . Otherwise .\n\nAccess: R IJ Dialysis cath, L IJ central line.\n\nPlan: Pt. remains DNR/. Family continues to refuse withdrawal from ventilator d/t religious beliefs. Continue with support to family and pt. comfort.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611813, "text": "npn 7p-7a (see also carevue for objective data)\n\nPt admitted to ICU ; pt remains seriously ill; family has been discussing pt's prognosis since and direction of care; consulting with family's religious guidance re end of life issues;\nPt made DNR yesterday, ; pt remains on fentanyl and versed for comfort;\n\nPt remains unresponsive except for opening of eyelids to noxious stimuli; no eye tracking observed; no spontaneous movements observed;\n\nRemains in a-fib with controlled ventricular response; b/p adequate, vasopressors remains off; b/p does trend down when not stiumlated for awhile; when turned or stimulated, sbp goes up to 110's, even 130's with noxious stimuli;\n\nVentilator support witout changes; O2 sats remain in 90's;\nContinues on tube feedings at this time;\n\nturned approx. q 3 hrs to prevent further skin breakdown; duoderm on ; skin remains with much interstitial fluid; no more SQ FS's or injections per plan;\n\nPLAN:\ncontinued plan of care MD team and Family\nDNR\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611814, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnoc. MDI's DC'd. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-27 00:00:00.000", "description": "Report", "row_id": 1611815, "text": "NPN\n\nPt remains sedated, the fent was increased to 350mcg/hr and the versed to 12 mg/hr. She had been opening her eyes with any care and now she does not, she appears comfortable. Her husband has been in the room since 11 am. The PEEP was decreased to 5k, her 02 SATS have been 100%, overbreathing the vent by 1, she conts on comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-28 00:00:00.000", "description": "Report", "row_id": 1611816, "text": "S/MICU Nursing Progress Note\n Pt remains on the vent with settings of 450/16/50/5 sedated on fentanyl 350mcg/hr and versed 12mg/hr, BP and HR elevates with care, turning requiring some boluses of meds. Pt DNR\n Cardiac: HR 80-100's afib, with rare PVC, BP ranged from low of 90 to 130/'s\n GI: Tf of deliver with promod rate at 35cc/hr abd firm hypoactive BS, fair amount of oral drainage, creamy purlent, difficult to give mouth care as pt is still clenching her jaw. +loose stool.\n social: son called and updated on his mother. states her other son is trying to come home on Sunday.\n Plan: goal is comfort care. Per husband and rabbi with feeding and vent support.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-28 00:00:00.000", "description": "Report", "row_id": 1611817, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..no changes made today..\nSuctioned for large amts tan secretions. Large amt of oral secretions..often blood tinged. Sats in high 90's..rare spont rr.\n Cardiovascular: BP on lower side this am..in 80's..by late afternoon..in the 60's. A-line dc'd..following with NBP More tachycardic..?d/t fever..\n ID: Febrile..given tylenol\n GI: TF continue..no stool..\n GU: Poor u/o..<10cc hr.\n Pt remains comfort care..on 350 mic fentanyl and 12mgm versed..appears comfortable.\nHusband in and son from called..updated.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611698, "text": "Addendum to Nursing Progress Note\n Cardiac: Pt dropped her HR to 48 at 1500 with a drop in SBP to 88/ treated with suctioning and NS instill, slight improvement in hr up to 60's with BP up to 90-100/ started on hydralazine tonight to tx afterloading her.... unable to given 1800 dose. EKG done after episode of bradycardia.\n Plan: vagal response. cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611699, "text": "FULL CODE Contact precautions - MRSA in wound\nAllergies: PCNs, Sulfas, Clindamycin and keflex\n\n\nNeuro: Opens eyes/grimaces to stim w/ sucioning, turning, etc. Does not track or follow commands. Does not move extrems. Versed at 4mg/hr and fent at 100mcg/hr. Pupils pinpoint.\n\nCV: HR at beginning of shift was 40-50s, SB w/ no ectopy and SBP was 88-90s/. No intervention and BP came up to 140s/50s and HR to 60-70s. Started on hydralazine 10mg q6hr to reduce afterload. Procainamide stopped at midnight and started on po. Weak periph pulses, hands and feet cool bilat. +anasarca., scleral edema.\n\nResp: PVC 60%, RR=26, P=18 and Vt=500. ABG=7.39/28/94/-. Sx for thick bloody secretions. Lungs clear bilat earlier in the shift but coarse now and sx more freq for same bloody secretions - brown/tan oral secretions. At 0400, pt dropped SBP to 88/ for no apparent reason - pt stimulated, sx'd and BP up to 100-110s since.\n\nGI/GU: abd firm/distended, hypo BS. NPO. Pt stooled x2 small amt thick brown BM. NGT to LCWS, draining small amt dark brown bilious drainage - heme +. Foley cath w/ << u/o - 0-30cc/hr. HOs aware. No rx ordered at this time. BUN/Cr: 71/1.6 (sl ^ from yesterday's labs)\n\nPain: Fent and Versed gtts.\n\nSkin: Acquacell drsg , R leg calf still w/ large hematoma - seen by surgery tonight for calf.\n\nID: Tmax 99.3, not on antibx.\n\nEndo: FS range from 89-133 w/ insulin gtt at 1.0 unit/hr. HCT=27.7 (down from 28.9)\n\nPlan: Monitor resp/cardiac/neuro status. Drainage from NGT and ETT bloody.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-28 00:00:00.000", "description": "Report", "row_id": 1611700, "text": "Resp. Care Note\nPt remains intubated and vented on PCV settings as charted on resp. flowsheet. Vent changed this shift included driving pressure reduction from 25-22 and FiO2 decreased from 60-55%. Acceptable ABG's with these changes. Cont to receive Albuterol and Atrovent Inhalers Q vent check, sxn for blood tinged secretions. Stable on present settings, follow ABG's, wean FiO2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611762, "text": "RESPIRATORY CARE\nPt remains on mechanical ventilation, oxygenation remaining a high priority issue. Increase in PEEP as well a decrease in Vt as a result of ABG results. Breath sounds diminished throughout.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611733, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated and vented on settings 500/20/0.5/8 suctioning for thick creamy blood tinged sputum q3-4hr. BS remain coarse throughout. O2 sat cont 98-100%.\n Cardiac: Hr 80-100's ST with frequent APC's received lasix at 2200 and output averaging 50-100cc/hr. still total body edema.\n GU: foley again leaking in large amounts. replaced foley again. only leaking in sm amts. urine clear.\n GI: abd distended. +BS, no stool. low residuals on TF only 20-30cc, cont on nepro with promed at 35cc/hr.\n SKIN: rash in groin area, improving. less reddened. cream and powder applied. numberous areas of eccymotic areas. right calf area, lower area of abd... ?from SC heparin, right chin area. and right shoulder area.\n Neuro; pt cont on sedation of versed 1mg/hr and fentanyl 50mcg/hr with fair response, pt will open eyes to name, moves left arm better than right but will move right arm... both very edeamtous. .. difficult to move. bolused once for replacing foley as pt grimacing during procedure.\n ID: afebrile. cont on vanco(dosed last night) and atroeznam. MRSA in sputum and yeast in urine. (yeast in groin on supporitories)\n SOcial: updated via phone tonight.\n Plan: ?cont to diuresis as long as pt tolerated, monitor I&O's closely. attempt to wean vent further.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611734, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes overnoc, though increased FiO2 this am for poor PaO2. BS's coarse, sxing bloody secretions. Administering Albuterol and Atrovent MDI's in line with vent ~q4hrs. See flowsheet for further data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611735, "text": "Respiratory Care Note:\n There are no vent changes to note. BS remain coarse and wheezy at times. She continues to be suctioned for moderate amounts of thick brownish-blood tinged sputum. ABGs maintained without increased support despite fever and need for dopamine at times. Plan to continue monitoring and maintain support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611736, "text": "NPN\n\nNeuro: Remains on fent 50 mcg/hr and versed 1 mg/hr, more sedate than when I saw her on Monday, she only required 1 fent bolus on 50 mcg for fighting the vent.\n\nCV: Her BP dropped this morning to the low 70s, temp 100.8, she was started on dopa but with in a few hours she started to have short runs of Afib and then went into a rapid (~ 150) SVT; she was changed to levo. Her SBP has since been 90s-120s, levo is on .08 mcg/kg/min. She remains in afib, her K was repleated, she was given 2 units of blood for a HCT of 25.\n\nResp: No changes were made on the vent, conts to have thick, old bloody secreations.\n\nGI: Her residuals were as high as 150 today, she was given lactulose - no results yet, she had 65cc on her last residual check. TF changed to 3/4 strength nepro with 40 gms of promod.\n\nGU: U/O ~ 20-45cc/hr, no plans for CVVHDF per renal due to her hypotention. A u/a was sent - it showed 53 WBC, mod bacteria, many yeast.\n\nHeme: HCT was 25, given 2 units of PRBC, she bled from her SC line - this stopped after 10 min of pressure.\n\nEndo: Conts on an insulin gtt, her BS have been high today, she is up to 4 units/hr.\n\nID: T max 100.8, u/a sent showed many yeast, mod bacteria, and 53 WBC, fungal clx were sent.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1611737, "text": "Correction - Pt is on strength Deliver with 40gms of promod - goal rate of 35cc/hr\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611763, "text": "MSICU NPN 0700-1900\n\nPlease see flowsheet for further details...\n\n\nRemains sedated on Fentanyl and versed gtt. No changes made. Grimaces with stimuli. No spont mvmt. Anasarca continues.\n\nOn CVVHD. Tol well. Able to wean Levophed off without problem. UO has progressively decreased. Currently she is anuric but is 1228cc neg since midnight. 1 interruption in therapy d/t clotted filter. Resumed without problem. Is now being ultrafiltrated only. Labs pnd. Miscellaneous (not measured) output of mod-lg amt of PO secretions as well as mod-lg amt of serosanguinous drainage from around L SC. Dialysis cath oozing sm amt blood.\n\nAfebrile. On steroids. Previous sputum growing 3+ GNR. Given Gentamycin x1. Will need trough at 1100 tomorrow. No other antibiotic changes made.\n\nABG w/PaO2 56 despite O2sat via oximetry of 97-98%. PEEP increased to 15cm (from 12) with increased PaO2 to 60s. ABG pnd. Suctioned q4-6hrs for sm amt brown sputum. PIPs 50s. Overbreathing vent at times w/ spont RR 4-8.\n\nTFs at goal rate. Promod increased d/t improved renal function. No stool via mushroom catheter. Hypoactive bowel sds. Abd remains firm and distended. Lactulose given x1. Previous stool sample C-diff +.\n\nHusband in all day. Updated by MD. called.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611764, "text": "Smicu nsg progress note\nNeuro- Well sedated on 170mcg/hr fent and 5mg/hr versed. Requiring only one additional bolus of fent when turning pt. Does grimice with any stimulation. No spontaneous movement of extremities noted.\nResp- Remains intub/vented on ac 470x28 60% 15peep breathing above with 02 sats 99-100%. Abg 82/38/7.41. Suctioned for sm amts thick tan secretions via et bloody secretions from mouth. Oral ulcers noted. Et tube rotated and bite block applied.\nCardiac- Bp remains stable off levo (see flow sheet) Able to maintain cvvhd goal of -100cc/hr. Pt ~1700 cc neg at 12m. Cont with total body anacarcia weeping from iv sites/arms/legs. Lytes remain stable.\nRenal- Cont on cvvhd- hemofiltration only/no dialysate. Bun/creat stable at 68/1.2. Cont with minimal urine output. Lytes/cal stable.\nGi- On goal tube feeds. Passing sm amt liquid brown stool via mushroom cath.\nId- T-max 97 ax. Blankets appied. No changes in antibiotics. 1000mg vanco- level 13.5. Will need to check random gent level at 11am .\n" }, { "category": "Nursing/other", "chartdate": "2152-07-14 00:00:00.000", "description": "Report", "row_id": 1611765, "text": "RESP CARE: Pt remains orally intubated/on vent on settings per carevue. PIPs high this shift 40-55. Dysynchronous breathing pattern noted,No auto-peep. ABGs acceptable but Pa02 only 75 on 15PEEP/.60FI02. Lungs coarse bilat. Sxd thick tan bld tinged sputum. ETT retaped/rotated and new bite block placed at lip line 22. Continue full support\n" }, { "category": "Nursing/other", "chartdate": "2152-08-02 00:00:00.000", "description": "Report", "row_id": 1611836, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift, sats at 100%. for small amounts of thick tan secretions. current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611837, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 5. Bs coarse with few rhonchi bilaterally. Sx'd for sm amounts of thick yellow secretions. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611793, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. No vent changes made this shift. Cont to receive MDI's as ordered, by RN for thick secretions. Cont current vent support, no weaning planned as peep level remains at 12.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611794, "text": "micu/sicu nsg note: 7:00-19:00\nthis is an 80 y.o. woman adm originally to 12 from epic rehab hospital for elevated bun of 80, dehydration with hx dm, recent uti. pt developed hypercarbic resp failure and was intubated for management of chf. pt has been difficult to wean from vent currently on same settings as previous shift per team plan (see resp). pt has received cvvh with last course from -am of until system clotted off and pt was trialed on lasix gtt. pt currently on lasix gtt until machine and supplies ready for restart of cvvh. pt remains full code with cpr not indicated.\n\nneuro: pt remains sedated on fentanyl 300mcg/hr and versed 10mg/hr appearing comfortable at rest but grimacing with repositioning and suctioning requiring boluses with good effect. perrla pinpoint and brisk. opens eyes to suctioning and repositioning, otherwise no movement noted.\n\ncv: hr ranging 70s-low 100s afib with occas pvcs in pm. awaiting pm k results. sbp ranging 80s-130s with levophed titrated up to .030mcg/kg/min. continues with generalized anasarca, weeping small amts serous fluid from l arm. + pp. remains on iv lasix gtt (see gu).\n\nresp: remains intubated on ac: fi02 50%, tidal volume 450, rr 16, 12 peep. lungs coarse t/o. suctioned via ett for small to moderate amts very thick white secretions requiring ns instillation q2-4hrs. also suctioned small amts whitish clear blood tinged secretions from mouth with small tip catheter as pt clenching teeth together making it hard to suction with yankauer. pt not biting down on tube, has some missing teeth. frequent mouth care given.\n\ngi/gu: abd firm, distended, +bs, tolerating tube feedings at goal rate of 35cc/hr with 10-50cc residuals via ogt that was replaced yesterday and reconfirmed via cxr. had lg brown liquid stool in am inc. on pad as mushroom cath found out. new mushroom cath reinserted with 400cc liquid brown ob negative stool. lactulose held but continues on reglan and narcan iv as pt remains on high dose narcotics and was recently having min bms and was off tube feedings when found to have asp when prior ogt was found in the esophagus. foley patent draining poor u.o. in am down to as low as 15cc/hr with iv lasix gtt increased to 8 units/hr. u.o. now remains > 30cc/hr but pt still remains positive with +470 last 24hrs and + los. awaiting cvvhd machine and supplies to restart cvvh per team. cr also starting to rise, currently at 1.4.\n\nskin: with duoderm with skin care rn up to see wound but not due to be changed today so per wound care rn, duoderm remained on. per skin care rn, wound was last seen to have pink stage 2 area with small amt serosanguinous drainage-cleansed with wound spray cleanser followed by aquacel over wound and covered with duoderm. abd with bruising from heparin sc injections noted. weeping from l arm with pad around l arm.\n\nid: t max 97.8 ax, remains on iv meropenem day #7 for pseudomonas, po flagyl day #11 for cdiff. pt was recently tx'd with vanco and aztreonam empir\n" }, { "category": "Nursing/other", "chartdate": "2152-07-21 00:00:00.000", "description": "Report", "row_id": 1611795, "text": "micu/sicu nsg note: 7:00-19:00\n(Continued)\nically for likely vent associated pna. pt was also recently tx'd with fluconazole for yeast in urine. bld cx negative to date.\n\nlines: quad lumen l ij placed , l rad. aline placed , r ij quinton cath placed . all lines .\n\nsocial: husband in to see pt for a few hours early this afternoon and briefly spoke with ethics md dr. re: issue of continuing all care for pt. husband verbalized to myself and dr. that he doesn't know what his wife would have wanted for care/if she would have wanted to continue to live on vent, have cvvh and other invasive procedures despite not much improvement in pt's condition. husband also verbalized he wishes to continue with all care as he feels he cannot make the decision to stop this care. this rn gave update to pt's son in . no contact with son in . this rn encouraged husband to contact to come in to see his mother in this condition as it has bveen a few weeks since has last seen his mother per husband. Dr. is available by page this weekend if staff and or pt's family needs to speak with him for support.\n\nendo: fs down to 69 this am with insulin gtt off, restarted when >100 and currently infusing at 4 units/hr. received full dose lantus this pm as pt now at goal rate of tube feedings and tolerating well.\n\nplan: start cvvh this pm when machine/supplies available. continue iv lasix until cvvh started. monitor lytes. continue vent settings with no current changes and reassess in am, continue iv sedation and give boluses with repositioning to maintain comfort. continue to monitor bld glucose q1hr with insulin ss- ? change over to ssri in am if bld sugars remain stable overnight. continue iv/po abx, monitor temp, consult dr. prn for support. encourage son to see pt if he calls, pt remains full code with no cpr indicated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611796, "text": "NPN 1900-0700:\n\nEVENTS: CVVH intiated and Lasix gtt stopped. Weaned off Levophed.\n\nROS:\nNEURO: Pt remains sedated on Fentanyl and Versed gtts; rates increased d/t pt appearing uncomfortable. She has also required boluses for turning/bathing. No spontaneous movement; extremities very stiff (possibly at least in part d/t fluid overload). Pupils pinpoint and reactive.\nRESP: PEEP decreased to 10; no other vent changes made. Most recent ABG 7.39/43/100 on CMV .5/450/16/10. Minimal secretions despite NS lavage. LS slightly coarse at times, diminished at bases. CXR to be done this AM.\nC-V: HR and BP gradually increasing overnight, ? d/t undersedation. Fentanyl and Versed gtts increased; will monitor response. Levophed gtt weaned off. Remains in afib with occasional PVC's. Lytes WNL.\nID: Afebrile, WBC increased to 17.4 (10.4). Cont's on same abx.\nGU/RENAL: Lasix gtt stopped and CVVH initiated at 2130 with goal PFR of 100cc/hr (not being dialyzed). She has tolerated this very well and there have been no problems with the system thus far. U/O ~20cc/hr on Lasix, now <10cc/hr. BUN/creat down a bit to 63/1.4.\nGI: TF's at goal of 35cc/hr; continues to tolerate this well. OGT clogged a couple of times and was cleared with Coke. Remains on numerous bowel meds, passing liquid brown stool via mushroom catheter.\nHEME: no active issues\nENDO: Insulin gtt currently at 1u/hr; FSBS stable and within desired range.\nSKIN: Remains anasarcic; Duoderm remains on ; skin otherwise .\nSOCIAL: no calls or visits\nACCESS: RIJ Quinton, LIJ quad lumen, L radial a-line\n\nA: tolerating fluid removal; improved oxygenation; off pressors; increased sedation needs\n\nP: Ensure pt comfort; continue CVVH for goal PFR 100cc/hr as tolerated; follow lytes q6 hours, particularly Ca++; follow temps and use Bair Hugger prn; consider changing to SSRI given minimal insulin requirements; wean PEEP/FiO2 as able; continue bowel meds prn. Plan to revisit goals of care on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611797, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. Bs coarse bilaterally. Sx'd for sm amount of thick white secretions. Albuterol/Atrovent MDI given Q4hr. Peep weaned to 10. Abg's within limits with PaO2 100. Current vent settings Vt 450, A/c 16, Fio2 50%, and Peep 10. ETT retaped 22cm/lip on L side. No further changes made. Continue with mechanical support and wean peep/A/c rate as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611798, "text": "ADDENDUM:\nCVVH system clotting; new system primed and started at 0700. A-line becoming very positional, NBP utilized. BP dropping, so Levophed restarted at previous rate of 0.030mcg/kg/min.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611695, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS VARIED WITH A RANGE FROM 122/54-161/68. CM PATTERN HAS REMAINED SB/SR WITH H/R RANGING IN THE 50-60 RANGE. NO ECTOPY NOTED NO AFIB/FLUTTER THROUGHOUT SHIFT. CVP 21-23 RANGE. PPP BILAT, PT HAS 3+ PERIPH EDEMA IN THE HANDS AND FEET. PT RESTARTED ON PRONESTYL GTT AT 2MG/MIN. ECHO ORDERED FOR TODAY.\n\nRESP: REMAINS ON PCV WITH FIO2 OF 50%, INS PRESSURE OF 35, RATE OF 26, SAO2 HAS BEEN 97-100% WITH VOLUMES OF 363-445. SX SEVERAL X FOR LG AMTS OF THICK REDDISH SECRETIONS. LUNGS COARSE THROUGHOUT BUT ARE CLEAR FOR SHORT PERIODS OF TIME AFTER SX.\n\nNEURO: SEDATED ON VERSED 4MG/HR AND FENTANYL 100MIC/HR. PUPILS 2MM BIL AND SLUGGISH. DOES NOT FOLLOW COMMANDS, WITHDRAWS TO PAIN.\n\nGI/GU: PT ACID 50 MG. U/O TENDS TO DWINDLE AND THE GOAL IS TO DIURESE PT. FOLEY IS PATENT AND NO LEAKING NOTED. ABD IS FIRMLY DISTENDED. PT WAS ON PREVIOUS SHIFT FOR LG AMT OF HARD STOOL. ABD STILL REMAINS FIRMLY DISTENDED. NPO WITH VERY HYPO BS.\n\nENDO: INSULIN GTT OFF, BS RANG FROM 82-117. GOAL IS TO KEEP BS BETWEEN 80-120.\n\nSOCIAL: HUSBAND DOES COME IN AND SPEND TIME WITH PT DURING THE DAY, VERY CONCERNED ABOUT THE HEALTH OF WIFE. SONS CALL IN FOR UPDATES.\n\nPLAN: CONT TO SUPPORT PT ON VENT UNTIL PT IS ABLE TO TOL WEAN. MONITOR LYES AND REPLENISH AS NEEDED. FOLLOW HCT AND PROVIDE BLOOD RPODUCTS AND NEEDED. PROVIDE EMOTIONAL SUPPORT TO FAMILY WITH UPDATES. CONT TO DIURESE PT.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611838, "text": "S/MICU Nursing Progress Note\n PT on same vent settings, suctioning thick tan/green sputum. BS remain coarse through out. settings 450/16/50/5\n Cardiac: HR 90-110's afib, BP hovering at 40-50/40's remains sedated on fentynl and versed. no urine output.\n GI: abd distended and with residuals. no feeding as now.\n Social: husband aware of low BP, son still with his father. went home pt conts DNR\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611839, "text": "d: pt'd status unchanged. fentanyl gtt at 375 mcg/hr and versed at 14 mg/hr. pt unresponsive to verbal or painful stimuli. vent settings unchanged: 50%/450/ac 16 and 5 peep with o2 sats of 100%. no weaning of the vent done per recommendations of pt's rabbi who states that pt experiencing air hunger is not comfort. suctioned ett for sm amts of thick tan/greenish sputum. coarse bs bil on auscultation. foley cath in place and pt anuric. pt's husband in today and his son has espressed concern that his father is depressed. have been ordering kosher meal at lunch for pt's husband and have kept him updated. hr in the 80's afib and sbp 44-60. pt is dnr/ . not drawing labs,giving tuube fdgs b/cause of high residuals in the past. pt also not receiving ivf because of total body fluid overload and renal failure. continue wiht present medical management.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-03 00:00:00.000", "description": "Report", "row_id": 1611840, "text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. No vent changes made. for thick tan secretions, current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611841, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. O2 sats 100%. Vent settings unchanged. Vt 450, A/c 16, Fio2 50%, and Peep 5. Sx'd for sm amount of thick yellow secretions. ETT retaped 22cm/lip. Bs coarse with few rhonchi bilaterally.\nPlan: Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611842, "text": "Smicu nsg progress note\nS/O- Status remains unchanged. Unresponsive on fent/versed gtts with bp 40-50s. Remains ventilated with no changes made. Suctioned for thick yellow/tan secretions. Copious nasal/oral secretions. Still with essentually no urine output.\nA- Unchanged\nP- with . to support family.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-04 00:00:00.000", "description": "Report", "row_id": 1611843, "text": "Respiratory Care Note\nPt remains on AC as noted with no changes. BS rhonchi with slight exp wheezes bilaterally. Pt suctioned for moderate amts thick yellow-green secretions. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611799, "text": "Smicu nsg progress note\nNeuro- Remains sedated on 350mcg fent and 12 mg midaz. Cont to grimise and bite down on tube with increasing bp when turned but easily settles. No spontaneous movement noted.\nCardiac- Bp stable on .03mcg levo. No attempt to wean levo at this time. Will cont while on crrt and wait for family meeting on Monday to discuss further tx. Pt has become hypotensive in past when levo d/c'd.\nResp- Intub/vented. No changes made in ventilation. Abg/02 sats stable. Suctioned for minimal secretions. Cont with oral ulcers. Very difficult to do mouth care or suction mouth as pt bites down cramping jaw. Unable to place oral airway at this time.\n Pt crrt thoughout day. Able to maintain goal of 100cc neg. Pt 1600 cc neg by 1600. By 5pm clots noted in system with increasing pressures. Will d/c cvvt for night and restart in am. Lytes remain stable.\nEndocrine/Gi- Insulin gtt d/c'd for fs 63. Will hold on gtt and cover with s/s and fixed dose glargine in pm. Cont on goal tube feeds. Passing mod amts liquid brown stool.\nId- remains afebrile. No changes in antibiotics\nSocial- No family in to visit today. No calls. Plan for family meeting on Monday to discuss further care.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-22 00:00:00.000", "description": "Report", "row_id": 1611800, "text": "Resp Care\n\nPt remains intubated and on full vent support. No changes made during the shift. BS are coarse with small white sputum being suctioned. receiving albuterol/atrovent as ordered\n" }, { "category": "Nursing/other", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 1611686, "text": "Resp Care Note, Pt placed on Pressure Control ventilation overnight due to ^ PIP'S. Bleedind from ETT lrg amts thick bldy secretions. Also ^ sedation.Sedated with fentanyl and versed. MDI'S given. ABG'S improving.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 1611696, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt remains intubated with settings of PCV driving pressure of 25cm, PEEP of 10 inserted esphogeal balloon and increased PEEP to 15cm ABG remained hypoxic with p02 57 increased PEEP to 18cm. O2 sat have been 93-95% now are presently at 98-99%. suctioning thick blood tinged sputum. plugs at times. Bs cont to be coarse throughout. with fine crackles at the bases.\n Cardiac: HR 60-70 NSR, with occasional APC, BP 110-130/60-70's erthynic acid 100mg given with fair diuresis, Output is -177cc for shift. Is LOS +660cc. serum K 4.8 Cardiac Echo done this morning. showing MR,(+), AR mild,\n GI: abd remains firm, +BS, milk & molass enema done at 11am, without much results, difficult to pass the emema, lactlose given x2, and placed on LIS to help decompress abd.\n GU: foley in place BUN68 Creat 1.4 unchanged in the past 24hr.\n Nuero: sedated on Versed, and fentanyl. bolused for activity, and care. will open eyes to pain, no spont movement of extremites.\n Skin: skin RN to evaluate sacral wound her recommendations are to use aquacel in the wound then douderm over the site... changing Q3days. skin anascara, noted hematoma on the right leg under the pnuemoboot sleeves. stopped the pnuemoboots and there is a 4x4 hard area mid calf. Md aware.\n Family: husband in visiting, in contact with sons and via phone today. updated.\n Plan:Cont to diuresis, monitoring I&O's need pt to stool. decompress abd. monitor ABG's adjust vent accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-13 00:00:00.000", "description": "Report", "row_id": 1611760, "text": "Respiratory Care:\nVentilatory parameters manipulated to compensate for decreased PO2 and increased hypercarbia. Final settings at this time consists of A/C mode, 500 X 28 X 60%, 12 cm PEEP. Last abg results on 30 BPM, revealed a normal acid-base balance with moderate hypoxemia. Rate was brought down in an attempt to lower the PIP, while maintaining the acid-base balance.\n\nNo RSBI measured due to the level of PEEP and FIO2 currently required.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611719, "text": "NPN\n\nNeuro: Pt conts on 50 mcg of fent and 1 mg of versed, she was occationally arrousible, not following any commands, she was given boluses of 50 mcg fent and 2 mg versed for aggitation.\n\nCV: VSS stable, SBP 100-120/50s, HR 60s-70s, started on amiodorone today for hx of aflutter. She was tolerating the CVVHDF, though it clotted off x2 (within a half an hour after restarting it) and it is now off. K was repleated - repeat K is pending.\n\nResp: Remains on A/C, no changes were made, conts to have bloody secreations. She has a bloody secreations from her mouth most likey from her bloody lip. She was going to be bronched today but the machine was not working properally.\n\nGI: She was given lactulose - she had a BM today, loose, golden, slightly OB pos. Her ABD conts to be distended and somewhat firm though less firm than yesterday. Her TF were off for part of the day for the bronch - they are now back on.\n\nGU: U/O 0-15cc/hr, she was tolerating with the CVVHDF with a SBP of 100-120 though we were only able to keep her fluid status even. Her CVVHDF pressures were ok, when she suddenly clotted off, the machine was restarted but clotted off within 30 min - we will wait until tomorrow to talk with renal, they may want to use citrate.\n\nEndo: Conts on an insulin gtt to try and maintain a BS of 80-120.\n\nSoc: Her husband was in for much of the day.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611720, "text": "Respiratory \nPt remains on same a/c settings 500/20/12peep/50%. Pt continues to have mod to large amts of bloody secrections. Attempted bronch today, however cancelled due to poor visibility of bronchcart. IP notified.\nCVVHD stopped due to clotting of machine. Will continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611721, "text": "S/MICU Nursing Progress Note\n Respiratory: pt remains intubated with settings of A/C 500cc x 20 breaths spont RR 0-6 over the vent. PEEP 12cm, Fio2 50%. suctioned q3hr for thick bloody sputum. BS cont to be coarse throughout. sedation fentanyl at 25mcg/hr and versed at 2 mg/kg.\n Cardiac: Hr 60-80's NSR with frequent to rare APC, BP ranged from a low of 80/ to 120/ increased with stimulation. started on Arimorine 200mg po. with episode of Hypotension at midnight pt was due for antibx so did recievd a fluid bolus with fair response.\n GU: foley in place, urine cloudy yellow in color. ua and culture sent tonight. output averaging around 10-15cc/hr. cont off the CVVHD to be re-evaluated today.\n GI: abd distend, +BS sounds, stool x 1 mod amount.\n ID: temp max, 101.6 cultured, blood x2, and urine sent. started on aztroenam and vanco.\n Skin: remains on kinair bed. eccymontic areas note in the right upper arm, right calf, douderm over sacral decub.\n Ednocrine: cont on insulin infusion, titrated to FS level\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 1611722, "text": "Resp Care\nPt. remains intubated/sedated overnight with no vent changes overnight.\nBs: coarse rhonchi t/o, cleared with sxn. Scattered exp. wheezes tx'd with mdis as ordered. Sxn'd copious amts. of thick bloody.\nabgs:within acceptable parameters.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611864, "text": "Status quo! Patient remains on mechanical ventilation with good sat. No recent ABG drawn,DNR,DNI,BP labile @ 62/24.Pilot ilne has a hole was clamped for 2 days,self repaired clamp is removed.BS wheezy,some rhonchi,suctioned for small amount of secretion.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611865, "text": "Progress Note 7p-7a\nNo change from previous assessment. Pt. remains unresponsive. Sedated with fentanyl and versed. Intubated and on ventilator 50%/500/16/5. Thick yellow secretions noted with suctioning. Pt. remains in A-fib with rate 80's to low 100's. SBP 50's to 70's. Pitting/weeping edema throughout trunk and limbs. Pulses difficult to palpate. Abd. distended. BS absent. Pt. remains NPO d/t absent BS and increased residuals. OGT remains in place. Foley with no urine output. Pt had R IJ dialysis cath and L IJ triple lumen central line.\n\nPlan: continue with DNR/DNI status including no lab draws. Continue to provide support to family.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611866, "text": "Resp: Pt remains intubated on a/c 16/450/+5/50% with no changes. Bs are coarse bilaterally, suctioning for moderate to copious amounts of thick greenish/yellow secretions. Pilot ballon is presently patent with Vt's 500's, 02 sats 98%. No abg's. Will maintain support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611867, "text": "NPN 0700-1900\nNo change from previous assessment. Pt remains unresponsive, sedated with fentanyl and versed IV. Contiues on CMV see careview for settings, HR 80-105 Afiv. MAP 30-40's. Continues with general Anasarca. Remains NPO d/t absent Bowel Sounds. Foley with 7cc total UO for the day. DNR status.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-10 00:00:00.000", "description": "Report", "row_id": 1611868, "text": "Respiratory Care\nPt remains on a/c vent without changes. BS coarse, suctioned for moderate amts of thick yellow. Code status remains dnr.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-11 00:00:00.000", "description": "Report", "row_id": 1611869, "text": "Progress Note 7p-7a\nNot significant events this shift. DNR/DNI status . Pt. remains sedated with versed and fentanyl. No response noted. Pt. remains intubated and on ventilator. No ventilator changes noted. Pt AFib with rate 70s-90s, SBP 50's throughout night. Pitting/Weeping edema. NPO. OGT in place. Foley with no urine output. Skin at this time. redness on . L IJ TL central line patent. Continue offering support to pt. and family.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611714, "text": "NPN\n\nNeuro: Pt is arousible at times, able to have some purposful movements, other times she is very sedate. She conts on fent at 50 mcg/hr and versed at 1 mg/hr, I gave her one bolus of fent of 2 mg and fent of 50 mcg for coughing which set off the CVVDHF.\n\nCV: She dropped her SBP to a low of 79 today and a mean to 47, she seemed to do this when I was trying to take off some fluid (50cc/hr). At present her PFR is 0, renal and the team are aware and are in agreement since she does not appear to tolerate any fluid removal. She has not been hypotensive since we have stopped removing fluid with the CVVHDF, if she does become so than the plan it to give her blood (her HCT was 27). Her CVP has been 15-23, she conts to have anasarca.\n\nResp: Remains on A/C 500x23/.4/12 PEEP. Her secreations are old blood - a speck was sent. If her Pa02 tolerates it than we can continue to decrease her PEEP.\n\nGI: ABD firm, pos BS, her TF has been off all day because her BP has not tolerated her being at 30 degrees semifowlers. No stool today.\n\nGU: Poor u/o, some hours she did not make any urine, her u/o has picked up a very little with the PFR at 0.\n\nEndo: Her BS has been 133-73, insulin gtt was titrated to keep her BS 80-120\n\nSkin: Her wound is covered in a duoderm, a kinair was ordered and she will be put on it today. She has been turned and she tolerates this.\n\nSoc: Her son called for an update.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-01 00:00:00.000", "description": "Report", "row_id": 1611715, "text": "Respiratory Care\nPt remains on A/C vent cont on cvvhd. Pt increased to 50% decreased rate to 20 abg pending. Pt continues to have bloody secrections after move to kinair bed, awaiting pt to settle down. Tube repositioned,MDI's as ordered will continue to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611716, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick bldy secretions.MDI'S given. Sedated with fentanyl.On CVVHD.HR-PAC'S.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611717, "text": "S/MICU Nursing Progress Note\n Events: CCVHDF cont filter changed x 2 for clotting\n Neuro: cont on the fentanyl 50mcg/kg/min and versed 1mg/hr requires bolus for turning in bed as pt is grimacing with all turns. will move her arms slightly on the bed. tryign to mouth words to staff.\n Respiratory: vented with settings of A/C 500cc tV rate of 20 PEEP of 12cm. FIO2 50% still suctioning blood sputum. coarse BS Right worse than left. (see carevue for ABG details)\n Cardiac: BP stable all night. range 110-130/60's HR 70-80 NSR rare APC or PVC,\n Renal: cont on CCVHDF have adjusted PRF to 70cc as BP has tolerated it. goal of neg 100cc/hr has not been reached. ended yesterday - 300cc and present is neg 200cc. system clotted x2 during the night. is making urine only about 10-15cc/hr. urine amber and cloudy. labs pnd this morning.\n Skin: sacral dsg changed today. still some moisture reapplied aquacel in the inner wound and duoderm over both. yeast rash noted in the groin and folds of skin.... nyastin powder applied. reddened area on the inner aspects of theighs... antifungal cream applied.\n Social: spoke with sons and both on mother's progress.\n Plan: cont to monitor. wean vent as tolerated. re-evaluate CVVHD follow labs as needed.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611774, "text": "NPN\n\nNeuro: Sedation was increased to 300mcg/hr fentand 10mg/hr versed due to her decreased VTs and worsening oxygenation (she was moving her mouth - this is one way to tell if she is under sedated). She has not been fighting the vent today as she did yesterday.\n\nCV: Levo was restarted, she has been on a low dose of .02-.04 for most of the day. She remains in afib in the 60s-70s.\n\nResp: Conts on A/C 400x28/PEEP 15, FI02 was increased to .7 from .6 for a Pa02 of 57 - last ABG was 7.42/36/65. LS diminished and coarse\n\nGI: ABD conts to be firm and distended, she conts on TF at her goal rate of 35cc/hr, no stool today, lactulose was given.\n\nGU: CVVHDF conts, she clotted off this afternoon, her replacement rate was increased to 1800cc/hr and can be further increased to 2000cc/hr if she conts to clot. We are trying to take off ~ 80cc/hr today and she has been tolerating this.\n\nEndo: FS were 70-120 this morning, this afternoon they started to increase, she is now back on an insulin gtt.\n\nSoc: Her husband was in today, we talked to him about why his wife is now CPR not indicated, also told him that the ethics team would be following this case to give another perspective to both him, his family and the team.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-16 00:00:00.000", "description": "Report", "row_id": 1611775, "text": "resp care\nremains oett/vented in ac mode. settings titrated per abgs, again with worsened oxygenation although stable on vent today d/t incr.sedation level. no significant episodes of dysynchrony. mdi's given q4h.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611776, "text": "Resp Care\nPt. remains intubated/sedated on mechanical ventilation,CVVHD. No changes made overnight.\nBS: coarse bilat. secreations minimal this shift.\nabgs:ess. normal parameters with exception of oxygenation which is marginal (considering .7 fio2/15 PEEP.)\nPlan: cont. support, pt. is now CPRNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611777, "text": "MICU NPN 1900-0700\nNeuro: Pt remains sedated on fentanyl at 300mcg/hr and versed 10mg/hr. Pt with facial grimacing, attempting to open eyes and increased resp effort with stimulation. Responds fairly to some supplemental bolusing.\n\nCV: HR 70's-90's, Afib with occassional PAC. Remains on .03mcg/kg/min levofed with BP 110's-120's/40's. Pt with MAP <60 when levo off. Cont on CRRT, running approx -50cc/hour. Filter changed at 0300 because of clotting. Lytes remain WNL, no dialysate running.\n\nResp: LS diminished throughout. Remains vented on AC 400x28, PEEP 15, FiO2 70%. O2 sat 98-100%, ABG's WNL. Suctioned for minimal clear secretions.\n\nGI: Abd firm with edema, +BS's. Tolerating TF at goal rate 35cc/hour via oral dobhoff. Mushroom cath in place draining small amount of brown liquid stool.\n\nGU: Remains on CRRT. BUN/cr improved, am labs pending. Foley draining 0-15cc/hour clear, yellow urine.\n\nSkin: Pt on kinnair airbed. Generalized edema. Turned and repositioned as tolerated. Pressure sore to healing well, aquacel dressing chaned with duoderm .\n\nEndo: Pt off of insulin gtt at 2300 after receiving 35units glargine at 1800 yesterday. BS's 80's-90's overnight.\n\nSocial: No family contact overnight. Pt's code status changed to CPR not indicated.\n\nPlan: Continue with supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-07 00:00:00.000", "description": "Report", "row_id": 1611856, "text": "NPN 0700-1900;\nPT APPEARS TO HAVE BITTEN PILOT LINE OF ETT CUFF, ABLE TO MAINTAIN INFLATION WITH CLAMP.\nHUSBAND SPOKE WITH RABBI , WHO HAD A CONVERSATION AROUND CHOICES HE COULD MAKE IN FUTURE, PLEASE SEE NOTE IN CHART FEELS THAT MR STILL HAS SOME FANCIFAL THOUGHTS AROUND MRS MAKING IT TO LABOUR DAY THEIR 51 ST WEDDING ANNIVERSARY.\n\nNEURO; SEDATED WITH VESED AND FENTANYL AT SAME RATE. REMAINS UNRESPONSIVE, NO MOVEMENTS SPONTANEOUSLY OR TO COMMAND. PERLA 1-2MM.\n\nRESP; SEE ABOVE, NO VENT CHANGES REQUIRED SATS R95-97 % SUCTIONED FOR SMALL AMOUNTS THICK YELLOW SECRETIONS.\n\nCVS; BP STILL 50-60/19-20. AFIB RATE CONTROLLED. PLEASE SEE CAREVUE FOR FURTHER DETAILS.\n\nGU; OLIGURIC. FOLEY REMAINS IN PLACE.\n\nGI; NO BS NO STOOL NO FLATUS. CONTINUES TO BE NPO.\n\nSKIN; WEEPING FROM ARMS LINEN CHANGED Q4 DUODERM ON .\n\nSOC; HUSBAND AT BEDSIDE DAY SONS AND COMING THIS EVENING.LISW STATED THAT IS AT HOME TRYING TO CLEAR UP AS HUSBAND DOES NOT APPEAR TO BE TAKING CARE OF THINGS AND LOOKING AT SOME FORM OF FOR FATHER.\n\nA/P CONTINUE WITH PRESENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611857, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings unchanged. Vt 450, A/c 16, Fio2 50% and Peep 5. Bs slightly coarse R lung, clear L lung. Sx'd for moderate amount of thick yellow secretions. 02 sats 96-100%. ETT secure and stable with clamp on pilot line. No volume loss. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611858, "text": "S/MICU Nursing Progress Note\n Respiratory: remains intubated on the same vent settings... 450/16/50/5 with O2 sat ranging form 97-100%. suctioning for thick cream sputum. BS coarse throughout. sedated on fentanyl and versed. bolused once for grimacing as turning.\n Cardiac: HR 80-100's afib, no VEA, BP range from 50-70/30's higher levels of BP after turning or stimulatioin.\n Renal: no urine output, remains total body anascara. oozing from arms and legs.\n GI: no TF as no stool no BS, high residuals via OGT.\n\n Social: husband and two sons in most of evening. still aware of prognosis. with supportive measures as family will not withdraw any further supports.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611859, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..no changes made. I/E wheezes noted. Suctioned for mod amts tan secretions..Continues to bite down on ETT at times.\n Cardiac: BP in 70/s..hr 90's af..occassional PVC\n GU: No urine output\n Neuro: Continues on fentany @ 375mic and movement of extremites..no response to name calling or noxious stimuli\n Social: Husband and son in..updated by Dr .\nPt remains DNR/comfort care.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-08 00:00:00.000", "description": "Report", "row_id": 1611860, "text": "Tracheostomy tube pilot line is still clamped.Patient bit the line yesterday during stimulation from bronchial hygien.Status quo,remains on same vent settings,labile BP,DNR,DNI.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-02 00:00:00.000", "description": "Report", "row_id": 1611718, "text": "addendum: Nursing Note\n Endocrine: wa on IVF insulin at 1.5unit/hr turned off for FS 57 at 5am. repeat in 30minutes was 78 .. insulin IVF still remains off.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611778, "text": " 4ICUNPN 0700-1900\n\nBecoming hypotensive to 80's. Levophed increased to 0.144. HR 70's 90's AF. No VEA noted. Able to wean levo to 0.021. (SBP drops to 80's when levo d/c'd)\n\nOn a/c 28 X 400 X60%, PEEP 15. ABG 7.51/33/69/27/3. No spont resp. Scant brown secretions. ETT not rotated because pt biting down on tube when attempting to suction mouth.\n\nCont on fent & versed gtts. Does not open eyes or follow commands. Extremities stiff.\n\nCont on CVVH. Goal 100 cc negative in AM. No fluid removed after pt becoming hypotensive. At 1800 when BP stable restarted slow fld removal (negative 30 CC hr)\n\nTF at goal. Large loose OB negative stool. Abd remains firm. Positive BS.\n\nGiven glargine 35U at 1800. BS 80's\n\nHusband in to visit throughout the day. He was updated by this nurse.\n\nA/P; Decrease rate to 24. Chack ABG.\n\nTitrate levo to MAP >60.\n\nCont fent, versed.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-17 00:00:00.000", "description": "Report", "row_id": 1611779, "text": "REMAINS ON MECHANICAL VENTILATION WITH PERIODS OF HYPOTENSION.CVVHD CONTINUOUS,EDEMATOUS AT EXTREMITIES.SUCTIONED FOR MINIMAL AMOUNT OF BROWN SECRETION,WILL CONTINUE TO FOLLOW\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611780, "text": "Smicu nsg progress note\nNeuro- Well sedated on 300mcg fent and 10mg midaz. Not requiring additional boluses. Will grimice with suctioning/turning. No spontaneous movement noted. Cont with total body anacarcia.\nResp- Remain intub/vented intially on ac 400x24 60% 15peep with sats 99%. Abg back at 52/36/7.48. Fio2 increased to 70% with abg pending. Suctioned for mod amts thick yellow/tan secretions requiring saline instillation.\nCardiac- Bp 100-120s on .02mcg levo. As removal rate on cvvd increased bp down to 95-98s. Levo increased to .03mcg with stable bp. Slowly able to reach goal of 100cc neg/hr.\nRenal- Cont on cvvd. Pt~350cc neg at 12m. By 2am able to reach goal of 100cc neg/hr. Cont with very little uo 0-10cc/hr. Bun/creat pending.\nGi- Tolerating goal tube feeds. Cont to pass sm amts liquid brown stool. Fs stable off insulin gtt.\nId- Afebrile with bair hugger on. T-max 97.6ax. No changes in antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-18 00:00:00.000", "description": "Report", "row_id": 1611781, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Few changes made overnoc. Administering Albuterol and Atrovent MDI's in line with vent. BS's coarse at times. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611861, "text": "Smicu nsg progress note\nS/O: Remains essentually unresponsive on fent/versed. intub/vented (of note pt with continuous air leak from broken pilot) Suctioned for mod amts thick yellow/green secretions. Still with minimal bp and no urine output.\nA: No change\nP: with . family support.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611862, "text": "RESP CARE\nPT. REMAINS INTUBATED/SEDATED WITH NO CHANGES OVERNIGHT. PILOT CUFF NOT PATENT, CLAMPED, HOWEVER LEAK APPEARS TO BE MORE PROXIMAL TO TUBE ITSELF, SINCE CUFF IS SOMEWHAT TAUT.\nBS: COARSE BILAT. 'D Q2 FOR COPIOUS GREENISH-YELLOW FROM MOUTH/LUNGS.\nPLAN:. CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2152-08-09 00:00:00.000", "description": "Report", "row_id": 1611863, "text": "S/MICU Nursing Progress Note\n Remains unresponsive, vented on same settings 450/16/.50/5 suctioning q3-4 hr for thick yellow sputum. BS coarse. BP minimal 50-70/30's HR 80-100's afib, on fentanyl and versed. bolused for grimacing by pt. increased fentanyl to 400mcg/hr. no changes/ DNR/ and to support family.\n" }, { "category": "Radiology", "chartdate": "2152-06-28 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872685, "text": " 3:46 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please evaluate for pneumothorax s/p successful cordis place\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation difficult to ventilate\n\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumothorax s/p successful cordis placement in left\n subclavian and failed attempt at line change over wire in right IJ\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION OF THE CHEST\n\n HISTORY: 80-year-old with respiratory distress and status post intubation.\n Evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to the prior examination of \n obtained earlier at 9:33 hours. Since the prior study, the right IJ line was\n removed, and a left subclavian Swan-Ganz catheter was placed. The tip is in\n the right pulmonary artery. Bilateral patchy infiltration involving both\n lungs and left pleural effusion are again noted, unchanged. No evidence of\n pneumothorax.\n\n IMPRESSION: Interval removal of the right IJ line and placement of a left\n subclavian Swan-Ganz catheter. No evidence of pneumothorax. No other\n significant changes are noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 874619, "text": " 12:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Line placement - L IJ (now w/ L sublclavian pulled)\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 yo F s/p L IJ central line placement, pls assess for PTX, hemothorax, s/p\n line placement (w/ X-ray showing line in place), now w/ removal of other\n central line that had been in same area.\n REASON FOR THIS EXAMINATION:\n Line placement - L IJ (now w/ L sublclavian pulled)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Removal of the left subclavian line.\n\n PORTABLE CHEST X-RAY, AP: Comparison study .\n\n Supine study at 1:04 a.m. demonstrates removal of the left subclavian line.\n The left IJ catheter has its tip over the SVC. The right IJ catheter is also\n in good position over the SVC. The endotracheal tube is in good position\n above the carina. The feeding tube is again noted with its tip over the\n stomach. The lungs are unchanged with multiple areas of\n infiltrate/opacification. There is no pneumothorax.\n\n IMPRESSION: Support lines in good position. No pneumothorax. No significant\n change from the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-10 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 874009, "text": " 12:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval infiltrate\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n MRSA (+) VAP\n REASON FOR THIS EXAMINATION:\n Eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Multifocal infiltrates and respiratory failure.\n\n Lines and tubes remain in place. There has been slight advancement of an\n endotracheal tube, which is now terminating about 2 cm above the carina.\n Other indwelling tubes and catheters are unchanged in position. Cardiac\n silhouette is enlarged but stable. Multifocal consolidative changes are again\n demonstrated. There has been some associated volume loss developing in the\n left upper lobe with apparent elevation of an accessory planar fissure on the\n left. An area of band like discoid atelectasis could potentially mimick an\n elevated accessory fissure, however. Overall, compared to the recent study,\n there has been slight improved aeration in the lung bases, with otherwise no\n significant additional changes.\n\n IMPRESSION: Slight improved aeration in the lung bases. Multifocal opacities\n otherwise unchanged except for some degree of volume loss developing in the\n left upper lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 872936, "text": " 1:51 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: catheter placement.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p swan pulled and changed to quad lumen catheter.\n REASON FOR THIS EXAMINATION:\n catheter placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Exchange of Swan-Ganz to a central line.\n COMPARISONS: Comparison is made to radiograph performed in the same day,\n approximately 5 hours earlier.\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: Interval removal of the Swan-Ganz catheter and interval placement\n of a left subclavian central line. The tip is in the left brachiocephalic\n vein near the junction of the SVC. The NG tube and ET tube are in unchanged\n position. There is no evidence of pneumothorax. radiograph is seen. There is\n interval worsening of bilateral multifocal consolidations.\n\n IMPRESSION:\n 1. Central line tip is in the distal left subclavian vein near the junction of\n the SVC. No other significant change.\n 2. There is interval worsening of bilateral multifocal parenchymal\n consolidations which could be due to multifocal pneumonia versus CHF.\n\n" }, { "category": "Radiology", "chartdate": "2152-06-26 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 872430, "text": " 12:13 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: abominal bleeding?\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fall & RUQ tenderness, possible rib fractures - eval\n for liver injury\n REASON FOR THIS EXAMINATION:\n abominal bleeding?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with fall and right upper quadrant tenderness.\n Evaluate for fractures or liver injury. The patient also has shortness of\n breath. Evaluate for pulmonary embolism.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen and pelvis were\n obtained. Multiplanar reconstructions were obtained for further evaluation of\n the anatomy and pathology.\n\n CONTRAST: 150 ml of IV Optiray was administered.\n\n COMPARISON: Abdominal CT from in .\n\n CT CHEST WITH AND WITHOUT IV CONTRAST: The soft tissue window images reveal\n no significant axillary, mediastinal, or hilar lymphadenopathy. The heart,\n pericardium and the great vessels are unremarkable. There are no filling\n defects within the pulmonary vasculature to suggest the presence of a\n pulmonary embolism. There are bilateral moderate sized pleural effusions,\n right greater than left.\n\n The lung window images reveal bilateral patchy opacities with a large area of\n consolidation involving the right upper lobe and a smaller area of\n consolidation in the left upper lobe. The airways appear patent.\n\n A right IJ line is visualized with its tip in the mid SVC. An endotracheal\n tube is present with its tip about 1 cm above the carina. A feeding tube is\n also present with its tip in the stomach.\n\n CT ABDOMEN WITH IV CONTRAST: There is stable prominence of the intrahepatic\n biliary ducts. No focal liver lesions are identified. There is a stable 14 x\n 19 mm low density area in the head of the pancreas. The spleen is\n unremarkable. The adrenal glands are normal. The kidneys appear slightly\n atrophic but are stable in appearance. Atherosclerotic changes are seen in\n the aorta. The intra-abdominal loops of small and large bowel are\n unremarkable. Scattered large bore diverticula are again noted without\n evidence of diverticulitis. There is no free air or free fluid. A few\n nonpathologically enlarged para-aortic lymph nodes are present.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder, rectum, and sigmoid colon are\n (Over)\n\n 12:13 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: abominal bleeding?\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. There is stable appearance of a left groin hernia with loops of\n small bowel. There is no evidence of obstruction. There is no free air\n present. Again, noted is a calcified fibroid posteriorly. There is no pelvic\n or inguinal lymphadenopathy.\n\n Degenerative changes in the spine are again noted along with diffuse\n osteopenia.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the absence of\n pulmonary embolism.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Moderate sized bilateral pleural effusions, right greater than left.\n Patchy opacities in both lungs along with areas of consolidation in the upper\n lobes, right greater than left. These could represent multifocal pneumonia.\n 3. Stable appearance of cystic lesion in the head of the pancreas.\n 4. Stable mild intrahepatic biliary ductal prominence. No liver laceration.\n 5. Stable left groin bowel containing hernia.\n 6. Stable multiple anterior abdominal wall nodules likely representing\n injection sites.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "INT.SHTH NOT/GUID,EP,NONLASER", "row_id": 872947, "text": " 3:19 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please place Quentin catheter in L groin. (Tried to place R\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with anuric renal failure in need of CVVHD.\n REASON FOR THIS EXAMINATION:\n please place Quentin catheter in L groin. (Tried to place R groin line 5 days\n ago and got into artery. Pt also has large hematoma on R calf).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient sustained acute renal failure and requires dialysis.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. with Dr.\n being present throughout. After sterile preparation of the right neck\n ultrasound was used to locate the right internal jugular vein which was found\n to be patent and compressible. Using ultrasonographic guidance and 5 ml of 1%\n lidocaine in the right internal jugular vein was entered with a 21 gauge\n needle. Over and 018 guide wire which was advanced under fluoroscopy the\n exchange was made for 4.5 micropuncture sheath. An 035 guide wire was then\n advanced into the superior vena cava. After serial dilatation exchange was\n made for 14.5 FR hemodialysis catheter. The tip was placed under fluoroscopy\n at the cavoatrial junction. A final radiograph was obtained which\n demonstrates the catheter in appropriate positioning and the absence of a\n pneumothorax. As on the prior chest x-ray there are areas of marked\n consolidations throughout. There is no pneumothorax. The tip of the left-\n sided central venous catheter ends in the left brachiocephalic vein. There\n were no immediate complications.\n\n Hardcopy images of ultrasound had been obtained at the level of the right\n internal jugular vein before and after placement of the needle.\n\n IMPRESSION: Successful placement of a 15 cm long temporary dialysis catheter\n via the right internal jugular vein ready for use. No pneumothorax.\n\n\n\n" }, { "category": "Echo", "chartdate": "2152-06-22 00:00:00.000", "description": "Report", "row_id": 98426, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. R/O Cor pulmonale.\nHeight: (in) 63\nWeight (lb): 226\nBSA (m2): 2.04 m2\nBP (mm Hg): 130/50\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 10:43\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nStudy technically suboptimal due to limited patient cooperation with the\nstudy.\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. Minimally increased gradient c/w\nminimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve is not well seen. There is a minimally increased gradient consistent\nwith minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The pulmonary artery systolic pressure could not be determined. There\nis no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 98425, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 228\nBSA (m2): 2.07 m2\nBP (mm Hg): 128/68\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 13:12\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild to moderate\n(+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) are mildly thickened. There is a\nminimally increased gradient consistent with minimal aortic valve stenosis.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric (posteriorly directed). The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof (sub-optimal study), the severity of mitral regurgitation seen is\nnow mild to moderate. Mild pulmonary hypertension is now detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872304, "text": " 8:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NG tube placement\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation\n\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Nasogastric tube placement.\n\n A nasogastric tube has been placed and terminates within the stomach.\n Allowing for differences in technique, there is otherwise no significant\n change from the previous study performed several hours earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 872293, "text": " 5:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable upright chest that is dated .\n\n Comparison is made to previous study of earlier the same day.\n\n INDICATION: Intubation.\n\n An endotracheal tube has been placed, terminating approximately 3.5 cm above\n the carina. The cardiac silhouette remains enlarged, and there is bilateral\n vascular engorgement. There has been interval slight progression in the\n degree of a bilateral slightly asymmetrical alveolar pattern with a perihilar\n predominance. Interstitial opacities are seen predominantly at the lung\n bases, and there are persistent small bilateral pleural effusions.\n\n As compared to the recent study, there has not been a significant interval\n change allowing for differences in lung volumes.\n\n IMPRESSION:\n 1. Satisfactory placement of endotracheal tube.\n\n 2. Persistent bilateral combined alveolar and interstitial pattern, most\n likely due to pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 873710, "text": " 11:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Check OGT placment.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n with increasing WBC. NGT pulled and OGT placed.\n REASON FOR THIS EXAMINATION:\n Check OGT placment.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST\n\n INDICATION: 80-year-old female with respiratory failure and multifocal\n infiltrates. The patient is status post OG tube placement.\n\n TECHNIQUE: AP portable single view of the chest.\n\n COMPARISONS: Comparison is made to radiograph performed in the same day\n approximately 2 hours earlier.\n\n FINDINGS: There is interval placement of feeding tube, (Dobhoff) with the tip\n in the fundus of the stomach. There is a left subclavian central line with\n the tip in the distal brachiocephalic vein near the junction of the SVC. There\n is a right IJ large bore central line with the tip in the distal subclavian\n vein/upper SVC. The ET tube is in good position. There is no evidence of\n pneumothorax. There is noted pulmonary edema and stable bilateral focal\n opacities consistent with multifocal pneumonia.\n\n IMPRESSION: Placement of feeding tube with the tip in the fundus of the\n stomach.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-06-30 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 872880, "text": " 7:37 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ? resolving edema.\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with resp distress s/p intubation difficult to ventilate\n\n REASON FOR THIS EXAMINATION:\n ? resolving edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, status post intubation, evaluate for\n resolving edema.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: An endotracheal tube is in place in unchanged position. Left\n subclavian venous access sheath with PA catheter with tip terminating in the\n right lower lobe pulmonary artery, advanced in the interval. Nasogastric tube\n with tip in the gastric fundus. The heart size and mediastinal contours are\n unchanged. In comparison with the previous examination, there is interval\n improvement in bilateral patchy opacity suggestive of improving congestive\n heart failure. No pneumothorax. The osseous structures appear unchanged.\n\n IMPRESSION:\n 1) Endotracheal tube and nasogastric tube in stable position. Interval\n advancement of pulmonary artery catheter. 2) Interval improvement in\n bilateral alveolar opacities, likely due to asymmetric pulmonary edema,\n although underlying infection is not excluded.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-12 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 874318, "text": " 9:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?pneumothorax/effusion/consolidation/infiltrate\n Admitting Diagnosis: HYPERKALEMIA;HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with respiratory failure, with multi-focal infiltrates. Now\n MRSA (+) VAP. On appropriate abx, but WBC increasing.\n REASON FOR THIS EXAMINATION:\n ?pneumothorax/effusion/consolidation/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA positive to rule out pneumothorax, effusion, or\n consolidations.\n\n CHEST AP PORTABLE VIEW.\n\n COMPARISON: .\n\n The endotracheal tube, the Dobbhoff tube, left subclavian and right internal\n jugular venous lines are unchanged. The cardiac size and mediastinal contours\n are stable. Multiple patchy alveolar opacities are seen with stable pulmonary\n edema.\n\n IMPRESSION: Patchy alveolar opacities which may represent pulmonary edema\n superimposed with areas of consolidation in the right lung and left upper\n lobe.\n\n\n" }, { "category": "ECG", "chartdate": "2152-06-24 00:00:00.000", "description": "Report", "row_id": 276317, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , atrial fibrillation now absent\n\n" }, { "category": "ECG", "chartdate": "2152-06-25 00:00:00.000", "description": "Report", "row_id": 276318, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-23 00:00:00.000", "description": "Report", "row_id": 276319, "text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of atrial fibrillation with a rapid ventricular response has\nappeared.\n\n" }, { "category": "ECG", "chartdate": "2152-06-20 00:00:00.000", "description": "Report", "row_id": 276320, "text": "Sinus rhythm\nBorderline first degree A-V block\nPoor R wave progression - probable normal variant\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-20 00:00:00.000", "description": "Report", "row_id": 276321, "text": "Sinus bradycardia\nBorderline first degree A-V block\nPoor R wave progression - probable normal variant\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 276311, "text": "Atrial fibrillation with ventricular premature beats. Low voltage. Non-specific\nST-T wave changes. Compared to the previous tracing atrial fibrillation is new.\n\n\n\n" }, { "category": "ECG", "chartdate": "2152-07-03 00:00:00.000", "description": "Report", "row_id": 276312, "text": "Sinus rhythm\nConsider left atrial abnormality\nRightward axis - is nonspecific\nBorderline low QRS voltage - is nonspecific\nClinical correlation is suggested\nSince previous tracing of , QRS voltages lower but may be no significant\nchange\n\n" }, { "category": "ECG", "chartdate": "2152-06-29 00:00:00.000", "description": "Report", "row_id": 276313, "text": "Sinus rhythm. Possible left atrial abnormality. Compared to the previous\ntracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 276314, "text": "Baseline artifact\nSinus rhythm\nProbable left atrial abnormality although baseline artifact makes assessment\ndifficult\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-27 00:00:00.000", "description": "Report", "row_id": 276315, "text": "Sinus rhythm\nLeft atrial abnormality\nRightward axis - is nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2152-06-26 00:00:00.000", "description": "Report", "row_id": 276316, "text": "Baseline artifact\nSinus rhythm\nProbable left atrial abnormality although baseline artifact makes assessment\ndifficult\nRightward axis - is nonspecific\nSince previous tracing of -, probably no significant change\n\n" } ]

20,522

142,117

1. Upper GI bleed: The patient had an NG tube placed in the Emergency Department, and coffee-ground emesis was suctioned out which did not clear. GI was immediately consulted who did an EGD and found no active sights of bleeding; however, they did find a grade III esophagitis and some gastritis. At that time it was decided that we should stop the anticoagulation, and the patient was to be started on Protonix 40 mg p.o. b.i.d. In addition, GI recommended that the patient go for barium swallow. At that time, it was believed that the upper GI bleed was probably secondary to gastritis, worse with anticoagulation and hiatal hernia. The patient had barium swallow that was done on , that showed a large paraesophageal hernia but no evidence of any twisting or infarction at this time. According to the Radiology attending, it would be ideal if Surgery was consulted. The results were discussed with the patient, by both myself and by the attending Dr. , about the importance of getting Surgery involved, but the patient refused any surgery and stated that she would just take the oral medications at this time. The patient also was informed that if the patient does not go for surgery, then the patient may have her stomach infarcted and could possibly die. She is willing to take those chances. During the hospital course, the patient did not have any coffee-ground emesis, and the patient was tolerating p.o. well. 2. Hypoxia: This was most likely secondary to aspiration pneumonia as per the chest x-ray. The patient did have 8-10 episodes of emesis which would account for that. At this time it was decided that the patient should be started on Levofloxacin and Flagyl for a 14-day course for treatment of aspiration pneumonia. The patient was initially requiring oxygen through nasal cannula, but two days before her discharge, her nasal cannula was removed, and she was doing well in room air, maintaining an oxygen saturation anywhere between 92-96%. The patient continued on antibiotics for ten more days after discharge. 3. Urinary tract infection: The patient's urinalysis showed some white cells and some bacteria in her urine. At that time it was decided that since the patient is getting Levofloxacin for aspiration pneumonia, she will be covered for urinary tract infection. A sensitivity was sent, but it was not back at the time of discharge. 4. Cardiology: As per her echocardiogram report in , the patient has an ejection fraction of 30-35%. The patient is currently not on any cardiac medications. The question was brought up during her hospital course whether to start her on ACE inhibitors, but given the fact that she had an elevated BUN and creatinine, we decided to hold off on any medications at this time. In addition, beta-blocker was also not started because the patient was having a blood pressure anywhere between 90-100 systolic. In addition, Aspirin was also held off because of her bleeding episode. The patient is to follow-up with her primary care physician . in about one week, and this issue needs to be readdressed, and the patient could possibly be restarted on any cardiac medications. 5. Psychiatric: The patient has a history of schizo-affective disorder. The patient is currently stable and is to continue on current medications. 6. Alkalosis: The patient initially presented with a bicarb of 37. Her Alkalosis was most likely secondary to contraction alkalosis given the fact that she was volume depleted and she had these multiple episodes of emesis. The patient received intravenous fluids throughout her hospital course, and her alkalosis had resolved. 7. FEN: The patient was receiving intravenous fluids during her hospital course because she was NPO and also because she developed alkalosis and an elevated creatinine which could indicate the patient was dry and was having prerenal acute renal failure. After receiving intravenous fluids, the patient's creatinine had dropped from 1.6-0.9, and on the day of discharge, her creatinine was 0.9, and her bicarb was down to 27. 8. Heme: The patient's hematocrit has been in the range between 27 and 32-33. Her initial hematocrit was 45, but on recheck was 33. Her initial elevated hematocrit could be secondary to the fact that the patient was very dry. After intravenous fluids, this improved. The question was brought up whether we should transfuse her with 1 U to have her hematocrit above 30 given the fact that she has coronary artery disease, but the patient refused any blood transfusion. It was thoroughly discussed by both myself and the attending, but the patient still refused, and so transfusion was not given. The patient was started on Iron Sulfate 325 mg p.o. q.d.

PT. TRANSFUSE AS NEEDED. K THIS AM 3.1 & BEING REPLACED. PERIPHERAL PULSES PALPABLE. WBC 18.4. MAE X4. 18 G IV X2 LFA. PAN CULTURED. POSITIVE UTI. PLEASE OBTAIN SPUTUM IF EXPECTORATES. 0300 HCT 32.6 FROM 35.7. THANK YOU.. GIVE SUPPORT. REORIENTS EASILY. RIGHT ARM CONTRACTURE WITH WEAKNESS NOTED R/T OLD CVA. SPUTUM NEEDED IF EXPECTORATES. BP STABLE 110-120/40'S. PLEASE RECHECK LATER THIS AM. STATES IS SMOKER. REMAINS IN MICU FULL CODE. COOPERATIVE IN CARE.CV: MONITOR NSR 70-80 NO ECTOPY. D5.45 NS@ 100 CC/HR.RESP: NON PRODUCTIVE COUGH. CONVERSES LITTLE. DENIES SOB.GI: RIGHT NARE NG TO LCWS WITH SMALL COFFEE GROUND LIQUID POSITIVE HEMACULT. BREATH SOUNDS DIMINISHED. INR 1.6 AFTER RECEIVING 4 U FFP & VITAMIN K. TEAM IS AWARE. O2 3L NC SATS 93-96%. WITH SCHIZO AFFECTIVE DISORDER, MONOTONE VOICE. DENIES NAUSEA OR ABDOMINAL TENDERNESS. FOLLOWS ALL COMMANDS. RESUME MEDS THIS AM PER DR. . DISORIENTED TO PLACE & YEAR AT TIMES. NO BM. CONTINUE 6 HOUR HCT DUE @ 0900. CIPRO PER NG STARTED.SOC: LIVES AT CHRONIC CARE FACILITY.PLAN: REPLACE K. CONTINUE Q 6 HOUR HCT. REQUIRING FREQUENT ORAL CARE.GU: FOLEY TO GRAVITY DRAIN WITH CLEAR YELLOW URINE 30-100 CC/HR.ID: T MAX 100.3 ORAL. NURSING TRANSFER NOTE 0700-1500PLS SEE NURSING TRANSFER NOTE IN THE SECTION MARKED 'NURSING TRANSFER NOTE'.

2

[ { "category": "Nursing/other", "chartdate": "2179-11-05 00:00:00.000", "description": "Report", "row_id": 1531917, "text": "MICU NPN 1900-0700:\n\n60 YEAR OLD FEMALE ADMITTED @ WITH UGIB FROM ED, HCT 40, INR 3.7.\n\nNEURO: PT. WITH SCHIZO AFFECTIVE DISORDER, MONOTONE VOICE. CONVERSES LITTLE. DISORIENTED TO PLACE & YEAR AT TIMES. REORIENTS EASILY. MAE X4. RIGHT ARM CONTRACTURE WITH WEAKNESS NOTED R/T OLD CVA. FOLLOWS ALL COMMANDS. COOPERATIVE IN CARE.\n\nCV: MONITOR NSR 70-80 NO ECTOPY. K THIS AM 3.1 & BEING REPLACED. PLEASE RECHECK LATER THIS AM. BP STABLE 110-120/40'S. PERIPHERAL PULSES PALPABLE. 18 G IV X2 LFA. D5.45 NS@ 100 CC/HR.\n\nRESP: NON PRODUCTIVE COUGH. PT. STATES IS SMOKER. SPUTUM NEEDED IF EXPECTORATES. O2 3L NC SATS 93-96%. BREATH SOUNDS DIMINISHED. DENIES SOB.\n\nGI: RIGHT NARE NG TO LCWS WITH SMALL COFFEE GROUND LIQUID POSITIVE HEMACULT. DENIES NAUSEA OR ABDOMINAL TENDERNESS. NO BM. 0300 HCT 32.6 FROM 35.7. INR 1.6 AFTER RECEIVING 4 U FFP & VITAMIN K. TEAM IS AWARE. CONTINUE 6 HOUR HCT DUE @ 0900. RESUME MEDS THIS AM PER DR. . REQUIRING FREQUENT ORAL CARE.\n\nGU: FOLEY TO GRAVITY DRAIN WITH CLEAR YELLOW URINE 30-100 CC/HR.\n\nID: T MAX 100.3 ORAL. WBC 18.4. PAN CULTURED. POSITIVE UTI. CIPRO PER NG STARTED.\n\nSOC: LIVES AT CHRONIC CARE FACILITY.\n\nPLAN: REPLACE K. CONTINUE Q 6 HOUR HCT. TRANSFUSE AS NEEDED. GIVE SUPPORT. PLEASE OBTAIN SPUTUM IF EXPECTORATES. REMAINS IN MICU FULL CODE.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-11-05 00:00:00.000", "description": "Report", "row_id": 1531918, "text": "NURSING TRANSFER NOTE 0700-1500\nPLS SEE NURSING TRANSFER NOTE IN THE SECTION MARKED 'NURSING TRANSFER NOTE'. THANK YOU..\n" } ]

13,638

181,754

The patient was admitted to the Surgical Intensive Care Unit for close monitoring. He had a CT angiogram of his brain, which was negative and the conventional angiogram, which was also negative. The patient has had difficulty with blood pressure control and is now running in the 130s to 140s systolically and will be discharged on new medication for his blood pressure and will follow up with his primary care physician for blood pressure control. He was seen by physical therapy and occupational therapy and cleared for discharge to home. His vital signs have been stable. He has been afebrile.

IN UNIT FOR NEURO CHECKS AND BP CONTROL.NEURO: INTACTCV: A-FEBRILE. RESUMED PREVIOUS ANTIHYPERTENSIVES W/O EFFECT. + BS.ENDO~BS Q 4/HRS. IV ZANTAC ADDED.HEME: STABLE. CONDITION UPDATED.AFEBRILE SR TO SINUS BRADY. LUNGS CLEAR.RENAL: LABS WNL. PT HAS USED URINAL.BREATHSOUNDS CLEAR. ABP >200, NBP L ARM 160 SYS, R ARM 130 SYS- NSURG AWARE. TECHNIQUE: Pre and postcontrast multiplanar T1W images, axial T2W, susceptibility and FLAIR images were obtained. As expected, the T1 hyperintense methemoglobin is, to some extent, visible on the MRA. 0430 GIVEN PERCOCET 2 TABS FOR C/O THROBBING HA. K REPLACEMENTS IN IVF.A. Note is made that the right A1 segment is atretic. MAINTAIN CUFF BP <160 WITH NIPRIDE.R. U/O qs, +BS pt able to tolerate solids. PNEUMOBOOTS ON.ENDO: BS STABLE.ID: LOW GRADE TEMPS. L radial A-line placed, significant ammt fling noted, so NBP monitored for now. BRIEFLY STARTED ON NIPRIDE TO KEEP SBP <160. RETURNED TO ON AND FOUND TO HAVE INTRAVENTRICULAR BLEED. UPDATERETURNED FROM INTERVENTIONAL ARTERIOGRAM. NIPRIDE WEANED.P: FOLLOW UP WITH MRI. CONDOM CATH OFF (PLACED FOR ARTERIOGRAM). Shift NotePt is neurologically intact, MAE to command. Pt c/o some nausea immediately on admission, subsided without intervention. SATS WELL ON 2LNC.GI: TOL GEN DIET.GU: VOIDS PER URINAL.SKIN: INTACT.PAIN: PT DENIES PAIN. NEURO~A+O X3. PT REMAINS NPO FOR ON CALL ANGIO.IVF AT 80ML/HR.PT VOIDING WITHOUT DIFFICULTY. Nitro gtt off, Nipride gtt started MD orders. IMPRESSION: Normal MRA of the brain. R FEMORAL SITE WITHOUT ECHHYMOSIS OR BLEEDING. Pt with 2 periph IVs, both flush easily and sites benign.Resp: Lungs CTAB, sats 94-96% on 2L NP.GI: Abd soft, good BS. IMPRESSION: There is a right lateral ventricle intraventricular hemorrhage with little change from the study performed at approximately 3 AM on . NEURO CHECKS Q 2/HR'S, WNL. Pt c/o lightheadedness that resolved spontaneously, HO aware. R CUFF PRESSURE~126/55/76. NOT REQUIRING SS COVERAGE ON NIGHTS.A/P~ PER NEURO ATTENDING.WEAN SNP OFF THIS AM. AT 0500 NOTICED PT'S FACE AND NECK WERE RED BP UNCHANGED REMAINED 160'S. The distal internal carotid arteries, basilar artery, and major branches of the cerebral arteries are normal. Injection of the right external carotid artery is within normal limits with no evidence of arteriovenous malformation or shunting. Nipride gtt titrating to maintain SBP 140-160's (currently 1mcg/kg/min). RM AIR O2 SAT=95-98,RR=. NEUROSIGNS APPEAR NORMAL. Hct, coags WNL. Injection of the left vertebral artery in the cervical portion is smoothly contoured and injection of the left vertebral artery shows that the vascular apex lacks an origin for the right posterior cerebral artery consistent with its fetal type origin. NIPRIDE WEANED OFF AND PO HYDRALAZINE AND LOPRESSOR BEGUN. PLACED ON 2L NP SATS 97%.LUNGS CLEAR BILAT.GI/GU~NPO EXCEPT MEDS. EKG THIS AM. L ARM CUFF PRESSURE~133/55/77. ART BP~159/59/79. RESULTS: Injection of the right common carotid artery reveals a smooth (Over) 4:18 PM CAROT/CEREB Clip # Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO Contrast: OPTIRAY Amt: 260 FINAL REPORT (REVISED) (Cont) bifurcation in the cervical region. It is characterized by T1 hyperintense methemoglobin, as well as smaller areas of suscptibility effect, most likely deoxyhemoblobin. AS LOW AS 39 TRANGIENTLY DESPITE LOPRESSOR BEING HELD. 1 EPISODE OF P WAVES INVERTING.PLAN TO CHECK BLOODGLUCOSE, CONTINUE TO MONITOR NEURO SIGNS AS ORDERED AND NEEDED. The sheath was kept in the heparinized saline drip. TRANSFER TO NSURG ICU. NO NEURO DEFICITS.TOL REG DIET. PLAN TO RESUME ALL PRE-PROCEEDURE MEDS INCLUDING LOPRESSOR AND WEAN SNP KEEPING SBP <180.NS @ 70CC/HR. Injection of the left external carotid artery is within normal limits with no evidence of abnormality. BP CONTROLLED WITHIN MD PARAMETERS WITH ORAL HYDRALAZINE, LOPRESSOR, AND IV INJECTION OF CLONIDINE.PT READY FOR TRANSFER TO 5.REPORT CALLED TO RN.HISTORY: PT IS 51 Y.O. RSICU NURSING PROGRESS NOTEREVIEW OF SYSTEMS:NEURO: A+OX3. MAP:82, HR 58. Pt moving all extremties, denies any numbness or tingling, visual disturbances. Pt reports +BM on AM. DR. DR. PT C/O "JUST A TOUCH" OF A FRONTAL HEADACHE.L NBP CUFF MEASURING BP ALONG WITH L RADIAL A LINE. TO MAINTAIN A SBP </=160. Injection of the right subclavian artery reveals smooth anatomy and no evidence of stenosis or dissection, and injection of the right vertebral artery shows it to be diminutive vessel with a small caliber and is otherwise free of stenosis or disease. Continue nipride as needed BP WNL OFF OF NIPRIDE. RASH LESS SEVERE THIS AM.CARIAC~REMAINS ON SNP @ 2.5 UCG/KG/MIN. The brain parenchyma is normal. TO GO BY NBP. brother in listed as next of , aware of his hospitalization.A/P: Continue close neuro/hemo monitoring, f/u with Dr. in AM. IVF AT KVO. Comparison is made to the CT exam of the same day. The source images show no abnormal vessels extending to the ependymal region. HR 50'S-6O'S SB W/ OCC PVS'S NOTED.RESP~DROP IN SATS TO 90'S ON RA. TRANSFERRED TO . DC A-LINE. PT REMAINS ORIENTED X3,MOVES ALL EXTREMITIES EQUALLY TO COMMAND. Hemodynamically pt with HTN, SNP infusing, unable to wean SNP.

10

[ { "category": "Radiology", "chartdate": "2130-11-30 00:00:00.000", "description": "MR-ANGIO HEAD", "row_id": 747898, "text": " 4:14 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: 51 yr old s/p intraventricular hemorrhage please evaluate w\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n 51 yr old s/p intraventricular hemorrhage please evaluate with mra/mri with\n and without contrast to r/o vascular malformation or underlying tumor\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Intraventricular hemorrhage.\n\n TECHNIQUE: Pre and postcontrast multiplanar T1W images, axial T2W,\n susceptibility and FLAIR images were obtained. Comparison is made to the CT\n exam of the same day.\n\n FINDINGS:\n\n As seen on the CT study from approximately 3 AM, there is hemorrhage in the\n temporal , atrium and posterior body of the right lateral ventricle. The\n amount of hemorrhage has changed very little. It is characterized by T1\n hyperintense methemoglobin, as well as smaller areas of suscptibility effect,\n most likely deoxyhemoblobin. No hydrocephalus is seen. On the FLAIR images no\n subarachnoid hemorrhage is identified.\n\n There is no evidence of a mass or abnormal enhancement. The brain parenchyma\n is normal.\n\n IMPRESSION: There is a right lateral ventricle intraventricular hemorrhage\n with little change from the study performed at approximately 3 AM on . No\n mass is seen.\n\n MRA OF THE HEAD:\n\n CLINICAL HISTORY: Intraventricular hemorrhage, ? underlying vascular\n malformation.\n\n TECHNIQUE: A 3D time of flight study was derived from overlapping axial slabs\n through the cranium.\n\n FINDINGS:\n\n No abnormal vessels are seen to suggest an AVM. As expected, the T1\n hyperintense methemoglobin is, to some extent, visible on the MRA. The source\n images show no abnormal vessels extending to the ependymal region. Note is\n made that the right A1 segment is atretic. The distal internal carotid\n arteries, basilar artery, and major branches of the cerebral arteries are\n normal. There is no MRA evidence of aneurysm.\n\n IMPRESSION: Normal MRA of the brain. No anbormal vessels are seen near the\n (Over)\n\n 4:14 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: 51 yr old s/p intraventricular hemorrhage please evaluate w\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right lateral venricle hemorrhage to suggest underlying vascular malformation.\n As discussed previously, a conventional arteriorgram is probably more\n sensitive to a small lesion.\n\n" }, { "category": "Radiology", "chartdate": "2130-12-01 00:00:00.000", "description": "VERT/CAROTID A-GRAM", "row_id": 747982, "text": " 4:18 PM\n CAROT/CEREB Clip # \n Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO\n Contrast: OPTIRAY Amt: 260\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNOSTIC ANGIO TO R/O\n VASUCULAR ABNORMALITY\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Intracranial hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of intracranial aneurysm or\n arteriovenous malformation.\n\n INDICATION: This angiogram is being performed to find source of possible\n intracranial hemorrhage in this patient.\n\n CONSENT: Consent was obtained from the patient's family. They were given\n full and complete explanation of the procedure including the risks, benefits,\n and possible complication. They understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought to the endovascular suite and\n placed on the table in supine position. Right and left groin areas were\n prepped and draped in the usual fashion and a 5 FR vascular sheath was\n inserted into the right common femoral artery. The sheath was kept in the\n heparinized saline drip. At this point, a 5 FR Berenstein type 2 catheter was\n used to selectively catheterized the vessels in the following order: Right\n common carotid artery, right external carotid artery, right internal carotid\n artery, right subclavian artery, left common carotid artery, left internal\n carotid artery, left external carotid artery, left subclavian artery, left\n vertebral artery, right subclavian artery, right vertebral artery. With the\n cath in each of these locations, a biplane angiographic run were performed in\n order to acquire multiple digitally acquired angiographic images and digital\n subtraction angiography mode. The catheter was withdrawn from the patient,\n and the 5 FR vascular sheath was removed and an arteriotomy site was sealed\n using a perclose device. The patient tolerated the procedure well and was\n returned to the recovery room in stable condition.\n\n RESULTS: Injection of the right common carotid artery reveals a smooth\n (Over)\n\n 4:18 PM\n CAROT/CEREB Clip # \n Reason: 51YR OLD MALE S/P INTRAVENTRICULAR HEMORRHAGE , NEEDS DIAGNO\n Contrast: OPTIRAY Amt: 260\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n bifurcation in the cervical region. No evidence of stenosis or dissection.\n Injection of the right internal carotid artery reveals a fetal type posterior\n cerebral artery on the right side. In addition, there is an aplastic right A1\n segment of the anterior cerebral artery. Otherwise, the internal carotid\n artery intracranially shows no evidence of intracranial aneurysm or\n arteriovenous malformation. Injection of the right external carotid artery is\n within normal limits with no evidence of arteriovenous malformation or\n shunting. Injection of the left common carotid artery reveals a smooth\n bifurcation with no evidence of stenosis or disease and injection of the left\n internal carotid artery reveals a prominent left A1 segment of the anterior\n cerebral artery with no evidence of intracranial aneurysm or arteriovenous\n malformation. Injection of the left external carotid artery is within normal\n limits with no evidence of abnormality. Injection of the left subclavian\n artery is free of disease or stenosis or dissection, and the origin of the\n left vertebral artery is free of stenosis. Injection of the left vertebral\n artery in the cervical portion is smoothly contoured and injection of the left\n vertebral artery shows that the vascular apex lacks an origin for the right\n posterior cerebral artery consistent with its fetal type origin. In addition,\n the posterior cerebellar arteries on both the right and left side are\n duplicated and there is a prominent AICA and PICA complex bilaterally.\n Injection of the right subclavian artery reveals smooth anatomy and no\n evidence of stenosis or dissection, and injection of the right vertebral\n artery shows it to be diminutive vessel with a small caliber and is otherwise\n free of stenosis or disease.\n\n IMPRESSION: Negative study for intracranial aneurysm or arteriovenous\n malformation to explain the noted intracranial hemorrhage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439915, "text": "SICU Admit note\nPt is a 51 yr old male who was admitted to from with an Intracranial bleed (R ventricle). Pt recalls having a severe headache with occasional GI upset over the past week. Pt had gone to his PCP and rec'd a prescription for Fioranol which offered little relief. Pt reported to the EW at on with c/o worsening headache and was noted to have blood in his R ventricle. Pt was transferred to under the care of Dr. .\n\nPt arrived to the SICU via CT-Angio at approximately 4AM. Pt was alert and oriented X3, very pleasant and appropriately anxious. Pt moving all extremties, denies any numbness or tingling, visual disturbances. Nitro gtt off, Nipride gtt started MD orders. PT monitored overnight in the SICU.\n\nPMH/PSH:\nHTN\nHypercholestremia\n\"high sugars\" per PCP, diabetes diagnosed\nS/P Wisdom teeth extracted\ns/p chin implant in his early 20's for cosmetic reasons\n\nALL: NKDA\n\nROS:\nNeuro: Pt pleasant, alert and oriented X3. Pupils 3mm and equally reactive to light. Pt moves all extremities, denies any weakness, numbness or tingling. Pt c/o headache, specifically severe in back of head/neck area, some relief from MSO4 IV.\n\nCardiac: Bradycardic, HR 40's without ectopy. Nipride gtt titrating to maintain SBP 140-160's (currently 1mcg/kg/min). L radial A-line placed, significant ammt fling noted, so NBP monitored for now. Hct, coags WNL. Pt with 2 periph IVs, both flush easily and sites benign.\n\nResp: Lungs CTAB, sats 94-96% on 2L NP.\n\nGI: Abd soft, good BS. Pt reports +BM on AM. Pt c/o some nausea immediately on admission, subsided without intervention. NPO except meds maintained overnight.\n\nGU/renal: Pt voiding spontaneously in urinal, claims to have used urinal in EW, has not voided yet in SICU.\n\nSkin: Intact\n\nID: Low grade temp, no treatment\n\nEndo: FS stable, no insulin coverage required\n\nSocial: Pt denies any local family or close friends. brother in listed as next of , aware of his hospitalization.\n\nA/P: Continue close neuro/hemo monitoring, f/u with Dr. in AM. Continue nipride as needed\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439916, "text": "RSICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: A+OX3. NO DEFICITS. HOB UP AT 30.\n MORPHINE X1 FOR HEADACHE PAIN.\n HEADACHE IMPROVING AS DAY PROGRESS.\n\nCV: HR 40-60 SB. NIPRIDE WEANED OFF AND PO\n HYDRALAZINE AND LOPRESSOR BEGUN.\n SBP<160. COZAAR GIVEN.\n\nRESP: ON 3LNC WITH SATS 93%. LUNGS CLEAR.\n\nRENAL: LABS WNL. USING URINAL.\n\nGI: NPO EXCEPT SIPS WITH PILLS. IV ZANTAC ADDED.\n\nHEME: STABLE. PNEUMOBOOTS ON.\n\nENDO: BS STABLE.\n\nID: LOW GRADE TEMPS. NO ANTIBXS.\n\nSKIN: NO ISSUES. TURNS SELF.\n\nSOCIAL: BROTHER IN TOUCH FROM .\n\nA: STABLE. NIPRIDE WEANED.\nP: FOLLOW UP WITH MRI. TRANSFER TO NSURG ICU.\n" }, { "category": "Nursing/other", "chartdate": "2130-11-30 00:00:00.000", "description": "Report", "row_id": 1439917, "text": "NURSING UPDATE\nADMITTED FROM MRI WITH RN. ABP >200, NBP L ARM 160 SYS, R ARM 130 SYS- NSURG AWARE. TO GO BY NBP. BRIEFLY STARTED ON NIPRIDE TO KEEP SBP <160. NO NEURO DEFICITS.\nTOL REG DIET. IVF AT KVO. 2L NC -O2 SAT ON RA 92%\n" }, { "category": "Nursing/other", "chartdate": "2130-12-01 00:00:00.000", "description": "Report", "row_id": 1439918, "text": "CONDITION UPDATE\nD.AFEBRILE SR TO SINUS BRADY. AS LOW AS 39 TRANGIENTLY DESPITE LOPRESSOR BEING HELD. SBP BY CUFF=150-160 (EQUAL IN BOTH ARMS) WHILE A-LINE= 180-200, NIPRIDE TITRATED BY CUFF PER DR. AND SICU/TRAUMA TEAM.\n RM AIR O2 SAT=95-98,RR=.\n PT C/O HA ALL OVER #4 WHICH RESPONDED WELL TO PERCOSET.\n PT REMAINS ORIENTED X3,MOVES ALL EXTREMITIES EQUALLY TO COMMAND. PSERL.\n PT REMAINS NPO FOR ON CALL ANGIO.IVF AT 80ML/HR.PT VOIDING WITHOUT DIFFICULTY.\n K REPLACEMENTS IN IVF.\nA. MAINTAIN CUFF BP <160 WITH NIPRIDE.\nR. CONDITION STABLE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-01 00:00:00.000", "description": "Report", "row_id": 1439919, "text": "UPDATE\nRETURNED FROM INTERVENTIONAL ARTERIOGRAM. R FEMORAL SITE WITHOUT ECHHYMOSIS OR BLEEDING. NEUROSIGNS APPEAR NORMAL. PT C/O \"JUST A TOUCH\" OF A FRONTAL HEADACHE.\n\nL NBP CUFF MEASURING BP ALONG WITH L RADIAL A LINE. SNP INFUSING AT 2.3MCG/KG. DR. HERE. PLAN TO RESUME ALL PRE-PROCEEDURE MEDS INCLUDING LOPRESSOR AND WEAN SNP KEEPING SBP <180.\n\nNS @ 70CC/HR. CONDOM CATH OFF (PLACED FOR ARTERIOGRAM). PT HAS USED URINAL.\n\nBREATHSOUNDS CLEAR. PT BREATHING ROOM AIR WITH SP02 98%.\n\nSB AND NSR. 1 EPISODE OF P WAVES INVERTING.\n\nPLAN TO CHECK BLOODGLUCOSE, CONTINUE TO MONITOR NEURO SIGNS AS ORDERED AND NEEDED. PLAN TO GIVE MEDICATIONS FROM EARLIER TODAY.\n\nPT TALKING ON THE PHONE TO HIS \"NEXT OF \" BROTHER FROM CURRENTLY. PROBABLE TRANSFER OUT OF THE UNIT TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439920, "text": "NEURO~A+O X3. NEURO CHECKS Q 2/HR'S, WNL. NO CHANGES THRU NIGHT. 0430 GIVEN PERCOCET 2 TABS FOR C/O THROBBING HA. AT 0500 NOTICED PT'S FACE AND NECK WERE RED BP UNCHANGED REMAINED 160'S. MAP:82, HR 58. PT MENTIONED NOTHING AND STATED THAT HE FELT FINE EXCEPT HIS VISION WAS FUZZY. \"LIKE THINGS WERE MOVING\". STATED THAT VISION WAS NOT BLURY. HE CALLED IT A FUZZY FEELING AND THATS THE ONLY WAY HE COULD EXPLAIN IT. RESOLVED W/IN 10 MIN. ALSO AT THAT TIME I NOTICED A PETECHIAL TYPE RASH ON HIS LEFT ARM FROM HIS ELBOW TO HIS FINGERS. NO C/O OF ITCHING. DR. AWARE. QUESTIONING IF PERCOCET RELATED. RASH LESS SEVERE THIS AM.\n\nCARIAC~REMAINS ON SNP @ 2.5 UCG/KG/MIN. TO MAINTAIN A SBP </=160. RESUMED PREVIOUS ANTIHYPERTENSIVES W/O EFFECT. 0600 HR~82. ART BP~159/59/79. L ARM CUFF PRESSURE~133/55/77. R CUFF PRESSURE~126/55/76. HR 50'S-6O'S SB W/ OCC PVS'S NOTED.\n\nRESP~DROP IN SATS TO 90'S ON RA. PLACED ON 2L NP SATS 97%.\nLUNGS CLEAR BILAT.\n\nGI/GU~NPO EXCEPT MEDS. + BS.\n\nENDO~BS Q 4/HRS. NOT REQUIRING SS COVERAGE ON NIGHTS.\n\nA/P~ PER NEURO ATTENDING.WEAN SNP OFF THIS AM. DC A-LINE. CHANGE LOPRESSOR TO ATENOLOL HOLD FOR HR < 55. EKG THIS AM. PLAN TO TRANS TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439921, "text": "Shift Note\nPt is neurologically intact, MAE to command. Hemodynamically pt with HTN, SNP infusing, unable to wean SNP. HO aware, hydralazine po dose increased. U/O qs, +BS pt able to tolerate solids. Pt with transient episode of nausea. Pt c/o lightheadedness that resolved spontaneously, HO aware. Pt cleared for floor once SBP <140mmhgx3 hours. See flowsheet for details.\n\n" }, { "category": "Nursing/other", "chartdate": "2130-12-02 00:00:00.000", "description": "Report", "row_id": 1439922, "text": "NIPRIDE OFF AT 1530. BP CONTROLLED WITHIN MD PARAMETERS WITH ORAL HYDRALAZINE, LOPRESSOR, AND IV INJECTION OF CLONIDINE.\nPT READY FOR TRANSFER TO 5.\n\nREPORT CALLED TO RN.\n\n\nHISTORY: PT IS 51 Y.O. MALE WITH HX: HTN, HYPERCHOLESTREMIA. PT WENT TO PCP WITH 4 DAY HISTORY OF HEADACHE. RETURNED TO ON AND FOUND TO HAVE INTRAVENTRICULAR BLEED. (NO NEURO DEFECITS). TRANSFERRED TO . IN UNIT FOR NEURO CHECKS AND BP CONTROL.\n\n\nNEURO: INTACT\n\nCV: A-FEBRILE. BP WNL OFF OF NIPRIDE. NORMAL SINUS RHYTHM WITH SINUS BRADY WHEN ASLEEP.\n\nRESP: BREATH SOUNDS CLEAR. RATE AND EFFORT WNL. SATS WELL ON 2LNC.\n\nGI: TOL GEN DIET.\n\nGU: VOIDS PER URINAL.\n\nSKIN: INTACT.\n\nPAIN: PT DENIES PAIN. NO HEADACHE.\n\nACTIVETY: PT HAS BEEN ON BEDREST.\n\nPLAN: TRANSFER TO 5.\n\n\n\n\n" } ]

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55 year old male with a history of transferred from with NSTEMI status post drug eluting stent to LAD for intravascular ultrasound. . # CORONARIES: Per the patient's history he likely has a history of stable angina with NSTEMI on the day of admission. At the outside hospital a cardiac catheterization was done which showed prox LAD 80-90% lesion and a drug eluting stent was placed to proximal LAD. There was concern at the outside hospital over the patency of the stent. He was transferred here for intravascular ultrasound which showed widely patent stent. Previous concern was likely effect. No re-intervention was done. Peak CK 450, MB 58, TnT 1.14. Aspirin 325 po qday, Atorvastatin 80 po qday, Plavix 75 po qday were started. Nitro sublingual tabs were given prn for chest pain. . # PUMP: There was no previous history of heart failure or heart failure symptoms. LV gram at the outside hospital showed hypokinesis of anterior wall and apex. Lisinopril 10 po qday and Metoprolol 37.5 po bid were started. . # RHYTHM: The patient has no history of abnormal rhythms. No events were seen on telemetry during admission. ECGs have been showing slightly slurred upstroke of R wave in precordial leads - possible delta waves concerning for accessory pathway. . #Discharge: On , after a thorough workup revealed no ongoing coronary ischemia, and the patient was asymptomatic, he was discharged to home from in good, ambulatory conditions, with stable vital signs. Prior to discharge, post myocardial infarction education was reviewed with the patient including reduction of risk for coronary disease, appropriate exercise after myocardial infarction, and a review of his discharge medications.

He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. 2+ DP and PT pulses b/l . Rt femoral cath site with slight induration and tenderness (unchanged from prior exam). Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt has remained pain free. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. There is some distal dx that will be medically managed. He is tolerating it well and autodiuresing. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. He R/I for NSTEMI. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: He has previously been on antihyptertensive. Clinical correlation is suggested.TRACING #1 The T wave is now inverted in lead aVL and slight terminalbiphasic appearance of the T wave in lead I. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. L groin was used and angiosealed. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. He has previously been on anti-hyptertensive. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Ultrasound showed stent is open. Rule out active lateral myocardial ischemicprocess. CKs , platelets and K+ pending. CKs , platelets and K+ pending. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Response: Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. # CORONARIES: Pt with history of stable angina with NSTEMI today. # CORONARIES: Pt with history of stable angina with NSTEMI today. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: On admit pt with c/o cp. NPO for repeat cath in AM with IVUS of proximal LAD. # CORONARIES: Pt likely has history of stable angina with ACS today. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: ECG with NSSTTW and initial cardiac enzymes negative. Rt femoral cath site with slight induration and tenderness (unchanged from prior exam). At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. At OSH he received , , Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. Became painfree and bp in the 120s to 130s. Became painfree and bp in the 120s to 130s. Became painfree and bp in the 120s to 130s. Now s/p cath with DES to proximal LAD. Now s/p cath with DES to proximal LAD. Now s/p cath with DES to proximal LAD. Proximal portion of the stent looked hazy so pt was transferred to for IVUS. Proximal portion of the stent looked hazy so pt was transferred to for IVUS. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. He has been started on and is tolerating ACE and beta , , plavix and statin. LV gram at OSH showed hypokinesis of anterior wall and apex. LV gram at OSH showed hypokinesis of anterior wall and apex. LV gram at OSH showed hypokinesis of anterior wall and apex. DISPO: CCU for now ICU Care Nutrition: NPO for cath tomorrow Glycemic Control: None Lines: PIV 20 Gauge - 12:11 AM Prophylaxis: DVT: Angiomax Stress ulcer: Not indicated Code status: Full Code Disposition: CCU care for now

27

[ { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232890, "text": "Sinus bradycardia. Low precordial lead voltage. Early precordial R wave\ntransition. Continued biphasic T wave in lead I and T wave inversion in\nlead aVL which is more prominent. Rule out active lateral myocardial ischemic\nprocess. Followup and clinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232891, "text": "Sinus rhythm. Biphasic T wave in lead I and more prominent T wave inversion in\nlead aVL. Rule out active lateral myocardial ischemic process. Followup\nand clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2158-10-18 00:00:00.000", "description": "Report", "row_id": 232892, "text": "Sinus rhythm. The T wave is now inverted in lead aVL and slight terminal\nbiphasic appearance of the T wave in lead I. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2158-10-17 00:00:00.000", "description": "Report", "row_id": 232893, "text": "Sinus rhythm. Early precordial R wave transition. No previous tracing available\nfor comparison.\n\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485899, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable.\n Action:\n CKs cycled.\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on antihyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485887, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable.\n Action:\n CKs cycled.\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486013, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs now down\n to 292. Ensure he has been seen by PT tomorrow. He is voiding through\n condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Height:\n 69 Inch\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH: Angina, CAD, Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:73\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,006 mL\n 24h total out:\n 3,625 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 06:25 AM\n Potassium:\n 4.1 mEq/L\n 04:10 PM\n Chloride:\n 107 mEq/L\n 06:25 AM\n CO2:\n 25 mEq/L\n 06:25 AM\n BUN:\n 10 mg/dL\n 06:25 AM\n Creatinine:\n 0.9 mg/dL\n 06:25 AM\n Glucose:\n 116 mg/dL\n 06:25 AM\n Hematocrit:\n 39.1 %\n 06:25 AM\n Valuables / Signature\n Patient valuables: None.\n Other valuables:\n Clothes: Sent home with wife\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1830\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486011, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485916, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485918, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen: Well nourished, No acute distress.\n HEENT: NCAT, PERRL, OP clear, no LAD\n Cardiovascular: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Abd: + BS, soft, NT, ND\n Pulm: CTAB\n Extrem: no c/c/e. Rt femoral cath site with slight induration and\n tenderness (unchanged from prior exam). Small ecchymosis. No bruit.\n Left femoral cath site with no induration, tenderness or bruit. 2+ DP\n and PT pulses b/l\n .\n Tele: NSR with no significant ectopy\n .\n A/P:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485857, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485859, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485953, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485955, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen. He is receiving 1/2NS at 125cc/hr X 750cc/hr.\n He is tolerating it well and autodiuresing.He is eating and drinking\n without problem.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow. He is\n voiding through condom and >1000cc neg.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow. Keep careful I & O.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485956, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485762, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485942, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485944, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) , and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He R/I for NSTEMI. He arrives to CCU on\n iv ntg and angiomax. He remained pain free until going to lab at 0800\n for intravenous ultrasound. Ultrasound showed stent is open. There is\n some distal dx that will be medically managed. He was pain free\n throughout the procedure. L groin was used and angiosealed. He returned\n to CCU at 1000. Both groins dry, All pulses dopplerable.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt has remained pain free. Peak CKs at 0630 was 450/59/12.9. Pt\n expected to have little or no residual from N-stemi. Groin site dry\n with no ooze or hematoma. Pulses all palpable. He has no ectopy.\n Action:\n CKs cycled. He has been started on and is tolerating ACE and beta\n , , plavix and statin. He had HOB up to 90 degrees at 1230\n and has no bleeding. He can be OOB as tolerated. PT consult called, but\n he has not yet been seen.\n Response:\n BP ranging 120-140/60s. HR in 60s. Pt continues pain free. CKs ,\n platelets and K+ pending. Ensure he has been seen by PT tomorrow.\n Plan:\n Increasing medications as ordered. Monitor groin site and pulses. Check\n results of labs. Likely D/C tomorrow.\n Knowledge Deficit\n Assessment:\n Pt and his wife are unfamiliar with procedures, MI and medications. He\n has previously been on anti-hyptertensive.\n Action:\n Teaching begun about betablockers, ace, and antiplatelet medications.\n Teaching packets about N-stemi, stents and heart health diet given and\n discussed. Information about activity post MI also discussed.\n Response:\n Pt and wife packets and asking questions. They are feeling more\n comfortable knowing what to expect and how to proceed.\n Plan:\n Continue with med teaching and give pt information drug sheets as meds\n and doses are finalilzed. Ensure all appts are given to pt prior to\n d/c. Review teaching literature with pt and his wife to ensure they are\n comfortable with discharge.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485705, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485815, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 485693, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads (per report only). Drug eluting stent was placed to the\n prox LAD. Proximal portion of the stent looked hazy so pt was\n transferred to for IVUS. At OSH he received , ,\n Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1,\n Lisinoprol 2.5 x1. Post-cath CK 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55 yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt with history of stable angina with NSTEMI today. Now\n s/p cath with DES to proximal LAD. 2^nd set of cardiac enzymes CK 321,\n MB 45.9, Index 14.3, TnT 0.33 (post-cath). Concern at OSH over patency\n of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n HR titrate goal 60\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Full Code\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO for cath tomorrow\n Glycemic Control: None\n Lines: PIV\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT: Angiomax\n Stress ulcer: Not indicated\n Code status: Full Code\n Disposition: CCU care for now\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Fellow Admission Note - MICU", "row_id": 485695, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads (per report only). Drug eluting stent was placed to the\n prox LAD. Proximal portion of the stent looked hazy so pt was\n transferred to for IVUS. At OSH he received , ,\n Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1,\n Lisinoprol 2.5 x1. Post-cath CK 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55 yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt with history of stable angina with NSTEMI today. Now\n s/p cath with DES to proximal LAD. 2^nd set of cardiac enzymes CK 321,\n MB 45.9, Index 14.3, TnT 0.33 (post-cath). Concern at OSH over patency\n of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n HR titrate goal 60\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Full Code\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO for cath tomorrow\n Glycemic Control: None\n Lines: PIV\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT: Angiomax\n Stress ulcer: Not indicated\n Code status: Full Code\n Disposition: CCU care for now\n ------ Protected Section ------\n Patient seen and examined, discussed with housestaff Dr. .\n Please see above H&P for complete details. Briefly, 55M recently\n diagnosed hypertension presented with anginal-type chest pain while\n working out today. Improved but not resolved with nitro, aspirin en\n route. ECG with NSSTTW and initial cardiac enzymes negative. Plavix 600\n loaded. Taken to cath where found to have proximal 90% LAD lesion with\n ruptured thrombotic plaque and thrombus in the terminal ramus and D1\n sidebranch. Promus 3.5x18mm stent delivered successfully to LAD lesion\n however note of some proximal stent edge haziness at the LAD ostium\n (?flow artifact vs. small clot vs. plaque shift). Transferred to \n for IVUS evaluation of suspect lesion. Initially planned for\n cardiology floor but developed chest pain prior to transfer and\n therefore diverted to CCU for closer observation. On arrival complained\n of substernal chest discomfort that has now resolved after\n receiving single dose morphine. Plan to continue aspirin, plavix,\n lipitor, metoprolol, lisinopril, and . NPO for repeat cath\n in AM with IVUS of proximal LAD. HR well controlled in 60s. BP\n currently slightly elevated, would titrate lisinopril for goal SBP<130.\n Consider echocardiogram to further assess LV function.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:34 ------\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485812, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2158-10-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 485690, "text": "TITLE:\n Chief Complaint: chest pain\n HPI:\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS to evaluate patency of stent. The pt has been\n troubled by occasional episodes of chest pressure while exercising for\n the past year. He characterized the discomfort as substernal chest\n pressure, and relieved after 5min with rest. He only experienced\n this chest pressure ~5 times until - of this year when he\n went to his PCP to get it evaluated. He had an exercise stress test in\n which was repeated a week later with nuclear imaging and both\n tests showed excellent functional capacity with exercise duration of 14\n min and no evidence of ischemia.\n .\n On the morning on admission () the pt developed gradual onset of\n substernal chest pain while riding on the elliptical treadmill. He\n rested for 5 minutes and the pain resolved. He then went back on the\n elliptical and CP returned within 1 minute. He then decided he was\n going to the ER to get this pain evaluated, but decided to shower\n first. While exiting the shower he developed excruciating central chest\n pressure and heaviness, rated and radiated to his neck/throat and\n down the inside of both arms. He also noticed some diaphoresis but\n denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was\n called and pt was given and nitro spray en route to the hospital.\n Nitro spray did not change discomfort, nitro SL did improve pain in\n ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial\n EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03,\n CK 141, CKMB 3.9, BNP 59.\n .\n Cardiac cath was done which showed prox LAD 80-90% lesion and 40%\n occlusion of RCA. Plaques were also found in an LAD ramus and diag.\n During cath the pt developed 4/10 chest pain with ST elevations in the\n inferior leads. Drug eluting stent was placed to the prox LAD. Proximal\n portion of the stent looked hazy so pt was transferred to for IV\n ultrasound. At OSH he received , , Plavix 600, Nitro gtt,\n Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. Post-cath CK\n 321, MB 45.9, Index 14.3, TnT 0.33.\n .\n Upon transfer the pt has residual substernal chest pain. The pain\n has been waxing and , does not radiate and has no associated\n symptoms. On review of systems, he denies fevers, chills, HA,\n lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion,\n PND, ankle swelling, palpitations, syncope or presyncope. He is\n scheduled with Dr. tomorrow morning for IVUS for stent\n evaluation.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: HTN\n 2. CARDIAC HISTORY:\n -CABG: none.\n -PERCUTANEOUS CORONARY INTERVENTIONS: cath wtih drug eluting\n stent to prox-LAD\n -PACING/ICD: none.\n 3. OTHER PAST MEDICAL HISTORY: tonsillectomy\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death. Father died of lung cancer/asbestosis, mother died of\n stroke.\n Occupation: software developer for health company\n Drugs: none\n Tobacco: 1-2packs per year for 20 years. Quit 17yrs ago.\n Alcohol: drinks per week\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 12:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 69 (68 - 71) bpm\n BP: 140/80(95) {131/71(85) - 142/80(95)} mmHg\n RR: 19 (17 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 4 mL\n 3 mL\n PO:\n TF:\n IVF:\n 4 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4 mL\n -547 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic.\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : bilaterally, Crackles :\n posterior bases)\n Abdominal: normoactive BS, soft NTND\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing. Right femoral cath site\n no ecchymosis, no induration, no oozing, no bruits.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55yo M hx transferred from OSH s/p DES to LAD now with residual\n chest pain for IVUS for evaluation of stent patency.\n .\n # CORONARIES: Pt likely has history of stable angina with ACS today.\n Now s/p cath with DES to proximal LAD. CEs rising post cath. Concern at\n OSH over patency of stent.\n - Continue to trend CEs\n - 325 po qd\n - Atorvastatin 80 po qd\n - Plavix 75 po qd\n - gtt\n - Morphine 1-2mg po q2 for chest pain\n - Nitro SL prn for chest pain\n - For IVUS tomorrow with Dr. for evaluation of stent\n .\n # PUMP: No history of HF or HF symptoms. LV gram at OSH showed\n hypokinesis of anterior wall and apex.\n - Lisinopril 5 po qd\n - Metoprolol 25 po bid\n - Will need TTE in the future\n .\n FEN: low sodium heart healthy diet. Senna, colace.\n .\n ACCESS: PIV's\n .\n CODE: Presumed full\n .\n COMM: patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:11 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485814, "text": "55yo male with past med hx of htn. Has had angina in past that was w/u\n in with stress test and nuclear stress test, both (-) per pt.\n Today () pt at gym where he experienced cp , rested and pain\n was relieved. Pain returned when he cont to exercise. He again\n stopped, went to shower and pain increased to , therefore emt's\n called. He was given 4 (81mg) asa, and slntg. On admit to \n Ew he had no ekg changes but team felt he was (+) for ACS therefore\n went to cath lab where they found a prox LAD lesion, which they placed\n a drug eluding stent, after the case he cont with 3/10 cp, stent\n appeared to be hazy proximally and the decision was made to be\n transferred to for IVUS. He arrives to CCU on iv ntg and\n angiomax.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n On admit pt with c/o cp. Angiomax and Ntg dc\nd on admit. Hr 70\n with bp 140\ns. Lungs with crackles R base otherwise clear. O2 at 2lnp\n with sats in the mid to upper 90.s R groin with small hematoma\n outlined. Distal pulses are easily palpable. He is voiding easily via\n urinal.\n Action:\n Given extra dose of both lopressor (25mg) and lisinopril (5mg).\n Started on heparin at 1200 units/hr and given 1mg morphine iv.\n Explained reason for transfer to .\n Response:\n Decided to d/c heparin and restart angiomax at 0.2mg/kg/hr. Became\n painfree and bp in the 120\ns to 130\ns. Has been NPO for cath this am.\n He is concerned about post MI activity.\n Plan:\n Cath today. Follow bp/hr, to give increase dose of lisinopril again\n today.\n" }, { "category": "General", "chartdate": "2158-10-18 00:00:00.000", "description": "ICU Event Note", "row_id": 485921, "text": "Clinician: Resident\n S: Patient reports feeling well currently. Denies CP, SOB,\n palpitations, and dizziness. Denies pain at cath sites or other\n complaints currently.\n .\n O:\n Vitals: T 98.6, HR 61 (60-70s), BP 127/75 (120-130s/65-80), RR 20, SaO2\n 94% on RA\n Gen: Well nourished, No acute distress.\n HEENT: NCAT, PERRL, OP clear, no LAD\n Cardiovascular: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Abd: + BS, soft, NT, ND\n Pulm: CTAB\n Extrem: no c/c/e. Rt femoral cath site with slight induration and\n tenderness (unchanged from prior exam). Small ecchymosis. No bruit.\n Left femoral cath site with no induration, tenderness or bruit. 2+ DP\n and PT pulses b/l\n .\n Tele: NSR with no significant ectopy\n .\n A/P: 55 yo M hx transferred from OSH s/p DES to LAD for IVUS for\n evaluation of stent patency. IVUS showed widely patent LAD stent with\n moderate mid LAD disease (40-50%).\n - continue to trend MB to peak\n - callout to 3, likely home tomorrow.\n" }, { "category": "Nursing", "chartdate": "2158-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485808, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

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182,335

The patient was admitted to the Cardiac Surgery Service for a surgical intervention. On , the patient underwent coronary artery bypass grafting times four with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to diagonal branch, saphenous vein graft to obtuse marginal branch and saphenous vein graft to the posterior lateral branch of the right coronary artery. The procedure was without complications, please see the full operative report for details. The patient was in stable condition. The patient was transferred to the Cardiac Intensive Care Unit for initial management. The patient remained intubated. The patient was gradually weaned off the ventilator as tolerated. The patient was extubated on postoperative day #1 requiring continuous Neosynephrine requirement which was weaned gradually. The patient's vital signs remained stable. His electrolytes were repleted as needed. The patient remained in regular rhythm, although slightly tachycardiac. On postoperative day #2, the patient was transferred to the regular floor in stable condition. The patient continued to do very well. His chest tubes were removed on postoperative day #2. His urine catheter was removed on postoperative day #2 as well. Diabetes consult saw the patient and evaluated his current management of diabetes. The pacing wires were removed on postoperative day #3. The patient remained in sinus rhythm during his stay on the service. The patient was ambulating without difficulty and was cleared by the physical therapy. The patient was discharged on to home with services in stable condition.

PT ASSESSMENT AS FOLLOWS:N: SEDATED ON PROPOFOL, WEANED OFF AFTER REVERSAL, CALM AND FOLLOWING COMMANDS.CV: NSR , NO ECTOPY NOTED, BP STABLE WITH 500CCS LR GIVEN FOR BORDERLINE BP (SYSTOLIC 88). MINIMAL FACIAL AND HAND EDEMA NOTED, + PEDAL PULSES. NO C/O'S NAUSEA.GU; URINE OP WNL AND NOT AN ISSUE OVER NOC.ENDO; PT ON INSULIN GTT AND TITRATED TO BLD SUGARS. PT STARTED ON PERCOCETS DURING THE NOC WITH MINIMAL EFFECT.PLAN; CONT TO ASSESS AND MONITOR TRANSFER TO 2 IF REMAINS STABLE AND ABLE TO PULL WITHOUT DIFFICULTY.CARDIOVAS; SR NO ECTOPY PT DID HAVE A SHORT 7 BEAT RUN OF AFIB DURING THE NOC SELF LIMITING. Sinus rhythmNormal ECGSince previous tracing of : no significant change Sinus rhythmNormal ECGSince previous tracing, no significant change Sinus rhythmNormal ECGSince previous tracing, no significant change INSULIN GTT ON AT 2-4 U PER FLOW WITH 4 U BOLUS GIVEN.SKIN: MED DSG CDI, LEFT LEG WITH ACE WRAP INTACT, NO NOTABLE DRAINAGE. CT TO SUCTION, OUTPUT IS MINIMAL AND SEROSANGUINOUS, SITES INTACT WITH NO NOTABLE CLOTTING AT INSERTION SITE.GI/ GU: ABDOMEN BENIGN, NO COMPLAINTS OF PAIN. PT given calcium 2 amps IV for low value, ct output wnl, pt calm, insulin gtt adjusted per flow. Pt cpap gas is wnl, but pt is still sleepy/ sluggish. PT ADMITTED TO ACCOMPANIED BY ANESTHESIOLOGY TEAM, BILATERAL LUNG SOUNDS CLEAR AND PRESENT. There has been interval resolution of a previous right pleural effusion. The heart size is normal and the mediastinal and hilar contours are unremarkable. BP INITALLY LABILE ON NEO GTT. A AND V WIRES ATTACHED.R: VENT SETTINGS PER FLOW, PT WEANED FROM VENT AS TOLERATED, PROJECTED EXTUBATION FOR THIS SHIFT. INSULIN GTT OFF THIS AM WITH BLD SUGARS WNL.COMFORT; C/O LOTS OF INCISIONAL PAIN TX WITH MS04 SQ AND IV WITH NO EFFECT. LUNGS CLEAR BUT DIMINISHED IN BASES. The pulmonary vascularity is within normal limits. CHEST TUBES DRAINING MOD AMT THIN SEROSANQ DRAINAGE. PT GIVEN 500CC LR WITH GOOD EFFECT AND NEO GTT OFF THIS AM WITH MAP >60.GI; TAKING ICECHIPS AND SIPS OF H20 WITH MEDS. Addendum/ Correction:In initial admission note, Rn noted that Vfib was in or when in fact it happened in cath lab on . SLIGHTLY ANXIOUS AT TIMES.RESP; LUNGS CLEAR DIM THRUOUT. UOP STABLE WITH AVERAGE OF 200CC/HR, CLEAR, YELLOW. LIMA AND SVG USED TO BIPASS LAD, RCA, OM, DIAG. Pt does lift head off pillow only for 1-2 seconds. Frontal and lateral radiographs of the chest were obtained and compared to the next prior study dated . 02 VIA N/C AT 4LM WITH 02 SAT'S AND RR WNL. DENIES ANY C/O'S SOB. ADMISSION TO NOTEPT 62 YO MALE ADMITTED S/P EXPERIENCING CP WITH EXERTION, WITH A + EXERCISE STRESS TEST , FOLLOWED BY A CATH SHOWING 4VESSEL DZ. 7P-7A SHIFT SUMMARY NOTE;NEURO; INITALLY SLEEPY AND EXTUBATED WHEN MORE AWAKE WITH OUT EVENT AT . PT ENCOURAGED TO USE I.S. NO OTHER SKIN BREAKDOWN, SACRUM CDI.PT WIFE INT TO VISIT PT, EDUCATED ABOUT TYPICAL POST OPERATIVE COURSE.RN TO FOLLOW CLOSELY AND WEAN TO EXTUBATE AS TOLERATED. PT HAD VFIB WITH RCA INJECTION AND DEFIBRILLATED 300 JOULES X 1. PT WITH STEROIDS BEFORE CATH SECONDARY TO PRIOR ANAPHYLAXIS FOLLOWING IODINE ADMINISTRATION IN PAST. TODAY, PT HAD C4 BY DR. () CROSS CLAMP 54 MINUTES, BIPASS 67 MINUTES. PCER FUNCTIONING APPROPRIATELY, ON ADEMAND AT 60. KCL 40 MEQ GIVEN FOR KCL OF 3.9. O2 SATS 100%. There are surgical sutures and linear scarring at the right lung base consistent with patient's history of prior wedge resection of fibroelastin scar. Surgical sutures and linear scarring at the right lung base. Preop for CABG. POST OP ABG WNL. ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. PREOP,PT ON AN INSULIN GTT FOR HYPERGLYCEMIA MAX 500+). 10:29 PM CHEST (PRE-OP PA & LAT) Clip # Reason: +ETT\CATH MEDICAL CONDITION: 62 year old man with IDDM, CAD for CABG tomorrow morning REASON FOR THIS EXAMINATION: pre-op cabg FINAL REPORT PREOP CHEST X-RAY, : CLINICAL INDICATION: 62 year old man with diabetes and coronary artery disease. No effusions are currently identified and there are no focal areas of consolidation. COUGHING AND RAISING THICK YELLOWISH SECREATIONS.

8

[ { "category": "Radiology", "chartdate": "2153-10-01 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 770228, "text": " 10:29 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with IDDM, CAD for CABG tomorrow morning\n REASON FOR THIS EXAMINATION:\n pre-op cabg\n ______________________________________________________________________________\n FINAL REPORT\n PREOP CHEST X-RAY, :\n\n CLINICAL INDICATION: 62 year old man with diabetes and coronary artery\n disease. Preop for CABG.\n\n Frontal and lateral radiographs of the chest were obtained and compared to the\n next prior study dated .\n\n The heart size is normal and the mediastinal and hilar contours are\n unremarkable. There are surgical sutures and linear scarring at the right\n lung base consistent with patient's history of prior wedge resection of\n fibroelastin scar. There has been interval resolution of a previous right\n pleural effusion. No effusions are currently identified and there are no\n focal areas of consolidation. The pulmonary vascularity is within normal\n limits.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n Surgical sutures and linear scarring at the right lung base.\n\n" }, { "category": "ECG", "chartdate": "2153-10-03 00:00:00.000", "description": "Report", "row_id": 140693, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 140694, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2153-10-01 00:00:00.000", "description": "Report", "row_id": 140695, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of : no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-03 00:00:00.000", "description": "Report", "row_id": 1451563, "text": " 7P-7A SHIFT SUMMARY NOTE;\n\nNEURO; INITALLY SLEEPY AND EXTUBATED WHEN MORE AWAKE WITH OUT EVENT AT . ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL. SLIGHTLY ANXIOUS AT TIMES.\n\nRESP; LUNGS CLEAR DIM THRUOUT. COUGHING AND RAISING THICK YELLOWISH SECREATIONS. 02 VIA N/C AT 4LM WITH 02 SAT'S AND RR WNL. DENIES ANY C/O'S SOB. CHEST TUBES DRAINING MOD AMT THIN SEROSANQ DRAINAGE. PT ENCOURAGED TO USE I.S. AND ABLE TO PULL WITHOUT DIFFICULTY.\n\nCARDIOVAS; SR NO ECTOPY PT DID HAVE A SHORT 7 BEAT RUN OF AFIB DURING THE NOC SELF LIMITING. BP INITALLY LABILE ON NEO GTT. PT GIVEN 500CC LR WITH GOOD EFFECT AND NEO GTT OFF THIS AM WITH MAP >60.\n\nGI; TAKING ICECHIPS AND SIPS OF H20 WITH MEDS. NO C/O'S NAUSEA.\n\nGU; URINE OP WNL AND NOT AN ISSUE OVER NOC.\n\nENDO; PT ON INSULIN GTT AND TITRATED TO BLD SUGARS. INSULIN GTT OFF THIS AM WITH BLD SUGARS WNL.\n\nCOMFORT; C/O LOTS OF INCISIONAL PAIN TX WITH MS04 SQ AND IV WITH NO EFFECT. PT STARTED ON PERCOCETS DURING THE NOC WITH MINIMAL EFFECT.\n\nPLAN; CONT TO ASSESS AND MONITOR TRANSFER TO 2 IF REMAINS STABLE\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451560, "text": "ADMISSION TO NOTE\nPT 62 YO MALE ADMITTED S/P EXPERIENCING CP WITH EXERTION, WITH A + EXERCISE STRESS TEST , FOLLOWED BY A CATH SHOWING 4VESSEL DZ. PT WITH STEROIDS BEFORE CATH SECONDARY TO PRIOR ANAPHYLAXIS FOLLOWING IODINE ADMINISTRATION IN PAST. PREOP,PT ON AN INSULIN GTT FOR HYPERGLYCEMIA MAX 500+). TODAY, PT HAD C4 BY DR. () CROSS CLAMP 54 MINUTES, BIPASS 67 MINUTES. LIMA AND SVG USED TO BIPASS LAD, RCA, OM, DIAG. PT HAD VFIB WITH RCA INJECTION AND DEFIBRILLATED 300 JOULES X 1. PT ADMITTED TO ACCOMPANIED BY ANESTHESIOLOGY TEAM, BILATERAL LUNG SOUNDS CLEAR AND PRESENT. PT ASSESSMENT AS FOLLOWS:\n\nN: SEDATED ON PROPOFOL, WEANED OFF AFTER REVERSAL, CALM AND FOLLOWING COMMANDS.\n\nCV: NSR , NO ECTOPY NOTED, BP STABLE WITH 500CCS LR GIVEN FOR BORDERLINE BP (SYSTOLIC 88). MINIMAL FACIAL AND HAND EDEMA NOTED, + PEDAL PULSES. KCL 40 MEQ GIVEN FOR KCL OF 3.9. PCER FUNCTIONING APPROPRIATELY, ON ADEMAND AT 60. A AND V WIRES ATTACHED.\n\nR: VENT SETTINGS PER FLOW, PT WEANED FROM VENT AS TOLERATED, PROJECTED EXTUBATION FOR THIS SHIFT. O2 SATS 100%. LUNGS CLEAR BUT DIMINISHED IN BASES. POST OP ABG WNL. CT TO SUCTION, OUTPUT IS MINIMAL AND SEROSANGUINOUS, SITES INTACT WITH NO NOTABLE CLOTTING AT INSERTION SITE.\n\nGI/ GU: ABDOMEN BENIGN, NO COMPLAINTS OF PAIN. UOP STABLE WITH AVERAGE OF 200CC/HR, CLEAR, YELLOW. INSULIN GTT ON AT 2-4 U PER FLOW WITH 4 U BOLUS GIVEN.\n\nSKIN: MED DSG CDI, LEFT LEG WITH ACE WRAP INTACT, NO NOTABLE DRAINAGE. NO OTHER SKIN BREAKDOWN, SACRUM CDI.\n\nPT WIFE INT TO VISIT PT, EDUCATED ABOUT TYPICAL POST OPERATIVE COURSE.\nRN TO FOLLOW CLOSELY AND WEAN TO EXTUBATE AS TOLERATED.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451561, "text": "Pt cpap gas is wnl, but pt is still sleepy/ sluggish. Pt does lift head off pillow only for 1-2 seconds. PT given calcium 2 amps IV for low value, ct output wnl, pt calm, insulin gtt adjusted per flow. Rn to endorse info to night staff.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-02 00:00:00.000", "description": "Report", "row_id": 1451562, "text": "Addendum/ Correction:\nIn initial admission note, Rn noted that Vfib was in or when in fact it happened in cath lab on .\n" } ]

24,811

143,739

Mr. a tonsillectomy, uvulectomy, septoplasty, and intramural cauterization of nasal turbinates on . He had 75cc of blood loss and tolerated the procedure well without complications. He was extubated in the PACU but was unable to be weaned from oxygen. He was transferred to the for continuous O2 sat monitoring. He was maintained on humidified oxygen by shovel mask overnight. He was kept off his home BiPAP to prevent bleeding and irritation postoperatively. He had improvement in his O2 saturations with intensive incentive spirometry. His hypoxia was therefore thought to largely be due to postoperative atelectasis, with contribution from his baseline problems with sleep apnea. His O2 saturations were measured with ambulation and were found to be 92-94%. He had mild postoperative pain that was well-controlled with Percocet elixir. He was advanced to a full diet before discharge. He was discharged to home with instructions to follow up with Dr. in 1 week.

IN 1 WK AND CALL DR. HIS PRIMARY MD WITH NEXT F/U APPOINTMENT. PT INSTRUCTED TO MD IF TEMP > 100, CALL IF BLEEDING DOESN'T STOPPED AFTER PRESSURE APPLIED TO NOSE/MOUTH, OR IF PAIN IN NOSE/MOUTH NOT RELIEVED WITH ROXICET. MICU/SICU NSG NOTE: 7:00-3:00PT S/P SEPTOPLASTY/TONSILECTOMY/UVULOPLASTY . HE WAS TRANSFERRED FROM PACU YESTERDAY AND MONITORED OVERNIGHT B/C OF PERSISTENT DESATURATION. MD TEAM, PT STABLE FOR D/C. IN AFTERNOON, AFTER PT ATE LUNCH, PT STATED HE FELT MUCH BETTER AND 02 SATS 91-94% ON RM AIR WITH AMBULATION. PT AMB AROUND RN STATION AND TOLERATING WELL ALTHOUGH 02 SAT IN AM DROPPED TO 82%. PT TO TAKE KEFLEX AS DIRECTED AND ROXICET PRN PAIN. PT INSTRUCTED TO FOLLOW UP WITH DR. NPN -0700Pt is 35 y/o male with hx of sleep apnea who had septoplasty/ tosillectomy/ uvuloplasty and removal of uvular lesion on , transferred to MICU from PACU for O2sat monitoring b/c of persistent desaturation upon removal of O2.Neuro: A&Ox3, follows commands, answers questions appropriately, c/o discomfort to back of throat, pt describes his throat as "feeling swollen." 02 SATS UP TO 95%. THIS AM PT TO HIGH 80S ON RM AIR. Given total of 15ml of Oxycodone-Acetaminophen elixir for discomfort which pt states has not resolved completely but refuses more medicine.Resp: Lungs coarse bilat., O2 on 100%cool neb, RR 12-20, O2 sats 96-100%, no c/o SOB or difficulty breathing.CV: HR 90-105 SR-ST no ectopy, SBP's 130's-150's, pedal pulses palpable.GI: BS (+), no c/o nausea, NPO except for sips of H2O with meds.GU: Voiding into urinal in adequate amts.Skin: Drsg changed x 2 for small amts of sanguinous drainage, current drsg and . PT SIGNED CONSENT FORM AND WIFE ARRIVED AND PICKED UP PT FOR D/C TO HOME. No bloody drainage noted to back of throat.Social: Wife is contact person, no phone calls from family since adm. to MICU.PlanS: Continue to montitor O2 sats, dc home possibly today if O2 sats hold without the assistance of O2 therapy. PT IN AGREEMENT WITH DISCHARGE PLAN.

2

[ { "category": "Nursing/other", "chartdate": "2124-09-12 00:00:00.000", "description": "Report", "row_id": 1584625, "text": "MICU/SICU NSG NOTE: 7:00-3:00\nPT S/P SEPTOPLASTY/TONSILECTOMY/UVULOPLASTY . HE WAS TRANSFERRED FROM PACU YESTERDAY AND MONITORED OVERNIGHT B/C OF PERSISTENT DESATURATION. THIS AM PT TO HIGH 80S ON RM AIR. GIVEN INCENTIVE SPIROMETER AND USING WITH EXCELLENT TECHNIQUE TO FULL VITAL CAPACITY. 02 SATS UP TO 95%. PT AMB AROUND RN STATION AND TOLERATING WELL ALTHOUGH 02 SAT IN AM DROPPED TO 82%. IN AFTERNOON, AFTER PT ATE LUNCH, PT STATED HE FELT MUCH BETTER AND 02 SATS 91-94% ON RM AIR WITH AMBULATION. MD TEAM, PT STABLE FOR D/C. PT INSTRUCTED TO FOLLOW UP WITH DR. IN 1 WK AND CALL DR. HIS PRIMARY MD WITH NEXT F/U APPOINTMENT. PT INSTRUCTED TO MD IF TEMP > 100, CALL IF BLEEDING DOESN'T STOPPED AFTER PRESSURE APPLIED TO NOSE/MOUTH, OR IF PAIN IN NOSE/MOUTH NOT RELIEVED WITH ROXICET. PT TO TAKE KEFLEX AS DIRECTED AND ROXICET PRN PAIN. PT IN AGREEMENT WITH DISCHARGE PLAN. PT SIGNED CONSENT FORM AND WIFE ARRIVED AND PICKED UP PT FOR D/C TO HOME.\n" }, { "category": "Nursing/other", "chartdate": "2124-09-12 00:00:00.000", "description": "Report", "row_id": 1584624, "text": "NPN -0700\nPt is 35 y/o male with hx of sleep apnea who had septoplasty/ tosillectomy/ uvuloplasty and removal of uvular lesion on , transferred to MICU from PACU for O2sat monitoring b/c of persistent desaturation upon removal of O2.\n\nNeuro: A&Ox3, follows commands, answers questions appropriately, c/o discomfort to back of throat, pt describes his throat as \"feeling swollen.\" Given total of 15ml of Oxycodone-Acetaminophen elixir for discomfort which pt states has not resolved completely but refuses more medicine.\n\nResp: Lungs coarse bilat., O2 on 100%cool neb, RR 12-20, O2 sats 96-100%, no c/o SOB or difficulty breathing.\n\nCV: HR 90-105 SR-ST no ectopy, SBP's 130's-150's, pedal pulses palpable.\n\nGI: BS (+), no c/o nausea, NPO except for sips of H2O with meds.\n\nGU: Voiding into urinal in adequate amts.\n\nSkin: Drsg changed x 2 for small amts of sanguinous drainage, current drsg and . No bloody drainage noted to back of throat.\n\nSocial: Wife is contact person, no phone calls from family since adm. to MICU.\n\nPlanS: Continue to montitor O2 sats, dc home possibly today if O2 sats hold without the assistance of O2 therapy.\n\n" } ]

3,482

156,471

This patient is a 56 year-old man with history of severe COPD (FEV1 19%) on home oxygen, with history of CAD s/p MI with CABG and BMS, admitted for COPD exacerbation, intubated and transferred to MICU for hypercarbic respiratory failure, readmitted to floor with trigger for hypoxemia/hypercarbia/respiratory distress. After family discussion , patient decided to go home on hospice and was medically stablized for discharge home to .

Delayed R wave progression is likely a normal variant. Since the previous tracing of P waves are less prominentand precordial lead QRS voltage is more prominent. Compared to the previous tracing of the P wave changes arenew. Delayed R wave progression with late precordial QRS transition.ST-T wave configuration suggests early repolarization pattern. Sinus rhythm. Sinus rhythm. Comparedto the previous tracing the rate has decreased.TRACING #2 Findings arenon-specific. Delayed R wave progression is probably a normal variant.Compared to the previous tracing of the rate has increased.TRACING #1 Consider biatrial abnormality with marked peaked andtall P waves in leads II, III and aVF and marked negative P waves inleads V1-V3. Sinus tachycardia. Otherwise, no diagnostic interval change, although there is a moderatebaseline which makes comparison difficult.

4

[ { "category": "ECG", "chartdate": "2153-05-12 00:00:00.000", "description": "Report", "row_id": 282171, "text": "Normal sinus rhythm. Consider biatrial abnormality with marked peaked and\ntall P waves in leads II, III and aVF and marked negative P waves in\nleads V1-V3. Compared to the previous tracing of the P wave changes are\nnew. Otherwise, no diagnostic interval change, although there is a moderate\nbaseline which makes comparison difficult.\n\n" }, { "category": "ECG", "chartdate": "2153-05-08 00:00:00.000", "description": "Report", "row_id": 282172, "text": "Sinus rhythm. Delayed R wave progression with late precordial QRS transition.\nST-T wave configuration suggests early repolarization pattern. Findings are\nnon-specific. Since the previous tracing of P waves are less prominent\nand precordial lead QRS voltage is more prominent.\n\n" }, { "category": "ECG", "chartdate": "2153-05-07 00:00:00.000", "description": "Report", "row_id": 282173, "text": "Sinus rhythm. Delayed R wave progression is likely a normal variant. Compared\nto the previous tracing the rate has decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-05-07 00:00:00.000", "description": "Report", "row_id": 282174, "text": "Sinus tachycardia. Delayed R wave progression is probably a normal variant.\nCompared to the previous tracing of the rate has increased.\nTRACING #1\n\n" } ]

4,268

121,889

Patient was admitted to the general surgery team with a partial small bowel obstruction. Initially, there had been a report of some coffee ground emesis which was not witnessed. A Hct was checked and remained stable. A GI consult was called. He was kept NPO with an NGT in place. Serial abdominal exams were performed. An endoscopy was not performed secondary to the partial small bowel obstruction and the risk of perforation. The patient was closely monitored with serial KUB's which remained stable. Clinically, his abdomen remained soft and nontender and his hematocrit remained stable. He did demonstrate persistent asymptomatic tachycardia during his first days in the hospital which could not be controlled with metoprolol. He was started on a diltiazem drip and then eventually transitioned to po digoxin with good control of his heart rate. His NGT was discontinued and he was slowly advanced on a diet which he tolerated well. He was tolerating a regular diet, and remained hemodynamically stable and was discharged to rehab on HD9 in stable condition.

ekg obtained indicated a-flutter - dr aware, pt currently in afib. COMPARISON: abdomen portable. endoscopy, serial hcts. Small-bowel obstruction. soft/non-distended, +hypoactive BS. Pt is DNR/DNI. Colon is decompressed. Residual contrast is seen within the large bowel. bs covered with ssri. NA 151 and Dr. aware. Patchy left lung base opacity. Atrial flutter with 2:1 A-V block. cvl placement, ? is soft, +bs, +flatus. Lungs clear and diminished. ABDOMEN SUPINE PORTABLE PLAIN FILM: There has been interval progressive dilation of small bowel into smaller degree large bowel. NG tube is in distal body of stomach. NGT to LCWS. Clincal correlation recommended. Also, it was noted this am that a small amt. Afebrile. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Findings are consistent with partial small-bowel obstruction that could be resolving. These findings are consistent with small-bowel obstruction. COMPARISON: , abdomen plain film. FINDINGS: There is a patchy left lower lobe opacity. c/o to floor. The heart is upper limits of normal in size. UOP adequate via foley. Abdomen soft and hyperactive bowel sounds. Hct stable, last level 34.0. IMPRESSION: Multiple dilated loops of small bowel likely representing partial small bowel obstruction. There are possible decompressed loops of relatively distal small bowel seen in the right pelvis. Dictated. These findings may represent a mechanical small-bowel obstruction. These findings are consistent with persistent small-bowel obstruction with component of colonic ileus. sent for c. diff, dr. was notified. of small loose bm. INDICATION: Shortness of breath. serial hct's initiated. ABDOMEN: Again seen are multiple dilated loops of small bowel, grossly unchanged compared to prior study. Since the previous tracing of asingle ventricular premature beat is seen.TRACING #2 pt without c/o pain. Duoderm to coccyx. HR 90-130s a-fib w/occ. Duoderm intact on sacral area. BP stable. These findings are consistent with unchanged small bowel obstruction. There are multiple sigmoid diverticula. Rule out obstruction. There is loss of joint space in the hips bilaterally that are consistent with degenerative changes. Warm extremities, weak distal pulses. 2 liters nasal cannula. Dilated loops of small bowel in the imaged portion of the upper abdomen. Ulcers on left great toe and foot, covered w/ dry drsg. HR afibb tachy up to 130s. Long segment of dilated small bowel with possible decompressed more distal loops of small bowel in the right pelvis with no identifiable transition point. is soft, nontender, +bs. Weakness noted in LLE, otherwise good strength. Evaluate for passage of contrast into colon. frequency inc. to Q4h. PERLA. Evaluate for resolving obstruction. + peripheral pulses, no edema. The majority of the small bowel is dilated. There are vascular calcifications. Small brown BM x1. COMPARISON: Plain film of . Code status discussed w/pt. abd. Abd. Please see subsequently dictated CT of the abdomen which was obtained following this radiograph and is dictated separately. The large bowel is not dilated. 2. 2. 2. 2. BP stable, sbp 90-120. Rectum and sigmoid colon are filled with stool. Please refer to carevue for details. 3. +MRSA, on abx coverage.PLAN: Monitor hemodynamic status. to monitor. Productive cough. Denies pain. adjust lopressor dosing, transfer to floor. dr. is aware. Dr. is aware. bp 100's-120's. mushroom catheter was placed, spec. Evaluate for progression. ABDOMINAL PLAIN FILM: There are multiple distended loops of small bowel seen throughout the abdomen, predominantly on the right. Sclerotic changes seen within the hips with loss of joint space consistent with degenerative change. Within the imaged portion of the upper abdomen, there are dilated loops of bowel, incompletely evaluated on this chest radiograph examination. Lungs clear bilaterally, O2 sat high 90s on 2L NC. ngt to wall suction draining brown drainage (~ 400cc) Pt was incont. Pelvic bone is sclerotic with thickened cortex/trabeacule and multiple lytic lesions. Large bowel is not dilated and is filled with stool. Possible atrial flutter with variable blockMarked left axis deviationLow QRS voltages in limb leadsNo change from previous A-fib with occasional pvc's, hr frequently up to 130-140's, controlled with q 4hr lopressor and 2 additional single doses. SMall liquid stool. plan: ? Monitor NG output. Emotional support provided. Continue to monitor mental status. LR @ 80cc/h. TECHNIQUE: MDCT acquired images of the abdomen were obtained after the administration of oral contrast. PO lopressor increased with good, but temporary effect. condition updatesee carevue for specifics;pt is alert and oriented x's 3, no c/o pain, moves all extremities. Diffuse mottled appearance of the pelvis and sacrum and lower lumbar spine consistent with patient's reported history of multiple myeloma. Abnormal pelvic bones, suggestive of Paget's disease. NGT to LCS, putting out brown/coffee-ground material. Evaluation for free fluid is limited on this study. PVCs. u/o 15cc'f for 1 hr, primary team was notified, will cont. Gas and contrast are present throughout the colon. 02 sat 99-100 on 2 l n.c., ls are clear. Nursing Progress Note 7a-7pPt is A&Ox3, follows commands and communicates appropriately. condition updateadmitted from er at 0400 - hr in 130-140's (afib), pt received 3mg iv lopressor with good effect, hr down to 80's. (Over) 12:29 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: delineation of obstruction Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE Field of view: 36 FINAL REPORT (Cont) Multiple air fluid levels are seen. ABDOMEN: There are multiple dilated loops of small bowel in the left abdomen consistent with partial small bowel obstruction. There is extensive Paget's disease of the pelvis and sacrum. Non-contrast, limited evaluation of the liver, spleen, pancreas, adrenal glands, and kidneys is grossly unremarkable. Continue to monitor HR. There are a few gas-distended loops of small bowel that are less distended than on the previous film of .

16

[ { "category": "Nursing/other", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 1317578, "text": "condition update\nadmitted from er at 0400 - hr in 130-140's (afib), pt received 3mg iv lopressor with good effect, hr down to 80's. ekg obtained indicated a-flutter - dr aware, pt currently in afib. bp 100's-120's. 02 sat 99-100 on 2 l n.c., ls are clear. pt without c/o pain. alert and oriented x's 3, follows commands and moves all extremities. LR running at 150cc/hr. serial hct's initiated. abd. is soft, +bs, +flatus. ngt to wall suction draining brown drainage (~ 400cc) Pt was incont. of small loose bm. u/o 15cc'f for 1 hr, primary team was notified, will cont. to monitor. plan: ? cvl placement, ? endoscopy, serial hcts.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 1317579, "text": "Nursing Progress Note 7a-7p\n\nPt is A&Ox3, follows commands and communicates appropriately. Weakness noted in LLE, otherwise good strength. Denies pain. Lungs clear bilaterally, O2 sat high 90s on 2L NC. BP stable. HR 90-130s a-fib w/occ. PVCs. HR comes down to 90s after lopressor but only for few hours. frequency inc. to Q4h. Warm extremities, weak distal pulses. No edema. Afebrile. Abd. soft/non-distended, +hypoactive BS. NGT to LCS, putting out brown/coffee-ground material. NPO x ice chips. Small brown BM x1. UOP adequate via foley. Duoderm intact on sacral area. Ulcers on left great toe and foot, covered w/ dry drsg. LR @ 80cc/h. Hct stable, last level 34.0. +MRSA, on abx coverage.\n\nPLAN: Monitor hemodynamic status. Monitor NG output. c/o to floor. Code status discussed w/pt. Pt is DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-12 00:00:00.000", "description": "Report", "row_id": 1317580, "text": "condition update\nsee carevue for specifics;\npt is alert and oriented x's 3, no c/o pain, moves all extremities. A-fib with occasional pvc's, hr frequently up to 130-140's, controlled with q 4hr lopressor and 2 additional single doses. Dr. is aware. + peripheral pulses, no edema. Na+ 154 this am, dr. was notified.\nLS are clear bilaterally, 02 sat 99-100% on 2 liters n.c. Abd. is soft, nontender, +bs. Ngt to lws draining brown drainage. Pt was incontinent of very large liquid brown bm this evening, guiac negative. mushroom catheter was placed, spec. sent for c. diff, dr. was notified. foley is draining adequate atms. clear yellow urine. bs covered with ssri. plan: monitor stool output, monitor heart rate, ? adjust lopressor dosing, transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-12 00:00:00.000", "description": "Report", "row_id": 1317581, "text": "addendum\nto treat na+, ivf changed to d51/2 ns at 100cc/hr as per Dr. . Also, it was noted this am that a small amt. of blood was draining out of ng tube, and has since returned to brown. dr. is aware.\n" }, { "category": "Nursing/other", "chartdate": "2138-03-13 00:00:00.000", "description": "Report", "row_id": 1317582, "text": "Nursing Note 7p-7a:\nNursing Assessment 7p-7a:\n\nPt pleasant and cooperative with care. Alert and orientated x 3 except frequently talking about being afraid of someone out to hurt him and after his wife's money. Dr. aware and social worker to be contact in morning. Emotional support provided. Orientated to person, place, and time. PERLA. HR afibb tachy up to 130s. PT has a floor bed available but awaiting blue team to decide if ready to go to floor d/t tachy 130s. PO lopressor increased with good, but temporary effect. 90-110 an hour after po and lasts approximately 3 hours. Dr. aware and awaiting morning rounds prior to any further med changes or interventions. BP stable, sbp 90-120. NA 151 and Dr. aware. Lungs clear and diminished. Productive cough. 2 liters nasal cannula. Abdomen soft and hyperactive bowel sounds. SMall liquid stool. NPO except ice chips. NGT to LCWS. IVF D5 1/2 NS with 20 KCL at 100 cc/hr. Duoderm to coccyx. Plan: awaiting final decision to transfer to floor. Continue to monitor HR. Continue to monitor mental status. Please refer to carevue for details.\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903532, "text": " 3:42 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for passage of contrast into colon\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n REASON FOR THIS EXAMINATION:\n please evaluate for passage of contrast into colon\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with partial small bowel obstruction. Evaluate\n for passage of contrast into colon.\n\n ABDOMEN: There are multiple dilated loops of small bowel in the left abdomen\n consistent with partial small bowel obstruction. Colon is decompressed. There\n is extensive sclerosis seen within the right hemipelvis greater than left\n hemipelvis, which probably represents Paget's disease.\n\n IMPRESSION: Multiple dilated loops of small bowel likely representing partial\n small bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903395, "text": " 4:55 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for progressions of pSBO\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n REASON FOR THIS EXAMINATION:\n eval for progressions of pSBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old male with partial small bowel obstruction. Evaluate\n for progression.\n\n COMPARISON: , abdomen plain film.\n\n ABDOMEN: Again seen are multiple dilated loops of small bowel, grossly\n unchanged compared to prior study. These findings are consistent with\n unchanged small bowel obstruction.\n\n\n" }, { "category": "ECG", "chartdate": "2138-03-16 00:00:00.000", "description": "Report", "row_id": 270579, "text": "Possible atrial flutter with variable block\nMarked left axis deviation\nLow QRS voltages in limb leads\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2138-03-11 00:00:00.000", "description": "Report", "row_id": 270793, "text": "Possible atrial flutter\nPremature ventricular contractions or aberrant ventricular conduction\nLVH with ST-T changes\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince previous tracing, ventricular rate is slower\n\n" }, { "category": "ECG", "chartdate": "2138-03-10 00:00:00.000", "description": "Report", "row_id": 270794, "text": "Atrial flutter with 2:1 A-V block. Since the previous tracing of a\nsingle ventricular premature beat is seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-03-10 00:00:00.000", "description": "Report", "row_id": 270795, "text": "Atrial flutter with a rapid ventricular response. Since the previous tracing\nof the ventricular rate is increased and non-specific ST-T wave\nabnormalities are seen.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2138-03-10 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 903362, "text": " 6:26 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with abd distension, vomiting\n REASON FOR THIS EXAMINATION:\n obstruction\n ______________________________________________________________________________\n WET READ: JVg MON 9:06 PM\n Multiple dilated loops of small bowel concerning for obstruction. Sclerotic\n changes in pelvis, loss of hip jt spaces, c/w degenerative disease. Dictated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with abdominal distention and vomiting. Rule out\n obstruction.\n\n No comparison studies.\n\n ABDOMINAL PLAIN FILM: There are multiple distended loops of small bowel seen\n throughout the abdomen, predominantly on the right. Multiple air fluid levels\n are seen. These findings are consistent with small-bowel obstruction.\n Pelvic bone is sclerotic with thickened cortex/trabeacule and multiple lytic\n lesions. There is loss of joint space in the hips bilaterally that are\n consistent with degenerative changes.\n\n IMPRESSION:\n\n 1. Small-bowel obstruction.\n\n 2. Abnormal pelvic bones, suggestive of Paget's disease. Clincal correlation\n recommended.\n\n 2. Sclerotic changes seen within the hips with loss of joint space consistent\n with degenerative change.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-12 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903620, "text": " 10:44 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?interval change\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with pSBO\n\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM\n\n History of partial small bowel obstruction.\n\n There are a few gas-distended loops of small bowel that are less distended\n than on the previous film of . Gas and contrast are present\n throughout the colon. NG tube is in distal body of stomach. Findings are\n consistent with partial small-bowel obstruction that could be resolving.\n There is extensive Paget's disease of the pelvis and sacrum.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-13 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 903750, "text": " 8:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: resolving PSBO\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with PSBO\n REASON FOR THIS EXAMINATION:\n resolving PSBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with partial small-bowel obstruction. Evaluate\n for resolving obstruction.\n\n COMPARISON: abdomen portable.\n\n ABDOMEN SUPINE PORTABLE PLAIN FILM:\n\n There has been interval progressive dilation of small bowel into smaller\n degree large bowel. Residual contrast is seen within the large bowel. These\n findings are consistent with persistent small-bowel obstruction with component\n of colonic ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 903361, "text": " 6:26 PM\n CHEST (PA & LAT) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST\n\n COMPARISON: .\n\n INDICATION: Shortness of breath.\n\n The heart is upper limits of normal in size. There is no mediastinal or hilar\n lymphadenopathy. The lungs are clear, and there are no pleural effusions or\n pneumothoraces.\n\n Within the imaged portion of the upper abdomen, there are dilated loops of\n bowel, incompletely evaluated on this chest radiograph examination.\n\n IMPRESSION:\n 1. No evidence of acute cardiopulmonary process.\n 2. Dilated loops of small bowel in the imaged portion of the upper abdomen.\n Please see subsequently dictated CT of the abdomen which was obtained\n following this radiograph and is dictated separately.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-03-11 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 903384, "text": " 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: delineation of obstruction\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with obstruction, GIB\n REASON FOR THIS EXAMINATION:\n delineation of obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obstruction.\n\n COMPARISON: Plain film of .\n\n TECHNIQUE: MDCT acquired images of the abdomen were obtained after the\n administration of oral contrast. IV contrast was not administered secondary\n to elevated creatinine.\n\n FINDINGS: There is a patchy left lower lobe opacity. No pleural effusion.\n\n The majority of the small bowel is dilated. No wall thickening is\n demonstrated or pneumatosis. There are possible decompressed loops of\n relatively distal small bowel seen in the right pelvis. Large bowel is not\n dilated and is filled with stool. No transition point can be identified.\n There is no intra-abdominal free air. Evaluation for free fluid is limited on\n this study.\n\n Non-contrast, limited evaluation of the liver, spleen, pancreas, adrenal\n glands, and kidneys is grossly unremarkable. There are vascular\n calcifications.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter within the\n bladder. Rectum and sigmoid colon are filled with stool. There are multiple\n sigmoid diverticula.\n\n Bone windows reveal diffuse mottled appearance of the lower lumbar spine and\n pelvis consistent with patient's reported history of multiple myeloma.\n\n IMPRESSION:\n 1. Long segment of dilated small bowel with possible decompressed more distal\n loops of small bowel in the right pelvis with no identifiable transition\n point. The large bowel is not dilated. These findings may represent a\n mechanical small-bowel obstruction. No free air or pneumatosis is seen.\n 2. Patchy left lung base opacity.\n 3. Diffuse mottled appearance of the pelvis and sacrum and lower lumbar spine\n consistent with patient's reported history of multiple myeloma.\n\n This was discussed with Dr. , covering for surgery.\n (Over)\n\n 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: delineation of obstruction\n Admitting Diagnosis: GI BLEED,ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

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1. Hypotension - The patient was initially mildly hypotensive with systolic blood pressures in the 80s. Upon admission it was unclear whether or not the patient was volume overloaded or volume depleted. Initially he was treated with intravenous fluids with a dramatic response in his systolic blood pressure. However, subsequent it was determined that the patient's hypotension may have been related to his rapid ventricular response and right heart failure. Therefore the focus of treatment was changed to controlling his rate. 2. Atrial fibrillation - The patient's Digoxin had been weaned off prior to his admission. It was felt that this potentially had lead to his atrial flutter and atrial fibrillation with rapid ventricular response. The patient was loaded once again with Digoxin and his beta blocker was increased to 100 mg of Lopressor, three times a day. In addition the patient was started on Verapamil since his heart rate had remained mildly tachycardiac in the low 100s. 3. Congestive heart failure - During the initial course of the patient's admission, it was unclear as to whether or not he was volume overloaded or volume depleted. The patient was initially treated with intravenous fluids, however, subsequently he was diuresed when he became symptomatic and short of breath. Chest x-rays revealed evidence of congestive heart failure. The decision was made to have the patient undergo a cardiac catheterization to fully evaluate the hemodynamics to determine the etiology of the patient's heart failure. In addition, plans were made to evaluate the patient's cardiac arteries to determine if he had any component of ischemic cardiomyopathy. 4. Abnormal liver function tests - The patient had an isolated, elevated alkaline phosphatase with a confirmatory elevation in his gamma glutamyl transferase. An ultrasound of the right upper quadrant did not reveal any cholelithiasis or cholecystitis, however, an irregular hepatic contour was seen which is suggestive of underlying chronic liver disease. There was some concern that the patient may have a partial biliary obstruction and the patient was sent for an magnetic resonance cholangiopancreatography to further evaluate the biliary system. Magnetic resonance cholangiopancreatography did not reveal any evidence of biliary dilatation or of any obstructing pancreatic mass. Again seen was a slightly irregular contour of the liver with dilated hepatic veins suggesting chronic hepatic vascular congestion. The patient also revealed a prior history of heavy alcohol use for approximately 20 years, during the mid to mid . It was felt that he may have had some component of vascular congestion from his congestive heart failure as well as possibly some mild cirrhotic changes secondary to his previous alcohol use. 5. Fall - The patient had a mechanical fall during his admission. He did not sleep at all the night before and was extremely fatigued. He was walking in the , dragging his intravenous pole when he tripped over the foot of the pole and lost his balance. He fell backwards, landing on his buttocks and bumped his head. His neurological examination at that time was nonfocal and the head was atraumatic without any evidence of a hematoma. A computerized axial tomography scan of his head at that time did not reveal any extra or intracranial hemorrhage. 6. Rectal bleeding - The patient has a history of rectal bleeding, ever since his brachytherapy for his prostate cancer. The patient has been treated with Argon laser therapy in the past for his rectal bleeding and it is recommended that he follow up with his gastroenterologist for repeat Argon laser therapy. The remainder of the hospital course will be dictated by the covering intern. , M.D. Dictated By: MEDQUIST36 D: 22:34 T: 06:55 JOB#:

Regular tachycardia ( except for 1 beat) - mechanism uncertain - consideratrial flutter or possible atrial tachycardiaLeft bunch branch blockSince previous tracing of , ventricular response more regular History of ASD repairHeight: (in) 70Weight (lb): 215BSA (m2): 2.15 m2BP (mm Hg): 100/67HR (bpm): 110Status: InpatientDate/Time: at 09:21Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Regular tachycardia - mechanism uncertain - consider atrial flutter with 2:1response or possible atrial tachycardiaLeft bunch branch blockSince previous tracing of , no significant change left bundle branch blockSince previous tracing of ,ventricular rate slower AfebrileCV: Hr initially low to mid 100's st with no vea noted. "O: See vs/objective data per carevue.CV: HR 100's afib with no vea. Moderate tosevere (3+) mitral regurgitation is seen.TRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.There is moderate pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Image quality was suboptimal.Conclusions:The left atrium is moderately dilated. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.The aortic valve leaflets are mildly thickened. There is moderatepulmonary artery systolic hypertension. Would hold off on sleeper d/t pt lethargy this am. IV NTG WEANED OFF. Rec'd lasix 10mg x 2 with mild diursis.GI/GU: Abd soft with good bowel sounds, no bm. Compared to the previous tracing atrial flutter persists (again as evidenced byflutter waves in lead VI and the regularity of portions of the ventricularresponse). Correlation with recent ultrasound examination dated confirms the absence of gallstones. There is focal hypokinesis ofthe apical free wall of the right ventricle. R groin has remained d/i with distal pulses palpable.Resp: O2 at 4lnp with sats in mid 90's. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. ?OVER-DIURESED. There is focal hypokinesisof the apical free wall of the right ventricle. High ST take-offs in the precordial leads arenon-diagnostic with the intraventricular conduction delay. (Over) 6:28 PM MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # Reason: r/o partial biliary obstruction Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) PAD 29->15, CVP 10->6, W 15-17, CO 4.4->5.0, CI 2.02->2.29, SVR 1709->1072. Supraventricular tachyarrhythmia - mechanism uncertain - consider atrialtachycardia/"slow" atrial flutterIntraventricular conduction delay - ? MVO2 64-67%.CARDIAC: HR 95-105 SR/ST, NO ECTOPY. ADMISSION NOTEPLEASE SEE FHP FOR DETAILS PMH & CURRENT ADMISSION.NEURO: A&O X3, BUT WHILE DOZING ATTEMPTS MADE TO D/C SWAN X3--NOT RE- ALIZING WHAT HE IS DOING. Compared to the previous tracing the ventricular rate is somewhat slower.Flutter waves are clearly seen in lead VI.TRACING #3 Supraventricular tachycardia which is regular with intermittent increasedR-R intervals, basic ventricular rate about 100. Poor initial R wave progression.Indeterminate QRS axis. Overall left ventricular systolic function is severely depressed.The right ventricular cavity is moderately dilated. Compared to the previous tracing of nodiagnostic change. VERY APOLOGETIC.RESP: O2->5L NP. Right ventricular function. There is no pericardial effusion.Compared with the findings of the prior study (tape reviewed) of ,there has been a marked decrease in overall LV function. Thin and thick slab maximum intensity projection MRCP images were generated. Ambian dc'd. Intraventricularconduction delay of left bundle-branch block type. BP stable high 90's- 110's, on lopressor, verapamil, amiodarone and valsartan. PRESENTLY, U/O 25-80CC/HR. The spleen appears within normal limits. He states a doctor was suppose to start a new med for him to help with the symptoms.A: Decreased ef now on natrecore Gently diuresed with lasix 10mg x 2 Sleep apnea without sign decrease in O2 sat Restless leg syndromeP: ^ activity when able to tolerate Probable c/o in am He is hemodynamically stable with this rhythm, and it was noted that he has been in and out of afib since admit. Tired after 90minutes.Access-2PIV, RIJ PA catheter.Social- /son called pt health care proxy #h , cell# . BOLUSED WITH NATRECOR, & GTT STARTED AT .01MCG/KG. Overall left ventricular systolic function is severely depressed.RIGHT VENTRICLE: Right ventricular wall thickness cannot be determined. However, the overall ventricular response raet is somewhat faster atapproximately 110.TRACING #4 CCU NPNS/O: See vs/objective data per carevue. K 4.1, HCT 40.5, PLAT CT 364K.GI: ABD. HYPERTENSION. The kidneys and adrenal glands appear within normal limits. Noted while sleeping Hr down to the 80's with his apneic periods.Resp: Lungs with diminished aeration throughout, taking his inhalers on own. Supraventricular tachy-arrhythmia with ventricular rate of about 100. Conts on natrecor at .1mcg/kg/min. PT COMFORTABLE, DENIES RESP DISTRESS. RESP CARE NOTEAPPLIED NASAL CPAP @ MIDNOC, EPAP 5CMH20 W/5LPM O2 BLEED IN. At 0030 placed on cpap but cont to notice apneic periods this time with sats decreasing to 89% and hr decreasing to the 80's. Underlyingintraventricular conduction delay. Atrialmechanism cannot be determined with certainty but could be relatively slowatrial flutter with 2:1 conduction, although other atrial tachy-arrhythmias arenot excluded. Compared to the previoustracing of the underlying atrial mechanism now appears to be atrialflutter rather than atrial fibrillation and the overall ventricular responserate is faster.TRACING #1 CO 5.4/CI 2.48/SVR 785. Moderate to severe (3+) mitral regurgitation is seen.Moderate to severe [3+] tricuspid regurgitation is seen. LS I/E wheezes with diminshed BS at bases. Tolerating po cardiac meds well. +BPPP. Pad's basically unchanged, upper teens to low 20's with cvp low 10's.

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[ { "category": "Nursing/other", "chartdate": "2145-01-25 00:00:00.000", "description": "Report", "row_id": 1573596, "text": "CCU NPN\nS:\"They have to talk to the other doctor about this (cpap), he said I didnt need it anymore.\"\nO: See vs/objective data per carevue.\nCV: HR 100's afib with no vea. BP stable high 90's- 110's, on lopressor, verapamil, amiodarone and valsartan. Pad's basically unchanged, upper teens to low 20's with cvp low 10's. Noted while sleeping Hr down to the 80's with his apneic periods.\nResp: Lungs with diminished aeration throughout, taking his inhalers on own. O2 at 4lnp with sats upper 90's. At 0030 placed on cpap but cont to notice apneic periods this time with sats decreasing to 89% and hr decreasing to the 80's. Resp therapist aware>increased cpap to 8, with no real change in events. He wanted cpap machine off at 3am therefore dc'd.\nGI/GU: Foley drng clear yellow urine. No lasix given. No BM.\nMS: Alert and oriented throughout night, cooperative with care. Rec'd trazadone 25mg for sleep with good effect.\nA: conts with apneic periods\n hemodynamically stable, restarted on dig\nP: prepare for d/c to floor\n increase activity\n check with pulmonary about apnea during sleeping\n" }, { "category": "Nursing/other", "chartdate": "2145-01-25 00:00:00.000", "description": "Report", "row_id": 1573597, "text": "RESP CARE NOTE\nAPPLIED NASAL CPAP @ MIDNOC, EPAP 5CMH20 W/5LPM O2 BLEED IN. PT COMFORTABLE, DENIES RESP DISTRESS. DURING SLEEP, OBSTRUCTIVE PATTERN NOTED W/DESAT FROM 98 TO 89%. EPAP INCR TO 8CMH2O & O2 INCR TO 10LPM. AFTER 2.5HRS OF USE PT C/O INABILITY TO SLEEP AND WANTED MASK REMOVED. MAINTAINED ON 4LPM NC O2 W/SPO2 96-98%. PLAN TO CONTINUE CURRENT SUPPORT AND WILL CONTINUE TO OFFER CPAP QHS. *** NEED TO FIND RESULTS OF MOST RECENT POLYSOMNOGRAPHY STUDY DONE IN @ OUTSIDE FACILTY FOR OPTIMAL CPAP SETTINGS.\n" }, { "category": "Nursing/other", "chartdate": "2145-01-23 00:00:00.000", "description": "Report", "row_id": 1573593, "text": "CCU Nursing PRogress Note\nS-\"I need a beer\" \"I don't mean to get OOB, but\"\nO-Neuro- short term memory issues today. Needs frequent assessment for safety reasons. Found pt standing at side of bed 3 times, despite freq explaination to call for help first. Pt is apologetic but really does not remember why he needs to call for help. Overheard pt tell a visitor \"I could use a nice cold beer\". Unclear how much pt drinks at home. Intern will talk to pt this evening.\nCV-VSS MAPs 58-72 on Natrecor at .01mcg/kg/min, hemodynamics PAD 20-24 with PWP 16-17 CO/CI/SVR 4.7/2.16/851. No c/o chest pain. To restart coumadin this evening.\nResp-freq apneic periods in the am. Pt would be talking to you then fall off to sleep and become apenic for 25seconds, awake and then c/o SOB with rr 32. The cycle persisted most of the morning. Pt states he stopped using his BIPAP machine at home because he thought it wasn't working. Pt to be placed on BIPAP tonight at HS. Would hold off on sleeper d/t pt lethargy this am. O2 sats 88-90% this am on 3lnp increased O2 to 5lnp with improved O2 sats 97%. LS I/E wheezes with diminshed BS at bases. Occ productive cough thin/blood tinged.\nID-afebrile with WBC 15\nGU-foley draining amber urine 30-40cc/hr\nGI-Appetite good, LBM 2 days ago per pt.\nSkin-warm and dry, right groin no hematoma, RIJ PA site eccymotic with small hematoma at site.\nActivity-OOB chair this am with 2 assist, tolerated fairly well. Tired after 90minutes.\nAccess-2PIV, RIJ PA catheter.\nSocial- /son called pt health care proxy #h , cell# . Fiancee into visit and concerned about pt short term memory, states pt took an antidepressant at home, which he has not been on in the hospital-she did not know the name.\nA/P-Pulmonary HTN with severe LV dysfunction prob r/t sleep apnea?\nGOAL MAP> 60 PWP 16-20, lasix prn goal to keep pt even.\nMOnitor for change in MS, sitter at door overnight.\nObsere sleep apnea with BIPAP also Keep O2 sats >92%\n\n" }, { "category": "Nursing/other", "chartdate": "2145-01-24 00:00:00.000", "description": "Report", "row_id": 1573594, "text": "CCU NPN\nS/O: See vs/objective data per carevue. Afebrile\nCV: Hr initially low to mid 100's st with no vea noted. 12:30am noted increasing hr to 110-120's afib, 12lead ekg done, and team aware. He is hemodynamically stable with this rhythm, and it was noted that he has been in and out of afib since admit. Tolerating po cardiac meds well. Bp 90-110's. Conts on natrecor at .1mcg/kg/min. Pad's mid teens to low 20's with cvp 9-11. R groin has remained d/i with distal pulses palpable.\nResp: O2 at 4lnp with sats in mid 90's. Lungs with diminshed aeration, taking inhalers. Attempted bipap but unable to tolerate therefore dc'd, noted 15-25 sec apneic periods while asleep, o2 sats stay above 95% with apnea. Pt states that he does not wear it at home. Rec'd lasix 10mg x 2 with mild diursis.\nGI/GU: Abd soft with good bowel sounds, no bm. Foley drng clear yellow urine.\nMS: Alert and oriented. Knows that he was confused last night, stating that he had a fever, had no sleep and that he had to be tied down which upset him. Cooperative tonight, no attempts to get oob, has 1:1 sitter. Has restless leg syndrome which is very troubling for him. He states a doctor was suppose to start a new med for him to help with the symptoms.\nA: Decreased ef now on natrecore\n Gently diuresed with lasix 10mg x 2\n Sleep apnea without sign decrease in O2 sat\n Restless leg syndrome\nP: ^ activity when able to tolerate\n Probable c/o in am\n\n" }, { "category": "Nursing/other", "chartdate": "2145-01-24 00:00:00.000", "description": "Report", "row_id": 1573595, "text": "CCU NPN 7A-7P\nCV: Natracor dc'd this AM, started on Lasix 20mg po qd, UO 50cc/hr, ~1L neg. BP 100/40's, HR 90-110 afib. PAD's 16-20, PCWP 20, now down to 16. CO 5.4/CI 2.48/SVR 785. No SOB/CP, LS clear. Sating 94% on RA, 98% on 3L. R groin C&D, pulses weak palp.\n\nResp: napping during the day, no apnea noted, maintained sats>90%. Team spoke to him re: importance of wearing CPAP. Goal to try CPAP again tonight.\n\nNeuro: cont with restless leg syndrome, A&Ox3, cooperative. Ambian dc'd. Cont Trazadone. Ordered for his antidepressant Lexapro, it is nonformulary, family stated they would bring it in, possibly tomorrow.\n\nGU: cr up sl today to 1.6, will follow.\n\nGI: appetite good, no BM today.\n\nSoc: S.O. in visiting, pt anxious to go home.\n\nA/P: plan to watch in unit overnight off Natracor, dc swan in AM if does well and transfer to floor. CPAP at hs.\n" }, { "category": "Nursing/other", "chartdate": "2145-01-23 00:00:00.000", "description": "Report", "row_id": 1573592, "text": "ADMISSION NOTE\nPLEASE SEE FHP FOR DETAILS PMH & CURRENT ADMISSION.\n\nNEURO: A&O X3, BUT WHILE DOZING ATTEMPTS MADE TO D/C SWAN X3--NOT RE-\n ALIZING WHAT HE IS DOING. VERY APOLOGETIC.\nRESP: O2->5L NP. O2 SAT 96-98%. RR 16-20. BS CLEAR. MVO2 64-67%.\nCARDIAC: HR 95-105 SR/ST, NO ECTOPY. BRIEFLY IN AF 85-115. HO AWARE.\n BP 107-141/48-82. IV NTG WEANED OFF. BOLUSED WITH NATRECOR,\n & GTT STARTED AT .01MCG/KG. PAD 29->15, CVP 10->6, W 15-17,\n CO 4.4->5.0, CI 2.02->2.29, SVR 1709->1072. R.GROIN SITE C&D\n NO EVIDENCE BLEEDING/HEMATOMA. +BPPP. DENIES CP/SOB. K 4.1,\n HCT 40.5, PLAT CT 364K.\nGI: ABD. SOFT. BS+. NO STOOL. APPETITE GOOD.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. DIURESED WELL\n AFTER LASIX IN CATH LAB. PRESENTLY, U/O 25-80CC/HR. -3.5L FOR\n 24 HRS. HO AWARE. ??OVER-DIURESED. TO DISCUSS ON ROUNDS.\nID: AFEBRILE. WBC 15.5.\nAM LABS SENT. COAGS & CHEMISTRIES PENDING.\n\n59 YR. OLD MALE S/P RIGHT/LEFT HEART CATH. HIGH FILLING PRESSURES.\nPULM. HYPERTENSION. NO CAD.\n" }, { "category": "Radiology", "chartdate": "2145-01-19 00:00:00.000", "description": "MR CONTRAST GADOLIN", "row_id": 818473, "text": " 6:28 PM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: r/o partial biliary obstruction\n Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with elevated alk phos and GGT without transaminitis or\n elevated TBili.\n REASON FOR THIS EXAMINATION:\n r/o partial biliary obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 59 year old male with elevated liver function\n tests.\n\n TECHNIQUE: Nonbreath-holding protocol was used as the patient was unable to\n hold his breath. This includes axial T1 and T2W images precontrast as well as\n multiphasic Gadolinium enhanced 2D axial T1W images. Thin and thick slab\n maximum intensity projection MRCP images were generated.\n\n FINDINGS: The examination is somewhat limited by the inability of the patient\n to hold his breath. There is no evidence of intrahepatic or extrahepatic\n biliary dilatation. The gallbladder is collapsed. Correlation with recent\n ultrasound examination dated confirms the absence of\n gallstones. The common duct is small in caliber. The panreatic duct also is\n within normal limits in size and contour. There is no evidence of obstructing\n pancreatic mass.\n\n The liver has a slightly irregular contour and a prominent caudate lobe. These\n findings may represent the sequela of chronic liver disease. The hepatic\n veins are prominent in size. This fact, coupled with the large bilateral\n pleural effusions, suggest hepatic congestion as a possible etiology. Clinical\n correlation is recommended. No enhancing hepatic masses are seen. No\n significant lymphadenopathy is seen. The spleen appears within normal limits.\n The kidneys and adrenal glands appear within normal limits.\n\n Maximum intensity projection images were generated on a 3D workstation and\n were essential to the interpretation of this case.\n\n IMPRESSION:\n\n 1) No evidence of biliary dilatation. No evidence of obstructing pancreatic\n mass.\n\n 2) Slightly irregular contour of the liver with dilated hepatic veins and\n bilateral pleural effusions, suggesting chronic hepatic vascular congestion as\n a possible etiology. Clinical correlation is recommended.\n\n\n (Over)\n\n 6:28 PM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: r/o partial biliary obstruction\n Admitting Diagnosis: HYPOTENSION;SHORTNESS OF BREATH\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Echo", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 95405, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Right ventricular function. Shortness of breath. History of ASD repair\nHeight: (in) 70\nWeight (lb): 215\nBSA (m2): 2.15 m2\nBP (mm Hg): 100/67\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:21\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. No atrial\nseptal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular wall thickness cannot be determined. The\nright ventricular cavity is moderately dilated. There is focal hypokinesis of\nthe apical free wall of the right ventricle. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Image quality was suboptimal.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\nThe right ventricular cavity is moderately dilated. There is focal hypokinesis\nof the apical free wall of the right ventricle. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Moderate to severe (3+) mitral regurgitation is seen.\nModerate to severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nthere has been a marked decrease in overall LV function. Because the study was\ntechnically difficult, views of the atrial septum were limited. The mitral\nregurgitation is more severe.\n\n\n" }, { "category": "ECG", "chartdate": "2145-01-26 00:00:00.000", "description": "Report", "row_id": 270990, "text": "Supraventricular tachyarrhythmia - mechanism uncertain - consider atrial\ntachycardia/\"slow\" atrial flutter\nIntraventricular conduction delay - ? left bundle branch block\nSince previous tracing of ,ventricular rate slower\n\n" }, { "category": "ECG", "chartdate": "2145-01-22 00:00:00.000", "description": "Report", "row_id": 270991, "text": "Supraventricular tachy-arrhythmia with ventricular rate of about 100. Atrial\nmechanism cannot be determined with certainty but could be relatively slow\natrial flutter with 2:1 conduction, although other atrial tachy-arrhythmias are\nnot excluded. Compared to the previous tracing of multiple abnormalities\nare as previously reported. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-01-20 00:00:00.000", "description": "Report", "row_id": 270992, "text": "Regular tachycardia - mechanism uncertain - consider atrial flutter with 2:1\nresponse or possible atrial tachycardia\nLeft bunch branch block\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2145-01-21 00:00:00.000", "description": "Report", "row_id": 271217, "text": "Supraventricular tachycardia which is regular with intermittent increased\nR-R intervals, basic ventricular rate about 100. Atrial mechanism is not\ncertain but could be atrial flutter with variable block. Underlying\nintraventricular conduction delay. Poor initial R wave progression.\nIndeterminate QRS axis. High ST take-offs in the precordial leads are\nnon-diagnostic with the intraventricular conduction delay. Non-specific\nST-T wave changes elsewhere. Compared to the previous tracing of no\ndiagnostic change. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-01-19 00:00:00.000", "description": "Report", "row_id": 271218, "text": "Regular tachycardia ( except for 1 beat) - mechanism uncertain - consider\natrial flutter or possible atrial tachycardia\nLeft bunch branch block\nSince previous tracing of , ventricular response more regular\n\n" }, { "category": "ECG", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 271219, "text": "Compared to the previous tracing atrial flutter persists (again as evidenced by\nflutter waves in lead VI and the regularity of portions of the ventricular\nresponse). However, the overall ventricular response raet is somewhat faster at\napproximately 110.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2145-01-15 00:00:00.000", "description": "Report", "row_id": 271220, "text": "Compared to the previous tracing the ventricular rate is somewhat slower.\nFlutter waves are clearly seen in lead VI.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2145-01-14 00:00:00.000", "description": "Report", "row_id": 271221, "text": "Compared to the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-01-14 00:00:00.000", "description": "Report", "row_id": 271222, "text": "Probable atrial flutter with atrial rate 250 and variable A-V block.\nPredominant ventricular response rate is approximately 100. Intraventricular\nconduction delay of left bundle-branch block type. Compared to the previous\ntracing of the underlying atrial mechanism now appears to be atrial\nflutter rather than atrial fibrillation and the overall ventricular response\nrate is faster.\nTRACING #1\n\n" } ]

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Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be hypoxic and hypotensive on presentation diagnosed with RSV pneumonia and superimposed bacterial pneumonia requiring MICU stay for respiratory distress. # RSV/Bacterial Pneumonia/Hypereosinophilic syndrome-Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy. He was recently admitted to the hospitalist service with pulmonary and ID following and treated for pneumonia with voriconazole, azithro and cefepime. ABx except for vori were discontinued and he was ruled out for TB. The cause was thought to be fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was negative for growth at the time. Recently AFB was positive for non-TB. At the time of this presentation his RSV viral culture was found to be positive and patient was treated empirically for superimposed bacterial infection in setting of neutropenia with vancomycin, cefepime, and levofloxacin. ID was consulted and the option of RSV antibody treatment was discussed with the patient and his family who was declined its use. He was aggressively diuresed in attempts of helping his respiratory status. On Mr. continued to decline clinically and requested transition in goals of care to focus on comfort. His empiric antibiotics were discontinued and he left the ICU in accordance with his goals of care. He was transferred to the floor and transitioned to comfort care. Palliative care was consulted at this time. He passed away on at 10:40 AM with his family at his bedside. His family declined an autopsy.

Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. His ARF is most likely pre-renal from diuresis and poor PO. His ARF is most likely pre-renal from diuresis and poor PO. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: BP now improved from admit, and running at baseline (runs low per fmaily and onc) #CHF--BNP elevated from prior baseline, suspect this may be contribtuing to hypoxemia, though primarry issue is RSV --gentle diuresis and repeat BNP --TTE # tachycardia Likely driven by resp distress/failure Improving # ARF: Cr improving with IVF - monitor UOP and urine lytes # Cavitary lung nodule: seen on prior imaging, now appears slightly smaller, s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. AM CXR worsening w/PNA Action: Continue w/ABX regimen, levofloxacin added, and CT chest done. His ARF is most likely pre-renal from diuresis and poor PO. - F/u stool, blood, urine, stool and sputum - CXR today, f/u final report - Add levo, cont vanc/cefepime/vori # AMS: Likely delerium. - F/u stool, blood, urine, stool and sputum - CXR today, f/u final report - Add levo, cont vanc/cefepime/vori # AMS: Likely delerium. - Monitor creatinine - Judicious diuresis, goal will be net even - Hold ace-i #. - Monitor creatinine - - Hold ace-i #. - Monitor creatinine - - Hold ace-i #. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: legally blind -Hypereosinophilic syndrome and associated course: Diagnosed in after presenting with transient ischemic episode (with reported exotropia) and bilateral deep venous thrombosis. Current intervention if any, listed below: Comments: Diagnosis: Hypoxia, CHF HT: 67 WT: 63.7kg WT Hx: 65.1kg (), 66.77kg (), 73.3kg () PMH: legally blind -Hypereosinophilic syndrome and associated course: Diagnosed in after presenting with transient ischemic episode (with reported exotropia) and bilateral deep venous thrombosis. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. -pan cx as above -echo -lasix gtt -consider IVF boluses for persistant hypotension. Hypoxemia Assessment: Action: Response: Plan: #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. #hypereosinophilic syndrome-Details above. 96 11.9 9.7 Pnd 29.8 N:13 Band:0 L:1 M:0 E:86 Bas:0 Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy: 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Low . 96 11.9 9.7 Pnd 29.8 N:13 Band:0 L:1 M:0 E:86 Bas:0 Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy: 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL Plt-Est: Low . #CHFdiurese, holidng ace-I given cr elevation--at this time does not apepar volume overloaded, neck are flat and xr without eveidence of pulm edema, labs suggest overdiuresis will hold on diurses at thsintime # tachycardia Likely driven by resp distress/failure now diuresis will follow # ARF: cr increaing, suspect this is from diuresis and poor. will hold lasix and monitorup, likely from poor forward flow, may improve with diuresis # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. - f/u heme/onc recs - cont prednisone #. - f/u heme/onc recs - cont prednisone #. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. He has been diuresed and at this time does not appear volume overloaded, neck veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o overdiuresis and his PO intake is minimal --will hold on additional lasix at this time # ARF: BUN and cr increasing, suspect from diuresis, will hold lasix, monitor UOP, check urine sediment and renally dose meds # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB, and penicillium species, final probe pending. Tachycardia: Sinus tach, stable. Tachycardia: Sinus tach, stable. Progressive mild cardiomegaly, particular left (Over) 11:27 AM CT CHEST W/O CONTRAST Clip # Reason: Please eval for change in size of mass Admitting Diagnosis: HYPOXIA; CHF FINAL REPORT (Cont) ventricular enlargement.

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[ { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724331, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile.\n - CXR today\n - UA/urine cx and stool cx r/o c diff\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724333, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - CXR today\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Echo", "chartdate": "2197-03-07 00:00:00.000", "description": "Report", "row_id": 75513, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. Atrial fibrillation. Cerebrovascular event/TIA. Hypoxia. Congestive heart failure.\nHeight: (in) 67\nWeight (lb): 136\nBSA (m2): 1.72 m2\nBP (mm Hg): 89/61\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 12:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- dyskinetic; mid inferior - dyskinetic; lateral apex - akinetic;\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root. Normal ascending aorta diameter. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Significant\nPR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. The patient\nappears to be in sinus rhythm. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with basal inferior mild\ndyskinesis and more distal akinesis as well as akinesis of the distal lateral\nwall. There is mild hypokinesis of the remaining segments (LVEF = 30%). No\nmasses or thrombi are seen in the left ventricle. The diameters of aorta at\nthe sinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\nposterior leaflet is relatively fixed/immobile. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the left\nventricular cavity is slightly smaller and the severity of mitral\nregurgitation and pulmonary artery systolic pressure are slightly reduced.\nRegional left ventricular systolic function is similar.\n\n\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724005, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD:\n EXT:\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Pt w/ increased oxygen requirement\n overnight. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. Patient\n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). Also,\n with elevated BNP element of CHF exacerbation w/ volume overload. PE\n also on the differential, though less likely given viral findings as\n above.\n - F/u final sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 20mg iv x1, goal diuresis negative 1L\n - Repeat echo to eval for changing EF\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724008, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) admitted sepsis (sputum,\n fever, hypotension, hypoxia)\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Cardiovascular: tachy\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : ), tachypenic\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) w/ hypoxic resp failure\n and sepsis\n # Sepsis: baseline BPs in the 80s-90s per family and Oncology team, now\n at baseline, still tachy and low-grade temps, so still meeting sespsis\n criteria. Also with low EF, but does not appear grossly overloaded on\n exam now.\n - continue judicious IVF prn hypotension\n - consider stim/ stress dose steroids if hypotension\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - check urine legionella\n Broad antbx\n # hypoxic resp failure\nPneumonitis. High suspcion this is viral from\n RSV, probable bacterial superinfection, does not appear to have\n significant component of volume overload with insensible losses and neg\n fluid balance. No evidence of hemorrhage and dfa neg for PCP. ? med\n related, etoposide.\n --diuresed gently with good UOP response.\n --cont broad antbx coveragere address utilityt of monoclonal ab\n treatment with ID team\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole, appears slightly smaller on repeat CT\n 3. Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management and repeat bnp\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n # tachycardia\n Likely driven by resp distress/failure\n f/u TTE\n # ARF: Cr up to 1.8 on admit, improving with IVF\n - monitor UOP and urine lytes\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724009, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line to obtain CVP if hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1 per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724011, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n - Hem/onc recommending diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n - Place picc line for better access/iv abx\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line or evaluating w/ US to obtain CVP if\n hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724166, "text": "Chief Complaint: hypoxemia, resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n diuresed\n pt and family declined RSV monoclonal ab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 08:00 AM\n Bactrim (SMX/TMP) - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.1\nC (96.9\n HR: 106 (94 - 108) bpm\n BP: 89/58(66) {78/40(50) - 94/72(77)} mmHg\n RR: 29 (23 - 30) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 165 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 165 mL\n Blood products:\n Total out:\n 1,350 mL\n 475 mL\n Urine:\n 1,350 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -310 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 80 K/uL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BNP 16K\n Microbiology: --induced sputum mod resp florse growth, gpc on gs, 2+\n gpr, 1+ gnr\n bl/urine ngtd\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains very hypoxic, but subjectively more\n comfortable. Suspect pneumonitis likely all from RSV. With possibly\n also with bacterial superinfection, and component of volume overload\n given bnp elevateion.\n --cont cough supression, nebs, consider NPPV if fatigues\n --increase diuresis ( 1L neg)\n - broad empiric antbx\n --pt declined RSV monoclonal ab rx\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit, and running at baseline (runs low per fmaily and onc)\n #CHF\ndiurese\n # tachycardia\n Likely driven by resp distress/failure\n Improving\n # ARF: cr up, likely from poor forward flow, may improve with diuresis\n - monitor UOP and urine lytes\n - resume ace-when cr improves\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis: , picc placement\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU for now, improving and possible floor transfer late in\n day\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724167, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n *\n [2] 12:10PM\n *\n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). He has\n refused monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb, can re-offer as last\n resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724173, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n GEN: Elderly gentleman, tachypneic, alert/oriented.\n CV: Tachycardic, SM at apex, JVP mildly elevated\n PULM: tachypneic, Bl crackles appreciated on anterior breath sounds.\n ABD: Soft NTND +BS\n EXT: No edema, +petechiae\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n *\n [2] 12:10PM\n *\n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). He has refused\n monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724386, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724387, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724456, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species (but final probe pending) admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724582, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Goal\n ------ Protected Section Addendum Entered By: , MD\n on: 15:38 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724586, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Goal\n ------ Protected Section Addendum Entered By: , MD\n on: 15:38 ------\n Addendum\n GOC discussion with pt and his wife. Oncology involved as well. Pt at\n this time wishes to transition to aggressive comfort. All questions\n answered. Pt not interested in home hospice but prefers to remain in\n hospital at this time. Will discontinue blood draws, fluids and\n antbx. Palliative care consulted. Will use ativan for anxiety and\n morphine for airhunger/pain. Can transfer to private floor room.\n Crit care time spent in discussion and meetings: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:26 PM ------\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724097, "text": "Chief Complaint: sepsis/hypoxic resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + for RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Alert, tachypneic with talking\n Cardiovascular: tachy, rr\n Peripheral Vascular: 2+ pedal pulses\n Respiratory / Chest: rales, tachypneic\n + BS, soft, NT\n Skin: warm, diaphoretic\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\ndiffuse asd on imaging from pneumonitis likely\n all from RSV. Possibly also with bacterial superinfection, does not\n appear to have significant component of volume overload, though BNP\n elevated and pulm edema may also be contributing. No evidence of\n hemorrhage and dfa neg for PCP. also includes toxic effect from\n med/ ? etoposide.\n --supportive care with cough supression, nebs, consider NPPV if\n fatigues\n --gentle diuresis\n - broad antbx\n --d/w ID team use of RSV monoclonal ab rx\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit, and running at baseline (runs low per fmaily and onc)\n #CHF--BNP elevated from prior baseline, suspect this may be\n contribtuing to hypoxemia, though primarry issue is RSV\n --gentle diuresis and repeat BNP\n --TTE\n # tachycardia\n Likely driven by resp distress/failure\n Improving\n # ARF: Cr improving with IVF\n - monitor UOP and urine lytes\n # Cavitary lung nodule: seen on prior imaging, now appears slightly\n smaller, s/p FOB with BAL and biopsy, now growing, AFB, ----non-MTB,\n and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724381, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=130 and\n creat this am =1.8. most likely overdiuresed in the last couple of\n days. Cxr unchanged and without evidence of pulm edema/effusions. Pt\n currently receiving cefepime,vancomycin and voriconazole to cover\n bacterial and fungal pna( recently has grown penicillin species in\n cx). Pt n no apparent resp distress. Pt with poor appetite and c/o\n difficulty swallowing. Sbp ranging 70-90\ns but no interventions ordered\n by medical icu team\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% and o2 sats followed closely. No further\n diuretics ordered for now. Pt medicated with tessilon pearls for dry\n and nonproductive cough. Nutrition consult placed. Pt drinking\n ensure..\n Response:\n Resp status worse compared to last 24 hrs. still requiring high amts of\n 02\n Plan:\n Continue to follow resp status closely. Will send off repeat sputum\n for gm stain /c&s when able. hold on further diuresis at present\n time. Wean o2 as tolerated to maintain o2 sats> 90%. Dr. and\n oncologist spoke with pt\ns wife and pt remain dnr/dni. We will\n continue to treat but there will be no escalation of care.\n" }, { "category": "Rehab Services", "chartdate": "2197-03-10 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 724566, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 60yo M on chemotherapy with\nhistory of hypereosinophilic syndrome, h/o CVA, afib, and\n syndrome who was previously admitted to from \n- 1/12 cavitary lesion in lung. Patient presented to \nED on w/ concerns of 1 day of fever, productive cough,\nsore throat, weakness, and orthopnea. CT chest on \nrevealed that \"persistent diffuse bilateral pulmonary\nopacifications likely represent severe pneumonia.\" Patient w/\nconcerns for CAP, viral respiratory pathogen such as influenza\nvs. other infection immunocompromised state. We were\nconsulted to evaluate patient's oral and pharyngeal swallowing\nfunction and rule out aspiration while eating and drinking. RN\nreported patient coughing on ice chips and jello, and has had\nminimal PO intake during hospitalization.\nPatient was seen by our department for a bedside swallow\nevaluation in , and was recommended for thin liquids and\nregular solids.\nPMH:\n- DVT three years ago.\n-Hypereosinophilic syndrome (HES)\n-Multiple CVAs, miost recent in (Old R parieto-occipital\n& left parietal infarcts)\n-Atrial Fibrillation\n- syndrome (endomyocardial fibrosis with embolic\nphenomenon/stroke)\n-CHF thought secondary to eosinophilic myocarditis: EF 30% on\nTTE \nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on . Wife and RN present for evaluation.\nFull face mask and nasal cannula in place.\nCognition, language, speech, voice:\nPatient was awake, alert, and oriented to name and place, and\nyear when given two choices. Though output was limited, speech\nappeared fluent and was intelligible. Weak vocal quality.\nTeeth: Intact w/ some debris.\nSecretions: Normal oral secretions.\nORAL MOTOR EXAM:\nTongue protruded midline. Adequate lingual ROM and strength.\nFunctional Labial ROM, mildy reduced strength. Adequate buccal\ntone. Symmetrical palatal elevation. Gag deferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquid (tsp, straw),\nnectar-thick liquid, and puree (alone, and w/ crushed meds).\nPatient had adequate labial seal, but needed to be prompted to\nsuck in through the straw rather than blow out, and to open mouth\nwide to receive puree. Did not assess mastication limited\nPOs. At times, patient appeared to be piecemealing liquid\nboluses. Otherwise, oral transit appeared timely. No oral\nresidue noted following POs. Swallow trigger present. Laryngeal\nelevation felt adequate to palpation. No overt changes in vocal\nquality following POs. Patient noted w/ reflexive coughing on\nthin liquids when following puree. No further coughing noted on\nnectar-thick liquid following puree. No further POs were given,\nas patient was very weak and reported feeling like he was going\nto gag on puree, so it was felt that solid trials were not\nappropriate. O2 sats remained stable at 96-97%%.\nSUMMARY / IMPRESSION:\nMr. presents w/ fatigue, generalized weakness, and s/sx\nof aspiration (coughing) on thin liquid when following puree,\nlikely due to pharyngeal residue. All other trials of\nnectar-thick liquid following puree tolerated w/out coughing.\nGiven patient's current physical state, and his own report that\nhe felt like he was going to gag following puree, we feel that\nsolid POs are not appropriate at this time. Recommend PO diet of\nnectar-thick liquids and purees. PO meds crushed in applesauce.\n1:1 supervision and strict aspiration precautions. Alternate\nbites and sips. If there are concerns of aspiration on this diet\nover the weekend, please keep patient NPO. Recommend Nutrition\nconsult to provide suggestions for high calorie supplements, as\npatient is lactose intolerant, and cannot take Ensure pudding,\nand Ensure liquid would need to be thickened to nectar\nconsistency. Patient's PO intake has been limited, and likely\npoor nutrition is contributing to weakness. Recommend discussion\nregarding supplemental nutrition as indicated, and within goals\nof care pending prognosis. We will follow up early next week to\nsee how patient is tolerating diet.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5 out of 7.\nRECOMMENDATIONS:\n1. Recommend PO diet of nectar-thick liquids and purees.\n2. PO meds crushed in puree.\n3. 1:1 supervision and strict aspiration precautions.\n4. Alternate bites and sips.\n5. If there are concerns of aspiration on this diet over the\nweekend, please keep patient NPO.\n6. Recommend Nutrition consult to provide suggestions for high\ncalorie supplements, as patient is lactose intolerant, and cannot\ntake Ensure pudding, and Ensure liquid would need to be thickened\nto nectar consistency.\n7. Recommend discussion regarding supplemental nutrition as\nindicated, and within goals of care pending prognosis.\n8. We will follow up early next week to see how patient is\ntolerating diet.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\nRamya B.A., SLP/S\n____________________________________\n M.S., CCC-SLP\nPager #\nFace time: 1120-1145\nTotal time: 120 minutes\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724567, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset.\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724569, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) p/w sepsis and progressive\n bl ASD/hypoxermia found to have RSV infection course c/b ARF\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC\n O2 weaned to 50% + 4L NC\n diuresis held\n confused / agitated this morning-> haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Now alert, answering questions appropriately\n NAD but tired appearing, flat JVP\n Rales\n RR\n + BS, soft, NT\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n Problems include:\n \n leukocytosis\n hypoxic resp failure\n --RSV pna\n --Presumed bacterial superinf\n --Pulm edema (ards/cardiogenic)\n ARF\n Hyponatremia\n FTT/poor nutritional status\n Cavitary lung nodule (, penicillium)\n Hypereosinophilic syndrome\n Remains hypoxic, no improvement after diuresis and now with progressive\n ARF. Clinically with slow decline. Suspect his chronic\n hypereosinophilia is further complicating his picture, but in setting\n of underlying infection we are very limited in terms of treatment\n options. We continue supportive care with cough suppression, nebs,\n morphine for air hunger, broad empiric antbx. Will follow VBG and\n consider NPPV if pt will tolerate in setting of fatigue.\n Suspect the increased leukocytosis is from his eosinophilia, but will\n pursue infection eval (repeat ua/cx, c diff) and add levo for double GN\n coverage. He has remained AF, BP low from his low baseline.\n His ARF is most likely pre-renal from diuresis and poor PO. Bactrim\n could be contributing. He appears dry on exam. We continue to hold\n lasix and will give slow IVF, following uop and urine lytes. Will\n renally dose meds and avoid nephrotoxins.\n In terms of delirium-this is likely multifactorial-- sundowning, poor\n sleep, uremia, hypoxemia, poor PO, hyponatremia. He is now clear after\n haldol. Will optimize sleep wake as possible, use haldol or zydis,\n slow IVF bolus.\n His hyponatremia is most likely hypovolemic and we will monitor with\n hydration.\n He remains on vori for his lung cavitary lesion, prednisone for HES.\n His prognosis is poor and he seems tired. We will continue to work\n with oncology and address pt desired GOC, have discussed palliative\n option and will readdress this. Nutrition remains problem. \n pursue swallow eval pending GOC discussion.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724572, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GEN: Agitated, confused\n CV: RRR, no MRG, No JVD\n PULM: Tachypneic, no rales\n ABD: Soft, NTND +BS\n EXT: No edema\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Continues to remain short of breath and\n tachypneic, now also with confusion which could also be contributed by\n hypoxemia. Underlying process primarily secondary to progressive\n infection (RSV). CHF exacerbation on admission, but now appears\n dehydrated. Continues to require supplemental oxygen despite diuresis\n and antibiotics for superimposed infection. Resp viral screen positive\n for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and urine\n leg neg. DFA negative for PCP. currently, cefepime, vanc, and\n vori to cover bacterial and fungal pna (recently has grown penicillium\n species in culture). He has refused monoclonal antibody. Cont to\n consider PE, though less likely. Increasing white count worsening\n eosinophilia, however, possible resistant UTI, follow up cultures.\n - Add levoflox\n - Check vanc trough\n - Cont vanc, cefepime ( for 14 day course) and vori (fungal infxn)\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n - Morphine prn\n - We are likely moving toward CMO\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - F/u stool, blood, urine, stool and sputum\n - CXR today, f/u final report\n - Add levo, cont vanc/cefepime/vori\n # AMS: Likely delerium. Ddx includes ICU induced delerium, uremia \n to ARF, infection (RSV and UTI), hypoNa\n - Gentle boluses of IVFs\n - Cont to treat vanc/cefepime and vori; add levo\n - Haldol prn\n # HypoNa: Likely volume depletion\n - IVFs\n - Urine lytes\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n - IVFs\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n -\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724578, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset. Dr spoke with pt and his wife\n and pt now made cmo. All meds d/c\nd except for prn morphine for\n pain and ativan for anxiety. O2 dace tent mask d/c\nd per request of pt\n and his wife and he remains on 4l/m nc. Will continue with comfort care\n measures and offer emotional support to pt\ns wife and children\n" }, { "category": "Social Work", "chartdate": "2197-03-10 00:00:00.000", "description": "Social Work Admission Note", "row_id": 724557, "text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: This admission at is\n the patient's fifth.\n Past psychiatric history: Unknown.\n Past addictions history: Unknown.\n Employment status: Disable\n Legal involvement: Unknown.\n Mandated Reporting Information:\n Additional Information:\n Patient/Family HX: Dr. admitted this 60 y/o MWM with\n hypereosinophilic syndrome to with hypoxia and CHF. SW met with pt\n and his wife who talked about their hoping to again walk on the beach,\n but then laughed when they eventually discovered that they do not like\n the sand, water, sun, or noise but being able to walk hand-in-hand. Mr.\n talked about feeling that he \"was dead.\" This writer asked if\n he sometimes felt dead or wondered about dying given his medical\n condition, which he said that he did. Shortly afterwards, the pt said\n that he was tired.\n Afterwards, this worker spoke with his wife about the conversation re\n his dying and if she felt that the discussion felt premature. She said\n that after this writer left, he asked if she felt better having talked\n about death. Ms. said that it is difficult for her to raise\n such emotional issues and is appreciative of others broaching the\n topic.\n Assessment: The couple seems to struggle with hopeful talk about the\n future, e.g., walking hand-in-hand, while appearing to try and cope\n with what they see as EOL issues. Ms. seems to be experiencing\n a great deal of stress; it is not clear at this time as to how she\n copes and what supports she has, which this worker will explore in a\n future meeting.\n Plan / Follow up:\n 1. SW will continue to meet with the s to assess their\n coping and to offer support.\n , PhD, LICSW\n PAGE \n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724529, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Tachypneic, no rales\n No JVD\n No edema\n Agitated, confused\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Continues to remain short of breath and\n tachypneic, now also with confusion which could also be contributed by\n hypoxemia. Underlying process primarily secondary to progressive\n infection (RSV). CHF exacerbation on admission, but now appears\n dehydrated. Continues to require supplemental oxygen despite diuresis\n and antibiotics for superimposed infection. Resp viral screen positive\n for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and urine\n leg neg. DFA negative for PCP. currently, cefepime, vanc, and\n vori to cover bacterial and fungal pna (recently has grown penicillium\n species in culture). He has refused monoclonal antibody. Cont to\n consider PE, though less likely. Increasing white count worsening\n eosinophilia, however, possible resistant UTI, follow up cultures.\n - Add levoflox\n - Check vanc trough\n - Cont vanc, cefepime ( for 14 day course) and vori (fungal infxn)\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n - Morphine prn\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - F/u stool, blood, urine, stool and sputum\n - CXR today, f/u final report\n - Add levo, cont vanc/cefepime/vori\n # AMS: Likely delerium. Ddx includes ICU induced delerium, uremia \n to ARF, infection (RSV and UTI), hypoNa\n - Gentle boluses of IVFs\n - Cont to treat vanc/cefepime and vori; add levo\n - Haldol prn\n # HypoNa: Likely volume depletion\n - IVFs\n - Urine lytes\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n - IVFs\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n -\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724531, "text": "Chief Complaint: resp distress, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n held family meeting to address GOC along with onc team yesterday\n O2 weaned to 50% + 4L NC\n diuresis held\n confused and agitated this morning\n ID recommended holding on double GNR coverage\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n per -reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 87 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 87 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -113 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.4 g/dL\n 86 K/uL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr yesterday without new focal process, stable diffuse b ASD\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, bacterial superinfection,\n Remains hypoxic, no improvement with diuresis and now inprogressive\n ARF.\n CXR appears unchanged with diffuse ASD/no effusions. At this time feel\n cardiogenic pulm edema is unlikely to be contibuting.\n Clinically declining. Suspect his chronic hypereosinophilia is further\n complicating this but in setting of underlying infection we are very\n limited in terms of treatment options at this time.\n --Continue supportive care with cough suppression, nebs\n --Consider NPPV if fatigues\n --holding on diuresis (ARF and minimal PO)\n --continue broad empiric antbx to compelte 14 day course and will add\n double GNR coverage given u/a and concern for additional\n superinfection.\n --Morphine for air hunger\n --Check VBG\n # CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # delirium-multiple reasons\nsundowning, uremia, hypxemia, poor PO\n Will optimzie sleep wake, use haldol, gentle hydration for hyponatremia\n # hyponatremia\nsuspect all from hypovolemia/poor PO\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure when MS\n allows\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO until MS \nmic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments: wife at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724510, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724513, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n URINE CULTURE - At 06:11 AM\n \n - Did not start mirtazapine\n - XRay showed PICC line tip at level of low SVC without kinking.\n - Increased leukocytosis: so sent off second sputum, stool, urine, got\n CXR, checked LFTs\n - Met w/ heme/onc and wife: Wanted to continue with treatment\n - O2 weaned down to 50% fio2 and 4L nc; put out net 200cc earlier in\n the day but then 700cc net in; however, his sbp was persistently in the\n 70s and as he was sating well on less oxygen did not give lasix.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Voriconazole - 08:00 AM\n Cefipime - 08:29 PM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 91 (91 - 112) bpm\n BP: 73/48(53) {70/46(51) - 89/62(67)} mmHg\n RR: 18 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 74 mL\n PO:\n 540 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 730 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 86 K/uL\n 8.4 g/dL\n 93 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 62 mg/dL\n 93 mEq/L\n 127 mEq/L\n 25.0 %\n 15.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n 05:45 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n 15.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n 25.0\n Plt\n 67\n 73\n 80\n 90\n 86\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n 2.0\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n 93\n Other labs: PT / PTT / INR:17.3/39.8/1.6, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:12/42, Alk Phos / T Bili:92/0.4,\n Differential-Neuts:3.0 %, Band:0.0 %, Lymph:0.0 %, Mono:0.0 %, Eos:97.0\n %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.5\n mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR AP :\n Currently, the left PICC line tip is at the level of low SVC with no\n evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-PENDING INPATIENT\n Immunology (CMV) CMV Viral Load-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now. Increasing white count worsening eosinophilia, however,\n possible resistant UTI, follow up cultures.\n - Given improvement, may consider staying the course\n - Consider modifying tx for eosinophilic syndrome although risky given\n active infection. Nonetheless, pt is not going to clear his infection\n with 97% eosinophils\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage esp give UTI and hypotension\n - Hold on Lasix, as pt hypotensive and satting better\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723888, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L. Patient RSV positive\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723875, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin SC TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels slightly improved from admission, coughing\n less, no CP or SOB at rest, still fatigued\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: awake, NAD, coughing intermittently\n Neck: supple, JVP 8cm\n Chest: rales throughout post and ant lung fields, loudest at B bases,\n no wheezes\n CV: RRR, no m/r/g, laterally displaced PMI\n Abd: soft NT/ND + BS\n Extr: warm, no edema\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Sputum with oral secretions, sample cancelled\n Studies:\n CXR: RUL cavitary nodule, seen on CT on , and new bilateral lower\n lung field consolidations with air bronchograms and peribronchial\n cuffing\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n 1. Sepsis: baseline BPs in the 80s-90s per family and Oncology team,\n now at baseline, still tachy and low-grade temps, so still meeting\n sespsis criteria. Also with low EF, but does not appear grossly\n overloaded on exam now.\n - continue judicious IVF prn hypotension\n - holding off on stress dose steroids now given that BPs now at\n baseline and has known pulm infections\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - continue vanco/cefepime empirically\n - add levoflox for atypical coverage\n - check urine legionella\n - non-contrast chest CT\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole\n 3. Hypereosinophilic syndrome: acute presentation with dense\n consolidation on CXR most c/w CAP.\n - continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n 5. ARF: Cr up to 1.8 on admision, now improving with IVF\n - monitor UOP and urine lytes\n 6. Prior CVA: per Oncology team, ?weaker than baseline, and c/o\n increased fatigue. Can be sepsis and woresening underlying\n deficits.\n - head CT\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n Communication: with patient and family\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723837, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Weight 135.6\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Fever, cough, hypoxia\n Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Also, recent h/o PNA, treated voriconazole, azithro and cefepime. ABx\n except for vori were discontinued. He was ruled out for TB. AFB was\n positive for non-TB. Also with penicillium species in culture.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state. Other things to be considered include CHF,\n PE or exacerbation of eosinophilic condition.\n -- repeat sputum cx\n -- f/u other bcx/ucx, flu\n -- consider repeat bronch/bal\n -- broad spectrum abx for now given immunosuppression\n - cefepime for neutropenic fever\n - vanc given recent hospitalization\n - vori given penicillium growth\n -- hold on diuresis given concern for infection\n -- repeat echo to eval for changing EF\n -- f/u LENI to eval for DVT, though PNA more likely cause given CXR\n 2. hypotension\n Pt with BP mid 80's at baseline per heme/onc fellow. Similar in the ED.\n Pt given 800cc fluid. Likely related to CHF (EF 30%) vs. possible\n infection/SIRS criteria.\n -- culture and treat for infection as above\n --f/u echo\n --hold on diuresis\n -- may require pressors to manage fluids given possible sepsis and EF\n 30%\n 3. hypereosinophilic syndrome-\n currently tx with etoposide Q2 weeks. Current presentation could be\n related to this syndrome.\n -- f/u heme/onc recs\n -- consider bal\n 4. ARF-baseline 1-1.4.\n Improved to 1.3 with some IVF though UOP still low. Fe Urea 35% and not\n helpful\n -- monitor UOP\n --renally dose meds, avoid nephrotoxins\n 5. CHF-EF 30%. Currently with elevated trop and BNP. Dry weight is 140\n lbs\n -- complete ROMI\n -- f/u ECHO\n -- strict Is and Os, daily weights\n 6. blood per rectum-seen on toilet paper while on commode. Pt did not\n notice symptoms at home.\n -- guaiac stools\n -- active T+S\n -- monitor HCTS.\n 7. s/p CVA-supportive care\n 8. afib-stable\n 9. Hyperkalemia\n Resolved with kayexylate\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724203, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Afebrile. SBP low 80\ns to\n low 90\ns, which is baseline. ST 90\ns to low 100\ns with PVC\ns and will\n rise to 120\ns during coughing spells. Pt diuresed yesterday\ncondom cath\n collecting 30-50 cc/hr of amber urine.\n Action:\n Placed pt on 4 L briefly this AM as pt had prolonged coughing attack\n and unable to bring Sp02 above 80%...guiafenesin PRN for coughs. IV\n abx.\n Response:\n Pt back on 2 L NC with the 100% face tent\nslept most of night except\n one coughing spell in the AM\n Plan:\n Pt DNR/DNI\nneeds CMV viral load\nIV abx\nSBP ok in mid 80\ns as it is pt\n baseline\nkeep Sp02 high 80\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724278, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Pt lungs with crackles in the bases and clear in upper lobes. RR 22-34\n labored at times. Pt having very frequent coughing and some productive\n cough with thick yellow sputum.\n Action:\n Received pt on 50% face tent and 2L N/C. during coughing spell\n increased face tent to 70% and 3 L N/C pt still only 88%. Increased to\n 100% face tent with 3L. sao2 increased when pt relaxed and stopped\n coughing. Decreased back to 70% and 2 L N/C pt is > 90% on this. Pt was\n diuresed yesterday but goal of 1L neg was not met. Pt 500cc neg at\n midnight. Pt had stated that the quiafenesin with codeine helped but\n upset his stomach. Tried 30mg of codeine without the guiafenesin which\n really was not effective. Pt given lasix 40 mg iv when sao2 dropped to\n 84 % and again face tent increased to 100%\n Response:\n Pt still coughs frequently and requires high o2.\n Plan:\n DNI/DNI. Titrate o2 as needed to keep sao2 >90%. Cont with antibiotics\n and lasix as needed. Plan is for a family meeting tomorrow to discuss\n treatment options and plan of care.\n Wife stated pt is legally blind\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724392, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724208, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Afebrile. SBP low 80\ns to\n low 90\ns, which is baseline. ST 90\ns to low 100\ns with PVC\ns and will\n rise to 120\ns during coughing spells. Pt diuresed yesterday, condom\n cath for urine collection.\n Action:\n Guiafenesin w/ codeine being given Q4H (written PRN), x1 dose IV lasix\n (40mg) w/ goal 1L neg today, weaning O2 requirement w/ goal o2sat >90%,\n Vanco and cefepime for abx. CMV load sent.\n Response:\n Pt states Guiafenesin w/ codeine working well though productive cough\n still noted @ times, responded well to 40mg IV lasix, currently\n negative 500cc today, o2 sat > 90% on 50% face tent and 2L NC. HR\n remains low 100\ns today, SBP 90\ns w/ MAP >60.\n Plan:\n Pt DNR/DNI. Adjust fio2 for goal sat > 90%, guiafenesin for cough,\n cont abx, ? additional lasix for goal 1L neg today.\n PICC placed in L arm brachial vein @ bedside and okay to use.\n Wife stated that pt is legally blind but seemed to be having more\n difficulty today. Pt denied difficulty though failed several bedside\n tests w/ this RN and ICU team. Pt states this is no different however\n and that he sees better with the overhead light off. Has hx of CVA but\n every thing appears to be @ baseline @ this time.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723810, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723811, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723815, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724393, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724394, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724395, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n kg\n 65.1kg (), 66.77kg (), 73.39kg () kg\n %\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724396, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Hypoxia, CHF\n HT: 67\n WT: 63.7kg\n WT Hx: 65.1kg (), 66.77kg (), 73.3kg ()\n PMH:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n ------ Protected Section------\n Disregard above note.\n ------ Protected Section Error Entered By: , RD, \n on: 05:00 PM ------\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724397, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated.\n Drinks the Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724405, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated. Had\n been drinking some Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Specifics:\n 60YO Male w/ h/o hypereosinophilic syndrome tx with etoposide, h/o\n CVA, a-fib, CHF (EF 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung, FOB/BAL(now growing AFB,\n non-MTB, and penicillium species but final probe pending) admitted w/\n sepsis (fever, hypotension, hypoxia) and progressive bl ASD. ARF likely\n d/t diuresing, now lasix on hold. Consulted for poor po\ns but now\n ordered for swallow evaluation for dysphagia. If concerned with\n aspiration, recommend change to NPO until swallow study is done. If\n passes swallow evaluation, would change Ensure to Ensure Plus for\n additional calories & protein. If fails swallow study, consider tube\n feeds if within plan of care. Noted plan for family meeting to discuss\n goals of care.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If patient is a risk for aspiration, change diet to NPO\n 2. Await swallow study results\n 3. If passes for po\ns, change to Ensure Plus TID w/ diet per\n speech recommendations.\n 4. Consider appetite/mood stimulants & encourage po\n supplements. Consider tube feeds if still unable to take adequate po\n 5. If fails swallow study, consider Tube feeds. Place NGT &\n strart feeds at 10mL/hr, advance by 10mL every 6hrs to goal 50mL/hr of\n Nutren Pulmonary. Check residuals every 4hrs & hold for 1hr if greater\n than 150mL\n 6. Monitor labs, renal function & hydration.\n Will follow plan.\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723820, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Studies:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723821, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen:\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Studies:\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n Sepsis\n -hypotension - IVF boluses judiciously - given CHF / elevated BNP\n careful fluid management\n -pan cx\n -empiric vanc, cefipime pending cx data guidance\n -source sounds respiratory in nature - CAP, flu, etc most likely but\n given recent travel to also think about other potential\n etiologies including PE , blasto. Cavitary lesion +AFB NonMTB not\n likely sepsis source.\n CHF\n -elevated BMP, +Trop, CK nl consistent with strain\n -EKG unchanged\n -careful fluid management\n -repeat echo\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n ARF\n -creat 1.8 up\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723823, "text": "Chief Complaint: fever, cough\n 24 Hour Events:\n URINE CULTURE - At 12:52 AM\n Did not diurese as BPs have been low, 70s.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical Known\n Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n dry weight 140\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Diarrhea\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.8\n HR: 91 (80 - 92) bpm\n BP: 83/59(65) {73/45(53) - 87/60(66)} mmHg\n RR: 31 (21 - 33) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Weight 135.6\n Total In:\n 315 mL\n 75 mL\n PO:\n TF:\n IVF:\n 315 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n to mid-fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, purpura\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs:\n PT / PTT / INR : 13.4 / 30.8 / 1.1,\n CK / CKMB / Troponin-T:48/8/ 0.29\n 0.22\n ALT / AST:18/41, Alk Phos / T Bili: 103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: creatinine trending down\n BNP \n FeUrea 35%\n Microbiology: sputum from contaminated\n Assessment and Plan\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Fever, cough, hypoxia\n Pt with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Recently admitted to the hospitalist service with\n pulmonary and ID following. Started on voriconazole, azithro and\n cefepime. ABx except for vori were discontinued. He was ruled out for\n TB. The cause was thought to be fungal/parasitic/reoccurrence of\n hypereosinophilic syndrome. BAL was negative for growth at the time.\n Recently AFB was positive for non-TB. Etiologies for the above\n presentation include, CAP, viral respiratory pathogen such as\n influenza/paraflu, or other infection that occurs in the\n immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2197-03-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 723827, "text": "Chief Complaint: hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16),\n h/o CVA, afib, CHF (ef 30% 8/09), syndrome with recent\n admission for cavitating lesion of lung- FOB/BAL now growing, AFB,\n non-MTB, and penicillium species but final probe pending now admitted\n from ED for cough (yellow sputum), fever 101.6, sore throat,\n hypotension, hypoxia and generalized weakness x one day. No sick\n contacts. Recent travel to to visit son. In BP 83/53,\n P103, Sat 86%RA, given IVF bolus without improvement of BP. Sat 92%\n on 2L NC. BNP 13k, Trop 0.29, CK 87. WBC 11.9 with 86% eos, 13%\n polys. Transferred to MICU for management of hypotension & fever in\n setting of patient with immunosuppression.\n 24 Hour Events:\n Admitted from the ED yesterday\n BPs in the 70s o/n, improved with IVF\n Sats stable on 4L NC\n Received Kayexalate, several BMs o/n\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Cefipime - 10:00 PM\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:20 AM\n Omeprazole (Prilosec) - 08:21 AM\n Other medications:\n Folate\n Vitamin D\n Omeprazole 20 daily\n Bactrim 1 tab MWF\n Valgancyclovir QOD\n Vanco 1 gm\n Heparin SC TID\n Prednisone 8 mg daily\n Voriconazole 200 Q12\n Cefepime\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: feels slightly improved from admission, coughing\n less, no CP or SOB at rest, still fatigued\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 90 (80 - 92) bpm\n BP: 81/58(64) {73/45(53) - 87/60(66)} mmHg\n RR: 25 (21 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 315 mL\n 205 mL\n PO:\n 120 mL\n TF:\n IVF:\n 315 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 315 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: awake, NAD, coughing intermittently\n Neck: supple, JVP 8cm\n Chest: rales throughout post and ant lung fields, loudest at B bases,\n no wheezes\n CV: RRR, no m/r/g, laterally displaced PMI\n Abd: soft NT/ND + BS\n Extr: warm, no edema\n Labs / Radiology\n 9.0 g/dL\n 67 K/uL\n 115 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 101 mEq/L\n 135 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n TropT\n 0.22\n Glucose\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/8/0.22, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %,\n Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Micro:\n Flu swab pending, blood cultures pending\n Sputum with oral secretions, sample cancelled\n Studies:\n CXR: RUL cavitary nodule, seen on CT on , and new bilateral lower\n lung field consolidations with air bronchograms and peribronchial\n cuffing\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness.\n 1. Sepsis: baseline BPs in the 80s-90s per family and Oncology team,\n now at baseline, still tachy and low-grade temps, so still meeting\n sespsis criteria. Also with low EF, but does not appear grossly\n overloaded on exam now.\n - continue judicious IVF prn hypotension\n - holding off on stress dose steroids now given that BPs now at\n baseline and has known pulm infections\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - continue vanco/cefepime empirically\n - add levoflox for atypical coverage\n - check urine legionella\n - non-contrast chest CT\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole\n 3. Hypereosinophilic syndrome: acute presentation with dense\n consolidation on CXR most c/w CAP.\n - continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n 5. ARF: Cr up to 1.8 on admision, now improving with IVF\n - monitor UOP and urine lytes\n 6. Prior CVA: per Oncology team, ?weaker than baseline, and c/o\n increased fatigue. Can be sepsis and woresening underlying\n deficits.\n - head CT\n Remainder of plan per resident note.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n Communication: with patient and family\n Code status: DNR/DNI\n Disposition : ICU, patient is critically ill\n Total time spent: 40 min CCT\n" }, { "category": "Nutrition", "chartdate": "2197-03-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 724401, "text": "Subjective\n Wife reports poor appetite due to possibly giving up & frustrated. Had\n been drinking some Ensure. Gradual weight loss over past year.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 63.7 kg\n 61.7 kg ( 08:00 AM)\n Down ~11.6kg in a year.\n 21.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 92%\n -\n 65.1kg (), 66.77kg (), 73.39kg () kg\n 84%\n Diagnosis: Hypoxia, CHF\n PMHx:\n legally blind\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Food allergies and intolerances: lactose intolerance.\n Pertinent medications: vancomycin, vitamin D, folic acid, prilosec\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:01 AM\n BUN\n 51 mg/dL\n 04:01 AM\n Creatinine\n 1.8 mg/dL\n 04:01 AM\n Sodium\n 130 mEq/L\n 04:01 AM\n Potassium\n 4.2 mEq/L\n 04:01 AM\n Chloride\n 94 mEq/L\n 04:01 AM\n TCO2\n 23 mEq/L\n 04:01 AM\n PO2 (arterial)\n 68 mm Hg\n 07:41 AM\n PO2 (venous)\n 52 mm Hg\n 04:44 PM\n PCO2 (arterial)\n 31 mm Hg\n 07:41 AM\n PCO2 (venous)\n 34 mm Hg\n 04:44 PM\n pH (arterial)\n 7.50 units\n 07:41 AM\n pH (venous)\n 7.48 units\n 04:44 PM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 07:41 AM\n CO2 (Calc) venous\n 26 mEq/L\n 04:44 PM\n Albumin\n 3.6 g/dL\n 05:32 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:01 AM\n Phosphorus\n 4.0 mg/dL\n 04:01 AM\n Magnesium\n 2.2 mg/dL\n 04:01 AM\n ALT\n 18 IU/L\n 05:32 AM\n Alkaline Phosphate\n 103 IU/L\n 05:32 AM\n AST\n 41 IU/L\n 05:32 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:32 AM\n WBC\n 11.1 K/uL\n 04:01 AM\n Hgb\n 9.0 g/dL\n 04:01 AM\n Hematocrit\n 26.9 %\n 04:01 AM\n Granulocyte count\n 1155 #/uL\n 04:01 AM\n Current diet order / nutrition support: Regular Lactose Restricted with\n Ensure TID\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low po intake, weight loss\n Estimated Nutritional Needs\n Calories: 1736- (BEE x or / 28-32 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team.\n Calculations based on: Current weight.\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724165, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n *\n [2] 12:10PM\n *\n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Likely secondary to infection (RSV) and\n CHF exacerbation. Clinically patient has improved with diuresis. He is\n with known eosinophilic syndrome, immunosuppressed on chemotherapy.\n Resp viral screen positive for RSV, sputum has preliminarily grown GPC,\n GPR, and GNR, and urine leg neg. DFA negative for PCP. \n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). He has\n refused monoclonal antibody. Cont to consider PE, though less likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb, can re-offer as last\n resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - Cont to monitor hemodynamics\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724461, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, S/P bronch , now growing AFB,\n non-MTB, and penicillium species (but final probe pending) admitted\n from ED with RSV, fever 101.6, hypotension, hypoxia and generalized\n weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723790, "text": "Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n Sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n It is reported that patient has SBP that hover in the 80\ns-90\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723792, "text": "Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n It is reported that patient has SBP that hover in the 80\ns-90\ns. On\n initial assessment in the ED he was treated with 800cc of IVF.\n Action:\n He has received one 500cc bolus overnight for a MAP less than 60mmHg.\n He has also received antibiotics totaling 300cc.\n Response:\n He has maintained he baseline SBP throughout the shift with no\n symptoms. He continues to deny any discomfort, is alert and oriented\n x3. Urinary output has been poor and the team is aware, he is being\n considered for diuresis.\n Plan:\n Team to discuss possible diuresis in the setting of increased O2\n requirements, poor output and h/o CHF with EF of 30%.\n Hypoxemia\n Assessment:\n As mentioned the patient did present with a new cough, fever and O2\n requirement.\n Action:\n His CXR did show bibasilar infiltrates, he continues on his\n voriconazole, Vancomycin and cefepime.\n Response:\n Patient has been afebrile overnight with persistent cough. He did\n receive Robitussin with some effect, last dose given at 0600.\n Plan:\n Continue to follow lab trends, monitor v/s and observed for respiratory\n distress.\n Patient\ns spouse did spend the night with him.\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723705, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibrosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lung\n sounds rhoncherous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns baseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723776, "text": "Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723729, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibrosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lung\n sounds rhoncherous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns baseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n Hypoxemia\n Assessment:\n Pt arrived to from ed on 2l/m nc in no apparent resp distress.\n Lungs cta but with bibasilar crackles on auscultation. Low grade\n temps.\n Action:\n Resp status monitored closely.\n Response:\n Stable resp status\n Administer\n Administer antibiotics as ordered. Monitor pt\ns resp status closely.\n medical team\ns examination of pt and admission orders.\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723732, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 26*1\n RUL BRONCH LAVAGE\n 01:32PM 10* 1* 2* 80* 3* 4*2\n BRONCH LAVAGE\n//RML\n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for PE\n -ID c/s.\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n .\n #ARF-baseline 1-1.4. Currentlyl 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/os\n -lasix gtt.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full\n # CONTACT:\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723734, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 26*1\n RUL BRONCH LAVAGE\n 01:32PM 10* 1* 2* 80* 3* 4*2\n BRONCH LAVAGE\n//RML\n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for PE\n -ID c/s.\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n .\n #ARF-baseline 1-1.4. Currentlyl 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/os\n -lasix gtt.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full\n # CONTACT:\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723735, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 26*1\n RUL BRONCH LAVAGE\n 01:32PM 10* 1* 2* 80* 3* 4*2\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723736, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 26*1\n RUL BRONCH LAVAGE\n 01:32PM 10* 1* 2* 80* 3* 4*2\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n ------ Protected Section ------\n Chart reviewed, pt examined, case discussed in detail with house\n officers caring for Mr. . In addition, I would add/emphasize\n the following:\n 60M h/o hypereosinophilic syndrome tx with etoposide, Cd4 16), h/o CVA,\n afib, CHF (ef 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung- FOB/BAL now growing, AFB, non-MTB, and\n penicillium species but final probe pending now admitted from ED for\n cough (yellow sputum), fever 101.6, sore throat, hypotension, hypoxia\n and generalized weakness x one day. No sick contacts. Recent travel\n to to visit son. In BP 83/53, P103, Sat 86%RA, given IVF\n bolus without improvement of BP. Sat 92% on 2L NC. BNP 13k, Trop\n 0.29, CK 87. WBC 11.9 with 86% eos, 13% polys. Transferred to MICU\n for management of hypotension & fever in setting of patient with\n immunosuppression.\n On exam:\n 99.2 P87 BP71/52, R22, sat 93% 2LNC\n Thin, NAD, supine in bed\n Lungs rales b/l\n CV - rrr\n Abd soft NTND BS+\n CXR- persistent Rt cavitary lesion noted. b/l hilar infiltrates c/w\n CHF\n Hypereosinophilic syndrome on etoposide with cavitary lesion of lung\n presents with sepsis in setting of immunosuppression.\n Sepsis\n -hypotension - IVF boluses judiciously - given CHF / elevated BNP\n careful fluid management\n -pan cx\n -empiric vanc, cefipime pending cx data guidance\n -source sounds respiratory in nature - CAP, flu, etc most likely but\n given recent travel to also think about other potential\n etiologies including PE , blasto. Cavitary lesion +AFB NonMTB not\n likely sepsis source.\n CHF\n -elevated BMP, +Trop, CK nl consistent with strain\n -EKG unchanged\n -careful fluid management\n -repeat echo\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n ARF\n -creat 1.8 up\n Remainder of plan per resident note.\n Patient is critically ill.\n Time spent on care: 45min\n ------ Protected Section Addendum Entered By: , MD\n on: 20:01 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 723738, "text": "Chief Complaint: ICU ADMISSION NOTE\n \n .\n PCP: /Primary , \n Hematology/Oncology Primary Nurse , \n Hematology/Oncology Attending Provider , MD\n .\n CHIEF COMPLAINT: fever\n REASON FOR MICU ADMISSION:hypoxia\n .\n HPI:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n .\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n .\n Time Pain Temp HR BP RR Pox\n - 12:01 5 99.6 103 83/53 20 86\n 99.3,100.3, 82/53, hr 96, 26 sat 92% on 2L.\n ED notes pt to have rales at the bases. She was given kayexylate for\n hyperkalemia. EKG stated to be unchanged. BNP 13,000, trop .29,given\n asa (no heparin), cards feels demand ischemia. CXR showing volume\n overload. ED d/w onc fellow who thought abx not needed given prior\n history. However, ED gave vanco/zosyn. Pt given total of 800cc fluids.\n Nebs given.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Valcyte 450 mg Tab QOD\n Codeine-Guaifenesin 10 mg-100 mg/5 mL Oral Liquid\n mL by mouth every 4-6 hours as needed for cough\n Vfend 200 mg Tab q12 hrs\n Calcium Carbonate 500 mg Chewable Tab 2, TID\n Bactrim DS 160 mg-800 mg Tab mon/wed/fri\n Captopril 12.5 mg Tab q8hrs\n Furosemide 20 mg Tab-0.5 - 1 Tablet(s) by mouth daily As instructed by\n MD\n Omeprazole 20 mg Cap, Delayed Release daily\n Prochlorperazine Maleate 10 mg Tab Q6hrs.\n Prednisone 1 mg Tab, 9mg daily\n Etoposide 20 mg/mL IV-given every 3-4 weeks per heme/onc\n Vitamin D 400 unit Cap 2 tabs once a day\n Trazodone 50 mg Tab, daily\n Folic Acid 1 mg Tab daily\n Metoprolol Succinate ER 25 mg 24 hr Tab daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n legally blind\n Past Medical History:\n PAST ONCOLOGIC HISTORY:\n ======================\n -Hypereosinophilic syndrome and associated course:\n Diagnosed in after presenting with transient ischemic\n episode (with reported exotropia) and bilateral deep venous\n thrombosis. He was treated was initially treated with\n prednisone, but changed to hydroxyurea as his condition was\n refractory. He had a one month long trial of imatinib 400 mg\n daily in the winter of , but did not have a response. He\n continued on hydroxyurea until the summer of when he had\n two hospitalizations, one with pneumonia and another with\n multiple infarctions. The infarctions were of the right\n parieto-occipital lobe and left parietal infarction with sudden onset\n left\n homonymous hemianopsia in . He subsequently deteriorated,\n with weight loss and fatigue. He was started on prednisone 60 mg\n daily in , then tapered to 20 mg daily and initiated\n on Sorafenib. He was seen by BMT for possible allogeneic stem\n cell transplant. Campath dose was increased to 2X/wk as\n eosinophil count increased to 60%. Interferon 1.5mu 3x/wk was\n started on on , increased to 4.5 million units three times a\n week. Interferon was d/c'd on .\n .\n PAST MEDICAL HISTORY:\n ====================\n - DVT three years ago.\n -Hypereosinophilic syndrome (HES)\n -Multiple CVAs, most recent in (Old R parieto-occipital\n & left parietal infarcts)-with R.sided deficits and L.eye blindness.\n -Atrial Fibrillation\n - syndrome (endomyocardial fibrosis with embolic\n phenomenon/stroke)\n -CHF thought secondary to eosinophilic myocarditis: EF 30% on\n TTE \n Non-Contributory. Lives with wife in .\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tobacco/alcohol\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 87 (87 - 92) bpm\n BP: 86/57(64) {86/56(63) - 87/57(64)} mmHg\n RR: 31 (31 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n VS: 99.2, BP 87/56, HR 92, RR 33, sat 91% on 2L\n GEN:The patient is in no distress and appears comfortable, thin\n SKIN:No rashes or skin changes noted\n HEENT:JVP-elevated 4cm above clavicle, neck supple, No lymphadenopathy\n in cervical, posterior, or supraclavicular chains noted.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi, anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: No apparent scars. Non-distended, and soft without tenderness\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriatex2 (did not know date). CN II-XII\n grossly intact. BUE , and BLE both proximally and distally.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na:134\n K:5.2\n Glu:112 Lactate:2.5\n Hgb:10.9\n CalcHCT:33\n .\n LIGHT GREEN\n Trop-T: 0.29\n cTropnT: At 1:20 Pm\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n .\n 133 95 38 112 AGap=22\n 5.3 21 1.8\n .\n estGFR: 39/47 (click for details)\n CK: 87 MB: Notdone\n Ca: 8.7 Mg: 2.0 P: 3.8\n Other Blood Chemistry:\n proBNP: \n .\n 96\n 11.9 9.7 Pnd\n 29.8\n N:13 Band:0 L:1 M:0 E:86 Bas:0\n Hypochr: OCCASIONAL Anisocy: 2+ Poiklo: 2+ Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: OCCASIONAL Ovalocy: 1+ Tear-Dr: OCCASIONAL\n Plt-Est: Low\n .\n PT: 12.6 PTT: 28.7 INR: 1.1\n Imaging: cath -FINAL DIAGNOSIS:\n 1. Coronary arteries are normal.\n 2. Biventricular diastolic dysfunction.\n 3. Normal systemic blood pressure.\n 4. RV endomyocardial biopsy performed.\n .\n echo -The left atrium is markedly dilated. The estimated right\n atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are\n normal. The left ventricular cavity is mildly dilated. LV systolic\n function appears depressed (ejection fraction 30 percent) secondary to\n severe hypokinesis/akinesis of the inferior and posterior walls, and\n extensive apical hypokinesis with focal apical akinesis. There is no\n ventricular septal defect. Right ventricular chamber size is normal.\n with depressed free wall contractility. There are focal calcifications\n in the aortic arch. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. There is no mitral\n valve prolapse. An eccentric, posteriorly directed jet of Moderate to\n severe (3+) mitral regurgitation is seen. The left ventricular inflow\n pattern suggests a restrictive filling abnormality, with elevated left\n atrial pressure. There is severe pulmonary artery systolic\n hypertension. The main pulmonary artery is dilated. The branch\n pulmonary arteries are dilated. There is no pericardial effusion.\n Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is significantly\n further depressed (in a distribution consistent with multivessel\n obstructive coronary artery disease); the pulmonary artery systolic\n pressure is significantly further increased, and the left ventricle is\n now dilated.\n .\n CT chest -IMPRESSION:\n 1. Slightly decreased overall size, increased necrotic center and\n decreased peripheral wall thickness of a cavitary right upper lobe\n mass. This most likely represents an infectious etiology. Followup to\n resolution is recommended to exclude underlying malignancy.\n 2. Marked improvement in diffuse ground-glass opacity in both lungs\n likely represents resolving inflammation, infection, or pulmonary\n edema.\n 3. Marked splenomegaly is stable.\n .\n CXR \n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification\n likely represents acute moderate interstitial pulmonary edema though\n infection is excluded, and recommend repeat radiographs status post\n diuresis to exclude pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n .\n PFTs \n Impression:\n Moderate restrictive ventilatory defect with a moderate gas exchange\n defect. The reduced DLCO suggests an interstitial process. Compared to\n the prior study of the FVC has increased by 0.63 L (+25%),\n the FEV1 has increased by 0.58 L (+30%) while the TLC has decreased by\n 0.91 L (-20%) and the DLCO has decreased by 4.13 ml/min/mmHg (-21%).\n Technician notes from indicated that spirometry quality was\n limited at that time due to\n patient cough.\n Actual Pred %Pred Actual %Pred %chg\n FVC 3.14 4.18 75\n FEV1 2.49 2.98 84\n MMF 2.40 2.96 81\n FEV1/FVC 79 71 111\n LUNG VOLUMES 8:25 AM Pre drug Post drug\n Actual Pred %Pred Actual %Pred\n TLC 3.64 6.35 57\n FRC 1.77 3.55 50\n RV 1.40 2.17 64\n VC 3.04 4.18 73\n IC 1.87 2.80 67\n ERV 0.37 1.39 27\n RV/TLC 38 34 112\n He Mix Time 2.75\n DLCO 8:25 AM\n Actual Pred %Pred\n DSB 14.87 26.06 57\n VA(sb) 3.84 6.35 61\n HB 13.40\n DSB(HB) 15.42 26.06 59\n DL/VA 4.01 4.10 98\n .\n Microbiology: -BAL, no microorganisms identified.\n OTHER BODY FLUID\n OTHER BODY FLUID ANALYSIS Polys Lymphs Monos Eos Mesothe Macro\n 01:33PM 7* 2* 3* 60* 2* 26*1\n RUL BRONCH LAVAGE\n 01:32PM 10* 1* 2* 80* 3* 4*2\n BRONCH LAVAGE\n//RML\n .\n EKG-diffuse TWF, TWI AVF, otherwise unchanged compared to \n .\n Assessment and Plan\n HYPOXEMIAPt is a 60 y.o male with h.o hypereosinophilic syndrome on\n chemo (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with\n fever, cough, found to be \"hypoxic\" and \"hypotensive\" in the ED.\n .\n # fever/cough/hypoxia-Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. He was recently admitted to the\n hospitalist service with pulmonary and ID following. He\n was started on voriconazole, azithro and cefepime. ABx except for vori\n were discontinued. He was ruled out for TB. The cause was thought to be\n fungal/parasitic/reoccurrence of hypereosinophilic syndrome. BAL was\n negative for growth at the time. Recently AFB was positive for non-TB.\n Etiologies for the above presentation include, CAP, viral respiratory\n pathogen such as influenza/paraflu, or other infection that occurs in\n the immunocompromised state such as fungal/MAC. Other things to be\n considered include CHF, PE or exacerbation of eosinophilic condition.\n -sputum cx\n -bcx/ucx\n -consider repeat bronch/bal\n -broad spectrum abx for now given immunosuppression\n -flu swab\n -diuresis with lasix gtt.\n -consider repeat echo\n -LENI to eval for DVT, heparin if clinical scenario indicates.\n -ID c/s.\n -fungal cx\n .\n #hypereosinophilic syndrome-Details above. Pt currently tx with\n etoposide Q2 weeks. Current presentation could be related to this\n syndrome.\n -heme/onc recs\n -consider bal for eosinophils\n .\n #hypotension-Pt with BP mid 80's at baseline per heme/onc fellow.\n Similar in the ED. Pt given 800cc fluid. Likely related to CHF (EF 30%)\n vs. possible infection/SIRS criteria.\n -pan cx as above\n -echo\n -lasix gtt\n -consider IVF boluses for persistant hypotension.\n .\n #ARF-baseline 1-1.4. Currently 1.8. Likely related to pre renal state\n given fever, signs of CHF and poor forward flow. Can also consider\n intrarenal and post renal etiologies.\n -ulytes\n -ua and cx\n -u eos\n -renally dose meds, avoid nephrotoxins\n .\n #CHF-EF 30%. Currently with elevated trop and BNP.\n -ROMI\n -repeat ECHO\n -i/o s\n -lasix gtt.\n -asa\n .\n #blood per rectum-seen on toilet paper while on commode. PT did not\n notice symptoms at home.\n -guaiac stools\n -active T+S\n -serial HCTS.\n .\n #s/p CVA-supportive care\n .\n #afib-rate controlled.\n .\n # FEN: cardiac diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: wife HCP\n # DISPOSITION:\n [ x] ICU\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control:\n Lines: PIV\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU o/n\n Will hold off on lasix gtt for now given persistent hypotension and\n likelihood of infection\n ------ Protected Section Addendum Entered By: , MD\n on: 20:14 ------\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723914, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L, RR in high 30\ns-40\ns. Patient RSV\n positive. VBG: 7.48/34/52 ( per ID if resp status worsening\n patient\n should get IVIG)\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Nursing", "chartdate": "2197-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723902, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED for\n cough with yellow sputum, fever 101.6, hypotension, hypoxia and\n generalized weakness\n Hypoxemia\n Assessment:\n Received patient on 4L NC with sats at high 80\ns to low 90\ns. B/L LS\n crackles, diminished at the bases. Intermittent productive cough, clear\n sputum. AM CXR worsening w/PNA\n Action:\n Continue w/ABX regimen, levofloxacin added, and CT chest done.\n Response:\n Patient report improvement in his resp status, denies SOB. However\n during the shift O2 up to 6L, RR in high 30\ns-40\ns. Patient RSV\n positive. VBG: 7.48/34/52 ( per ID if resp status worsening\n patient\n should get IVIG)\n Plan:\n Continue to monitor patient\ns status, continue w/ABX ASDIR. F/u CX\n data. F/u CT final read.\n Hypotension (not Shock)\n Assessment:\n B/P in the 80\ns. (Patient known to have b/p in the 80\ns as baseline).\n Patient denies CP or SOB. Hr in the 90-100\ns SR w/occasional PVC\ns. No\n peripheral edema noted. Peripheral pulses present.\n Action:\n Cardiac monitoring, trend labs and temp curve. No IVF given, low\n threshold to start pressors if needed.\n Response:\n Patient maintaining baseline pressures throughout the shift. UOP still\n poor. Patient is being considered for diuresis in the future. Patient\n on abx\n Plan:\n Continue to monitor patient status, diuresis vs. pressors depends on\n patient status.\n Neuro: alert oriented follows commands. Per onc MS\n baseline. Head\n CT done\n results pending.\n GI: abd soft non tender, positive for BS. On regular diet\n tolerates\n it well. Denies any nausea/ vomiting.\n GU: amber/icteric colored urine. Poor UOP. Team aware.\n IV access: 2 PIV\n patent.\n Social: patient is DNR/DNI. Wife at bedside at all times.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723985, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723989, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Respiratory Failure: Pt with known eosinophilic syndrome,\n immunosuppressed on chemotherapy. Resp viral screen positive for RSV.\n Patient currently, on levo, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture).\n Also, with elevated BNP element of CHF exacerbation w/ volume\n overload. PE also on the differential, though less likely given viral\n findings as above.\n -- repeat sputum cx\n -- f/u other bcx/ucx, flu\n -- consider repeat bronch/bal\n -- broad spectrum abx for now given immunosuppression\n - cefepime for neutropenic fever\n - vanc given recent hospitalization\n - vori given penicillium growth\n -- hold on diuresis given concern for infection\n -- repeat echo to eval for changing EF\n -- f/u LENI to eval for DVT, though PNA more likely cause given CXR\n 2. hypotension\n Pt with BP mid 80's at baseline per heme/onc fellow. Similar in the ED.\n Pt given 800cc fluid. Likely related to CHF (EF 30%) vs. possible\n infection/SIRS criteria.\n -- culture and treat for infection as above\n --f/u echo\n --hold on diuresis\n -- may require pressors to manage fluids given possible sepsis and EF\n 30%\n 3. hypereosinophilic syndrome-\n currently tx with etoposide Q2 weeks. Current presentation could be\n related to this syndrome.\n -- f/u heme/onc recs\n -- consider bal\n 4. ARF-baseline 1-1.4.\n Improved to 1.3 with some IVF though UOP still low. Fe Urea 35% and not\n helpful\n -- monitor UOP\n --renally dose meds, avoid nephrotoxins\n 5. CHF-EF 30%. Currently with elevated trop and BNP. Dry weight is 140\n lbs\n -- complete ROMI\n -- f/u ECHO\n -- strict Is and Os, daily weights\n 6. blood per rectum-seen on toilet paper while on commode. Pt did not\n notice symptoms at home.\n -- guaiac stools\n -- active T+S\n -- monitor HCTS.\n 7. s/p CVA-supportive care\n 8. afib-stable\n 9. Hyperkalemia\n Resolved with kayexylate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723991, "text": "Pt is a 60 y.o male with h.o hypereosinophilic syndrome\n (immunosuppressed-on etoposie, Cd4 16), h.o CVA, afib, \n syndrome who was admitted recently to the hospitalist service, found to\n have a cavitating lesion in his lung, s/p bronch, BAL growing, AFB,\n non-TB, and penicillium species but final probe still pending. Pt said\n to improve on voriconazole\n Pt reports that he developed a productive cough (clear/yellow sputum)\n x1 wk ago. Cough continued to worsen over the week and pt was given\n cough suppressant medication. In addition, he reports fever 101.6 today\n sore throat, weakness, and orthopnea. He denies\n headache/dizziness/LH/new visual changes/CP/paresthesias/SOB/abd\n pain/n/v/d/melena/brbpr/dysuria/skin rash/joint pain/paresthesias/\n sick contacts, but does report constipation. Pt states that this\n presentation is different than his prior admission in and cough is\n new.\n Hypotension (not Shock)\n Assessment:\n SBP normally run in the 90\ns at baseline.\n Action:\n No action required overnight for his BP.\n Response:\n He has maintained he baseline SBP throughout the shift with no\n symptoms. He continues to deny any discomfort, is alert and oriented\n x3. Urinary output has been poor and the team is aware, he is being\n considered for diuresis as respiratory status has worsened this am.\n Plan:\n Team to discuss possible diuresis in the setting of increased O2\n requirements, poor output and h/o CHF with EF of 30%.\n Hypoxemia\n Assessment:\n Patient received on O2 via NC at 5l/min with sats in the lower 90\ns. O2\n requirement has gone up overnight and now he is on 50% with 2l/min\n supplemental O2.\n Action:\n O2 increased as mentioned above, ABG done and results are still\n pending.\n Response:\n Patient has been febrile overnight with persistent cough. He did\n receive Robitussin with some effect, last dose given at 0430 with\n little effect. He has been given morphine 1mg IV for respiratory\n distress.\n Plan:\n Continue to follow lab trends, monitor v/s and observed for increased\n respiratory distress.\n Wife present with patient all night he does appreciate the support.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 723993, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n \n - Added levo for atypical coverage\n - CT head: No acute intracranial abnormalities. Hypodensities in\n bilateral PCA and left MCA regions, compatible with chronic infarcts at\n these sites. Age-related parenchymal atrophy. Extensive paranasal sinus\n mucosal thickening.\n - CT chest - radiologists concerned new bl diffuse ground glass\n opacities and patchy consolidations concern for massive infection, ddx\n includes ARDS or massive hemorrhage\n - Flu swab positive for RSV per virology\n - Discussed w/ ID re: monoclonal abx, efficacy unproven in this setting\n also has high sorbitol load concerning given his renal failure.\n Continued abx regimen (levo/vanc/cefepime) and held off on monoclonoal\n abs\n - Spiked to 101, pan-cultured, remained on 5L w/ sats mid 90s so\n continued abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 09:10 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 120 (88 - 120) bpm\n BP: 101/57(74) {78/46(57) - 101/67(90)} mmHg\n RR: 35 (25 - 43) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 310 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 70 mL\n Blood products:\n Total out:\n 1,000 mL\n 150 mL\n Urine:\n 1,000 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n Patient tachypneic, tachycardic. Bl crackles appreciated on anterior\n breath sounds. Alert/oriented.\n Labs / Radiology\nCT Head:\n 1. No acute intracranial abnormalities. However, MRI would be more\n sensitive\n if there is concern for acute infarct.\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n 3. Age-related parenchymal atrophy.\n 4. Extensive paranasal sinus mucosal thickening.\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n 67 K/uL\n 9.0 g/dL\n 115 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 136 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n WBC\n 9.0\n Hct\n 25.8\n 27.8\n Plt\n 67\n Cr\n 1.3\n 1.2\n TropT\n 0.22\n 0.26\n Glucose\n 115\n 115\n Other labs: PT / PTT / INR:13.4/30.8/1.1, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:35.3 %, Lymph:5.1 %, Mono:3.9 %, Eos:55.6 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Pt w/ increased oxygen requirement\n overnight. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. Patient\n currently, on levo, cefepime, vanc, and vori to cover bacterial and\n fungal pna (recently has grown penicillium species in culture). Also,\n with elevated BNP element of CHF exacerbation w/ volume overload. PE\n also on the differential, though less likely given viral findings as\n above.\n - F/u final sputum, blood and urine cx\n - Cont cefepime/vanc/vori\n - Lasix 20mg iv x1, goal diuresis negative 1L\n - Repeat echo to eval for changing EF\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics, may require\n pressors if bp drops\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv x1\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724248, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Pt lungs with crackles in the bases and clear in upper lobes. RR 22-34\n labored at times. Pt having very frequent coughing and some productive\n cough with thick yellow sputum.\n Action:\n Received pt on 50% face tent and 2L N/C. during coughing spell\n increased face tent to 70% and 3 L N/C pt still only 88%. Increased to\n 100% face tent with 3L. sao2 increased when pt relaxed and stopped\n coughing. Decreased back to 70% and 2 L N/C pt is > 90% on this. Pt was\n diuresed yesterday but goal of 1L neg was not met. Pt 500cc neg at\n midnight. Pt had stated that the quiafenesin with codeine helped but\n upset his stomach. Tried 30mg of codeine without the guiafenesin which\n really was not effective. Pt given lasix 40 mg iv when sao2 dropped to\n 84 % and again face tent increased to 100%\n Response:\n Pt still coughs frequently and requires high o2.\n Plan:\n DNI/DNI. Titrate o2 as needed to keep sao2 >90%. Cont with antibiotics\n and lasix as needed. Plan is for a family meeting tomorrow to discuss\n treatment options and plan of care.\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724373, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724375, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724077, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien qhrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724078, "text": "Chief Complaint: sepsis/hypoxic resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, a-fib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n FEVER - 101.2\nF - 11:46 PM\n flu + for RSV\n chest imaging with diffuse progressive process b and rul abscess\n (known, smaller)\n increasing O2 requirements\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:20 AM\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 07:39 PM\n Cefipime - 07:42 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 09:33 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.7\nC (99.9\n HR: 122 (88 - 131) bpm\n BP: 99/62(71) {78/46(57) - 106/72(90)} mmHg\n RR: 40 (27 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 900 mL\n 563 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 540 mL\n 203 mL\n Blood products:\n Total out:\n 1,000 mL\n 350 mL\n Urine:\n 1,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n 213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/22/1\n PaO2 / FiO2: 68\n Physical Examination\n Alert, NAD, tachypneic\n Cardiovascular: tachy, rr\n Peripheral Vascular: 2+ pedal pulses\n Respiratory / Chest: (Breath Sounds: Crackles : ), tachypenic\n + BS, soft, NT\n Skin: warm, diaphoretic\n Labs / Radiology\n 9.1 g/dL\n 73 K/uL\n 89 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.0 %\n 10.2 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n WBC\n 9.0\n 10.2\n Hct\n 25.8\n 27.8\n 28.0\n Plt\n 67\n 73\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n Other labs: PT / PTT / INR:14.4/32.6/1.3, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:5.0 %, Mono:2.0 %,\n Eos:72.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: sputum with gpc/gnr\n Assessment and Plan\n 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) w/ hypoxic resp failure\n and sepsis\n # Sepsis: baseline BPs in the 80s-90s per family and Oncology team, now\n at baseline, still tachy and low-grade temps, so still meeting sespsis\n criteria. Also with low EF, but does not appear grossly overloaded on\n exam now.\n - continue judicious IVF prn hypotension\n - consider stim/ stress dose steroids if hypotension\n - f/up blood cultures, flu swab\n - induced sputum for gs/cx/fungal/PCP/AFB\n - check urine legionella\n Broad antbx\n # hypoxic resp failure\nPneumonitis. High suspcion this is viral from\n RSV, probable bacterial superinfection, does not appear to have\n significant component of volume overload with insensible losses and neg\n fluid balance. No evidence of hemorrhage and dfa neg for PCP. ? med\n related, etoposide.\n --diuresed gently with good UOP response.\n --cont broad antbx coveragere address utilityt of monoclonal ab\n treatment with ID team\n 2. Cavitary lung nodule: seen on prior imaging, s/p FOB with BAL and\n biopsy, now growing, AFB, non-MTB, and penicillium species but final\n probe pending.\n - continue voriconazole, appears slightly smaller on repeat CT\n 3. Hypereosinophilic syndrome:\n continue prednisone and bactrim and valgancyclovir prophylaxis\n 4. CHF: BNP high on admission, trop up but CK nl consistent with\n strain. EKG unchanged.\n -careful fluid management and repeat bnp\n -repeat TTE\n -If requires pressors, levophed or dobutamine/neo to help with cardiac\n output\n # tachycardia\n Likely driven by resp distress/failure\n f/u TTE\n # ARF: Cr up to 1.8 on admit, improving with IVF\n - monitor UOP and urine lytes\n 7. Cultures + for RSV\n will consult ID about therapeutic options. CT\n does reveal very extensive infiltrates with diffuse pattern.\n Remainder of plan per resident note.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724080, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien q4hrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724145, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: .\n Microbiology: .\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724150, "text": "Chief Complaint: hypoxemia, RSV\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n - TTE: Compared with the prior study LV cavity is slightly smaller and\n the severity of mitral regurgitation and pulmonary artery systolic\n pressure are slightly reduced. Regional left ventricular systolic\n function is similar (30%).\n - Repeating BNP to see if changed\n - Gave a second shot of lasix 40mg IV ONCE at 1830\n - ID recommended giving anti-RSV antibody\n - DC'd valgan and levoflox per ID recs\n - Explained the risks of ab to wife and pt who decided to think about\n it. They had questions about the procedure they wanted to talk to Dr.\n about. They also wanted to know if the insurance company\n would pay for it since it costs 15,000 dollars.\n - Drug check: Neither valcyte or voriconazole cause pneumonitis\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Bactrim (SMX/TMP) - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:05 AM\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 108 (94 - 131) bpm\n BP: 91/64(70) {78/40(50) - 106/72(79)} mmHg\n RR: 25 (23 - 44) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 74 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 74 mL\n Blood products:\n Total out:\n 1,350 mL\n 325 mL\n Urine:\n 1,350 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.50/31/68/21/1\n PaO2 / FiO2: 68\n [image002.gif]\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image004.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, Differential-Neuts:21.0 %,\n Band:0.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:78.0 %, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n BNP\n [1] 04:28AM\n *\n [2] 12:10PM\n *\n Imaging:\n ECHO\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. Left ventricular wall thicknesses and cavity size are normal.\n There is mild regional left ventricular systolic dysfunction with basal\n inferior mild dyskinesis and more distal akinesis as well as akinesis\n of the distal lateral wall. There is mild hypokinesis of the remaining\n segments (LVEF = 30%). No masses or thrombi are seen in the left\n ventricle. The diameters of aorta at the sinus, ascending and arch\n levels are normal. The aortic valve leaflets (3) are mildly thickened\n but aortic stenosis is not present. No aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. The posterior leaflet\n is relatively fixed/immobile. Moderate (2+) mitral regurgitation is\n seen. The tricuspid valve leaflets are mildly thickened. There is mild\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity is slightly smaller and the severity of mitral\n regurgitation and pulmonary artery systolic pressure are slightly\n reduced. Regional left ventricular systolic function is similar.\n Microbiology:\n 11:27 am SPUTUM Source: Induced.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTER\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\nRESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora.\nNEGATIVE for Pneumocystis jirovecii (carinii)..\nACID FAST SMEAR (Final ): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEA\n ACID FAST and fungal cultures pending\n No growth in urine or blood\n Legionella negative\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worsening and progressive hypoxemia and\n respiratory failure and diffuse infectious infiltrates. He is with\n known eosinophilic syndrome, immunosuppressed on chemotherapy. Resp\n viral screen positive for RSV, sputum has preliminarily grown GPC, GPR,\n and GNR, and urine leg neg. DFA negative for PCP. currently,\n on levo, cefepime, vanc, and vori to cover bacterial and fungal pna\n (recently has grown penicillium species in culture). Also, with\n elevated BNP element of CHF exacerbation w/ volume overload. PE also\n on the differential, though less likely given viral findings as above.\n Primary problem is sepsis from pulmonary infection likely RSV with\n possible bacterial superinfection, do not suspect cardiogenic shock.\n - Resend sputum\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori/levofloxacin\n - Lasix 40 iv x1, goal diuresis negative 1L\n - Consider further diuresis if pt improves after diuresis\n - Repeat echo to eval for changing EF\n - Consider IV antibody paviluzameb as last resort effort\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous,\n - Appreciate hem/onc input\n - Place picc line for better access/iv abx\n 2. Hypotension: Baseline in mid 80s, currently sbp in low 100s. Will\n continue to follow given concern for SIRS/CHF. Cortisol wnl.\n - While diuresing neg 1L will need to monitor hemodynamics\n - Consider pressors if develops worse hypotension and would avoid more\n fluids\n - Consider placing central line or evaluating w/ US to obtain CVP if\n hypotension worsens\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Resolved with IVFs.\n - Monitor creatinine\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - f/u ECHO\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach. Likely secondary to sepsis.\n - Monitor\n - If becomes hypotensive and in a fib in RVR would consider rate\n control as opposed to ianotropy to maintain BP\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Patient and patient\ns wife\n status: DNR/DNI\n Disposition: ICU\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n" }, { "category": "Nursing", "chartdate": "2197-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724134, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n Received pt on 100% face tent and 2 L NC with Sp02 89-92%. Lungs clear\n in upper fields with some crackles at bases. Pt has strong productive\n cough producing yellow tinged thick sputum. Tachypneic in the 30\ns with\n shallow breathing. Afebrile. SBP low 80\ns to low 90\ns, which is\n baseline. ST 90\ns to low 100\ns with PVC\ns and will rise to 120\ns during\n coughing spells. Pt diuresed yesterday\ncondom cath collecting 30-50\n cc/hr of amber urine.\n Action:\n Placed pt on 4 L briefly this AM as pt had prolonged coughing attack\n and unable to bring Sp02 above 80%...guiafenesin PRN for coughs. IV\n abx.\n Response:\n Pt back on 2 L NC with the 100% face tent\nslept most of night except\n one coughing spell in the AM\n Plan:\n Pt DNR/DNI\nneeds CMV viral load\nIV abx\nSBP ok in mid 80\ns as it is pt\n baseline\nkeep Sp02 high 80\n" }, { "category": "Physician ", "chartdate": "2197-03-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724231, "text": "Chief Complaint:sepsis, hypoxemia, resp distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n Diuresed\n pt and family declined pavilizumab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Vancomycin - 09:00 PM\n Cefipime - 08:00 AM\n Bactrim (SMX/TMP) - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:41 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.1\nC (96.9\n HR: 106 (94 - 108) bpm\n BP: 89/58(66) {78/40(50) - 94/72(77)} mmHg\n RR: 29 (23 - 30) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 1,170 mL\n 165 mL\n PO:\n 580 mL\n TF:\n IVF:\n 590 mL\n 165 mL\n Blood products:\n Total out:\n 1,350 mL\n 475 mL\n Urine:\n 1,350 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -310 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n More comfortable appearing, alert\n Rales bl\n RR, tachy\n + BS, soft, NT\n No edema\n Labs / Radiology\n 8.9 g/dL\n 80 K/uL\n 93 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 94 mEq/L\n 129 mEq/L\n 27.6 %\n 8.5 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n WBC\n 9.0\n 10.2\n 8.5\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n Plt\n 67\n 73\n 80\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n Other labs: PT / PTT / INR:16.3/40.1/1.4, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: BNP 16K\n Microbiology: --induced sputum mod resp florse growth, gpc on gs, 2+\n gpr, 1+ gnr\n bl/urine ngtd\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains hypoxic, but subjectively more\n comfortable and requiring less supplemental O2. Suspect pneumonitis\n from RSV is primary issue, with possibly bacterial superinfection, and\n component of volume overload (cardiogenic and noncardiogenic)\n --supportive care with cough suppression, nebs, consider NPPV if\n fatigues\n --diuresis (goal 1L neg)\n - continue broad empiric antbx to compelte course\n #hypotension\nInitially met Sirs/sepsis criteria. BP now improved from\n admit and at baseline\n #CHF\ndiurese, holidng ace-I given cr elevation\n # tachycardia\n Likely driven by resp distress/failure\n Continues to improve\n # ARF: cr up, likely from poor forward flow, may improve with diuresis\n - Will monitor UOP and trend\n - resume ace-when cr improves\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n defer further treatment to onc pending clinical improvement from acute\n resp issues\n Remainder of plan per resident note.\n ICU Care\n Nutrition: would consult nutrition, encourage POs, ensure\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis: , picc placement\n DVT: Boots, sq hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated and all questions answered.\n Arrnaging for additional meeting with onc at family request.\n Code status: DNR / DNI\n Disposition :ICU for now, improving and probable floor transfer\n tomorrow\n Total time spent: during rounds, clinical discussion and family\n meeting: 80 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724061, "text": "Hypoxemia\n Assessment:\n On 50%CN and 6L NC. RR 40s. O2sats high 80s. Pt looking very\n uncomfortable using accessory muscles. T99.9ax. Coughing and desatting.\n Action:\n 3mg IV morphine given(total of 4mg), 650mg Tylenol 10ml guaffenisen\n (increased to q4hrs), 20mg IV Lasix given without effect then 40mg\n given. CN increased to 100% On 70% PaO2 was 68.\n Response:\n Diuresed 550cc urine. Temp down. O2sats improved and pt subjectively\n feeling better. RR 30s. CN changed to face tent. BP 80s-90s after\n diuresis with MAP>50.\n Plan:\n Wean FiO2 as tol. Cont guaffenien qhrs. Cont Tylenol. Lasix and\n morphine for acute resp distress.\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724353, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM for worsening hypoxia and\n increased O2 requirement\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724357, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM for worsening hypoxia and\n increased O2 requirement\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n #. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for double gram negative\n coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n #. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n #. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n #. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be net even\n - Hold ace-i\n #. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n #. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n #. afib-stable\n #. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Physical Exam:\n Pulm: + exp wheezes and anterior crackles; CV: tachy, No JVD; Abdom:\n Soft NT/ND; Neuro: Alert, oriented follows commands\n ------ Protected Section Addendum Entered By: , MD\n on: 12:56 ------\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724363, "text": "Chief Complaint: sepsis, resp distress/hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n more hypoxic overnight with increased FIO2 requirement\n weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Alert, flat affect, NAD\n Rales with scant exp wheeze\n RR\n + BS, NT, soft\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, possibly bacterial\n superinfection,\n He is hypoxic, requiring more FIO2 despite diuresis. CXR appears\n unchanged with diffuse ASD/no effusions. At this time feel cardiogenic\n pulm edema is unlikely to be contibuting.\n --Continue supportive care with cough suppression, nebs\n --consider NPPV if fatigues\n --will hold on additional diuresis, ? component of preload dependence\n with decline related to volume depletion\n --continue broad empiric antbx to compelte 14 day course\n --I suspect a new superinfection is unlikely, however, given\n immunosuppression and now mild leukocytosis -- will repeat nosocomial\n infection workup and add empiric double GNR coverage\n #CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure\n Remainder of plan per resident note.\n ICU Care\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724348, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Worse today, likely primarily secondary\n to progressive infection (RSV). CHF exacerbation another cocontributor\n but less likely. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection. Resp viral screen\n positive for RSV, sputum has preliminarily grown GPC, GPR, and GNR, and\n urine leg neg. DFA negative for PCP. currently, cefepime,\n vanc, and vori to cover bacterial and fungal pna (recently has grown\n penicillium species in culture). He has refused monoclonal antibody.\n Cont to consider PE, though less likely. Pt is probably intravascularly\n dry now.\n - CXR\n - Repeat sputum\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Consider adding a second antibiotic for gram negative coverage\n - Hold on Lasix, with goal of even fluids\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - Pan culture with stool, blood, urine, and sputum\n - CXR today, f/u final report\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n - Continue to hold home BP meds,\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - hold diuresis as pt likely volume deplete to goal even\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Consider mertazapine for mood and poor appetite\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724349, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n hypoxic overnight and placed on 100%--> weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n Active issues include:\n # Hypoxic resp failure\nremains hypoxic, requiring more FIO2 dspite\n diuresis. CXR appears unchanged with diffuse ASD. Suspect pneumonitis\n from RSV is primary issue, with possibly bacterial superinfection, at\n this time feel cardiogenic edema is less liekyl to be contibuting.\n --supportive care with cough suppression, nebs, consider NPPV if\n fatigues\n --will hold on diuresis\n --continue broad empiric antbx to compelte 14 day course, and would\n repeat nosocomial infection workup and add double GNR coverage\n there may be compnent of pre-load dependece with ome worsenign rrelated\n to volume shifts.\n #CHF\ndiurese, holidng ace-I given cr elevation--at this time does not\n apepar volume overloaded, neck are flat and xr without eveidence\n of pulm edema, labs suggest overdiuresis\n will hold on diurses at thsintime\n # tachycardia\n Likely driven by resp distress/failure now diuresis\n will follow\n # ARF: cr increaing, suspect this is from diuresis and poor. will hold\n lasix and monitorup, likely from poor forward flow, may improve with\n diuresis\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n continue prednisone and bactrim prophylaxis\n defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression\n #nuturional issues\n #goladsof care\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 724426, "text": "Chief Complaint: sepsis, resp distress/hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA,\n a-fib, CHF (EF 30% 8/09), syndrome with recent admission for\n cavitating lesion of lung, FOB/BAL(now growing AFB, non-MTB, and\n penicillium species but final probe pending) admitted w/ sepsis (fever,\n hypotension, hypoxia) and progressive bl ASD.\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n diuresed with lasix\n more hypoxic overnight with increased FIO2 requirement\n weaning slowly\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Voriconazole - 08:00 AM\n Cefipime - 08:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:11 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Omeprazole (Prilosec) - 08:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 99 (91 - 120) bpm\n BP: 85/58(64) {70/48(53) - 99/85(88)} mmHg\n RR: 21 (18 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 407 mL\n PO:\n 250 mL\n 240 mL\n TF:\n IVF:\n 540 mL\n 167 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n Alert, flat affect, NAD\n Rales with scant exp wheeze\n RR\n + BS, NT, soft\n Labs / Radiology\n 9.0 g/dL\n 90 K/uL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:10.0 %, Band:0.0 %, Lymph:2.0 %, Mono:1.0 %,\n Eos:87.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Imaging: cxr with diffuse bl asd, no effusions, unchanged\n Microbiology: cmv pending\n urine cx\n Assessment and Plan\n # Hypoxic resp failure\n Pneumonitis from RSV, possibly bacterial\n superinfection,\n He is hypoxic, requiring more FIO2 despite diuresis. CXR appears\n unchanged with diffuse ASD/no effusions. At this time feel cardiogenic\n pulm edema is unlikely to be contibuting.\n --Continue supportive care with cough suppression, nebs\n --consider NPPV if fatigues\n --will hold on additional diuresis, ? component of preload dependence\n with decline related to volume depletion\n --continue broad empiric antbx to compelte 14 day course\n --I suspect a new superinfection is unlikely, however, given\n immunosuppression and now mild leukocytosis -- will repeat nosocomial\n infection workup and add empiric double GNR coverage\n #CHF\nBNP elevated and initial concern for cardiogenic edema. He has\n been diuresed and at this time does not appear volume overloaded, neck\n veins are flat, cxr w/o evidence of pulm edema/effusion, labs s/o\n overdiuresis and his PO intake is minimal\n --will hold on additional lasix at this time\n # ARF: BUN and cr increasing, suspect from diuresis,\n will hold lasix, monitor UOP, check urine sediment and renally dose\n meds\n # Cavitary lung nodule: s/p FOB with BAL and biopsy, now growing, AFB,\n ----non-MTB, and penicillium species, final probe pending.\n --continue voriconazole\n # Hypereosinophilic syndrome:\n -continue prednisone and bactrim prophylaxis\n -defer further treatment to onc pending clinical improvement from acute\n resp issues\n # depression and goals of care\nSW following, will initiate joint\n meeting with onc team to assess pt desired goals, consider starting\n mirtazapine\n #nutritonal status\nPoor PO intake, nutrition input, ensure\n Remainder of plan per resident note.\n ICU Care\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: family updated at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n ------ Protected Section ------\n Addendum\n I met with Mrs. , along with pt\ns oncologist, pulmonary fellow\n , social worker and pt\ns nurse. Updated\n to pt\ns current status and answered all questions. We discussed goals\n of care, options of consulting palliative care to assist, concerns\n about pt\ns mood/ depression and nutritional status/ poor PO intake. We\n will also address these concerns directly with pt. At this time we\n continue with current level of aggressive care. We will ask for a\n formal swallow evaluation and nutrition consult.\n Crit care time spent in discussion and family mtg: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:27 PM ------\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 724620, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillin species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=127 and\n creat this am =3.0 with bun=66. most likely overdiuresed in the last\n couple of days. Cxr unchanged and without evidence of pulm\n edema/effusions. Pt currently receiving cefepime,vancomycin and\n voriconazole to cover bacterial and fungal pna( recently has grown\n penicillin species in cx). Pt n no apparent resp distress. Pt with\n poor appetite and c/o difficulty swallowing. Sbp ranging 70-90\ns but no\n interventions ordered by medical icu team. Vancomycin level=35.7 early\n this am pt stated\n shut off the movie- how old is that movie\n. Pt\n delirious and slightly agitated. Dr. called to bedside.\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 4lm nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt boluses\n with 250cc ns and started on ns infusion at 50cc\ns/hr. speech and\n swallow study done at bedside. Pt\ns oncologist approached the pt at\n bedside and he said to her\nm ready\n . with delirium pt medicated\n with 0.5 mg ivp morphine and then with 2 mg ivp haldol\n Response:\n Resp status stable in last 24 hrs . still requiring high amts of 02 but\n now with o2 sats of 96% on 50 face tent and 4l/m nc. Pt more alert\n since receiving haldol and more lucid. Based on speech and swallow\n study pt\ns diet has been changed to nectar thickened liqs and pureed\n diet.\n Plan:\n Continue to follow resp status closely. hold on further diuresis at\n present time. Wean o2 as tolerated to maintain o2 sats> 90%. When\n asked by oncologist wetehr pt would like to go home for his last days\n or sty in the hospital pt stated he would rather remain in the\n hospital. Pt\ns wife was at the bedside and witnessed the conversation\n and is understandably upset. Dr spoke with pt and his wife\n and pt now made cmo. All meds d/c\nd except for prn morphine for\n pain and ativan for anxiety. O2 dace tent mask d/c\nd per request of pt\n and his wife and he remains on 4l/m nc. Will continue with comfort care\n measures and offer emotional support to pt\ns wife and children\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n HYPOXIA; CHF\n Code status:\n DNR / DNI\n Height:\n 67 Inch\n Admission weight:\n 63.7 kg\n Daily weight:\n 61.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, CHF\n Additional history: hx of hypereosinophilic syndrome dx'd ' after\n presenting with transient ischemic episode and bil dvt,cardiomyupathy\n on chemo. dvt 3 yrs ago, multiple cva's(last in ), old\n parietal-occipital and left parietal infarcts,afib, \n syndrome( endomyocardial fibrosis with embolic phenomenon, chf\n secondary t o eosinophilic myocarditis, ef= 30% on tte and hx of\n cavitating lesion to lung.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:78\n D:52\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 91% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 929 mL\n 24h total out:\n 200 mL\n Pertinent Lab Results:\n Sodium:\n 127 mEq/L\n 05:45 AM\n Potassium:\n 4.4 mEq/L\n 05:45 AM\n Chloride:\n 93 mEq/L\n 05:45 AM\n CO2:\n 22 mEq/L\n 05:45 AM\n BUN:\n 62 mg/dL\n 05:45 AM\n Creatinine:\n 2.0 mg/dL\n 05:45 AM\n Glucose:\n 93 mg/dL\n 05:45 AM\n Hematocrit:\n 25.0 %\n 05:45 AM\n Finger Stick Glucose:\n 124\n 06:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 408\n Transferred to: 1183\n Date & time of Transfer: 1830\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724329, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Improving with diuresis and antibiotics for superimposed\n infection. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724335, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - Overnight received 40mg iv lasix at 0200AM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n SPUTUM ()\nGRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n MODERATE GROWTH Commensal Respiratory Flora.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\nECHO:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is mild regional\nleft ventricular systolic dysfunction with basal inferior mild dyskinesis and mo\nre distal akinesis as well as akinesis of the distal lateral wall. There is mild\n hypokinesis of the remaining segments (LVEF = 30%). No masses or thrombi are se\nen in the left ventricle. The diameters of aorta at the sinus, ascending and arc\nh levels are normal. The aortic valve leaflets (3) are mildly thickened but aort\nic stenosis is not present. No aortic regurgitation is seen. The mitral valve le\naflets are mildly thickened. The posterior leaflet is relatively fixed/immobile.\n Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mi\nldly thickened. There is mild pulmonary artery systolic hypertension. Significan\nt pulmonic regurgitation is seen. There is no pericardial effusion.\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Continues to require supplemental oxygen despite\n diuresis and antibiotics for superimposed infection, though clinically\n he states some improvement in his shortness of breath. New leukocytosis\n today. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely.\n - CXR\n - F/u sputum, blood, CMV and urine cx\n - Cont cefepime/vanc ( for 14 day course) and vori (for fungal\n infx)\n - Lasix as needed to keep goal -500cc out, judiciously as pt\n hypotensive/elevated Cr\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n # Leukocytosis: Elevated WBC count today, though patient has been\n afebrile. UA notable for pyuria/bacturia, currently on vanc/cefepime.\n - CXR today\n - Follow up urine cx and stool cx r/o c diff\n - Change condom cath\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n - cont prednisone\n 4. ARF-baseline 1-1.4: Elevated Cr to 1.8 s/p diuresis. Evidence of\n granular casts/cellular casts and possible UTI. No flank pain and\n afebrile to suggest pyelo.\n - Monitor creatinine\n - Judicious diuresis, goal will be -500cc\n - Hold ace-i\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. On admission,\n patient w/ some evidence of volume overload now s/p diuresis with some\n improvement in shortness of breath, though CXR continues to show\n diffuse infiltrates and patient remains with oxygen requirement. Have\n contact outpatient cardiologist who agrees w/ diuresis and holding\n anti-hypertensives for now.\n - strict Is and Os, daily weights\n - Continue holding ace-i/bb given low bps as well as ARF for ace-i\n - goal -500cc out\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Secondary to hypoxia, infx.\n - Monitor\n # Mood/Nutrition: Poor po intake worse since admission. Per wife,\n concerned that patient is giving up, and is frustrated.\n - Add ensure tid w/ meals\n - Nutrition consult\n - ? SSRI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: HSC\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724410, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, FOB/BAL(now growing, AFB, non-MTB, and\n penicillium species but final probe pending) now admitted from ED with\n RSV, fever 101.6, hypotension, hypoxia and generalized weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. Pt hypoxic requiring more o2. presently on 70% face\n mask with 6l/m nc. When pt removes his o2 to take pills or to eat, o2\n sats drop as low as 83%. Lungs with bibasilar crackles. Na=130 and\n creat this am =1.8. most likely overdiuresed in the last couple of\n days. Cxr unchanged and without evidence of pulm edema/effusions. Pt\n currently receiving cefepime,vancomycin and voriconazole to cover\n bacterial and fungal pna( recently has grown penicillin species in\n cx). Pt n no apparent resp distress. Pt with poor appetite and c/o\n difficulty swallowing. Sbp ranging 70-90\ns but no interventions ordered\n by medical icu team\n Action:\n Antibiotics administered as ordered. Resp status monitored closely.\n Face mask o2 decreased to 50% plus 6l m nc.sats followed closely. No\n further diuretics ordered for now. Pt medicated with tessilon pearls\n for dry and nonproductive cough. Nutrition consult placed. Pt drinking\n ensure..\n Response:\n Resp status worse compared to last 24 hrs. still requiring high amts of\n 02 but now with o2 sats of 96% on 50% cool neb mask and 6l/m nc.o2 now\n decreased to 50%cool neb mask and 4l/m nc\n Plan:\n Continue to follow resp status closely. Will send off repeat sputum\n for gm stain /c&s when able. hold on further diuresis at present\n time. Wean o2 as tolerated to maintain o2 sats> 90%. Dr. and\n oncologist spoke with pt\ns wife and pt remain dnr/dni. We will\n continue to treat but there will be no escalation of care. Pt to\n have bedside speech and swallow study tomorrow.\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724295, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2197-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 724297, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:00 PM\n - I/O - 535 + large amount inc from condom cath\n - PICC placed\n - c/o vision changes. may be codeine, monitoring for now\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Valgancyclovir - 08:20 AM\n Levofloxacin - 09:38 AM\n Voriconazole - 07:38 PM\n Bactrim (SMX/TMP) - 08:00 AM\n Vancomycin - 07:30 PM\n Cefipime - 07:31 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Furosemide (Lasix) - 02:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 120) bpm\n BP: 75/52(57) {75/52(57) - 99/85(88)} mmHg\n RR: 18 (18 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.7 kg (admission): 63.7 kg\n Total In:\n 790 mL\n 68 mL\n PO:\n 250 mL\n TF:\n IVF:\n 540 mL\n 68 mL\n Blood products:\n Total out:\n 1,325 mL\n 100 mL\n Urine:\n 1,325 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -535 mL\n -32 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 90 K/uL\n 9.0 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 51 mg/dL\n 94 mEq/L\n 130 mEq/L\n 26.9 %\n 11.1 K/uL\n [image002.jpg]\n 09:50 PM\n 05:32 AM\n 04:28 PM\n 04:28 AM\n 07:41 AM\n 03:14 AM\n 11:01 PM\n 04:01 AM\n WBC\n 9.0\n 10.2\n 8.5\n 11.1\n Hct\n 25.8\n 27.8\n 28.0\n 27.6\n 26.9\n Plt\n 67\n 73\n 80\n 90\n Cr\n 1.3\n 1.2\n 1.2\n 1.6\n 1.6\n 1.8\n TropT\n 0.22\n 0.26\n TCO2\n 25\n Glucose\n 115\n 115\n 89\n 93\n 106\n 98\n Other labs: PT / PTT / INR:18.4/45.5/1.7, CK / CKMB /\n Troponin-T:48/7/0.26, ALT / AST:18/41, Alk Phos / T Bili:103/0.5,\n Differential-Neuts:21.0 %, Band:0.0 %, Lymph:1.0 %, Mono:0.0 %,\n Eos:78.0 %, Lactic Acid:1.1 mmol/L, Albumin:3.6 g/dL, LDH:645 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOXEMIA\n ALKALOSIS, RESPIRATORY\n PNEUMONIA, VIRAL\n RSV\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n LEUKEMIA, ACUTE (ALL, AML, CANCER, MALIGNANT NEOPLASM)\n Hypereosinophilia\n ATRIAL FIBRILLATION (AFIB)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo\n (etoposide), DVT, CVA, afib, CHF EF (EF 30%), who presents with fever,\n cough, hypoxia and hypotension.\n 1. Hypoxic Respiratory Failure: Secondary to infection (RSV) and CHF\n exacerbation. Improving with diuresis and antibiotics for superimposed\n infection. He is with known eosinophilic syndrome, immunosuppressed on\n chemotherapy. Resp viral screen positive for RSV, sputum has\n preliminarily grown GPC, GPR, and GNR, and urine leg neg. DFA negative\n for PCP. currently, cefepime, vanc, and vori to cover bacterial\n and fungal pna (recently has grown penicillium species in culture). He\n has refused monoclonal antibody. Cont to consider PE, though less\n likely\n - F/u sputum, blood and urine cx\n - Cont cefepime/vanc/vori, levo has been d/c\nd as we are less concerned\n for atypical superinfection\n - Lasix 40 iv x1, goal diuresis negative 500cc-1L\n - Patient has refused IV antibody paviluzameb\n - Incentive spirometry, guiafenesin, tesslon pearls to clear mucous\n - Appreciate hem/onc input\n 2. Hypotension: Baseline in mid 80s\n - Cont to monitor hemodynamics, blood pressures appear to be stable and\n at his baseline.\n 3. hypereosinophilic syndrome- Currently tx with etoposide Q2 weeks.\n - f/u heme/onc recs\n 4. ARF-baseline 1-1.4: Elevated Cr, can be secondary to poor forward\n flow.\n - Monitor creatinine\n - Cont diuresis\n 5. CHF-EF 30%. Secondary to eosinophilic syndrome. Currently with\n elevated trop and BNP. Likely contributing to current respiratory\n failure with element of volume overload. Dry weight is 140 lbs. Has r/o\n for MI w/ three stable CE.\n - strict Is and Os, daily weights\n - Lasix iv per above\n 6. Blood per rectum-seen on toilet paper while on commode. Hct stable\n - guaiac stools\n - active T+S\n - Monitor HCTS.\n 7. s/p CVA-CT head negative for ischemic/hemorrhagic event.\n 8. afib-stable\n 9. Tachycardia: Sinus tach, stable. Can be secondary to hypoxia vs\n infx.\n - Monitor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2197-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 724485, "text": "60M h/o hypereosinophilic syndrome tx with etoposide, h/o CVA, afib,\n CHF (EF 30% 8/09), syndrome with recent admission\n for cavitating lesion of lung, S/P bronch , now growing AFB,\n non-MTB, and penicillium species (but final probe pending) admitted\n from ED with RSV, fever 101.6, hypotension, hypoxia and generalized\n weakness\n Hypoxemia\n Assessment:\n hypoxic resp failure\npneumonitis from rsv, and possibly bacterial\n superinfection. presently on 50% cool neb with 4lit NC . When off\n O2, O2 sats drop to 86-88%. Lungs with crackles/ diminished base on\n antibiotics cefepime ,vancomycin and voriconazole to cover bacterial\n and fungal pna, recently has grown penicillin species in cx. Pt looks\n comfortable without any resp distress. Pt with poor appetite SBP\n 70-90\ns but no interventions ordered by medical icu team as his\n basaline SBP 80\ns. having productive cough , using yankeur suction,pt\n with renal impairement, condom cath in place, low urine output.\n Action:\n Continued with broadspectrum Antibiotics . Resp status monitored\n closely. Continued with cool neb 50% and NC 4lit/min .sats 88-92%\n . No further diuretics during the shift . Nutrition consult placed.\n wife stayed with him overnight. Codeine 30mg q4h for cough, given when\n he is awake. Slept with trazadone. Pills crushed and given with apple\n sauce. Swallowed well without any difficulty. Per report he was choking\n on jello. For swallow eval today.\n Response:\n Condition remained unchanged during the shift . continued with same O2,\n slept well without any difficulty,denies any pain. Sats maintained\n 88-90\ns and SBP lowest with mid 70\n Plan:\n Continue to follow resp status closely. Wean o2 as tolerated to\n maintain o2 sats> 90%. Icu team and oncologist spoke with pt\ns wife\n and pt remain DNR/DNI . will continue to treat but there will\n be no escalation of care. Pt to have bedside speech and swallow\n study today.\n Blood c/s and urine c/s sent\n" }, { "category": "Social Work", "chartdate": "2197-03-13 00:00:00.000", "description": "Social Work Admission Note", "row_id": 724951, "text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record\n Family Spokesperson designated: Same ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: This admission at is\n the patient's fifth.\n Past psychiatric history: Unknown.\n Past addictions history: Unknown.\n Employment status: Disable\n Legal involvement: Unknown.\n Mandated Reporting Information:\n Additional Information:\n Patient/Family HX: Dr. admitted this 60 y/o MWM with\n hypereosinophilic syndrome to with hypoxia and CHF. SW met with pt\n and his wife who talked about their hoping to again walk on the beach,\n but then laughed when they eventually discovered that they do not like\n the sand, water, sun, or noise but being able to walk hand-in-hand. Mr.\n talked about feeling that he \"was dead.\" This writer asked if\n he sometimes felt dead or wondered about dying given his medical\n condition, which he said that he did. Shortly afterwards, the pt said\n that he was tired.\n Afterwards, this worker spoke with his wife about the conversation re\n his dying. She said that after this writer left, he asked if she felt\n better having talked about death. Ms. said that it is\n difficult for her to raise such emotional issues and is appreciative of\n others broaching the topic.\n Assessment: The couple seems to struggle with hopeful talk about the\n future, e.g., walking hand-in-hand, while appearing to try and cope\n with what they see as EOL issues. Ms. seems to be experiencing\n a great deal of stress; it is not clear at this time as to how she\n copes and what supports she has, which this worker will explore in a\n future meeting.\n Plan / Follow up:\n 1. SW will continue to meet with the s to assess their\n coping and to offer support.\n , PhD, LICSW\n PAGE \n" }, { "category": "ECG", "chartdate": "2197-03-05 00:00:00.000", "description": "Report", "row_id": 179927, "text": "Sinus tachycardia. Leftward axis. Non-specific anterior ST-T wave\nchanges. Compared to the previous tracing of no diagnostic\ninterim change.\n\n" }, { "category": "Nursing", "chartdate": "2197-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 723703, "text": "Pt is a 60 yo amle with nkda. Pnh significant for hypereosinphilic\n syndrome dx\n03 after presenting with transient ischemic episode and\n bil dvt,cardiomyopathy on chemo. Dvt 3 yrs ago, multiple cva\ns ( last\n in ), old right parietal-occipital and left parietal infarcts,\n afib, \ns syndrome(endomyocardial fibreosis with embolic\n phenomenon,chf secondary to eosinophilic myocarditis, ef= 30% on tte,\n cavitating lesion to left upper lobe. Presented to ed today with c/o\n generalized weakness. In ed o2 sats noted to be 86% on room air. Pt\n placed on 2l/m nc with o2 sat =94%. Goal for o2 sats are > 90%. Lungs\n sounds rhoncehrous but with crackles bil on auscultation. Sbp on admit\n to ed was 92. pt was given 500cc\ns ivf but was stopped because of ef of\n 30%. According to pt\n md pt\ns abseline sbp is 85-90. pt\n and c&r thick yellow sputum. Medicated with vancomycin and\n piperacillin . transferred to for further monitoring. Pt is a\n full code.\n" }, { "category": "Radiology", "chartdate": "2197-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121986, "text": " 11:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for volume overload, worsening infiltrates, and\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with h/o of eosinophilic syndrome CHF and + RSV, with new\n leukocytosis\n REASON FOR THIS EXAMINATION:\n please eval for volume overload, worsening infiltrates, and developing\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with history of eosinophilic syndrome, CHF, and\n positive RSV with new leukocytosis. Evaluate for volume overload or worsening\n pneumonia.\n\n COMPARISON: Portable chest radiograph, .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: Left PICC tip appears to loop upon itself within the region of the\n upper SVC or may be entering the azygous vein and should be pulled back 2cm to\n straighten the line. Cardiomegaly is stable. Unchanged diffuse bilateral\n pulmonary opacifications likely represent severe pneumonia; however, a\n component of pulmonary edema and ARDS cannot be excluded. Low lung volumes\n persist. There is no pneumothorax. Right upper lobe cavitary mass is\n unchanged since and improved since .\n\n IMPRESSION:\n 1. Left PICC tip appears to loop upon itself within the region of the upper\n SVC or may be entering the azygous vein and should be pulled back 2cm to\n straighten the line.\n 2. Persistent bilateral pulmonary opacifications likely represent severe\n pneumonia; however, a component of pulmonary edema and ARDS cannot be\n excluded.\n Dr. was notified of the results at 13:58 on .\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1121523, "text": " 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with weakness, eosinophilic syndrome, fever, h.o CVA in the\n past, now ?AMS\n REASON FOR THIS EXAMINATION:\n Pleaase eval for mass vs. infarct\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 12:30 PM\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n\n 4. Extensive paranasal sinus mucosal thickening.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old man with weakness, eosinophilic syndrome, fever and CVA\n in the past, now with altered mental status.\n\n CT HEAD: Axial imaging was performed through the brain without IV contrast\n administration.\n\n COMPARISON: CT head , MRI brain, .\n\n FINDINGS: Hypodensities and bilateral PCA territories have evolved compared\n to the earlier CT examination, compatible with chronic evolved infarcts. There\n is no hemorrhage, edema, mass effect, or evidence for acute vascular\n territorial infarction. There is no shift of normally midline structures.\n There is prominence of the ventricles and sulci, compatible with age-related\n parenchymal involution. There is mucosal thickening of bilateral sphenoid\n sinuses, ethmoid sinuses, and bilateral maxillary sinuses. The frontal\n sinuses appear well pneumatized. The right mastoid air cells are not well\n pneumatized and there is slight mucosal thickening within the left mastoid air\n cells.\n\n IMPRESSION:\n\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n (Over)\n\n 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. Extensive paranasal sinus mucosal thickening.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1121524, "text": ", F. OMED 11:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pleaase eval for mass vs. infarct\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with weakness, eosinophilic syndrome, fever, h.o CVA in the\n past, now ?AMS\n REASON FOR THIS EXAMINATION:\n Pleaase eval for mass vs. infarct\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PFI REPORT\n 1. No acute intracranial abnormalities. However, MRI would be more sensitive\n if there is concern for acute infarct.\n\n 2. Hypodensities in bilateral PCA and left MCA regions, compatible with\n chronic infarcts at these sites.\n\n 3. Age-related parenchymal atrophy.\n\n 4. Extensive paranasal sinus mucosal thickening.\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1121525, "text": " 11:27 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for change in size of mass\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide),\n DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be\n \"hypoxic\" and \"hypotensive\" in the ED.\n REASON FOR THIS EXAMINATION:\n Please eval for change in size of mass\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: SBNa MON 12:14 PM\n Right upper lobe cavitary lesion not sign changed in overall size, but more\n internal cavitation. Interval development of widespread, diffuse ground glass\n opacities and patchy consolidation concerning for infection, hemorrhage, ARDS.\n This is less likely edema. +Splenomegaly. No effusions or lymphadenopathy.\n dw at 12:15 pm via telephone.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, :\n\n HISTORY: Eosinophilic syndrome, DVT and CVA. Fever and cough, hypoxia and\n hypotension.\n\n FINDINGS: Instead of the diffuse, mild, ground-glass opacification that was\n present throughout both lungs on , which had improved since , there is now a much more severe peribronchial infiltrative process with\n large areas of coalescent consolidation as well as smaller acinar involvement\n also throughout both lungs. Etoposide related pulmonary toxicity is an\n extremely rare complication therefore diffuse infection, including\n pneumocystis and viral pathogens, as well as pulmonary hemorrhage are more\n likely. The 34 mm wide thick-walled right upper lobe abscess was 42 mm wide\n on mm on and showed greater marginal irregularity on\n the two prior studies. It no longer reaches mildly thickened costal pleura,\n and there is no pleural or pericardial effusion today. Central lymph nodes\n are not pathologically enlarged. Small granulomatous calcifications are\n present in the subcarinal and both hilar stations. Low-density cardiac\n contents indicate anemia. Moderate cardiomegaly has increased, particularly\n the dilated left ventricle. This study is not designed for subdiaphragmatic\n evaluation except to note severe chronic splenomegaly, the absence of adrenal\n mass or adenopathy in the upper abdomen, or lesions in the imaged portion of\n the unenhanced liver suspicious for malignancy or infection. Small stones\n pool in a moderately enlarged gallbladder, but there is no indication of\n cholecystitis.\n\n IMPRESSION:\n 1. Severe, global peribronchial infiltration, more likely infection\n (pneumocystis or virus) or hemorrhage than Etoposide drug reaction,\n particularly because the latter is extremely rare.\n 2. Persistent anemia. Progressive mild cardiomegaly, particular left\n (Over)\n\n 11:27 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for change in size of mass\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ventricular enlargement.\n 3. Granulomatous lymph node calcifications, probably due to prior\n histoplasmosis. That could be the pathogen for the slowly resolving right\n upper lobe cavity, which continues to involute very, very slowly, but is not\n the cause of the diffuse infection.\n 4. Distended gallbladder, tiny gallstones, no evidence of cholecystitis.\n 5. Chronic severe splenomegaly.\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1121850, "text": " 1:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 49cm SL L basilic PICC placed ? tip\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with CHF\n REASON FOR THIS EXAMINATION:\n 49cm SL L basilic PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with congestive cardiac failure with left PICC\n placement. Evaluate PICC placement.\n\n COMPARISON: Portable AP chest radiograph .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: Left PICC tip projects within at least 1 cm below the cavo-atrial\n junction and should be pulled back by 1 to 1.5 cm. Cardiomegaly is stable.\n Right upper lobe cavitary mass is improved since . Persistent\n diffuse bilateral pulmonary opacifications likely represent severe pneumonia.\n Low lung volumes persist. No pneumothorax.\n\n IMPRESSION:\n 1. Persistent bilateral pulmonary opacifications likely represent severe\n pneumonia. 2. Right upper lobe cavitary mass decreased since .\n 3. Right PICC tip 1cm below cavoatrial junction and should be pulled back 1 to\n 1.5 cm. IV nurse was notified at 14:19 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2197-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1122037, "text": " 3:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval PICC line placement\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ?PICC line curled over itself\n REASON FOR THIS EXAMINATION:\n eval PICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line.\n\n Portable AP chest radiograph, .\n\n Currently, the left PICC line tip is at the level of low SVC with no evidence\n of kinking. There is no short interval change in widespread parenchymal\n consolidations. The cardiomediastinal silhouette is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121611, "text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt is a 60 y.o male with h.o hypereosinophilic syndrome on chemo (etoposide),\n DVT, CVA, afib, CHF EF (EF 30%), who presents with fever, cough, found to be\n \"hypoxic\" and \"hypotensive\" in the ED.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with hypereosinophilic\n syndrome who presents with fever and cough.\n\n Portable AP chest radiograph was compared to chest\n radiograph and chest CT.\n\n Extensive bilateral consolidations are unchanged. The heart size is enlarged\n but stable. There is no apparent pleural effusion. The known cavitating\n lesion in the right upper lobe is unchanged.\n\n Overall compared with chest radiograph of .\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121401, "text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with shortness of breath, known cavitary lesion\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old male with shortness of breath and known\n cavitary lesion. Evaluate for pneumonia or effusion.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISON: Comparison is made to chest CT from .\n\n FINDINGS: Stable appearance of 3.6 x 2.7 cm known right upper lobe cavitary\n mass, given differences in technique. There has been interval development of\n perihilar opacification bilaterally, that likely represents acute moderate\n interstitial pulmonary edema though infection is not excluded. No other areas\n of focal parenchymal consolidation. No pleural effusions or pneumothorax.\n There are low lung volumes. Cardiomediastinal contours are stable.\n\n IMPRESSION:\n 1. Interval development of patchy perihilar bilateral opacification likely\n represents acute moderate interstitial pulmonary edema though infection is\n excluded, and recommend repeat radiographs status post diuresis to exclude\n pneumonia.\n 2. Known right upper lobe cavitary mass redemonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121486, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HYPOXIA; CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, to evaluate for change.\n\n FINDINGS: In comparison with study of , there is little change in the\n diffuse bilateral pulmonary opacifications. The right upper lobe cavitary\n mass is again seen. Diffuse bilateral pulmonary opacifications most likely\n reflect acute pulmonary vascular congestion, though supervening pneumonia can\n certainly not be excluded. Low lung volumes persist.\n\n\n" } ]

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The patient was admitted to the intensive care unit. CT surgery was requested to see the patient. The patient underwent CT chest, abdomen and pelvis with reconstruction and 3-D imaging. The chest portion showed extensive emphysema changes throughout both lungs. There was an 8.2 x 6.7 mm nodular density in the right upper lobe. There is atelectasis present in the base. There were several large intrathoracic mediastinal nodes. There were several scattered sub centimeter mediastinal lymph nodes. CT of the abdomen with and without contrast revealed the left kidney was absent. There is free fluid in the upper abdomen surrounding liver and spleen. The pancreas is atrophic. The right renal gland and right renal kidney appear unremarkable. The pelvis CT with and without contrast revealed streaked artifacts and bilateral hip replacements. Diverticular disease in the sigmoid colon without evidence of diverticulitis. There is no significant pelvic lymphadenopathy. Musculoskeletal shows degenerative changes present in the lumbar spine as well as a well defined sclerotic focus in the left iliac bone most likely a bone island. CT of the abdomen with extensive atherosclerotic disease of the aorta and its branches. The right and left coronary arteries arise from a normal expected anatomical location. The descending aorta at the level of the right main pulmonary artery is 38 x 38 mm. There is extensive concentric noncalcification plaque present in the descending thoracic and abdominal aortas. There are multiple ulcerative plaques throughout the entire course of the descending aorta. The descending aorta at the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. The abdominal aorta in the upper abdomen above the celiac access measures 37.3 x 49.3 mm. The celiac access, superior mesenteric artery are widely patent. Inferior mesenteric artery was not clear to visualize. There is an abdominal aortic aneurysm that measures 63.5 x 65.1 mm in maximum transverse diameter. There is a 24 x 24.6 mm right common iliac aneurysm which contains concentric mural thrombus. CT surgery was consulted after review of the CT scan. In discussion with Dr. and CT surgery Dr. __________ it was determined the patient was not a surgical candidate because of extensive medical problems, respiratory problems. The patient was made DNR, DNI. Blood pressure medications were adjusted to stabilize blood pressure. The patient was transferred out of the ICU to the regular nursing floor on . The patient was discharged to home with well controlled blood pressure without any symptoms. The patient's creatinine at discharge was 1.1. The patient should follow up with the primary care physician for continued blood pressure monitoring and blood pressure medication adjustment. She should call primary care if she develops any chest, back, abdominal pain or near syncopal episodes.

MUSCULOSKELETAL: Multilevel degenerative changes are present in the lumbar (Over) 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? (Over) 1:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT ABD&PELVIS W/C COLON TECHNIQUE Reason: please eval - ? For example, there is a 17.0 x 12.7 mm pretracheal lymph node, there is a 15.4 x 7.2 mm prevascular lymph node, there is a 22.5 x 16.2 mm precarinal lymph node, there is a 16.4 x 11.3 mm lymph node anterior to the descending thoracic aorta. There is extensive concentric noncalcified plaque present in the descending thoracic and the abdominal aorta. The pancreas is atrophic with prominence of the main pancreatic duct. stent candidate Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM FINAL REPORT (Cont) The abdominal aorta in the upper abdomen above the celiac axis measures 37.3 x 49.3 mm, the celiac axis, superior mesenteric artery are widely patent. Extensive noncalcified and ulcerated plaques throughout the course of the descending thoracic and abdominal aorta with an abdominal aortic aneurysm measuring 65.1 x 63.5 mm in maximum transverse diameter. There is a 8.2 x 6.7 mm nodular opacity in the right upper lobe (image 27, series 2). There is an abdominal aortic aneurysm that measures 63.5 x 65.1 mm in maximum transverse diameter. The right and the left coronary arteries arise from the normal expected anatomical locations. BP 116/67 HR 60-70 NSR with APC/PVC. Alerts The most most recent case for Ms. has triggered some of your PEMS alerts: The angle prox neck to aaa body measurement is greater than or equal to 45.0 (This alert has not been acknowledged.) FINDINGS: CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There are extensive emphysematous changes present throughout both lungs. stent candidate Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM FINAL REPORT (Cont) spine. A 24.6 x 24.6 mm right common iliac aneurysm that does not extend into the iliac bifurcation and 10.5 x 9.1 mm short-segment right external iliac artery aneurysm. CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: Streak artifact from the bilateral hip replacement producing extensive streak artifacts. Rhythm appears to be nsr with very frequent pac's and pvc.==plan medical management and pt is DNR + palpable pulses.Resp: LS exp wheezing. There is a widely patent single right renal artery. Denies pain.CV: HR 60-80s. Free fluid in the upper abdomen is of uncertain clinical significance. There is a 24.6 x 24.6 mm aneurysm of the right common iliac artery which contains concentric mural thrombus. 7a-3pneuro: a+ox2 (reoriented to time), pleasant, following commands, mae, turns with assist x1cv: wandering atrial pacemaker 45-85, occasional pvcs, sbp 125-175, ntg gtt started (now maxed out at 4 mcg/kg/min), nicardipine gtt to be started to keep sbp<120; afebresp: insp/exp wheeze to right side, clear left upper diminished to base, albuterol nebs given, strong productive cough, 02 sats 86-89% on 5L nc (sats >86% ok per )gi: bowel sounds present, npo, sliding scale startedgu: foley to gravity draining clear yellow urinelabs: repleting k+tests: cta thorax-no results at this timeassess: stableplan: maintain sbp<120, depending on ct results taaa repair vs aortic stent vs medical management, keep npo until plan known There is atelectasis present at the lung bases. Pt c/o of lt sided abd pain, team aware, morphine and ativan given. The descending aorta at the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. Her TAA volume is 464.3cc. The right adrenal gland and right kidney appear unremarkable. There are multiple calcified foci in the thrombus within the aneurysm. The ascending aorta at the level of the right main pulmonary artery measures 38.0 x 38.0 mm. Respiratory care:Patient followed for albuterol treatments Q6prn. Pt continues on iv NTG at 4mcg (vicu max) and restarted on po meds and hydralazine added. TECHNIQUE: CT of the chest, abdomen, and pelvis was performed without intravenous contrast followed by CT of the chest, abdomen, and pelvis post- administration of intravenous contrast, reconstructions were performed in the axial, sagittal and coronal planes. CT ANGIOGRAM: There is extensive atherosclerotic disease in the aorta and its branches. 4p-7pPt met with Dr. and Dr. pt not a surgical canidate and family aware. There are several enlarged intrathoracic mediastinal lymph nodes. Denies abd/back pain. Solitary 8.2 x 6.7 mm pulmonary nodule in the right upper lobe along with mediastinal lymphadenopathy may represent a lung primary neoplasm with metastatic disease to mediastinal lymph nodes and may be assessed further as per clinical need. 11:49 AM MMS SUGICAL PLANNING SERVICE Clip # Reason: AAA MEDICAL CONDITION: 69 year old woman with AAA ruptured - REASON FOR THIS EXAMINATION: please apply to above cta torso No contraindications for IV contrast FINAL REPORT This report is for reference only, generated by M2S.

7

[ { "category": "Radiology", "chartdate": "2133-09-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 975914, "text": " 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with AAA ruptured -\n REASON FOR THIS EXAMINATION:\n please eval - ? stent candidate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old female with abdominal aortic aneurysm, for evaluation of\n extent.\n\n TECHNIQUE: CT of the chest, abdomen, and pelvis was performed without\n intravenous contrast followed by CT of the chest, abdomen, and pelvis post-\n administration of intravenous contrast, reconstructions were performed in the\n axial, sagittal and coronal planes. The reconstructions were also performed\n in the 3D imaging lab.\n\n COMPARISON: There is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There are extensive\n emphysematous changes present throughout both lungs. There is a 8.2 x 6.7 mm\n nodular opacity in the right upper lobe (image 27, series 2). There is\n atelectasis present at the lung bases.\n\n There are several enlarged intrathoracic mediastinal lymph nodes. For\n example, there is a 17.0 x 12.7 mm pretracheal lymph node, there is a 15.4 x\n 7.2 mm prevascular lymph node, there is a 22.5 x 16.2 mm precarinal lymph\n node, there is a 16.4 x 11.3 mm lymph node anterior to the descending thoracic\n aorta. There are several scattered subcentimeter mediastinal lymph nodes as\n well.\n\n CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The left kidney is absent\n and most likely represents a congenital absence as there are no surgical clips\n or known history of a nephrectomy. There is free fluid in the upper abdomen\n surrounding the liver and spleen. The scan was performed in the early\n arterial phase. Within these limitations, the liver and spleen do not show\n any focal lesions. The pancreas is atrophic with prominence of the main\n pancreatic duct. The right adrenal gland and right kidney appear\n unremarkable.\n\n CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: Streak artifact from the\n bilateral hip replacement producing extensive streak artifacts. Within these\n limitations, the diverticular disease is present in the sigmoid colon without\n evidence of diverticulitis. There is no significant pelvic lymphadenopathy.\n\n MUSCULOSKELETAL: Multilevel degenerative changes are present in the lumbar\n (Over)\n\n 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n spine. There is a well-defined sclerotic focus in the left iliac bone most\n likely a bone island.\n\n CT ANGIOGRAM:\n\n There is extensive atherosclerotic disease in the aorta and its branches. The\n right and the left coronary arteries arise from the normal expected anatomical\n locations. The ascending aorta at the level of the right main pulmonary\n artery measures 38.0 x 38.0 mm.\n\n There is extensive concentric noncalcified plaque present in the descending\n thoracic and the abdominal aorta. There are multiple ulcerated plaques\n throughout the entire course of the descending aorta. The descending aorta at\n the level of the left inferior pulmonary vein measures 42.2 x 37.4 mm. The\n abdominal aorta in the upper abdomen above the celiac axis measures 37.3 x\n 49.3 mm, the celiac axis, superior mesenteric artery are widely patent. The\n inferior mesenteric artery was not clearly visualized. There is a widely\n patent single right renal artery. There is an abdominal aortic aneurysm that\n measures 63.5 x 65.1 mm in maximum transverse diameter. There are multiple\n calcified foci in the thrombus within the aneurysm.\n\n There is a 24.6 x 24.6 mm aneurysm of the right common iliac artery which\n contains concentric mural thrombus.\n\n CONCLUSION:\n\n 1. Extensive noncalcified and ulcerated plaques throughout the course of the\n descending thoracic and abdominal aorta with an abdominal aortic aneurysm\n measuring 65.1 x 63.5 mm in maximum transverse diameter.\n\n 2. Solitary 8.2 x 6.7 mm pulmonary nodule in the right upper lobe along with\n mediastinal lymphadenopathy may represent a lung primary neoplasm with\n metastatic disease to mediastinal lymph nodes and may be assessed further as\n per clinical need.\n\n 3. Free fluid in the upper abdomen is of uncertain clinical significance.\n\n 4. A 24.6 x 24.6 mm right common iliac aneurysm that does not extend into the\n iliac bifurcation and 10.5 x 9.1 mm short-segment right external iliac artery\n aneurysm.\n\n 5. Absent left kidney.\n\n\n (Over)\n\n 1:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT ABD&PELVIS W/C COLON TECHNIQUE\n Reason: please eval - ? stent candidate\n Admitting Diagnosis: THORACIC ABDOMINAL ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2133-09-09 00:00:00.000", "description": "MMS SUGICAL PLANNING SERVICE", "row_id": 981458, "text": " 11:49 AM\n MMS SUGICAL PLANNING SERVICE Clip # \n Reason: AAA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with AAA ruptured -\n REASON FOR THIS EXAMINATION:\n please apply to above cta torso\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n This report is for reference only, generated by M2S.\n\n ( ), DOB: (Age 69) AAA/TAA\n Date of Service: \n Physician : , MD\n Current Status\n\n\n was last scanned on and is a pre-operative\n AAA/TAA patient. Ms. was previously scanned at Pre-op on -. Her AAA volume is 327.3cc. Her TAA volume is 464.3cc. Her AAA\n diameter is 6.6cm. Her TAA diameter is 5.1cm.\n Alerts\n\n The most most recent case for Ms. has triggered some of your PEMS\n alerts:\n The angle prox neck to aaa body measurement is greater than or equal to 45.0\n (This alert has not been acknowledged.)\n Nb: This note was automatically generated.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-09-09 00:00:00.000", "description": "Report", "row_id": 1641384, "text": "11p-7a\nNeuro: Pt alert and oriented, forgetful of time. MAE. Follows commands. Denies pain.\n\nCV: HR 60-80s. SR occasional pacs, occasional pvcs. NTG weaned to off, see carevue. SBP 100-120s. Goal SBP<140. + palpable pulses.\n\nResp: LS exp wheezing. Sats 87-94%. Pt wears 6Lnc at home. Goal sats 88% or above. Face tent applied ~1 hour for sats 86-87%. Pt refused to wear the face tent, though sats improved 88% or better, see carevue.\n\nGI/GU: Abd softly distended, hypoactive BS. Tender to touch. Denies abd/back pain. Foley draining adequate amts of clear yellow urine, see carevue.\n\nEndo: Per pt's scale.\n\nPlan: Monitor hemodynamics. Goal SBP<140. ?transfer to floor/vicu.\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641380, "text": " 7a-3p\nneuro: a+ox2 (reoriented to time), pleasant, following commands, mae, turns with assist x1\n\ncv: wandering atrial pacemaker 45-85, occasional pvcs, sbp 125-175, ntg gtt started (now maxed out at 4 mcg/kg/min), nicardipine gtt to be started to keep sbp<120; afeb\n\nresp: insp/exp wheeze to right side, clear left upper diminished to base, albuterol nebs given, strong productive cough, 02 sats 86-89% on 5L nc (sats >86% ok per )\n\ngi: bowel sounds present, npo, sliding scale started\n\ngu: foley to gravity draining clear yellow urine\n\nlabs: repleting k+\n\ntests: cta thorax-no results at this time\n\nassess: stable\n\nplan: maintain sbp<120, depending on ct results taaa repair vs aortic stent vs medical management, keep npo until plan known\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641381, "text": "4p-7p\nPt met with Dr. and Dr. pt not a surgical canidate and family aware. At present pt medically management not CMO. Plan to transfer to VICU when be available. Plan to keep sbp<140. Pt continues on iv NTG at 4mcg (vicu max) and restarted on po meds and hydralazine added. Pt c/o of lt sided abd pain, team aware, morphine and ativan given. Pt affect very appropriate and realistic, family aware and agree as well. Rhythm appears to be nsr with very frequent pac's and pvc.==plan medical management and pt is DNR\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1641382, "text": "Nursing Progress Note 7PM-11PM:\nPt with stable BP weaned Nitro drip down to 3mcg/kg/min. Aware that she may be transferred to the floor tonight. Good UO via foley. BP 116/67 HR 60-70 NSR with APC/PVC. Family visiting most of the evening.\n" }, { "category": "Nursing/other", "chartdate": "2133-09-09 00:00:00.000", "description": "Report", "row_id": 1641383, "text": "Respiratory care:\nPatient followed for albuterol treatments Q6prn. Breathsounds are coarse with exp. wheezes. Please see respiratory section of carevue for further data.\nPlan: Continue to follow for bronchodilator therapy Q6prn\n" } ]

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169,858

Assesment: Mrs is a 72 year old female with a history of a mechanical mitral valve chronically anticoagulated with coumadin who presents with one week of lightheadedness now with known duodenal ulcer s/p endoscopic injection and clipping of visible vessel.

Osseous structures show degenerative change of the lumbar spine and appear otherwise within normal limits. There is a tortuous atherosclerotic aorta. COMPARISON: No prior abdominal radiograph. IMPRESSION: Post-cardiac surgery as above. HISTORY: Hypertension and weakness. Pulmonary vasculature is unremarkable. Moderate enlargement of the cardiac silhouette persists, as does tortuosity of the aorta. To sicu from EW- GI scoped pt at bedside- clot found in duodenum. Pt has hx htn, anemia and recent gout. To EW this am with c/o weakness, left sided chest pain, and melena. IMPRESSION: No evidence of bowel obstruction or free intraperitoneal air. SINGLE SUPINE VIEW OF ABDOMEN: A moderate amount of gas and stool is seen throughout the colon. No acute pulmonary process. MP-SR,no ectopy, BP stable in low 100's, s/p fluid bolus, FFP,PC's Hct 21.8> 20.5 this am, MICU resident paged. No free subdiaphragmatic gas is evident. A-V conduction delay. The visualized osseous structures are otherwise unremarkable. IMPRESSION: AP chest compared to . Chest x-ray of same date. Diffuse non-specific ST-T wave changes.No previous tracing available for comparison. Sinus rhythm. No effusion or pneumothorax is evident. Injected with epinephrine and clips placed. The cardiac silhouette is borderline enlarged. There is no evidence of free intraperitoneal air on the supine radiograph. trans to floor Small amounts of gas present in nondistended loops of small bowel. COMPARISON: None. Lungs are clear and there is no pleural effusion. Peripheral lines x2 intact, LS clear, NC3lpm,sao2 100% abd soft,no stool or bleeding overnight, s/p scope, epi and banding.Protonix gtt @ 8mg/hr Foley in place, dg lt yellow clr urine ~300/hr Plan-? Versed and fentanyl given for sedation, tol. Interval enlargement of the cardiac silhouette could be due to cardiac decompensation or more likely lower lung volumes difference in patient positioning. Cholecystectomy clips present in the right upper quadrant. The patient has undergone prior median sternotomy and valve replacement surgery. 1:38 PM CHEST (PA & LAT) Clip # Reason: eval for infiltrate Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with GIB and now with new temp to 101 REASON FOR THIS EXAMINATION: eval for infiltrate FINAL REPORT HISTORY: GIB, now with elevated temperature. transfuse ? However, no evidence of vascular congestion, pleural effusion, or acute pneumonia. 11:02 AM CHEST (PORTABLE AP) Clip # Reason: eval for free air Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with doudenal ulcer, s/p EGD with abdominal pain REASON FOR THIS EXAMINATION: eval for free air FINAL REPORT AP CHEST HISTORY: Duodenal ulcer and abdominal pain, look for free air. FINDINGS: The lungs are clear. Pt arouses to voice, denies pain, sleeping in long naps. FINDINGS: In comparison with the study of , the patient has taken a much better inspiration. Hct 18, INR 4.1- pt was on coumadin at home 2nd hx of mitral valve repair 20 yrs ago. 1:24 PM CHEST (PORTABLE AP) Clip # Reason: eval for pna, ptx MEDICAL CONDITION: 72 year old woman with hypotension, weakness REASON FOR THIS EXAMINATION: eval for pna, ptx FINAL REPORT AP CHEST, AT 1326 HOURS. NKDA pr family. 10:31 AM PORTABLE ABDOMEN Clip # Reason: ABDOMINAL PAIN FOLLOWING CLIPPING OF VISIBLE ULCER Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 72 year old woman with abdominal pain following cliping of visible ulcer REASON FOR THIS EXAMINATION: eval for free air FINAL REPORT INDICATION: Abdominal pain following clipping of visible ulcer. SICU Progress Note 1900-0700 Stable overnight, Hct trending down to 20.5 this am.INR2.6. nsg admit notePt is a+o x3- speaks mostly Cantonese.

7

[ { "category": "Radiology", "chartdate": "2156-03-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1001412, "text": " 10:31 AM\n PORTABLE ABDOMEN Clip # \n Reason: ABDOMINAL PAIN FOLLOWING CLIPPING OF VISIBLE ULCER\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with abdominal pain following cliping of visible ulcer\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain following clipping of visible ulcer.\n\n COMPARISON: No prior abdominal radiograph. Chest x-ray of same date.\n\n SINGLE SUPINE VIEW OF ABDOMEN: A moderate amount of gas and stool is seen\n throughout the colon. Small amounts of gas present in nondistended loops of\n small bowel. There is no evidence of free intraperitoneal air on the supine\n radiograph. Cholecystectomy clips present in the right upper quadrant.\n\n Osseous structures show degenerative change of the lumbar spine and appear\n otherwise within normal limits.\n\n IMPRESSION: No evidence of bowel obstruction or free intraperitoneal air.\n\n" }, { "category": "Radiology", "chartdate": "2156-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001315, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hypotension, weakness\n REASON FOR THIS EXAMINATION:\n eval for pna, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, AT 1326 HOURS.\n\n HISTORY: Hypertension and weakness.\n\n COMPARISON: None.\n\n FINDINGS: The lungs are clear. There is a tortuous atherosclerotic aorta.\n The patient has undergone prior median sternotomy and valve replacement\n surgery. The cardiac silhouette is borderline enlarged. No effusion or\n pneumothorax is evident. The visualized osseous structures are otherwise\n unremarkable.\n\n IMPRESSION: Post-cardiac surgery as above. No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001416, "text": " 11:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with doudenal ulcer, s/p EGD with abdominal pain\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: Duodenal ulcer and abdominal pain, look for free air.\n\n IMPRESSION: AP chest compared to .\n\n Interval enlargement of the cardiac silhouette could be due to cardiac\n decompensation or more likely lower lung volumes difference in patient\n positioning. Pulmonary vasculature is unremarkable. Lungs are clear and\n there is no pleural effusion. No free subdiaphragmatic gas is evident.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-03-26 00:00:00.000", "description": "Report", "row_id": 1661114, "text": "nsg admit note\nPt is a+o x3- speaks mostly Cantonese. To EW this am with c/o weakness, left sided chest pain, and melena. Hct 18, INR 4.1- pt was on coumadin at home 2nd hx of mitral valve repair 20 yrs ago. To sicu from EW- GI scoped pt at bedside- clot found in duodenum. Injected with epinephrine and clips placed. Versed and fentanyl given for sedation, tol. well. Pt has hx htn, anemia and recent gout. NKDA pr family.\n" }, { "category": "Nursing/other", "chartdate": "2156-03-27 00:00:00.000", "description": "Report", "row_id": 1661115, "text": "SICU Progress Note 1900-0700\n Stable overnight, Hct trending down to 20.5 this am.INR2.6.\n Pt arouses to voice, denies pain, sleeping in long naps.\n MP-SR,no ectopy, BP stable in low 100's, s/p fluid bolus, FFP,PC's\n Hct 21.8> 20.5 this am, MICU resident paged. Peripheral lines x2 intact,\n LS clear, NC3lpm,sao2 100%\n abd soft,no stool or bleeding overnight, s/p scope, epi and banding.Protonix gtt @ 8mg/hr\n Foley in place, dg lt yellow clr urine ~300/hr\n Plan-? transfuse\n ? trans to floor\n\n" }, { "category": "Radiology", "chartdate": "2156-03-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1001824, "text": " 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with GIB and now with new temp to 101\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GIB, now with elevated temperature.\n\n FINDINGS: In comparison with the study of , the patient has taken a much\n better inspiration. Moderate enlargement of the cardiac silhouette persists,\n as does tortuosity of the aorta. However, no evidence of vascular congestion,\n pleural effusion, or acute pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2156-03-26 00:00:00.000", "description": "Report", "row_id": 215477, "text": "Sinus rhythm. A-V conduction delay. Diffuse non-specific ST-T wave changes.\nNo previous tracing available for comparison.\n\n" } ]

54,382

166,909

Patient was admitted to the trauma service on . Extubated; serial Hcts stable; held overnight in ICU due to SOB. Transferred to floor, CT to water seal, foley d/c'd. Increased PTX, CT back to suction. No significant output, so CT pulled. CT chest done, small R PTX and hemothorax; new chest tube placed to suction. Adjusted pain meds; ambulated. CT placed to water seal; CT chest done, showing unchanged R PTX and hemothorax. Thoracics consulted. CXR with worsening R PTX. Thoracentesis by IP, drained 300cc of old thick blood. Stable, awaiting to go to OR with thoracics. On the patient was taken to the operating room for a right VATS washout, evacuation of hemothorax. The patient was noted to have, a fair amount of clot and fibrin as well as old blood in the chest. Two chest tubes were placed and the patient was admitted to the floor post-operatively. His diet was advanced and he was tolerating regular diet on POD1, his pain was controlled with IV medications, this was transitioned to PO. Chest tube outputs were monitored daily as well as vital signs and urine output. On POD #2 the posterior chest tube was d/c'd, and a CXR was completed showing a small apical pneumothorax. On POD#3 the anterobasilar chest tube was discontinued, a CXR was obtained. The patient was deemed fit for discharge on POD #3, at that time his pain was controlled with PO medications, he was ambulatory, voiding, tolerating a regular diet, and breathing without distress.

Response: Pt intubated, on propofol, right CT to sx. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Intubated d/t combativeness. Albuterol nebs prn. Albuterol nebs prn. HCT stablbe. HCT stablbe. Received on CMV, Propofol gtt. Received on CMV, Propofol gtt. Plan: CXR, serial crits, wean to extubate. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. CT placed @ OSH. R CT to wall sxn w/ moderate serosang output. R CT to wall sxn w/ moderate serosang output. Trace right medial pneumothorax. There is a trace right medial basal pneumothorax. Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. Right hemopnumo, ? HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. HPI: 24yoM s/p assault. Updated on pts status. Updated on pts status. Updated on pts status. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. PMH: Asthma Trauma, s/p assault Assessment: Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang output. CXR okay. CXR okay. Cont R-chest tube. Cont R-chest tube. Action: Admitted to T/SICU from ED at 0615. pt pan scanned in ED. IMPRESSION: PA and lateral chest compared to earlier on : A tiny right apical pleural air collection and right pleural tube unchanged in position may be fissural, with a side port in the right axillary subcutaneous tissue. IMPRESSION: AP chest compared to : Persistent small right pleural effusion and right basal atelectasis, right pleural tube still in place, side port extrathoracic. Right upper lobe anterior opacity, unchanged, likely contusion. There is a small right pneumothorax. There is a small right pneumothorax. There is a small right pneumothorax. Right pleural tube unchanged in position, crossing the right mid and lower chest with at least one side port in the soft tissues of the chest wall. PFI REPORT There is small right pneumothorax. Right lung atelectasis and contusion remain. Enlarging heterogeneous right pleural effusion, now moderate, consistent with progressing hemothorax. A small right pneumothorax is unchanged. IMPRESSION: AP chest centered at the diaphragm compared to earlier on : Very small right apical pleural air collection has increased slightly (see the lateral costal component). Mild thoracic scoliosis and thickened left paraspinal soft tissue, unchanged. Follow up right pneumothorax. SOFT TISSUE STRUCTURES: Very small amount of emphysema is noted in bilateral posterior wall, right more than left, paraspinal in distribution on the left and posterolateral chest wall in distribution on the right. New small right pneumothorax, with air-fluid levels, likely due to recent removal of the chest tube. Hazy opacification over the right lung base probably represents some posteriorly layering right pleural effusion. Minimal atelectasis in the left lung base is noted. IMPRESSION: No change in the degree of pneumothorax on the right. New tiny left pleural effusion. There is intermediate density right pleural effusion which could reflect a hemothorax. Right apical and right basal chest tubes are in place. Right chest tube is in place. Subcutaneous emphysema at the entrance of the old chest tube persists. There is emphysema in the right lateral subcutaneous soft tissues. Unchanged right hyoerdense pleural effusion consistent with hemothorax. Tiny right apical pneumothorax persists with the right chest tube removed. Right upper lobe anterior opacity, unchanged, likely contusion. Unchanged kink at the tip of the chest tube, abutting the right atrium. There is a tiny right apical pneumothorax. FINDINGS: In comparison with the earlier study of this date, the right chest tube has been removed. There is a small right pneumothorax. Small interval increase of the right apical pneumothorax, but the pneumothorax remains small. Opacities in the right lung greater in the lower lobe are unchanged from prior. Small right pneumothorax is also unchanged. Small right pneumothorax is also unchanged. Small right pneumothorax is also unchanged. Right basal chest tube remains in place. Previously described heterogeneous hyperdense fluid collection in the right hemithorax is unchanged in size and consistent with hemoperitoneum. There are persistent small linear opacities in the right mid lung consistent with atelectasis. Non-diagnostic inferior Q wave pattern, may be a normal variantbut cannot exclude prior inferior myocardial infarction. Some loculated right pleural effusion is again seen. REASON FOR THIS EXAMINATION: Status post Chest tube. Effusion consistent with hemothorax. Effusion consistent with hemothorax. Right-sided chest tube is kinked and malpositioned abutting the right atrium. Right-sided chest tube is kinked and malpositioned abutting the right atrium. Right-sided chest tube is kinked and malpositioned abutting the right atrium. There is mild increase in small-to-moderate loculated right pleural effusion. Right apical and right base chest tube remain in place. Chest tube looks kinked. Right pleural effusion and right lower lobe consolidation are stable. The heart is at the upper limits of normal. Since yesterday, a right chest tube is in unchanged position. Associated compressive atelectasis on the right side are noted. Mediastinal, hilar contours and pulmonary vasculature are normal. Right retrocardiac consolidation and left retrocardiac opacities are consistent with atelectasis, although some degree of aspiration cannot be excluded. Cardiomediastinal contours are unchanged. The current study demonstrates recently inserted chest tube.

46

[ { "category": "Respiratory ", "chartdate": "2125-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 667843, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n New admission, pt is SP multiple stab wounds to thorax , mostly\n posteriorly\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667830, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable\n PULM: wean to extubate today\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n RENAL: f/u u/o, f/u cre\n HEME: serial Hct, transfuse prn\n ENDO: RISS\n ID: no Abx\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 35 min\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668072, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Events this shift\n Pt c/o sob/difficulty breathing at 2250. LS clear with dim bases bilat.\n O2 sat 98-100%. Pt placed on 2L NC for comfort. Stat chest xray\n obtained which looked unchanged. Pt kept in ICU overnight for further\n monitoring. Will reassess floor transfer in am.\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Foley d/c at mn, DTV 0800\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable.\n Tolerating regular diet, denies nausea.\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid \n Transfer to floor today\n **Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk**\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667932, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable, monitor HR and BP\n PULM: wean to extubate today, hemothorax\n monitor CT output, make sure\n output decreasing before extubation\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n (serial HCT), belly exam benign currently\n RENAL: adequate UOP, f/u cr\n HEME: serial Hct Q4 hours for hemothorax,\n ENDO: RISS\n ID: monitor WBC and fver curve\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 33 min\n" }, { "category": "Physician ", "chartdate": "2125-05-19 00:00:00.000", "description": "Intensivist Note", "row_id": 668059, "text": "TSICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n stab wound\n PMHx:\n PMH: asthma\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:40 AM\n EXTUBATION - At 09:43 AM\n Post operative day:\n HD2\n 24hr events: admitted to TICU intubated, right chest tube in place\n admission Hct 40 after 1u transfused at OSH, received 1unit in the ED.\n Extubated in AM. Chest tube output declined. HCT stablbe. Pending tx\n to floor, but in evening developed SOB. CXR okay. Tx nebs.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:40 AM\n Other medications:\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.9\nC (98.4\n HR: 79 (70 - 107) bpm\n BP: 141/74(88) {87/37(49) - 146/94(104)} mmHg\n RR: 23 (17 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,848 mL\n 360 mL\n PO:\n 480 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n Blood products:\n 375 mL\n Total out:\n 3,005 mL\n 180 mL\n Urine:\n 2,115 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,843 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 455 (455 - 455) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 4.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), right chest tube\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 39.3 %\n 12.2 K/uL\n [image002.jpg]\n 08:24 AM\n 12:40 PM\n 04:21 PM\n 09:00 PM\n 02:03 AM\n WBC\n 15.6\n 12.2\n Hct\n 40.0\n 38.8\n 39.9\n 38.3\n 39.3\n Plt\n 304\n 280\n Creatinine\n 1.0\n 0.9\n Troponin T\n <0.01\n Glucose\n 105\n 110\n Other labs: PT / PTT / INR:14.2/25.0/1.2, CK / CK-MB / Troponin\n T:679/5/<0.01, ALT / AST:21/26, Alk-Phos / T bili:66/1.2, Amylase /\n Lipase:47/13, Ca:9.0 mg/dL, Mg:2.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 23yoM with stab wound to the right chest\n Neurologic: dilaudid prn for pain\n Cardiovascular: stable\n Pulmonary: s/p stab wound to R chest. Cont R-chest tube. Output\n minimal. Albuterol nebs prn.\n Gastrointestinal / Abdomen: NPO, H2, serial exams, No evidence of solid\n visceral injury\n Nutrition: Regular diet\n Renal: no issues. foley likely to d/c\n Hematology: serial Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: 36fr CT, foley, PIV, ETT\n Wounds:\n Imaging:\n Fluids: LR at 100 cc/h\n Consults:\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Other: Chest Trauma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 06:20 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667900, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt admitted approx 630 to TSICU. Received on CMV, Propofol gtt. When\n lightened, following all commands, appropriate. R CT to wall sxn w/\n moderate serosang output. VSS. HCT 40.\n Action:\n Vent quickly weaned to PS 5/5\n Propofol weaned\n Extubated approx 0945\n HCT checks q4hrs\n Response:\n Pt doing well, VSS. O2 sats 99%, currently on 40%FiO2 face\n tent. Pt w/ c/o back pain (stab wounds), Dilaudid administered PRN. HCT\n remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n **Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.**\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668148, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. Sats 99-100% on RA. HCT 40. Foley discontinued @\n midnight. Tol regular diet. Occassional c/o pain in back from/chest.\n Action:\n PRN Dilaudid for pain control\n Due to void\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pain well controlled\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n **Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk**\n" }, { "category": "Nursing", "chartdate": "2125-05-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668150, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. Sats 99-100% on RA. HCT 40. Foley discontinued @\n midnight. Tol regular diet. Occassional c/o pain in back from/chest.\n Action:\n PRN Dilaudid for pain control\n Due to void\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pain well controlled\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n **Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk**\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n S/P STABBING\n Code status:\n Full code\n Height:\n Admission weight:\n 100 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Asthma, no other PMH per pt\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:76\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 360 mL\n 24h total out:\n 730 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:03 AM\n Potassium:\n 3.7 mEq/L\n 02:03 AM\n Chloride:\n 104 mEq/L\n 02:03 AM\n CO2:\n 25 mEq/L\n 02:03 AM\n BUN:\n 8 mg/dL\n 02:03 AM\n Creatinine:\n 0.9 mg/dL\n 02:03 AM\n Glucose:\n 110 mg/dL\n 02:03 AM\n Hematocrit:\n 41.9 %\n 10:58 AM\n Finger Stick Glucose:\n 115\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: valuables w/ ED police\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: TSICU CC564\n Transferred to: CC620\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Respiratory ", "chartdate": "2125-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 667890, "text": "Pt received orally intubated and vented on full ventilatory support. Pt\n weaned to PSV tolerated well. Lung sounds clear, no secretions. Pt then\n extubated, good cuff leak heard prior to extubation. Pt placed on cool\n aerosol via face tent with 35% FiO2, Spo2 100%.\n" }, { "category": "Physician ", "chartdate": "2125-05-19 00:00:00.000", "description": "Intensivist Note", "row_id": 668101, "text": "TSICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n stab wound\n PMHx:\n PMH: asthma\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:40 AM\n EXTUBATION - At 09:43 AM\n Post operative day:\n HD2\n 24hr events: admitted to TICU intubated, right chest tube in place\n admission Hct 40 after 1u transfused at OSH, received 1unit in the ED.\n Extubated in AM. Chest tube output declined. HCT stablbe. Pending tx\n to floor, but in evening developed SOB. CXR okay. Tx nebs.\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:40 AM\n Other medications:\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.9\nC (98.4\n HR: 79 (70 - 107) bpm\n BP: 141/74(88) {87/37(49) - 146/94(104)} mmHg\n RR: 23 (17 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,848 mL\n 360 mL\n PO:\n 480 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n Blood products:\n 375 mL\n Total out:\n 3,005 mL\n 180 mL\n Urine:\n 2,115 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,843 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 455 (455 - 455) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 4.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), right chest tube\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 110 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 39.3 %\n 12.2 K/uL\n [image002.jpg]\n 08:24 AM\n 12:40 PM\n 04:21 PM\n 09:00 PM\n 02:03 AM\n WBC\n 15.6\n 12.2\n Hct\n 40.0\n 38.8\n 39.9\n 38.3\n 39.3\n Plt\n 304\n 280\n Creatinine\n 1.0\n 0.9\n Troponin T\n <0.01\n Glucose\n 105\n 110\n Other labs: PT / PTT / INR:14.2/25.0/1.2, CK / CK-MB / Troponin\n T:679/5/<0.01, ALT / AST:21/26, Alk-Phos / T bili:66/1.2, Amylase /\n Lipase:47/13, Ca:9.0 mg/dL, Mg:2.1 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 23yoM with stab wound to the right chest\n Neurologic: dilaudid prn for pain\n Cardiovascular: stable\n Pulmonary: s/p stab wound to R chest. Cont R-chest tube. Output\n minimal. Albuterol nebs prn.\n Gastrointestinal / Abdomen: NPO, H2, serial exams, No evidence of solid\n visceral injury\n Nutrition: Regular diet\n Renal: no issues. foley likely to d/c\n Hematology: serial Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: 36fr CT, foley, PIV, ETT\n Wounds:\n Imaging:\n Fluids: LR at 100 cc/h\n Consults: Trauma\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Other: Chest Trauma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 06:20 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667984, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt admitted approx 630 to TSICU. Received on CMV, Propofol gtt. When\n lightened, following all commands, appropriate. R CT to wall sxn w/\n moderate serosang output. VSS. HCT 40.\n Action:\n Vent quickly weaned to PS 5/5\n Propofol weaned\n Extubated approx 0945\n HCT checks q4hrs\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt w/ c/o back pain\n (stab wounds), Dilaudid administered PRN. HCT remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n **Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.**\n" }, { "category": "Physician ", "chartdate": "2125-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 667867, "text": "SICU\n HPI:\n 23 yM stabbed 3 x, intubated and chest tube placed at OSH for right\n hemothorax.\n Chief complaint:\n PMHx:\n unknown\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 06:20 AM\n INVASIVE VENTILATION - START 06:20 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.4\nC (95.8\n HR: 70 (70 - 84) bpm\n BP: 107/65(74) {107/65(74) - 132/94(104)} mmHg\n RR: 20 (18 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 370 mL\n PO:\n Tube feeding:\n IV Fluid:\n 89 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -130 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable ), right chest tube in place\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 23yoM with stab wound to the right chest\n NEURO: sedated with propofol\n Pain: dilaudid\n CVS: stable, monitor HR and BP\n PULM: wean to extubate today, hemothorax\n monitor CT output, make sure\n output decreasing before extubation\n GI: NPO, H2, serial exams, ?small spleen lac on CT f/u final read\n (serial HCT), belly exam benign currently\n RENAL: adequate UOP, f/u cr\n HEME: serial Hct Q4 hours for hemothorax,\n ENDO: RISS\n ID: monitor WBC and fver curve\n TLD: 36fr CT, foley, PIV, ETT\n IVF: LR at 100 cc/h\n CONSULTS: trauma surgery\n BILLING DIAGNOSIS: resp insufficency, chest trauma\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - H2\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: Full\n DISPOSITION: ICU\n Lines:\n 16 Gauge - 06:20 AM\n 18 Gauge - 06:20 AM\n Total time spent: 33 min\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 667852, "text": "Trauma, s/p\n Assessment:\n s/p assault from hospital, stab wounds to back and right side.\n Right hemopnumo, ? liver lac.\n Action:\n Admitted to T/SICU from ED at 0615. pt pan scanned in ED.\n Response:\n Pt intubated, on propofol, right CT to sx.\n Plan:\n CXR, serial crits, wean to extubate.\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668031, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n Extubated this am approx 0945\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid PRN\n ?Daily chest xrays\n **Pt on Privacy Alert. This RN able to get in contact w/ pts mother\n , and sister who both reside in .\n Updated on pts status. Visitor obtained.**\n" }, { "category": "Nursing", "chartdate": "2125-05-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 668038, "text": "HPI: 24yoM s/p assault. Injuries include: R hemothorax & stab\n wounds, ?liver lac. CT placed @ OSH. Intubated d/t combativeness.\n Medflighted to from hospital.\n PMH: Asthma\n Events this shift\n Pt c/o sob/difficulty breathing at 2250. LS clear with dim bases bilat.\n O2 sat 98-100%. Pt placed on 2L NC for comfort. Stat chest xray\n obtained which looked unchanged. Pt kept in ICU overnight for further\n monitoring. Will reassess floor transfer in am.\n Trauma, s/p assault\n Assessment:\n Pt s/p assault with R CT placed at OSH to wall sxn w/ moderate serosang\n output. VSS. HCT 40.\n Action:\n HCT checks q4hrs\n 0.5mg IV Dilaudid for pain\n Advanced to regular diet\n Response:\n Pt doing well, VSS. O2 sats 99%, on RA. Pt with c/o back\n pain (stab wounds), Dilaudid administered PRN. HCT remains stable.\n Tolerating regular diet, denies nausea.\n Plan:\n Cont to follow HCT\n Control pain, administer Dilaudid \n Transfer to floor today\n **Pt on Privacy Alert. Pts mother , and sister \n both reside in . Visitor list at desk**\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1072414, "text": " 5:13 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: acute inj, right ct placement, hemothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj, right ct placement, hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound acute injury, right\n chest tube placement, and hemothorax.\n\n COMPARISON: None.\n\n SUPINE FRONTAL RADIOGRAPH OF THE CHEST: ET tube is terminating just above the\n carina, approximately 1.5 cm. NG tube is terminating just below the\n gastroesophageal junction. Lung volumes are low causing bronchovascular\n crowding. There is a relative ground-glass appearance of the right lung which\n could be due to posteriorly layering right pleural effusion in the setting of\n trauma, suspicious for a hemothorax. Chest tube is noted projected over the\n right lower lung. There is a trace right medial basal pneumothorax. There are\n no displaced rib fractures. Aortic contour is well defined. Heart size is\n normal. There is no pulmonary edema. Subtle soft tissue emphysema is noted\n in the right lateral chest wall.\n\n IMPRESSION:\n 1. Low positioned ET tube terminating just above the carina.\n 2. Ground- glass appearance of the right lung could reflect a posteriorly\n layering effusion in the setting of trauma or hemothorax.\n 3. Right lateral chest wall emphysema.\n 4. Trace right medial pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072423, "text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u hemothorax, chest tube position\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with stab wounds, s/p chest tube\n REASON FOR THIS EXAMINATION:\n f/u hemothorax, chest tube position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n Comparison study of earlier the same date.\n\n INDICATION: Hemothorax.\n\n Side port of right chest tube is external to the pleural space, but there is\n no evidence of pneumothorax. Interval improvement in diffuse opacities in the\n right hemithorax, likely a combination of improving pleural effusion,\n atelectasis and contusion. Endotracheal tube tip terminates 3 cm above the\n carina, and a nasogastric tube terminates at the thoracoabdominal junction\n with side port well above the GE junction level, as communicated to Dr.\n on . Otherwise no relevant changes since the recent\n radiograph except for the presence of contrast within the renal collecting\n systems, likely related to recent CT examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072866, "text": " 10:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: inc in ptx\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax s/p Ct removal\n REASON FOR THIS EXAMINATION:\n inc in ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:40 P.M. \n\n HISTORY: Hemothorax. Chest tube removed.\n\n IMPRESSION: AP chest centered at the diaphragm compared to earlier on :\n\n Very small right apical pleural air collection has increased slightly (see the\n lateral costal component). Since removal of the right pleural tube there has\n been no increase in right pleural effusion loculated posteriorly. Moderate\n cardiac enlargement stable. Left lung grossly clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 1072421, "text": " 6:02 AM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: acute inj\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound evaluate for acute\n injury.\n\n COMPARISON: None.\n\n LEFT LEG, THREE VIEWS: There are no acute fractures or alignment\n abnormalities. The mineralization is normal and there are no focal lytic or\n sclerotic osseous lesions. Incidental note of fabella is made. Soft tissues\n are unremarkable.\n\n IMPRESSION: Normal radiographic appearance of the left knee.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072814, "text": " 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right hemothorax with a right chest tube\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 12:28 PM\n There is worsened right lower lobe atelectasis. Persistent low lung volumes.\n There is a small right pneumothorax. Right pleural effusion is mainly located\n posteriorly.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: SP right hemothorax drainage and right chest tube.\n\n Small right pneumothorax has increased from yesterday. There has been\n increase in right lower lobe atelectasis. There are persistent low lung\n volumes. Right chest tube is in place. The side hole is outside the pleural\n cavity. There is mild fluid overload. Cardiac size is accentuated by the low\n lung volumes.\n\n Findings were discussed with Dr. at the time of dictation.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072815, "text": ", E. CC6A 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right hemothorax with a right chest tube\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n There is worsened right lower lobe atelectasis. Persistent low lung volumes.\n There is a small right pneumothorax. Right pleural effusion is mainly located\n posteriorly.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072856, "text": " 7:07 PM\n CHEST (PA & LAT) Clip # \n Reason: Change in ptx - pt now on suction.\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax/ ptx\n REASON FOR THIS EXAMINATION:\n Change in ptx - pt now on suction.\n ______________________________________________________________________________\n WET READ: JRCi SUN 8:05 PM\n Small right apical pneumothorax is now trace after patient is on suction.\n Sideport of chest tube remains overlying the chest wall. No subcutaneous\n emphysema detected. Right lung atelectasis and contusion remain.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n HISTORY: Hemopneumothorax and change in chest drainage.\n\n IMPRESSION: PA and lateral chest compared to earlier on :\n\n A tiny right apical pleural air collection and right pleural tube unchanged in\n position may be fissural, with a side port in the right axillary subcutaneous\n tissue. Mild enlargement of the cardiac silhouette exaggerated by low lung\n volumes is stable. Left lung grossly clear. No left pleural abnormality.\n Mild thoracic scoliosis and thickened left paraspinal soft tissue, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072625, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change - PTX w/ CT\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing\n REASON FOR THIS EXAMINATION:\n Interval change - PTX w/ CT\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:46 A.M. ON \n\n HISTORY: 23-year-old man stabbed.\n\n IMPRESSION: AP chest compared to :\n\n Persistent small right pleural effusion and right basal atelectasis, right\n pleural tube still in place, side port extrathoracic. Mild-to-moderate\n enlargement of the cardiac silhouette is exaggerated by low lung volumes but\n stable since the earliest post-traumatic film on . Left lung is\n grossly clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1072878, "text": " 4:12 AM\n CHEST (PA & LAT) Clip # \n Reason: change in ptx\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with PTX? hemothorax s/p stabbing\n REASON FOR THIS EXAMINATION:\n change in ptx please perform at 4 am\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Assess pneumothorax.\n\n IMPRESSION: Small right pneumothorax increased between 7:10 p.m. and 10:40\n p.m. on following removal of the right pleural tube and has increased\n minimally subsequent to that. Atelectasis in the right lower lung has\n progressed. Today's lateral chest film raised the possibility of posterior\n pleural collection on the right residing in the major fissure rather than\n along the chest wall, but it is stable. Left lung is clear. Moderate cardiac\n enlargement has not changed.\n\n Dr. paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1072415, "text": " 5:18 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 6:04 AM\n no evidene of traumatic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with stab wounds, evaluate for acute injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT-acquired contiguous axial sizes were obtained through\n the brain. Reconstructions in 2.5 mm thin slices in bone algorithm were made.\n Multiplanar reformations were also generated.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, masses, mass effect,\n or shift of normally midline structures. There is no acute major vascular\n territorial infarcts. -white matter differentiation is well preserved.\n Ventricles and sulci are normal in size and configuration. There are no\n displaced skull fractures. Soft tissues are unremarkable.\n\n Please note there is residual contrast in the venous sinuses from outside\n hospital CT torso, which was done with IV contrast.\n\n IMPRESSION: No acute intracranial process. Evaluation of bleed is somewhat\n limited due to residual contrast in the venous sinuses from outside hospital\n performed CT torso.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072416, "text": " 5:20 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P STAB WOUND. ? ACUTE INJURY.\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stab wound\n REASON FOR THIS EXAMINATION:\n acute inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 6:13 AM\n Right Lower lobe contusion or hematoma. Right hemothorax, much smaller than\n prior outside hospital study. heart and great vessels are intact.\n\n no pneumothorax. No evidence of tramatic inury to abdomen and pelvis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with status post stab wound. Evaluate acute\n injury.\n\n COMPARISON: Outside hospital study from at 2:30 a.m.\n\n TECHNIQUE: Helical CT-acquired contiguous axial slices were obtained from the\n top of the lungs to the pubic symphysis after administration of intravenous\n contrast. Oral contrast was not administered. Multiplanar reformats were\n generated.\n\n Images are slightly degraded by arm position by the sides, resulting in streak\n artifact.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The right lateral chest tube with\n tip terminating in the medial pleural surface, abutting the right\n heart/pericardial margin. There is emphysema in the right lateral\n subcutaneous soft tissues. There is intermediate density right pleural\n effusion which could reflect a hemothorax. There is also a right lower lobe\n opacity which could reflect atelectasis or in the setting of trauma, pulmonary\n contusion (not well differentiated on this study). Minimal atelectasis in the\n left lung base is noted. There is no left pleural effusion. There is no\n pneumothorax. Heart and great vessels are intact. There is no evidence of\n mediastinal hemorrhage. NG tube is extending into the stomach. ET tube is\n terminating above the carina, 2.2 cm.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n stomach, pancreas, adrenals, kidneys, and abdominal bowel loops are normal in\n appearance. There is a high-attenuation focus in the posterolateral aspect of\n the spleen which in correlation with the sagittal and coronal images appears\n to be artifactual and due to streak. Outside hospital images also were\n unremarkable for the spleen. The NG tube is in good location. There is no\n evidence of solid organ injury. There is no intraperitoneal free fluid or\n free air. There is no mesenteric or retroperitoneal adenopathy. There is no\n evidence of vascular injury.\n (Over)\n\n 5:20 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P STAB WOUND. ? ACUTE INJURY.\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Rectum, sigmoid colon, pelvic\n bowel loops, prostate, seminal vesicles, and urinary bladder are all\n unremarkable.\n\n OSSEOUS STRUCTURES: There are no focal lytic or sclerotic osseous lesions.\n There is no evidence of fractures.\n\n SOFT TISSUE STRUCTURES: Very small amount of emphysema is noted in bilateral\n posterior wall, right more than left, paraspinal in distribution on the left\n and posterolateral chest wall in distribution on the right.\n\n IMPRESSION:\n\n Right pleural effusion and right lower lobe opacity could reflect\n atelectasis/collapse, and in the setting of trauma other consideration include\n contusion. The right chest tube is at the medial pleural reflection abutting\n the right heart margin with no fluid in that location\n\n No evidence of solid visceral injury in the abdomen or pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072591, "text": " 8:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for R sided hemothorax, kinked chest tube.\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with multiple stab to back, with R chest tube.\n REASON FOR THIS EXAMINATION:\n eval for R sided hemothorax, kinked chest tube.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:06 A.M., \n\n HISTORY: Multiple stab wounds. Right chest tube.\n\n IMPRESSION: AP chest compared to 7:16 a.m. on .\n\n There is no appreciable right pneumothorax. Hazy opacification over the right\n lung base probably represents some posteriorly layering right pleural\n effusion. Bibasilar atelectasis is more pronounced now than earlier today\n following extubation. Air in the mediastinum to the left of the trachea could\n be within the esophagus but should be followed to exclude pneumomediastinum.\n Mild-to-moderate enlargement of the cardiac silhouette is exaggerated by low\n lung volumes, comparable to the earlier post-traumatic film at 7:16 a.m.\n Right pleural tube unchanged in position, crossing the right mid and lower\n chest with at least one side port in the soft tissues of the chest wall.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073978, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval chest tubes\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p R VATS\n REASON FOR THIS EXAMINATION:\n Eval chest tubes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 1:05 PM\n Small right pneumothorax is unchanged. Right apical and right base chest tube\n remain in place.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: SP right VATS. Follow up right pneumothorax.\n\n Comparison is made with prior study performed 7 hours earlier. A small right\n pneumothorax is unchanged. Right apical and right basal chest tubes are in\n place. Minimally improved aeration in the right base. No other interval\n change.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073897, "text": " 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX?\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS\n REASON FOR THIS EXAMINATION:\n PTX?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 10:16 AM\n There is small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Persistent low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess pneumothorax S/P right VATS.\n\n Comparison is made with prior study .\n\n There is a small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Left lower lobe atelectasis is\n unchanged. There are low lung volumes. Cardiomediastinal silhouette is\n unchanged with cardiac size top normal.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073898, "text": ", E. CC6A 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX?\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS\n REASON FOR THIS EXAMINATION:\n PTX?\n ______________________________________________________________________________\n PFI REPORT\n There is small right pneumothorax. Right chest tubes are in place. Right\n lower lobe atelectasis has increased. Persistent low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072958, "text": " 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M stabbed 4x, initially placed chest tube, pulled out yesterday, now with\n worsening infiltrate vs effusion\n REASON FOR THIS EXAMINATION:\n assess infiltrate vs effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 8:00 PM\n All tubes and catheters were removed. Heterogeneous right pleural effusion\n increased, consistent with enlarging hemothorax. Small pneumothorax is new.\n Right lower lobe opacity increased, likely atelectasis but underlying\n contusion cannot be ruled out. Lung contusion along the previous chest tube\n course. Right upper lobe anterior opacity, unchanged, likely contusion.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITH CONTRAST\n\n REASON FOR EXAM: 23-year-old stabbed x4. Initially placed chest tube pulled\n out yesterday. Now with worsening infiltrate versus effusion. Please assess.\n\n TECHNIQUE: Chest MDCT was performed following 75 cc of intravenous Optiray\n using 5 mm and 1.25 mm axial slice thickness. Coronal and sagittal\n reformations were also obtained.\n\n FINDINGS: Since , right heterogeneous pleural effusion\n increased, consistent with enlarging hemothorax post-removal of the chest\n tube. A right pneumothorax is also new, with associated air-fluid levels.\n Subcutaneous emphysema at the entrance of the old chest tube persists.\n\n Lung opacities along the previous chest tube course could be related to\n contusion. Right upper lobe anterior opacities could also be contusions,\n unchanged since the prior study. Left basilar atelectasis increased, still\n small. Minimal left pleural effusion is new. All tubes and catheters were\n removed. Airways are patent to the subsegmental levels. There is no lymph\n node enlargement using CT criteria.\n\n This study was not tailored for subdiaphragmatic evaluation except to note\n heterogeneous attenuation of the liver, likely due to perfusion abnormality.\n There is no bone lesion suspicious for malignancy and no bone fracture.\n\n IMPRESSION:\n 1. Enlarging heterogeneous right pleural effusion, now moderate, consistent\n with progressing hemothorax. New small right pneumothorax, with air-fluid\n levels, likely due to recent removal of the chest tube.\n\n 2. Bibasilar atelectasis, mostly on the right, associated with\n parenchymal opacities, likely contusions, in the anterior segment of the right\n (Over)\n\n 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n upper lobe and along the prior chest tube course.\n\n 3. New tiny left pleural effusion.\n\n 4. Heterogeneous attenuation of the liver, likely due to perfusion\n abnormality; this could be evaluated by dedicated liver study if of clinical\n concern (e.g. if suspected hepatic injury).\n\n Results were discussed on the phone with Tevia at 1:40 p.m.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073608, "text": " 12:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for lung expansion\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax S/P thoracentesis\n REASON FOR THIS EXAMINATION:\n Evaluate for lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis, to evaluate for lung expansion.\n\n FINDINGS: In comparison with earlier study of this date, there is slightly\n less opacification of the right costophrenic angle. The chest tube remains in\n place with the possibly abnormally positioned tip. Basilar atelectatic\n changes are seen.\n\n IMPRESSION: No change in the degree of pneumothorax on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073008, "text": " 4:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TO CONFIRM PLACEMENT OF CHEST TUBE RIGHT SIDE\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with stab wound\n REASON FOR THIS EXAMINATION:\n to confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with stab wound.\n\n Portable AP chest radiograph was reviewed in comparison to \n study obtained at 04:12 a.m.\n\n The current study demonstrates recently inserted chest tube. There is\n significant decrease in the amount of pleural effusion compared to the prior\n studies. The pneumothorax seen on the prior chest CT is not well appreciated\n on the current study, although subcutaneous air collection is seen along the\n lower right chest wall. Note is made that the apices were not included in the\n field of view. Right retrocardiac consolidation and left retrocardiac\n opacities are consistent with atelectasis, although some degree of aspiration\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1072959, "text": ", E. CC6A 1:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: assess infiltrate vs effusion\n Admitting Diagnosis: S/P STABBING\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M stabbed 4x, initially placed chest tube, pulled out yesterday, now with\n worsening infiltrate vs effusion\n REASON FOR THIS EXAMINATION:\n assess infiltrate vs effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n All tubes and catheters were removed. Heterogeneous right pleural effusion\n increased, consistent with enlarging hemothorax. Small pneumothorax is new.\n Right lower lobe opacity increased, likely atelectasis but underlying\n contusion cannot be ruled out. Lung contusion along the previous chest tube\n course. Right upper lobe anterior opacity, unchanged, likely contusion.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073210, "text": " 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: assess PTX, fluid collection on right\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax; CT in place\n REASON FOR THIS EXAMINATION:\n assess PTX, fluid collection on right\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 6:08 PM\n PFI: No pneumothorax. No change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n REASON FOR EXAM: 23-year-old man with pneumothorax, chest tube in place,\n assess pneumothorax and fluid collection.\n\n Since yesterday, a right chest tube is in unchanged position. Right pleural\n effusion and right lower lobe consolidation are stable. There is no\n pneumothorax. Left basilar atelectasis is unchanged. There is no other\n change.\n\n Overall, there is no significant change since yesterday.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073211, "text": ", E. CC6A 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: assess PTX, fluid collection on right\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with hemothorax; CT in place\n REASON FOR THIS EXAMINATION:\n assess PTX, fluid collection on right\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax. No change.\n\n" }, { "category": "ECG", "chartdate": "2125-05-18 00:00:00.000", "description": "Report", "row_id": 242700, "text": "Sinus rhythm. Non-diagnostic inferior Q wave pattern, may be a normal variant\nbut cannot exclude prior inferior myocardial infarction. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1073394, "text": " 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing w/ chest tube placement, concerning for loculation\n of fluid\n REASON FOR THIS EXAMINATION:\n eval for effusion, empyema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRGe WED 3:27 PM\n PFI:\n 1. Effusion consistent with hemothorax. Small right pneumothorax is also\n unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post stabbing with chest tube placement, concerning for\n loculation of fluid.\n\n COMPARISON: Multiple studies, the most recent chest CT dated .\n\n TECHNIQUE: MDCT axial images through the chest with IV contrast. Multiplanar\n and lung reformats were displayed.\n\n CT OF THE CHEST WITH IV CONTRAST: There is a right-sided chest tube which is\n kinked and abutting the right atrium of the heart. Previously described\n heterogeneous hyperdense fluid collection in the right hemithorax is unchanged\n in size and consistent with hemoperitoneum. There is no evidence of loculated\n pleural fluid. Associated compressive atelectasis on the right side are noted.\n There is a small right pneumothorax. No enhancement of the pleura is noted.\n Dependent atelectasis on the left side. No evidence of pleural effusion on\n the left. The heart is at the upper limits of normal. There is no\n pericardial effusion. There is no mediastinal, hilar, or axillary\n lymphadenopathy.\n\n This study is not designed for infradiaphragmatic evaluation; however, the\n imaged portions of the upper abdomen are within normal limits.\n\n BONE WINDOWS: No suspicious lesions are identified.\n\n IMPRESSION:\n 1. Unchanged right hyoerdense pleural effusion consistent with hemothorax. No\n evidence of loculation. Small right pneumothorax is also unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n\n (Over)\n\n 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The findings were discussed with Dr. at the time of the dictation.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1073395, "text": ", E. CC6A 11:13 AM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for effusion, empyema\n Admitting Diagnosis: S/P STABBING\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p stabbing w/ chest tube placement, concerning for loculation\n of fluid\n REASON FOR THIS EXAMINATION:\n eval for effusion, empyema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Effusion consistent with hemothorax. Small right pneumothorax is also\n unchanged.\n 2. Right-sided chest tube is kinked and malpositioned abutting the right\n atrium. Repositioning is recommended.\n 3. Bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074128, "text": " 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS washout, now s/p CT removal\n REASON FOR THIS EXAMINATION:\n please evaluate for PTX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 12:52 PM\n There is a small right apical pneumothorax. Small-to-moderate pleural\n effusion is increased.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n There is a tiny right apical pneumothorax. Right basal chest tube remains in\n place. There is mild increase in small-to-moderate loculated right pleural\n effusion. Persistent low lung volumes. Cardiomediastinal contours are\n unchanged. Opacities in the right lung greater in the lower lobe are\n unchanged from prior.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-05-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074247, "text": " 11:42 AM\n CHEST (PA & LAT) Clip # \n Reason: ? interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p L VATS evacuation of hemothorax\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left VATS, evacuation of hemothorax.\n\n FINDINGS: In comparison with the study of , there is little change. Tiny\n right apical pneumothorax persists with the right chest tube removed. Some\n loculated right pleural effusion is again seen. The appearance of the heart\n and lungs is essentially clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1074129, "text": ", P. FA9A 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p right VATS washout, now s/p CT removal\n REASON FOR THIS EXAMINATION:\n please evaluate for PTX\n ______________________________________________________________________________\n PFI REPORT\n There is a small right apical pneumothorax. Small-to-moderate pleural\n effusion is increased.\n\n" }, { "category": "Radiology", "chartdate": "2125-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073027, "text": " 6:01 PM\n CHEST (PA & LAT) Clip # \n Reason: Status post Chest tube. XRAY not of great quality. Chest t\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p chest tube.\n REASON FOR THIS EXAMINATION:\n Status post Chest tube. XRAY not of great quality. Chest tube looks kinked.\n Please do PA and Lateral to assess placement of tube\n ______________________________________________________________________________\n WET READ: PXDb MON 7:37 PM\n Apparant kink near the tip, is not noted on lateral view and could reflect\n posterior turn. Increased RLL opacity, could reflect worsening atelectasis.\n ( )\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after insertion of the\n chest tube.\n\n PA and lateral upright chest radiograph was compared to several prior studies\n obtained between and .\n\n There is again worsening of the right lower lung consolidation with potential\n interval increase of pleural effusion. This also might represent recurrent\n aspiration or interval development of infection. There is no pneumothorax.\n The left basal opacity is minimal and consistent with atelectasis. There is\n no appreciable pneumothorax demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073655, "text": " 4:39 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p CT removal on right side please do BEFORE 5:30 pm\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n s/p CT removal on right side please do BEFORE 5:30 pm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, the right chest\n tube has been removed. There has been some increase in the degree of right\n pneumothorax since the previous study. Otherwise, little change except for a\n somewhat better inspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-05-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1073580, "text": " 10:08 AM\n CHEST (PA & LAT) Clip # \n Reason: assess hemothorax, interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old mans/p stabbing to back; now with CT in place\n REASON FOR THIS EXAMINATION:\n assess hemothorax, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old man, status post stabbin at the back, now with chest\n tube in place. Assess for hemothorax and interval change.\n\n COMPARISON: Chest radiograph on and chest CT on .\n\n PA AND LATERAL CHEST RADIOGRAPHS: A chest tube with right lateral approach is\n seen with the tip kinked and abutting the right atrium. The cardiac\n silhouette is top normal. Mediastinal, hilar contours and pulmonary\n vasculature are normal.\n\n In the right hemithorax, there is interval increase of apical pneumothorax,\n particularly compared to the prior chest radiograph two days ago, but only\n minimally increased compared to the CT yesterday. Increased opacity in the\n right basilar region is also noted, concordant with the CT finding of\n increased pleural effusion. There are persistent small linear opacities in the\n right mid lung consistent with atelectasis.\n\n In the left hemithorax there is minimal blunting at the left costophrenic\n angle, but no evidence of large pleural effusion. There is no left-sided\n pneumothorax. Linear basilar atelectasis persists, but the left lungs are\n otherwise clear.\n\n IMPRESSION:\n\n 1. Small interval increase of the right apical pneumothorax, but the\n pneumothorax remains small.\n 2. Unchanged kink at the tip of the chest tube, abutting the right atrium.\n Repositioning is again recommended.\n 3. Persistent bibasilar atelectasis, with interval increase of right-sided\n pleural effusion since .\n\n Dr. has discussed the findings with primary team, Dr. at\n 11:00 a.m. on the date of this study.\n\n jr\n\n" }, { "category": "Radiology", "chartdate": "2125-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073979, "text": ", P. FA9A 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval chest tubes\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p R VATS\n REASON FOR THIS EXAMINATION:\n Eval chest tubes\n ______________________________________________________________________________\n PFI REPORT\n Small right pneumothorax is unchanged. Right apical and right base chest tube\n remain in place.\n\n\n" } ]

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199,103

After being treated in the Medical Intensive Care Unit with Dilantin and Ativan for seizures, he was transferred to the neurology floor for further management. He was continued on Dilantin 100 mg three times a day. His levels were therapeutic. His Ativan was tapered to off. He had another routine electroencephalogram the day before discharge which did not demonstrate any epileptiform activity. He continued to receive dialysis for end stage renal disease and also Levaquin for a ten day course of five total doses. The patient was discharged home on .

PNA, he was started on reanal dose levaquin..GI- +bs, abd soft, nontender, no bm. He was brought to the ED where he was febrile, confused and his sbp was 200- 210, he was given labetolol, later in the day he had HD, and was then sent to EEG, it showed non-convulsive status epilepticus and he was given ativan iv and the event resolves itself. also started on ativan 2mg iv q6h.Cv- Hr 70s sr, no ectopy, bp stable, 128/54 - 135/72, denies cp or sob. Peripheral hl x2 intact and patent.Resp- Bil ls cta, sats 94 - 97%, rr low 20s, his cxr showed bibasal patchy infiltrate-? Kept npo x meds overnight. Pt had HD earlier, No urine overnight.Skin - warm, dry and intact.ID- adm temp 99.8, wbc 8.2, cxr,?pna, no cough, LP done in ed gram stain neg, cxs pending, continues on po levoquin. Left ventricular hypertrophy with ST-T wave changes. He was loaded with dilantin 600mg iv as dilantin level was only 4.9, stiil a ? Poor R wave progression - question due to left ventricularhypertrophy. head ct neg, LP cx pending. Left axis deviation - possible left anteriorfascicular block. He had HD yesterday, ? Tmax 99.9, all reflexes intact, MAE, no edema, good pulses. how many liters were taken off. The plan is to follow is dialantin level, make him therapeutic, maintain safety, treat his pNA, follow up on LP cx. He was transferred to micu overnight for poss ativan drip and closer monitoring.Review of system- Pt alert, pleasantly confuse, answer inquires with ease but without warning start removing clothes, monitor wires and heplock, several times he put siderails down by himself and tried to climb out of bed. Pt is a full code, he his on waiting list for a kidney. Compared tothe previous tracing of T wave changes have improved in lead aVL. Admission Note:53yr old with hx of tonic- clonic sz under controll x5 yrs, on dilantin at home, on he was reportedly wandering around in a theatre and then he called is family to say his wallet was missing, his responses were slow if any at all, he was also noted to have facial grimaces and squinting of the eyes, hx includes esrd(2 failed renal transplant) on HD 3x/wk, htn and hep c (please see h/p for more hx). Sinus rhythm. Long QTc interval. as to why his levels were that low.

2

[ { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1359589, "text": "Admission Note:\n53yr old with hx of tonic- clonic sz under controll x5 yrs, on dilantin at home, on he was reportedly wandering around in a theatre and then he called is family to say his wallet was missing, his responses were slow if any at all, he was also noted to have facial grimaces and squinting of the eyes, hx includes esrd(2 failed renal transplant) on HD 3x/wk, htn and hep c (please see h/p for more hx). He was brought to the ED where he was febrile, confused and his sbp was 200- 210, he was given labetolol, later in the day he had HD, and was then sent to EEG, it showed non-convulsive status epilepticus and he was given ativan iv and the event resolves itself. He was transferred to micu overnight for poss ativan drip and closer monitoring.\n\nReview of system- Pt alert, pleasantly confuse, answer inquires with ease but without warning start removing clothes, monitor wires and heplock, several times he put siderails down by himself and tried to climb out of bed. Tmax 99.9, all reflexes intact, MAE, no edema, good pulses. head ct neg, LP cx pending. He was loaded with dilantin 600mg iv as dilantin level was only 4.9, stiil a ? as to why his levels were that low. also started on ativan 2mg iv q6h.\n\nCv- Hr 70s sr, no ectopy, bp stable, 128/54 - 135/72, denies cp or sob. He had HD yesterday, ? how many liters were taken off. Peripheral hl x2 intact and patent.\n\nResp- Bil ls cta, sats 94 - 97%, rr low 20s, his cxr showed bibasal patchy infiltrate-? PNA, he was started on reanal dose levaquin..\n\nGI- +bs, abd soft, nontender, no bm. Kept npo x meds overnight.\n\n Pt had HD earlier, No urine overnight.\n\nSkin - warm, dry and intact.\n\nID- adm temp 99.8, wbc 8.2, cxr,?pna, no cough, LP done in ed gram stain neg, cxs pending, continues on po levoquin.\n\n Pt lives with brother (), he has 2 children and an ex-wife.\n\n Pt is a full code, he his on waiting list for a kidney. The plan is to follow is dialantin level, make him therapeutic, maintain safety, treat his pNA, follow up on LP cx.\n\n" }, { "category": "ECG", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 246806, "text": "Sinus rhythm. Long QTc interval. Left axis deviation - possible left anterior\nfascicular block. Poor R wave progression - question due to left ventricular\nhypertrophy. Left ventricular hypertrophy with ST-T wave changes. Compared to\nthe previous tracing of T wave changes have improved in lead aVL.\n\n\n" } ]

28,394

186,832

# Hematemesis Admitted with etoh cirrhosis complicated by hx of varices with hematemesis. S/p EGD where no active variceal bleeding was noted. Thought due to coagulopathy and gingival bleeding. Patient had EGD here showing grade 3 varices with evidence of recent bleed. 6 bands placed. No bleeding while in house and was discharged from the MICU in stable condition, with stable Hcts and off Octreotide gtt. Patient was tolerating a soft foods diet. He will continue on Cipro 500 mg for a total of 7 days and a ppi PO BID. . # Decompensated alcoholic cirrhosis Due to long-standing etoh. Complicated by portal hypertension, varices (grade III), splenomegaly and consumptive thrombocytopenia. No hx of prior liver biopsy. Current MELD score 20. No evidence of SBP on admission and patient did not receive a paracentesis. RUQ with patent portal flow and moderate ascites. Splenomegaly noted. Patient was continued on lactulose and nadolol. Autoimmune serologies were drawn and pending at the time of discharge. No evidence of alcohol withdrawal. . # Macrocytic Anemia Likely marrow toxicity from long standing etoh. B12/folate nml at OSH. Hct stable from OSH - no prior baseline. He may need outpatient Heme consult if counts do not respond within months of abstinence. . # Pancytopenia: Likely in part due to EtOH-induced marrow suppression, hypersplenism +/- other etiologies. Apparently B12 and folate normal at OSH. Patient did not require blood or platelet transfusion. ANC was 1590 on admission and it is thought that his counts will improve in the absence of EtOH. .

1 PIV dc'd, outof vein after bleeing from site intermittently.GI: tolerating soft solid, bowel sounds present, continues on lactulose. rr normalGI/GU: abd slightly distended-+ BS. Skin WDI.Resp: 95-97% on RA; LS diminished initially; increased aeration and clear after turning/positioning.GI: Abd softly distended, +BS, No BM. US of abdomen organs and blood vessels done, no bleeding or occlusion noted per preliminary read, official result not in yet.GU: -800cc since MN and - 1.6 L for LOS, urine culture atill pending.ID: continues on cirpofloxacin q24hrs, afebrile. 4) Coarse liver echogenicity consistent with history of cirrhosis. Lethargic post procedure. voided small amt of 20cc initially after removal.ID: afebrile. Able to move extremities, written for ativan PRN for CIWA scale > 10, scale had been .CV: hemodynamically stable, SR without ectopy. The liver is somewhat coarsened consistent with the history of cirrhosis. LIVER DOPPLER: GREY SCALE ULTRASOUND: There is a moderate amount of perihepatic ascites. C/O slight pain to right lower quadrant intially after egdCV: NSR with hr 60's, NBP 110-120's with maps >60. transferred to BIDNMC fro further treatment.in MICU, no further bleeding, hct stable. MICU 7: RN Note 1900-0700Events: Admitted to Hospital w/Hematemesis; EGD showed inactive varices. Nursing Progress Note 1900-0700 hours:** Full code** allergies: nkda** access: 2 piv'sIn brief: pt is a 43 yo M, pmh: mild portal htn, esoph varices, etoh withdrawal, s/p banding x 4 .Presented to OSH with hematemesis x 1 day, hct 32, placed on octreotide and ppi, NGL neg. #18 RUE (KVO and Octretide infusing); #16 LUE (KVO) w/very good blood return (first chem hemolyzed-re-sent K). PIVs wnl.Respi: sats > 95% at room air, lung sounds clear.GI: remains NPO for endoscopy with possible variceal banding this evening. Placed on Octerotide drip. Sm umb hernia. Bowel sound present, no BM this shift.Continues on lactulose TID for increased ammonia level ( titrate for 3 BM / day ). Tcx'd to for work-up.In MICU-no further bleeding noted. (Over) 9:41 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: eval liver with DOPPLERs. Started on clears last night-tol well with moderate amt PO intake. 9:41 AM ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # Reason: eval liver with DOPPLERs. In brief: 43 year old with PMH : mild portal htn, esphageal varices, etoh withdrawal, s/p banding x 4 last presented OSH with hematemesis x 1 day, hct 32, on octreotide and ppi, ng lavage and EGD neg for bleeding, thought ti be bleeding from gums. Octreotide dc'd 1600GU: voiding adequately, 1 1L for LOS.ID: continues on ciprofloxacin x 3 daysSkin: intactSocial: patient's brother update with plan of care. Hepatology following, recs to increase cipro to x 7 days for varices infection.Heme: hct monitor , remains stable.Skin: intactSocial: patient has been made aware of the importance of stopping ETOH intake and have agreed upon. EGD with no active bleed found-6 varices banded. Has been on octreotide gtt.NEURO: A & O x3. EGD with no active bleeding, 6 varices banded.neuro: dosing intermittently most of the day, denies pain. Underwent EGD with varices and found to have no active bleeding and thought to be from bleeding gums. Sent for Urinalysis and C&S.Endo: FS 113 and 99.Social: Lives w/roommate. addendum: EGD done 1830, no active bleeding seen. Admission hct is 32 at OSH, s/p NG lavage which was negative, EGD revealed no active bleeding but + for esophageal varices. patient says he is sleepy due to waking up early.respi: sats> 95% at room air, lung sounds clear, dim at bases.CV: hemodynamically stable, SR without ectopy. 5) Moderate ascites. monitor s/s of withdrawal. eval portal flow, r/o liver masse Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED FINAL REPORT (Cont) hct stable. hct stable. Banding of 6 esophageal varices done. Evaluate portal flow, rule out liver lesions. Gastric lavage neg. Main hepatic artery is patent. started on nodalol. TIPS REASON FOR THIS EXAMINATION: eval liver with DOPPLERs. 6) Splenomegaly. On cipro x 7 days for gi prophylaxis with scope.SKIN: no breakdown.SOCIAL: brother called on evenings-plans to visit today.PLAN: -monitor for S & S of bleed, hcts -advance diet as ordered/tol -contm ed regimen and icu plan of care -octreotide gtt -liver recommendations -assess void s/p foley removal -assess S & S of w/drawal Hct decr from 32 on arrival to 29 this morning. Goal tx keep >25.RESP: lungs clear. No bloody stools; no hematemesis.Neuro: AAO x3 but slow to respond. transferred to for further intervention, possible variceal banding and TIPS procedure.NKDAFull codeNeuro: alert and oriented x 3, denies any pain. octreotide gtt. Evaluate liver with Doppler. Hx Etoh (recent stay at detox facility-last drink was Sunday), UGIB, Banding x4 in . Rec'd on 2l nc from egd-placed on RA with sats 94-98%. Transferred to ; arrived ~. on supplemental O2 2 lpm, sats > 95%. Protonix adm. Pt requesting water. advance diet as needed. Cont ppi. Rec'd 6 pack plts. 3) No focal liver lesions. In brief: 43 year old male with histiry of ETOH cirrhosis, portal hypertension, and prior GI bleeding due to esophgeal varices transfered from OSH with hematemesis. OOB early this am, steady gait. Ammonia 144. Knows that it is detrimetal to his health. UOP varied between 30-120/hr after initial output. Enlarged spleen. Brother is primary contact (: number on board).Plan: NPO for Liver/Gall Bladder USN at 0930; TIPS procedure.

7

[ { "category": "Radiology", "chartdate": "2170-10-31 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 984657, "text": " 9:41 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval liver with DOPPLERs. eval portal flow, r/o liver masse\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with etoh cirrhosis, transferred here for ? TIPS\n REASON FOR THIS EXAMINATION:\n eval liver with DOPPLERs. eval portal flow, r/o liver masses\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with known cirrhosis, for possible TIPS. Evaluate\n liver with Doppler. Evaluate portal flow, rule out liver lesions.\n\n COMPARISONS: None.\n\n LIVER DOPPLER:\n\n GREY SCALE ULTRASOUND: There is a moderate amount of perihepatic ascites. The\n liver is somewhat coarsened consistent with the history of cirrhosis. No\n focal liver lesions are identified. There is no intra or extrahepatic biliary\n dilatation. The CBD measures 7 mm. There is equivocal gallbladder wall\n thickening, however, this could be due to third spacing. No cholelithiasis or\n sludge is seen. The right kidney measures 12.1 cm in length. The left kidney\n measures 11.2 cm in length. The spleen is enlarged measuring 15.0 cm in\n greatest diameter and appears bulky.\n\n LIVER DOPPLER ULTRASOUND: The evaluation is limited due to the patient's\n inability to hold his breath. Patency of the main portal vein, anterior\n branch of the right portal vein and left portal vein as well as hepatic veins\n are demonstrated. Evaluation of the posterior branch of the right right\n portal vein and the left portal vein is limited due to patient inability to\n hold his breath. Main hepatic artery is patent.\n\n IMPRESSION:\n 1) Technically limited Doppler study due to inability of the patient to hold\n his breath.\n\n 2) Within these limitations, No definite evidence for intraluminal thrombus,\n however nonocclusive thrombus cannot be excluded.\n\n 3) No focal liver lesions.\n\n 4) Coarse liver echogenicity consistent with history of cirrhosis.\n\n 5) Moderate ascites.\n\n 6) Splenomegaly.\n\n\n\n (Over)\n\n 9:41 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval liver with DOPPLERs. eval portal flow, r/o liver masse\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2170-11-01 00:00:00.000", "description": "Report", "row_id": 1632728, "text": "Uneventful day for Mr. \n\nIn brief: 43 year old with PMH : mild portal htn, esphageal varices, etoh withdrawal, s/p banding x 4 last \n\npresented OSH with hematemesis x 1 day, hct 32, on octreotide and ppi, ng lavage and EGD neg for bleeding, thought ti be bleeding from gums. received 6 units of platelets. transferred to BIDNMC fro further treatment.\n\nin MICU, no further bleeding, hct stable. EGD with no active bleeding, 6 varices banded.\n\nneuro: dosing intermittently most of the day, denies pain. OOB early this am, steady gait. patient says he is sleepy due to waking up early.\n\nrespi: sats> 95% at room air, lung sounds clear, dim at bases.\n\nCV: hemodynamically stable, SR without ectopy. started on nodalol. 1 PIV dc'd, outof vein after bleeing from site intermittently.\n\nGI: tolerating soft solid, bowel sounds present, continues on lactulose. no Bm this shift. Octreotide dc'd 1600\n\nGU: voiding adequately, 1 1L for LOS.\n\nID: continues on ciprofloxacin x 3 days\n\nSkin: intact\n\nSocial: patient's brother update with plan of care. waiting for bed, called out to floor.\n\nplan: transfer once with available bed, monitor s/s of bleed, hct. advance diet as needed. monitor s/s of withdrawal.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632726, "text": "addendum: EGD done 1830, no active bleeding seen. Banding of 6 esophageal varices done. patient given 2 mgs of IV midazolam and 100mcg of fentanyl IV push. Hemodynamically stable the whole procedure. on supplemental O2 2 lpm, sats > 95%. Lethargic post procedure.\n" }, { "category": "Nursing/other", "chartdate": "2170-11-01 00:00:00.000", "description": "Report", "row_id": 1632727, "text": "Nursing Progress Note 1900-0700 hours:\n** Full code\n\n** allergies: nkda\n\n** access: 2 piv's\n\nIn brief: pt is a 43 yo M, pmh: mild portal htn, esoph varices, etoh withdrawal, s/p banding x 4 .\n\nPresented to OSH with hematemesis x 1 day, hct 32, placed on octreotide and ppi, NGL neg. Underwent EGD with varices and found to have no active bleeding and thought to be from bleeding gums. Rec'd 6 pack plts. Tcx'd to for work-up.\n\nIn MICU-no further bleeding noted. hct stable. EGD with no active bleed found-6 varices banded. Has been on octreotide gtt.\n\nNEURO: A & O x3. No S & S of withdrawal. Slightly shakey on feet with ambulation to chair. Follows all commands. C/O slight pain to right lower quadrant intially after egd\n\nCV: NSR with hr 60's, NBP 110-120's with maps >60. hct stable. octreotide gtt. Goal tx keep >25.\n\nRESP: lungs clear. Rec'd on 2l nc from egd-placed on RA with sats 94-98%. rr normal\n\nGI/GU: abd slightly distended-+ BS. Started on clears last night-tol well with moderate amt PO intake. To advance diet today as tol. Cont ppi. foley dc'd at 2a due to discomfort-was voiding adeq amber, yellow urine (see carevue). voided small amt of 20cc initially after removal.\n\nID: afebrile. On cipro x 7 days for gi prophylaxis with scope.\n\nSKIN: no breakdown.\n\nSOCIAL: brother called on evenings-plans to visit today.\n\nPLAN: -monitor for S & S of bleed, hcts\n -advance diet as ordered/tol\n -contm ed regimen and icu plan of care\n -octreotide gtt\n -liver recommendations\n -assess void s/p foley removal\n -assess S & S of w/drawal\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632724, "text": "MICU 7: RN Note 1900-0700\n\n\nEvents: Admitted to Hospital w/Hematemesis; EGD showed inactive varices. Gastric lavage neg. Ammonia 144. Enlarged spleen. Rec'd six pack platelets. Hx Etoh (recent stay at detox facility-last drink was Sunday), UGIB, Banding x4 in . Transferred to ; arrived ~. Placed on Octerotide drip. Hct decr from 32 on arrival to 29 this morning. No bloody stools; no hematemesis.\n\n\nNeuro: AAO x3 but slow to respond. More clear in am. MAE. Holds arms with slight drift toward bed. No signs of ETOH w/d. Last drink was Sunday. Denies pain. Slept much of the night.\n\nCV: HR 60s SR; BP 1-teens/70s (100/57 at 6am). #18 RUE (KVO and Octretide infusing); #16 LUE (KVO) w/very good blood return (first chem hemolyzed-re-sent K). Compression sleeves on. Skin WDI.\n\nResp: 95-97% on RA; LS diminished initially; increased aeration and clear after turning/positioning.\n\nGI: Abd softly distended, +BS, No BM. Sm umb hernia. Lactulose adm at ~midnight. Protonix adm. Pt requesting water. NPO...ice chips only.\n\nGU: Pt incont x1 at outside hospital. Bedding wet on arrival. on admission with UOP 700 within first hour. UOP varied between 30-120/hr after initial output. Foul smell/Amber color. Sent for Urinalysis and C&S.\n\nEndo: FS 113 and 99.\n\nSocial: Lives w/roommate. Brother is primary contact (: number on board).\n\nPlan: NPO for Liver/Gall Bladder USN at 0930; TIPS procedure. Suggest social service consult for assistance with etoh.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-31 00:00:00.000", "description": "Report", "row_id": 1632725, "text": "In brief: 43 year old male with histiry of ETOH cirrhosis, portal hypertension, and prior GI bleeding due to esophgeal varices transfered from OSH with hematemesis. Admission hct is 32 at OSH, s/p NG lavage which was negative, EGD revealed no active bleeding but + for esophageal varices. No intervention given, thought that this is due to bleeding gums. transferred to for further intervention, possible variceal banding and TIPS procedure.\n\nNKDA\n\nFull code\n\nNeuro: alert and oriented x 3, denies any pain. Able to move extremities, written for ativan PRN for CIWA scale > 10, scale had been .\n\nCV: hemodynamically stable, SR without ectopy. pedal pulses easily palpable, no edema noted. PIVs wnl.\n\nRespi: sats > 95% at room air, lung sounds clear.\n\nGI: remains NPO for endoscopy with possible variceal banding this evening. Bowel sound present, no BM this shift.Continues on lactulose TID for increased ammonia level ( titrate for 3 BM / day ). US of abdomen organs and blood vessels done, no bleeding or occlusion noted per preliminary read, official result not in yet.\n\nGU: -800cc since MN and - 1.6 L for LOS, urine culture atill pending.\n\nID: continues on cirpofloxacin q24hrs, afebrile. Hepatology following, recs to increase cipro to x 7 days for varices infection.\n\nHeme: hct monitor , remains stable.\n\nSkin: intact\n\nSocial: patient has been made aware of the importance of stopping ETOH intake and have agreed upon. Knows that it is detrimetal to his health. brother called for update.\n\nplan:\n\nEGD and possible variceal banding this evening; possible call out to floor after EGD if continues to be stable; monitor hct , transfuse < 25\n" }, { "category": "ECG", "chartdate": "2170-10-30 00:00:00.000", "description": "Report", "row_id": 219748, "text": "Technically difficult study\nSinus rhythm\nInferior/lateral ST-T changes\nNo previous tracing available for comparison\n\n" } ]

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This is a 63 year old male with PMH of severe systolic HF with an EF=25%, afib on coumadin, who presented with hypotension and found to have questionable adrenal insufficiency in the setting of a likely gout flare. . #. Hypotension: Possibly due to adrenal insufficiency, given symptoms of fever, hypotension, diarrhea, high eosinophils, hyponatremia, and hyperkalemia with low cortisol failed ACTH stimulation ( stim 6->10->10). Confounding factors are that colchicine causes diarrhea and allopurinol induces hypereosinophilia. An abdominal CT without contrast showed no evidence of adrenal pathology. Initially, the patient had fever and tachypnea concerning for septic shock possibly from a pulmonary source as a possible pneumonia was seen on CT scan. He did have a normal lactate and no leukocytosis. Septic arthritis was considered given prominent joint complaints and history of gout, although his joint was tapped by and was negative for infection. He was on vasopressors on admission, but weaned off over 48 hours. He was subsequently normotensive with a normal lactate. He was started on IV hydrocortisone in the ICU which was transitioned to oral prednisone on . endocrine team recommended a quick prednisone taper to 20mg on , 10mg on , then off on . The patient's pressures remained stable off of prednisone for greater than 24 hours. Cortisol and free cortisol levels were sent on when the patient was off of steroids for 24 hours and he was sent home on prednisone 5mg daily until he can be followed up in the endocrine clinic. CMV, HIV, RPR, and TSH were all sent to rule out other causes of adrenal insufficiency. HIV, CMV, and RPR negative. TSH was low with high free T4 and low T3 attributed to SICU thyroid. It is therefore unlikely that the patient is panhypopit. The patient said that a PPD placed 3 months prior was negative for Tb. An adrenal MRI was considered to rule out hemorrhage while on coumadin or infection but could not be performed with his ICD in place. . #. Gout: The patient redeveloped right ankle swelling and pain on in the setting of decreasing his prednisone from 20mg to 10mg. Allopurinol was continued and he was restarted on daily colchicine. His uric acid level was 5.8 on . Colchicine was restarted with a 1.2mg dose followed by 0.6 mg dose on . He was started on low dose prednisone 5mg daily both to prevent gout and hypotension (from possible adrenal insufficiency) until he follows up as an outpatient with endocrinology. . #. Infection/sepsis: The patient was febrile and admission blood cultures were growing coag negative staph which was likely a contaminant. CT chest on admission showed an opacity that was read as being consistent with atelectasis vs. PNA. He received empiric broad spectrum antibiotics (Zosyn, vancomycin, flagyl) in the ICU until , but they were discontinued prior to transfer to the floor. The patient remained afebrile, but developed a leukocytosis with peak WBC count of 12.3 on which was likely secondary to a gout flare as the leukocytosis resolved after proper gout treatment and no abx. TTE showed no evidence of vegetations on valves or hardware. tapped his swollen joint in the ICU and it was negative for infection. His central line was removed on and the catheter tip culture was negative. All blood and urine cultures were negative. . #. Hyperglycemia: The patient initially had poor glucose control in the setting of high dose steroids. He required an insulin gtt in the ICU and was started on Lantus/HISS upon transfer from the ICU. His sugars improved dramatically as he was weaned off of steroids and he was discharged on his home Novolog sliding scale. . #. : The etiology was likely pre-renal given that his UA was bland. His creatinine peaked at 4.2 and improved with IVFs. A renal U/S was normal and his creatinine was his creatinine was back down to his baseline of 1.1 upon discharge. His home Diovan was restarted on . Torsemide was held given his hypotension and potential to provoke gout flare. Given his severe CHF, the torsemide may need to be restarted as an outpatient. His ankles did have 1+ edema, but his lungs were clear on discharge. . #. Elevated INR: The patient's INR trended up to 11.5 on requiring vitamin K administration. The etiology of this rise was unclear, but may have been secondary to poor PO intake prior to admission. His Coumadin dose was decreased to 2 mg daily before discharge with therapeutic INRs resulting. . #. CHF: The patient has non-ischemic cardiomyopathy with an EF=25% and severe TR. Initially, all of his cardiac meds except for digoxin were held given his hypotension requiring pressors. He was restarted on his home Diovan 40mg on and his carvedilol 3.125mg was restarted upon discharge. His home torsemide was not re-initiated given his hypotension and the potential of triggering another gout flare. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He should follow-up with Dr. ans an outpatient for further titration of his cardiac meds. . #. Atrial Fibrillation: His home carvedilol was held initially given his hypotension, but was restarted on discharge. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He was continued on Coumadin at discharge after it was initially held for an INR=11. . #. Sinusitis: The patient has had several months of sinus congestion and was started on fluticasone nasal spray. . #. Eosinophilia: His absolute eosinophil count on admission was about 900 and has been noted in past labs. This finding was concerning for malignancy, occult parasitic infection, or Churg-. However, his eosinophilia improved with steroids and ANCA was negative. . #. Communication: Patient and (wife) who works in Radiology for and can be reached at home , cell , work . #. Code: Confirmed full code.

- Hold carvedilol given shock - Hold diovan given shock - Restart digoxin given low level this AM - Hold torsemide and dose as needed. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) Allergies: Unasyn (Intraven.) ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. Mild retrocardiac atelectasis is again seen. - PM lytes/creatinine . Hypotension: Off of levophed. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. # Gout: Renally dose allopurinol. - Check cortisol given h/o recent prednisone use. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Hold carvedilol given shock - Hold diovan given shock - Hold digoxin and check level -> consider dosing for A. fib if level not elevated. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. - Vanco given ED, continue q48 - Zosyn -> trend LFT's given h/o allergy to unasyn - Levaquin given in ED. holding torsemide in setting of hypovolemia. Also consider adrenal insufficiency given eosinophilia. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. - Hold carvedilol given shock - Hold diovan given shock - Restart digoxin given low level this AM - Hold torsemide and dose as needed. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. States he feels a lot better than when he came in Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.3 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. Pt is being treated for pna with IV ABXs as noted. Pt is being treated for pna with IV ABXs as noted. Pt is being treated for pna with IV ABXs as noted. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. # Atrial Fibrillation: h/o and returned to with dopamine on board. # Atrial Fibrillation: h/o and returned to with dopamine on board. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Medicate for pain prn. Started on hydrocortisone 100mg q 6hr Response: Felt comfortable after pain med Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.8 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. ARF: Likely pre-renal from poor-perfusion of kidneys, but must consider ATN given hypotension. Hypotension (not Shock) Assessment: Pt on Levophed and Vasopressin at start of shift. Calcified granulomas in the right lower lobe (2:46 and 2:30) are noted. Blood pressures dropped to the 70s systolic and he was given 1L IVF, a CVL was placed and CVP was 13-16. # Atrial Fibrillation: h/o and returned to with dopamine on board. Started on hydrocortisone 100mg q 6hr Response: Felt comfortable after pain med Plan: Continue steroids, medicate for pain prn Atrial fibrillation (Afib) Assessment: HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from 4.3 PT 81.4 PTT 64.4 Hct 30.9 Action: Coumadin continues to be held. - F/u rheum recs - hold colchicine/ibuprofen given renal failure. Tubular blind ending structure in the right lower quadrant likely (Over) 2:21 AM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: ?

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[ { "category": "Radiology", "chartdate": "2179-05-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1131556, "text": " 2:12 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with leukocytosis\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Leukocytosis, rule out pneumonia.\n\n COMPARISON: .\n\n FRONTAL AND LATERAL CHEST: Marked enlarged cardiac silhouette is unchanged.\n Pulse generator electrode tip is in place and appears intact. A jugular\n catheter has been removed. The lungs are better expanded and well aerated.\n There is no pneumothorax or pleural effusion. The mediastinal and hilar\n contours are normal.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 592535, "text": "Chief Complaint: Hypotension/Shock (septic with adrenal insufficiency)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Arm/elbow pain better this AM\n 24 Hour Events:\n Levophed now off - but SBP on 80s\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 09:45 AM\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:51 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Gastrointestinal: Diarrhea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 71 (70 - 78) bpm\n BP: 93/55(67) {77/49(62) - 117/63(78)} mmHg\n RR: 26 (17 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 821 mL\n PO:\n 590 mL\n 60 mL\n TF:\n IVF:\n 1,097 mL\n 761 mL\n Blood products:\n Total out:\n 2,360 mL\n 990 mL\n Urine:\n 2,110 mL\n 990 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.6 g/dL\n 129 K/uL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension: Off of levophed. D/C vanco/zosyn/flagyl given lack of\n source\n Adrenal insufficiency: Cont hydrocort\n acute renal failure: Cr improving but not back to baseline, cont to\n monitor\n Elevated INR: Cont to hold Coumadin\n DM: Cont insulin gtt --> will need to while on steroids\n CHF: No active diuresis for now\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407113, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99% 2L\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n .\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n .\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n .\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension:\n - continue vancomycin, zosyn, flagyl\n - continue hydrocortisone 100IV Q6\n -\n Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean vasopressin, then levophed\n as tolerated\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n - PM lytes/creatinine\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n - 2.5 mg PO vitamin K\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale. Goal FS < 180.\n - Tighten sliding scale\n - consult\n .\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407192, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - trend lactate\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - consider d/c vancomycin, zosyn, flagyl\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n - PM lytes/creatinine\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407193, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - trend lactate\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - consider d/c vancomycin, zosyn, flagyl\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2179-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130656, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF a/w sepsis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF with sepsis.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is substantial enlargement of the cardiac silhouette\n without definite vascular congestion or pleural effusion. The right IJ\n catheter and ICD are unchanged. Mild retrocardiac atelectasis is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "LP ELBOW (AP, LAT & OBLIQUE) LEFT PORT", "row_id": 1130498, "text": " 8:42 AM\n ELBOW (AP, LAT & OBLIQUE) LEFT PORT; SHOULDER VIEWS NON TRAUMA LEFT PORTClip # \n Reason: Please evaluate for fractures, effusions, other abnormalitie\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man w/ h/o CHF p/w sepsis and severe left arm pain involving elbow\n and shoulder.\n REASON FOR THIS EXAMINATION:\n Please evaluate for fractures, effusions, other abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with severe left arm pain.\n\n COMPARISON: None.\n\n THREE VIEWS, LEFT SHOULDER: Examination is limited by nonstandard views as\n well as the overlying pacemaker. There is moderate degenerative change at the\n acromioclavicular joint with narrowing and subchondral sclerosis. The\n glenohumeral joint appears intact. There is no visualized fracture.\n\n THREE VIEWS, LEFT ELBOW: There is no fracture or abnormal alignment. There\n is no joint effusion. Mineralization is normal.\n\n DR. . \n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130499, "text": " 8:43 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: now s/p 3L volume resuscitation, please evaluate for interva\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man w/ h/o CHF p/w sepsis.\n REASON FOR THIS EXAMINATION:\n now s/p 3L volume resuscitation, please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with CHF, sepsis, post-volume resuscitation.\n\n COMPARISON: at 3:14 a.m., six hours prior.\n\n CHEST, AP: Moderate cardiomegaly persists. There is no pulmonary edema or\n pleural effusions. Right internal jugular line again terminates at the\n superior SVC. Right ventricular pacemaker/defibrillator courses in expected\n position. There is no pneumothorax.\n\n IMPRESSION: Cardiomegaly, no edema.\n\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407112, "text": "Chief Complaint: septic shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 63 yo man with h/o systolic HF, dil cardiomyopathy, admitted with\n septic shock. Vasopressin added yesterday. Levophed and vasopressin\n weaned overnight. Feels much better.\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 07:40 AM\n Metronidazole - 08:11 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n vanco\n SSI\n allopurinol\n levophed 0.15\n pepcid\n hydrocort 100mg q6h\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 35.9\nC (96.6\n HR: 77 (71 - 100) bpm\n BP: 112/66(81) {94/54(67) - 112/67(81)} mmHg\n RR: 24 (20 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,441 mL\n 587 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 587 mL\n Blood products:\n Total out:\n 800 mL\n 720 mL\n Urine:\n 800 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -133 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///15/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 10.9 g/dL\n 128 K/uL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:11/31, Alk Phos / T Bili:89/3.6,\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:205 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Fluid analysis / Other labs: Echo yesterday: EF: 15-20%\n Cortisol stim: 6.5-10.1-10.7\n Imaging: CXR: no pulmonary edema\n Microbiology: blood cx: NGTD\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION:\n Shock: have been a combination of dehydration, a viral syndrome,\n and adrenal insufficiency.\n acute renal failure: creatinine improved. continue to watch\n elevated INR: coumadin held. Got 2mg po vitamin K. likely due to\n antibiotics and lack of POs.\n DM: high glucoses. Increase sliding scale\n CHF: holding dig in setting of renal failure. Hold torsemide and\n carvedilol in setting of HOTN.\n AFib: well controlled.\n eosinophilia: check another eosinophil count today.\n Advance to PO diet.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Echo", "chartdate": "2179-05-13 00:00:00.000", "description": "Report", "row_id": 60017, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Valvular heart disease.\nHeight: (in) 68\nWeight (lb): 178\nBSA (m2): 1.95 m2\nBP (mm Hg): 95/43\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 13:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe global\nLV hypokinesis. No resting LVOT gradient. No VSD.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve. Dilated main PA. Dilated\nbranch PA.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. The\nestimated right atrial pressure is 10-20mmHg. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. There is\nsevere global left ventricular hypokinesis (LVEF = 25 %). There is no\nventricular septal defect. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. No masses or vegetations are seen on the\naortic valve. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. No vegetation/mass is seen on the pulmonic\nvalve. The main pulmonary artery is dilated. The branch pulmonary arteries are\ndilated. There is no pericardial effusion.\n\nNo vegetations seen\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is increased, the left ventricle\nis less dilated, and he tricuspid regurgitation is reduced.\n\n\n" }, { "category": "ECG", "chartdate": "2179-05-16 00:00:00.000", "description": "Report", "row_id": 108737, "text": "Probable atrial fibrillation with ventricular paced rhythm, intermittent\nintrinsically conducted beats and ventricular premature beats. Intrinsically\nconducted beats show delayed R wave progression and ST-T wave abnormalities.\nSince the previous tracing of the ventricular rate is slower and\nintermittent ventricular pacing is seen.\n\n" }, { "category": "ECG", "chartdate": "2179-05-13 00:00:00.000", "description": "Report", "row_id": 108738, "text": "Baseline artifact. Probable atrial fibrillation with rapid ventricular\nresponse although baseline artifact makes assessment difficult. Low\nQRS voltage. Delayed R wave progression with late precordial QRS transition.\nModest ST-T wave changes. Findings are non-specific but clinical correlation is\nsuggested. Since the previous tracing of ventricular paced rhythm is\nnow absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-05-12 00:00:00.000", "description": "Report", "row_id": 108739, "text": "Ventricular paced rhythm. Atrial mechanism is uncertain. Since the previous\ntracing of ventricular paced rhythm is now present.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407072, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407073, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407248, "text": "Chief Complaint: Adrenal Insufficiency, shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Needed to be back on levophed for much of the day yestreday but now\n back off\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 73 (69 - 92) bpm\n BP: 114/57(74) {73/37(48) - 136/78(97)} mmHg\n RR: 22 (17 - 25) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 2 (2 - 2)mmHg\n Total In:\n 2,131 mL\n 233 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 233 mL\n Blood products:\n Total out:\n 1,860 mL\n 1,255 mL\n Urine:\n 1,860 mL\n 855 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n 271 mL\n -1,022 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.8 g/dL\n 151 K/uL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension: Try to keep him off of pressors.\n Adrenal insufficiency: Cont hydrocort - switch to 50mg po q8 hrs\n today. Will repeat stim while in house\n acute renal failure: Cr continues to improve\n Elevated INR: Restart Coumadin\n DM: Cont insulin gtt\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407249, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Micro:\n - Stool studies pending\n - BCx NGTD\n - Urine legionella negative\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - Currently on levophed, but with stable BPs\n will attempt to wean\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - Off Abx\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral taper:\n - Hydrocortisone 50mg PO q 8 hours x 3 days\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n - insulin gtt change to tighter insulin SS this AM as takes PO (will\n confirm with )\n - diabetic diet\n - f/ consult recs\n - would like to transition to subcutaneous insulin today, but could be\n challenging in setting of tapering steroid doses. Will discuss with\n .\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n - d/c foley today\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - plan to restart Coumadin today (3.5 mg)\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - plan to restart Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407231, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR 2.2,..lytes Na 137 and K 4. HCT 27.8\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n BS 100-130\ns, insulin at 2units/hr\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs WBc normal, on low dose of levophed gtt\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407239, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407240, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407241, "text": "Chief Complaint:\n 24 Hour Events:\n :\n Patient continued on levophed.\n - patient had episodes of confusion that waxed and waned consistent\n with delirium. Pt. would no longer allow us to obtain finger sticks,\n saying \"you're with those people.\" Pt received Haldol 2mg IV x 1 with\n decent effect.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (69 - 79) bpm\n BP: 117/63(79) {73/37(48) - 120/68(84)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n Total In:\n 2,131 mL\n 188 mL\n PO:\n 740 mL\n TF:\n IVF:\n 1,391 mL\n 188 mL\n Blood products:\n Total out:\n 1,860 mL\n 525 mL\n Urine:\n 1,860 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 271 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///16/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 151 K/uL\n 9.8 g/dL\n 115 mg/dL\n 2.1 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 84 mg/dL\n 110 mEq/L\n 137 mEq/L\n 27.8 %\n 9.1 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n Plt\n 137\n 128\n 129\n 151\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n Other labs: PT / PTT / INR:22.9/35.5/2.2, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Micro:\n - Stool studies pending\n - BCx NGTD\n - Urine legionella negative\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - Currently on levophed, but with stable BPs\n will attempt to wean\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - Off Abx\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral in days and\n taper\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n - insulin gtt change to tighter insulin SS this AM as takes PO (will\n confirm with )\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - plan to restart Coumadin today (3.5 mg)\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - plan to restart Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407352, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors morning of at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to\n prednisone 30mg daily later per pharm recs (although lacks mineralocort\n activity). Will plan for 10-day taper; recommend patient undergo\n re-stimulation later this admission once called out to floor. A-line\n left in while monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Likely due to adrenal insufficiency, given symptoms of\n fever, hypotension, diarrhea, high eosinophils, hyponatremia,\n hyperkalemia then low cortisol with failed ACTH stimulation. Initially,\n patient with marked fever, tachypnea, vasodilated on initial exam\n concerning for septic shock possibly from pulmonary source as possible\n pneumonia on CT scan (although normal lactate and normal WBC count).\n Septic arthritis considered given prominent joint complains and history\n of gout although joint tap negative. On vasopressors at admit, but\n weaned off over 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph, likely contaminant. CT chest on admission with opacity\n atelectasis/pna. Patient has remained afebrile, normal white count.\n TTE w/ no evidence of vegetations on valves or hardware\n - discontinue vancomycin\n - appreciate rheumatology recs: consider repeat tap if clinically\n worsens and appropriate clinical scenario\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - continue glargine 15U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Digoxin continued\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, discontinue\n famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407307, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors this morning at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to pred\n 30mg daily later per pharm recs (although lacks mineralocort activity).\n Will plan for 10-day taper; recommend patient undergo re-stimulation\n later this admission once called out to floor. A-line left in while\n monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///17/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407308, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors this morning at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to pred\n 30mg daily later per pharm recs (although lacks mineralocort activity).\n Will plan for 10-day taper; recommend patient undergo re-stimulation\n later this admission once called out to floor. A-line left in while\n monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. On vasopressors at admit, but weaned off over\n 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph. CT chest on admission with opacity atelectasis/pna. Patient\n has remained afebrile, normal white count. TTE w/ no evidence of\n vegetations on valves or hardware\n - continue vancomycin\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - continue glargine 15U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Continue digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 407049, "text": "Chief Complaint: chest pain\n HPI:\n Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n .\n On arrival to the floor, patient c/o total body pain, and feeling cold.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies cough, shortness of breath, or wheezing. Denies chest pain,\n chest pressure, palpitations, or weakness. Denies nausea, vomiting,\n diarrhea, constipation, abdominal pain, or changes in bowel habits.\n Denies dysuria, frequency, or urgency. Denies rashes or skin changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Metronidazole - 03:29 PM\n Piperacillin - 04:25 PM\n Infusions:\n Norepinephrine - 0.45 mcg/Kg/min\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 09:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n Idiopathic cardiomyopathy, EF 15-20%, clean cath in \n severe tricuspid regurgitation\n diabetes type 2 on sliding scale insulin\n elevated LFTs, thought due to fatty liver\n atrial fibrillation on coumadin\n gout, recent flare treated with prednisone taper, confirmed\n cyrstals in , no other taps in the system.\n peripheral neuropathy\n chronic renal insufficiency, baseline creatinine 1.3-1.8\n hypertension\n .\n Medications:\n Allopurinol 250mg PO qday\n Carvedilol 3.125 PO BID\n Colchicine 0.6mg PO qday\n Digoxin 125mcg PO qday\n Insulin sliding sclae\n Lantus order -> does not need or take\n Spironolactone 12.5mg PO qAM -> d/c'd as per patient\n Torsemide 40mg PO BID\n Valsartan 40mg PO qday\n Warfarin 4mg M/W/Fri, 3.5mg the other 4 days\n .\n Not taking\n -Vivodin -> does not need\n -Ibuprofen -> does not need\n .\n Allergies:\n Unasyn ? causes LFT elevation per d/c summary \n No first-degree relatives with coronary artery disease. His mother had\n breast cancer.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is originally from currently living with his\n wife. Returned to this past fall, but came back to US after\n severe gout flare of his foot. No smoking. He quit alcohol use, no IV\n drug use. He says his diet is generally difficult because he\n feels like any food he eats causes gout flare\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: Joint pain, Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious\n Flowsheet Data as of 04:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.6\nC (99.6\n HR: 74 (74 - 118) bpm\n BP: 124/68(82) {80/43(54) - 124/68(82)} mmHg\n RR: 27 (23 - 32) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n CVP: 17 (10 - 22)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 5,403 mL\n PO:\n TF:\n IVF:\n 2,403 mL\n Blood products:\n Total out:\n 0 mL\n 420 mL\n Urine:\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,983 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n General Appearance: Anxious, Diaphoretic, uncomfortable, rigoring\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, tachycardic,\n irregular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : diminished)\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 137 K/uL\n 9.9 g/dL\n 198\n 3.7 mg/dL\n 60 mg/dL\n 18 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 132 mEq/L\n 28.4 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A4/15/ 08:14 AM\n \n 10:20 P4/15/ 02:00 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 28.4\n Plt\n 137\n Cr\n 3.7\n TropT\n <0.01\n Glucose\n 178\n 198\n Other labs: PT / PTT / INR:40.5/51.5/4.3, CK / CKMB /\n Troponin-T:65//<0.01, Alk Phos / T Bili:/3.2, Differential-Neuts:67.0\n %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %, Eos:11.0 %, Lactic Acid:1.2\n mmol/L, LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Fluid analysis / Other labs: On arrival, WBC 6.3, Hct 29 (baseline high\n 20's), Plt 135,\n Chemistries with Na 132, K 4.5, Cl 98, CO2 21, BUN 61, Cr 4.2, Plt 134\n CK 78\n INR 3.9,\n ABG 7.46/32/130\n Imaging: - Initial film: prominent pulm vasculature, clear lungs (my\n read)\n - Repeat film: decreased lung volumes, apparent increase in cardiac\n silhouette, and mild overhydration vs. artifact (my read)\n - CT C/A/P: Small pleural effusions L > R, prominent pulmonary venous\n system vs. lymphatics (my read), wet read from rads ->\n 1. no definite acute finding to explain pt sx's on this non- contrast\n CT.\n 2. Urinary bladder wall thickening likely under-distension\n Microbiology: -No h/o MRSA, VRE. Does have history of pseudomonas in\n past from wound cultures\n -Blood culture sent in ED.\n ECG: EKG: wide qrs at rate of 71 bpm. Regular. Slow ventricular\n escape rhythm vs. ventricular paced rhythm (pacer spikes in V3/v4/V5)\n .\n Repeat EKG on arrival to ICU: artifact, likely a. fib with rapid\n ventricular response.\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR therapeutic, pneumoboots,\n # Access: peripherals, CVL\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407051, "text": "62 y.o.m with cardiomyopathy, EF 10-15%, ICD/pacer, Afib, and diabetes.\n Has experienced frequent episodes of gout over past few months while in\n - on recent prednisone taper. Right arm pain recently. Then\n developed left should and elbow pain. Does report some cough and SSCP\n with coughing. Some sinus congestion. T 101.4, BP initially 90/40,\n and then dropped to 70s systolic. TLC placed CVP 13-16. Received 3L\n IVF. Dopamine initiated for BP support, Levophed added as pt was noted\n to become tachycardic secondary to dopamine. CT head and torso\n negative. Hx of CRI, creatinine 4.3-> therefore, did not receive\n contrast for imaging. Tx to TSICU as MICU border for further\n monitoring and sepsis workup.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid per resident.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n - Rigors & Tmax 102.5\n - SBP 60-70s\n - V paced with runs of Afib, HR 70-120s.\n - Low urine output 0-25cc/hr. Dark amber urine noted.\n - Creatinine 3.7\n - Anemic at baseline, Hct 28\n Action:\n - Blood cultures obtained, 1000mg Tylenol administered\n - Dopamine and Levophed running to maintain SBP > 90.\n - EKG obtained\n - Bedside ECHO performed\n - CXR for ? infiltrates. Xray\ns of L elbow and shoulder obtained\n - 250cc fluid boluses x4 and 500cc fluid bolus x1 for treatment of low\n uop & to maintain CVP between 15-20\n - Renal US obtained\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407054, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n Tx to TSICU as MICU border for monitoring and sepsis work up.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid. Pt started on prednisone taper.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n - Rigors & Tmax 102.5\n - SBP 60-70s\n - V paced with runs of Afib, HR 70-120s.\n - Low urine output 0-25cc/hr. Dark amber urine noted.\n - Creatinine 3.7\n - Lytes wnl\n - Anemic at baseline, Hct 28\n Action:\n - Blood cultures obtained, 1000mg Tylenol administered\n - Started on triple anbx coverage- IV Vanco, zosyn, and flagyl.\n - Dopamine and Levophed running to maintain SBP > 90.\n - EKG obtained\n - Bedside ECHO performed\n - CXR for ? infiltrates. Xray\ns of L elbow and shoulder obtained to r/o\n fractures, effusions, and/or other possible infectious processes.\n - stim test performed\n - 250cc fluid boluses x4 and 500cc fluid bolus x1 for treatment of low\n uop & to maintain CVP between 15-20\n - Renal US obtained\n Response:\n - Pt remains afebrile, Tmin 98\n - Dopamine gtt weaned off due to tachycardia, Levophed titrated to\n maintain SBP > 90.\n - ECHO & Renal US results pnding\n - Urine remains concentrated. UOP gradually increasing.\n Plan:\n - Hemodynamics\n - Follow up with pnding blood cultures\n - Administer anbx as ordered\n - Maintain SBP > 90, titrate Levophed gtt as necessary\n - Cont to administer fluid boluses- assess for CHF. Maintain CVP > 15.\n - Follow up with stim test and pnding lytes. Replete as necessary.\n - Follow up with Renal and ECHO results\n - Cont to maintain pt safety\n" }, { "category": "Physician ", "chartdate": "2179-05-13 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 407026, "text": "Chief Complaint: HOTN\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yo cardiomyopathy, EF 10-15%, ICD/pacer, AFib. Has had bad gout\n over past few months while in . Recent prednisone taper. Right\n arm pain recently. Then developed left should and elbow pain. Does\n report some cough and SSCP with coughing. Some sinus congestion. T\n 101.4, BP initiall 90/40, and then dropped to 70s systolic. TLC placed\n CVP 13-16. Got 3L IVF. intially got dopamin, and then added\n levophed. CT head and torso without infectious source. With renal\n failure, so didn't get any contrast. Initially tachycardic in TSICU,\n having chills and rigors.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 08:26 AM\n Infusions:\n Norepinephrine - 0.35 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 09:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Meds at home:\n carvedilolol\n allopurinol\n dig\n valsartan\n warfarin\n torsemide\n no CAD in family\n Occupation:\n Drugs:\n Tobacco: none\n Alcohol: none\n Other: from , wife works at \n Review of systems:\n Flowsheet Data as of 01:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.6\nC (99.7\n HR: 77 (77 - 118) bpm\n BP: 87/44(55) {80/44(55) - 96/52(63)} mmHg\n RR: 24 (23 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n CVP: 22 (10 - 22)mmHg\n Mixed Venous O2% Sat: 64 - 64\n Total In:\n 4,127 mL\n PO:\n TF:\n IVF:\n 1,127 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,827 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.46/32/130\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, dry mucous membranes\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 137 K/uL\n 28.4 %\n 9.9 g/dL\n 178 mg/dL\n 3.7 mg/dL\n 60 mg/dL\n 18 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 132 mEq/L\n 8.1 K/uL\n [image002.jpg]\n 08:14 AM\n WBC\n 8.1\n Hct\n 28.4\n Plt\n 137\n Cr\n 3.7\n TropT\n <0.01\n Glucose\n 178\n Other labs: PT / PTT / INR:40.5/51.5/4.3, CK / CKMB /\n Troponin-T:65//<0.01, Alk Phos / T Bili:/3.2, Differential-Neuts:67.0\n %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %, Eos:11.0 %, Lactic Acid:1.5\n mmol/L, LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Shock: Septic versus hypovolemic. Can check SVO2 from central\n line. Continue to give IVF boluses gingerly.\n Unclear source of infection. Last SVO2 was 65%. Also\n consider adrenal insufficiency given eosinophilia.\n Continue vanco/zosyn empirically\n Given eosinophilia and steroid courses. Will stim,\n and treat for adrenal insufficiency with hydrocort q6h\n Has rigors and fevers: worrisome for infection. Rheum did not get\n fluid from attempted elbow tap.\n chronic systolic HF: continue Dig. holding torsemide in setting of\n hypovolemia. f/u on TTE\n Afib: better controlled now that dopamine is off.\n eosinophilia: can check stool O+P\n diarrhea: check C. dif, and O+P, may be due to colchicine\n DM:\n NPO for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FUll\n Disposition: ICU\n Total time spent: 50 minutes\n Critically Ill\n" }, { "category": "Nursing", "chartdate": "2179-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407045, "text": "62 y.o.m with cardiomyopathy, EF 10-15%, ICD/pacer, Afib, and diabetes.\n Has experienced frequent episodes of gout over past few months while in\n - on recent prednisone taper. Right arm pain recently. Then\n developed left should and elbow pain. Does report some cough and SSCP\n with coughing. Some sinus congestion. T 101.4, BP initially 90/40,\n and then dropped to 70s systolic. TLC placed CVP 13-16. Received 3L\n IVF. Dopamine initiated for BP support, Levophed added as pt was noted\n to become tachycardic secondary to dopamine. CT head and torso\n negative. Hx of CRI, creatinine 4.3-> therefore, did not receive\n contrast for imaging. Tx to TSICU as MICU border for further\n monitoring and sepsis workup.\n Pain control (acute pain, chronic pain)\n Assessment:\n Acute pain noted to L elbow and shoulder upon admission to ICU. Unable\n to lift arm for extended period of time. No swelling noted. L radial\n pulse present.\n Action:\n 2mg IV morphine administered, followed by AM dose of PO allopurinol.\n Rheumatology into see pt, attempted to extract fluid from L elbow\n joint, gout crystals noted in fluid per resident.\n Response:\n Within an hour after receiving pain medication & allopurinol, pt stated\n pain to L elbow and shoulder decreased significantly. Now able to lift\n and move LUE without extreme discomfort.\n Plan:\n Cont to pain, administer pain medication as necessary. ? pain\n secondary to gout.\n Sepsis without organ dysfunction\n Assessment:\n Rigors & fever\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407225, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR 2.2,..lytes Na 137 and K 4. HCT 27.8\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n BS 100-130\ns, insulin at 2units/hr\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs WBc normal, on low dose of levophed gtt\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407097, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:11/31, Alk Phos / T Bili:89/3.6,\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:205 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407100, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >9\n Plan:\n Continue to wean vasopressors, fluid bolus prn for low cvp\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressure improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results, continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful around elbow no erythema noted\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med. States he feels a lot better than when\n he came in\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control steroids and\n sepsis,continue to monitor, ss insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output negative > 200cc, K+\n 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407101, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n - FeBUN 3.13%\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with likely septic shock.\n .\n #. Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407107, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM placed in ED\n BLOOD CULTURED - At 08:12 AM\n EKG - At 08:12 AM\n ULTRASOUND - At 11:30 AM\n TRANSTHORACIC ECHO - At 01:25 PM\n ARTERIAL LINE - START 10:41 PM\n FEVER - 102.5\nF - 09:00 AM\n - Patient hypotensive on norepinephrine alone even at 0.45, so\n vasopressin added\n - A- line placed\n - Cortisol stim test abnormal; patient started on hydrocortisone (vs.\n prednisone per rheum recs) but no ACTH added on as adrenal\n insufficiency seems likely critical illness (can discuss at rounds)\n - Rheumatology consult: no joint fluid to tap\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 11:55 PM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.1\nC (98.8\n HR: 85 (71 - 118) bpm\n BP: 101/65(78) {94/54(68) - 104/67(80)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 15 (9 - 24)mmHg\n Mixed Venous O2% Sat: 64 - 73\n Total In:\n 6,441 mL\n 350 mL\n PO:\n TF:\n IVF:\n 3,441 mL\n 350 mL\n Blood products:\n Total out:\n 800 mL\n 580 mL\n Urine:\n 800 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,641 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99% 2L\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 128 K/uL\n 10.9 g/dL\n 227 mg/dL\n 3.0 mg/dL\n 15 mEq/L\n 5.4 mEq/L\n 64 mg/dL\n 101 mEq/L\n 130 mEq/L\n 30.9 %\n 5.7 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n WBC\n 8.1\n 5.7\n Hct\n 28.4\n 30.9\n Plt\n 137\n 128\n Cr\n 3.7\n 3.6\n 3.0\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n Other labs: PT / PTT / INR:81.4/64.4/9.8,\n CK / CKMB / Troponin-T:65//<0.01,\n ALT / AST:11/31, Alk Phos / T Bili:89/3.6, Lactic Acid:1.2 mmol/L,\n Albumin:2.9 g/dL, LDH:205 IU/L\n Differential-Neuts:67.0 %, Band:0.0 %, Lymph:15.0 %, Mono:7.0 %,\n Eos:11.0\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Dig: 1.2, ANCA: Pending, RF: <3\n .\n Renal U/S: normal\n Elbow/Shoulder plain film: no fx or joint effusion\n .\n Echo: LVEF 25% (increased compared to prior), LV is less dilated, TR\n is reduced\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses are normal. The left ventricular cavity\n size is normal. There is severe global left ventricular hypokinesis\n (LVEF = 25 %). There is no ventricular septal defect. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. No mass or vegetation is seen on the\n mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\n valve leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. No vegetation/mass is seen on the pulmonic\n valve. The main pulmonary artery is dilated. The branch pulmonary\n arteries are dilated. There is no pericardial effusion. No vegetations\n seen\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n .\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension:\n - continue vancomycin, zosyn, flagyl\n - continue hydrocortisone 100IV Q6\n -\n Hemodynamics/Shock: Would favor septic shock in patient with chronic\n heart failure rather than primary cardiogenic shock given marked fever,\n vasodilation on exam, and elevated RR. No clear sources identified,\n but diffuse joint/muscle aches concerning for endocarditis. Unclear\n how to interpret lack of leukocytosis by labs given fever/hypotension\n on arrival. Also, given h/o severe gout is likely to have structurally\n abnormal joints that may predispose to bacterial infection and septic\n arthritis. Unusual about presentation is absence of WBC's, and normal\n lactate. PE unlikely given supratherapeutic by INR, but if no source\n identified after 24-48 hours would repeat scan of chest.\n - Small increment fluid boluses given h/o CHF with 250cc/30 minutes\n repeating prn.\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - MAP goal 60-65. need to be less aggressive with MAP target of 60\n rather than typical 65 given h/o EF 10-15%, but previous BP's noted to\n be normal.\n - CV O2 Sat: Currently less than 70%. Would not transfuse to thirty at\n this time, as anemia is baseline. Would consider inotropic agents in\n the future, but anticipate that arrhythmias will be limiting given A.\n Fib with RVR on dopamine earlier.\n - Check pulsus on arrival to ICU given enlarged heart on repeat CXR.\n CT not interpretable for pericardial effusion given lack of contrast\n and artifact from leads.\n - Levophed as primary pressor - try to wean dopamine.\n - Consider neo and/or vasopressin as needed, but try to limit given\n patients h/o severe CHF.\n - Foley\n - Follow UOP\n - Trend lactate\n - A-line later today\n - Vigileo would be useful if patient converts out of A. Fib.\n - Check cortisol given h/o recent prednisone use.\n - Check BNP for trend.\n .\n #. Infection/Sepsis: No clear source. Evaluate for septic arthritis\n with plain films. Would consult rheumatology given h/o severe gout,\n and possible septic arthritis for possible elbow tap.\n - Vanco given ED, continue q48\n - Zosyn -> trend LFT's given h/o allergy to unasyn\n - Levaquin given in ED. Hold for now and consider redosing in 48 hours\n prn.\n - blood cultures, uric acid, rheumatoid factor (for IE w/u), ferritin\n urine legionella, elbow/shoulder films, repeat CXR.\n - Echo to evaluate for vegetations on valves or hardware\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. No\n schistos noted on smear which is reassuring that TTP unlikely (given\n low plt's renal failure).\n - Urine bland.\n - renal U/S when able -> would not transport for renal ultrasound at\n this time until hemodynamics improved.\n - urine lytes\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - foley catheter\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n .\n # Acid/Base: Admission labs with primary respiratory alkalosis and\n metabolic acidosis. Trend with lactates.\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems.\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n - continue to trend, consider RUQ U/S if rising\n - check haptoglobin, LDH.\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Hold digoxin and check level -> consider dosing for A. fib if level\n not elevated.\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Rheum consult.\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol.\n - Rheum consult for possible tap (has elevated INR)\n - hold colchicine/ibuprofen given renal failure\n .\n # Diabetes: Continue humalog sliding scale.\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2179-05-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 407119, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n day. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Ht: 68\n Admit wt: 88 kg\n UBW: 81.8kg (dry wt)\n BMI: 27.3\n Pmh: severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Diet Order: clear liquids\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407182, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407204, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407205, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407298, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 285\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407299, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n > Off levophed gtt SBP 90-110mmhg\n >HR 60-70\ns, V paced with occasional pvc\n >voiding yellow clear urine\n > No complaints of pain\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 285\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407300, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n > Off levophed gtt SBP 90-110mmhg\n >HR 60-70\ns, V paced with occasional pvc\n >voiding yellow clear urine\n > No complaints of pain\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose glargine\n 15units given @ 4 pm, patient on diabetic diet\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n At 4 am blood sugar 251\n Plan:\n Continue monitor blood sugar prior to meals and adjust SS accordingly\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407087, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2. There were no immediate\n complications.\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407088, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2 in the evening after several\n unsuccessful attempts earlier in day over bilateral wrists. There were\n no immediate complications.\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407089, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >9\n Plan:\n Continue to wean vasopressors, fluid bolus prn for low cvp\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressure improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results, continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful around elbow no erythema noted\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med. States he feels a lot better than when\n he came in\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control steroids and\n sepsis,continue to monitor, ss insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output negative > 200cc, K+\n 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nutrition", "chartdate": "2179-05-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 407121, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n day. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Ht: 68\n Admit wt: 88 kg\n UBW: 81.8kg (dry wt)\n BMI: 27.3\n Pmh: severe TR, severe CM/chronic systolic HF\n DM II\n gout\n fatty liver\n chronic renal failure baseline 1.4-1.6\n HTN\n Labs: K 5.4 PO4 5.3 BUN 64 Creat 3.0\n Diet Order: clear liquids\n 63 year old male came to the ED with chest pain and L arm pain.\n Patient has had gout for the last few weeks. Patient reports poor pos x\n 1 week PTA due to everything he eating making the gout worse. Patient\n is +6.2 kg due to fluid. Patient denies nausea and vomiting. Plan is to\n advance diet. Page with questions.\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407187, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, vasodilation, tachypnea on\n initial exam more consistent with septic shock possibly from pulmonary\n source as possible pneumonia on CT scan (although normal lactate and\n normal WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Adrenal\n insufficiency considered given low cortisol on admission and <25%\n response to cosyntropin may be primary or functional in setting of\n acute illness . PE considered although supratherapeutic INR. Able to\n wean from vasopressin and wean from levophed over the past 24 hours.\n - MAP goal 60-65. need to be less aggressive with MAP target of\n 60 rather than typical 65 given h/o EF 10-15%, but previous BP's noted\n to be normal.\n - levophed as needed for MAP >60 and attempt to wean, may use small\n 250cc IVF bolus if necessary\n CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR. Would continue to\n give fluids for now and monitor respiratory status.\n - trend lactate\n .\n #. Infection/Sepsis: No clear source clinically although evidence of\n pneumonia on chest imaging. TTE showing no evidence of vegetations on\n the valves or hardware\n - f/u blood, sputum, urine cx\n - continue vancomycin, zosyn, flagyl\n - Zosyn -> trend LFT's given h/o allergy to unasy-\n - Rheum consult for possible elbow tap and assistance with gout\n management.\n - trend labs.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone and taper to prednisone once off pressors\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids\n -insulin gtt change to tighter insulin SS this AM\n - consult recs\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide this PM after more fluids or\n if any change to respiratory status.\n - PM lytes/creatinine\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin and trend given antibiotics.\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Non-specific CT findings: Unclear how to correlate clinically.\n - repeat CT head this PM for further evaluation.\n - consider dedicated sinus CT with this series.\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407194, "text": "Chief Complaint:\n 24 Hour Events:\n - Taken off vasopressin and levophed weaned down to 0.04\n - CT chest: Left lower lobe atelectasis or pneumonia.\n - Got total of 4PO Vit K for INR >10\n - Rheum: prednisone taper, consider re-tap if indicated\n - : consider adrenal MRI to eval adrenal insufficiency (CT NML)\n - loose bowel movements (subacute) - checking stool for c.diff\n - fingersticks >400 --> given 10 + 6 units insulin but continued to be\n in high 300s so started on insulin gtt overnight.\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin - 11:54 PM\n Metronidazole - 12:33 AM\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Infusions:\n Insulin - Regular - 5 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.4\nC (97.5\n HR: 70 (70 - 78) bpm\n BP: 99/52(66) {77/49(62) - 117/66(81)} mmHg\n RR: 21 (18 - 34) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (12 - 18)mmHg\n Total In:\n 1,687 mL\n 357 mL\n PO:\n 590 mL\n TF:\n IVF:\n 1,097 mL\n 357 mL\n Blood products:\n Total out:\n 2,360 mL\n 710 mL\n Urine:\n 2,110 mL\n 710 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -673 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///17/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 129 K/uL\n 9.6 g/dL\n 327 mg/dL\n 2.5 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 75 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.6 %\n 5.8 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n WBC\n 8.1\n 5.7\n 5.8\n Hct\n 28.4\n 30.9\n 28.6\n Plt\n 137\n 128\n 129\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 246\n 249\n 327\n Other labs: PT / PTT / INR:43.6/50.3/4.6 (11.5)\n ALT / AST:, Alk Phos / T Bili:70/2.3 (3.6), %, Lactic Acid:1.2\n mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L\n Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.7 mg/dL\n Dig: 0.7 (1.2)\n Assessment and Plan\n Assessment and Plan:\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Patient with marked fever, tachypnea, vasodilated on\n initial exam concerning for septic shock possibly from pulmonary source\n as possible pneumonia on CT scan (although normal lactate and normal\n WBC count). Septic arthritis considered given prominent joint\n complains and history of gout although joint tap negative. Evidence of\n adrenal insufficiency given symptoms of fever, hypotension, diarrhea,\n high eosinophils, hyponatremia, hyperkalemia then low cortisol with\n failed ACTH stimulation. Able to wean from vasopressin and wean down\n from levophed over the past 24 hours.\n - levophed off for now. Will follow UOP and re-start vasopressors as\n needed for MAP >60\n -CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n - lactate has been stable\n .\n #. ? infection/sepsis: No clear source clinically and patient has\n remained afebrile, normal white count without any growth on culture. CT\n chest on admission with opacity atelectasis/pna. TTE showing no\n evidence of vegetations on valves or hardware\n - fever curve\n - f/u blood, sputum, urine cx\n - d/c vancomycin, zosyn, flagyl as all cultures have been negative and\n monitor clinically\n - rheumatology recs, consider repeat tap if clinically worsens and\n appropriate clinical scenario.\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology.\n - continue hydrocortisone, but likely will start oral in days and\n taper\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Poor PO intake yesterday\n -insulin gtt change to tighter insulin SS this AM as takes PO\n - diabetic diet\n - consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - hold coumadin until INR <4 and trend given antibiotics then restart\n home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Restart digoxin at home dose given low level this AM\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level.\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - antibiotics\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen).\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # FEN: IVF, replete/trend electrolytes, ADAT\n # Prophylaxis: INR supratherapeutic, pneumoboots, famotidine\n # Access: peripherals, CVL, A-line\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 09:43 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407197, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow inr closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407199, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407200, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM. Elevated sugars in setting of being on\n steroids and having infection. BS thus far ranging from 200\ns to 160\n Action:\n Patient remains on insulin gtt.\n Response:\n Awaiting, adequate response to insulin gtt.\n Plan:\n Continue insulin gtt until prednisone is done being adjusted,\n Sepsis without organ dysfunction\n Assessment:\n Remains levophed gtt at 0.02 mcg/kg/min. A-line with occ. dampened wave\n form. Once wave form sharp, it correlated with NIBP. SBP 90-110 with\n MAP ~60 (goal). Bld cx data w/ GPC\ns in pairs and clusters, Afebrile.\n WBC normal.\n Action:\n CVP ~13. Levophed gtt weaned down as BP allows in order to maintain MAP\n > 65. DC\nd Zoysn and Flagyl. Vanco changed to . Remains on\n Hydrocort.\n Response:\n VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to as tolerated. Continue IV ABXs as\n ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. UE\ns and pt reports discomfort bilat. UE\ns. Pt\n reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Arms elevated on pillow. Pt given 2 mg morphine\n IVP for pain management with good effect. Pt continues on allopurinol\n for uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n V paced with a-fib as underlying rhythm. Coumadin held elevated\n INR. Pt was also gived vit K x 2 in CCU. Pt had had episodes of\n nosebleeds during the day (), but no further bleedings.\n Action:\n Cont. to monitor for s&s of bleeding. Holding Coumadin. Gave one time\n dose of Digoxin, will dose as appropriate by level.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow INR closely.\n ***Please note, this evening patient noted to become delirious and\n agitated. Refusing turns, blood sugars, dinner ect. Dr. \n made aware. Gave one time dose of Haldol 2.0mg, adequate effect.\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407215, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient, he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately, what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted. Of note, recent medication\n changes include up titration of allopurinol to 250mg PO qday for gout\n after recent gout flare . He has crystal proven gout with elevated\n uric acid levels to 12. Pt transferred to MICU 6 at 8pm from CCU.\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80\ns, V paced with a-fib as underlying rhythm with occasional\n pvc\ns. Coumadin held elevated INR (4.6). Pt had had episodes of\n nosebleeds during the day (), but no further bleedings. SBP 90-100,\n patient is off levophed gtt. Received one time of digoxin\n Action:\n Continue monitor HR, labs and BP. No c/o chest pain, Coumadin on hold\n and restarted levophed gtt for MAP<55\n Response:\n HR 70-80\ns, am labs INR\n..lytes\n Plan:\n Hold Coumadin, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on 11units of insulin gtt and patient refused to check\n the blood sugar for 2hrs. Pt has known type II DM. Elevated sugars in\n setting of being on steroids and having infection. Patient is on\n diabetic diet\n Action:\n Insulin gtt off for blood sugar of 80, frequent monitoring of blood\n sugar\n Response:\n Plan:\n Continue monitor finger sticks and insulin gtt accordingly\n Sepsis without organ dysfunction\n Assessment:\n Patient is afebrile, blood cx data w/ GPC\ns in pairs and clusters, and\n WBC normal. Patient is off levophed gtt, MAP>60\ns and A line is\n positional and monitoring via lt radial a line.\n Action:\n Continue vancomycin and steroids. Levophed gtt restarted for MAP< 55.\n Response:\n Afebrile, AM labs\n Plan:\n Wean levo gtt as tolerated, continue antibiotics and monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. Noted to\n have swelling in bilat. Patient is on allopurinol and arms elevated on\n pillow.\n Action:\n Pain level , morphine 2mg x1 given with good effect\n Response:\n Pain level \n Plan:\n Continue allopurinol and steroid therapy for gout flare. Continue PRN\n pain meds\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407267, "text": "Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407268, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407297, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received patient on insulin gtt @ 5units/hr, fixed dose given pm\n Action:\n Off insulin gtt and continued insulin SS and fixed\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2179-05-14 00:00:00.000", "description": "Arterial Line Insertion Procedure Note", "row_id": 407083, "text": "TITLE:\n A line placed for continuous blood pressure monitoring given continued\n need for pressors. Site prepped and catheter inserted in a sterile\n manner by , PGY-2. There were no immediate\n complications.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407168, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407169, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM.\n Action:\n FSBS at 10 pm found to be high at 403. MD notified and pt given 10\n units of MD.\n Response:\n FSBS 2 hrs later 396 and given additional 6 units of insulin. FSBS has\n been running high all shift as noted and treated as needed MD q2\n hrs.\n Plan:\n Continue to monitor FSBS q2hrs and treat as needed.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407174, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt has known type II DM.\n Action:\n FSBS at 10 pm found to be high at 403. MD notified and pt given 10\n units of MD.\n Response:\n FSBS 2 hrs later 396 and given additional 6 units of insulin. FSBS has\n been running high all shift as noted and treated as needed MD q2\n hrs. 5 am, pt started on insulin gtt as noted. FSBS now to be checked\n q1 hr.\n Plan:\n Continue insulin gtt until FSBS is 150.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from CCU on levophed gtt at 0.06 mcg/kg/min. A-line with occ\n dampened wave form. Once wave form sharp, it correlated with NIBP. SBP\n 96-110 with MAP > 65 (goal). Pt is being treated for pna with IV ABXs\n as noted. Afebrile. WBC normal.\n Action:\n CVP 12-13. Levophed gtt weaned down as BP allows in order to maintain\n MAP > 65.\n Response:\n Levophed gtt down to 0.04 this am. VSS. Afebrile and WBC normal.\n Plan:\n Continue to wean pressors to off. Follow up culture results. Continue\n IV ABXs as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt adm to with c/o LUE discomfort/weakness due to gout. LUE\n slight swollen and pt reports discomfort starting in Lt shoulder and\n runs all the way down to Lt hand. Pt reports this is\ngout\n pain.\n Action:\n Cap refill < 3 sec. Lt arm elevated on pillow. Pt given morphine IVP\n for pain management with good effect. Pt continues on allopurinol for\n uric acid. Pt also continues on steroid therapy for gout flare.\n Response:\n Pt has constant pain to Lt arm, but reported he will notify care takers\n when he is in need of pain medications. Pty given morphine IVP (2mg),\n with pain relief.\n Plan:\n Continue allopurinol and steroid therapy for gout flare. Medicate for\n pain prn.\n Atrial fibrillation (Afib)\n Assessment:\n Pt arrived from CCU Ventricular paced with a-fib as underlying rhythm.\n Coumadin was held due to high inr of 11.5 . Pt was also gived vit\n K x 2 in CCU. Pt had had episodes of nosebleeds during the day (),\n which has now stopped.\n Action:\n Close monitoring for bleed done.\n Response:\n Inr this am 4.6 and hct level stable at 28.\n Plan:\n Continue to monitor for bleeding closely and follow inr closely.\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407079, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm off coumadin x 1 day INR 9.8 up from\n 4.8 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 248 repeat blood\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407080, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressor improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.8 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.7. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output, K+ 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407081, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Hypotension (not Shock)\n Assessment:\n Continues on levophed and vasopressin. Levophed titrated to maintain\n map >60 HR 60-90 vpaced with afib underlying rhythm\n Action:\n Titrated levophed to maintain map > 60 continues on vasopressin 1.2u q\n hr. Aline placed. Given 250cc LR\n Response:\n u/o improved with fluids. Cvp >\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Temp 98.6 po wbc 5.6\n Action:\n Given Flagyl and zoysn as ordered. Monitored temp and wbc\n Response:\n Blood pressor improving able to begin to wean pressors, afebrile, wbc\n wnl\n Plan:\n Continue to wean pressors as tolerated, monitor cvp, temp, wbc, await\n culture results continue antibx\n Pain control (acute pain, chronic pain)\n Assessment:\n Left arm edematous and painful\n Action:\n Given morphine 2mg IV prn pain. Started on hydrocortisone 100mg q 6hr\n Response:\n Felt comfortable after pain med\n Plan:\n Continue steroids, medicate for pain prn\n Atrial fibrillation (Afib)\n Assessment:\n HR 70-80 afib with vpaced rhythm, off coumadin x 1 day INR 9.8 up from\n 4.3 PT 81.4 PTT 64.4 Hct 30.9\n Action:\n Coumadin continues to be held. Monitored for s+s of bleeding\n Response:\n Hct stable at present\n Plan:\n Repeat PT PTT, lytes and hct at 0900, continue to monitor for any signs\n of bleeding, maintain bleeding precautions\n Diabetes Mellitus (DM), Type II\n Assessment:\n On steroids blood sugar > 200\n Action:\n Given 6u humalog for blood sugar 264\n Response:\n Blood sugar 6hrs later 250\n Plan:\n Patient prob requires tighter glycemic control continue to monitor, ss\n insulin q 6hr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient with chronic renal insufficiency cr 1.3-1.8 presently BUN 64 cr\n 3.0 down from 3.6. Renal ultrasound negative. Cvp >9\n Action:\n Given 250cc LR x1 monitored cvp and urine output, K+ 5.4, NA 130\n Response:\n Urine output improving, K+ up NA down\n Plan:\n Repeat lytes at 0900am, monitor urine output and cvp\n" }, { "category": "Nursing", "chartdate": "2179-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407161, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt underlying rhythm Afib, currently V paced HR 70s. Pt off Coumadin,\n INR 11.5. Pt denies chest pain, palpitations. Denies dizziness or\n lightheadedness. Pt noted to have bloody nose x1 this evening. +BM this\n shift, guiaic negative.\n Action:\n Pt rec\nd 2mg PO vit K x2. Remains off coumadin. Stool sample sent.\n Nasal cannula removed and nasal spray given.\n Response:\n Nose bleed resolved. No s/s bleeding at this time.\n Plan:\n Continue to monitor CV and telemetry. Monitor ICD function. Monitor\n PT/INR trend. Monitor s/s bleeding.\n Diabetes Mellitus (DM), Type II\n Assessment:\n BS > 250 this shift. Pt diet advanced from NPO to regular diet. Pt\n reports increased appetite with IV steroid.\n Action:\n Sliding scale tightened recommendation. Pt rec\nd humalog SC\n per scale. Reinforced diet restrictions with pt.\n Response:\n Pt tolerated clears then regular diet for dinner, no N/V. No s/s\n hyperglycemia.\n Plan:\n Continue to monitor GI and FS.\n Hypotension (not Shock)\n Assessment:\n Pt on Levophed and Vasopressin at start of shift. BP MAP 60-70. CVP\n >12, BUN and Cr elevated, adequate u/o. Pt afebrile this shift. C/o\n shoulder pain/stiffness gout. C/o itchiness on back IV\n steroids.\n Action:\n Vasopressin gtt dc\nd. Levo gtt weaned to 0.06mcg/kg/hr. Repeat lytes\n drawn this shift. Medications renally dosed. Pt rec\nd 2mg IV morphine\n x1 and 1000mg tylenol x1, assisted with repositioning q2h for comfort.\n Hot packs for comfort. Sarna lotion to back.\n Response:\n MAP maintained >65. K+ elevated. Pt reports improved comfort. No skin\n breakdown noted.\n Plan:\n Continue to monitor need for vasopressors. Goal MAP >65. Monitor kidney\n function. Bedrest while on vasopressors. Monitor comfort and pain\n management. Continue to follow lytes.\n" }, { "category": "Nursing", "chartdate": "2179-05-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407167, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare . He has crystal\n proven gout with elevated uric acid levels to 12.\n Rheumatology fellow consulted he attempted to withdraw fluid from left\n elbow but no fluid returned\n Pt transferred to MICU 6 at 8pm from CCU.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 407255, "text": "TITLE: Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD\n placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin,\n elevated LFTs, who presented to the ED with chest pain and L arm pain.\n By report of wife and patient, he has had bad gout over the past\n several weeks to months. Principally this has been involving his right\n foot limiting his ability to walk. In the past few days had increasing\n right arm pain that patient thought was also his gout. Then starting\n about yesterday, patient had severe left arm pain at the shoulder and\n the elbow. This is ultimately, what prompted him to come to the ED.\n ROS notable for +sharp midsternal chest pain with coughing,\n non-productive cough, sinus congestion for several weeks, chills.\n Patient denied back pain, neck pain, pain with chewing, changes to his\n urine output or other complaints beyond those noted. Of note, recent\n medication changes include up titration of allopurinol to 250mg PO qday\n for gout after recent gout flare . He has crystal proven gout with\n elevated uric acid levels to 12. Pt transferred to MICU 6 at 8pm\n from CCU.\n UPDATE: Pt weaned off IV Levophed gtt this AM and doing well OOB\n sitting upright in chair. Insulin gtt cont to infuse awaiting \n recs to wean onto SQ dosing. Excellent dietary intake noted today.\n Clot and hold drawn/sent to blood bank today. The pt is currently net\n even today but remains net input five liters for LOS. The pt has a\n documented allergy to Unasyn. The pts supportive wife visited today\n and kept up to date with pts POC/status by myself and by HO. The pt\n remains a Full Code. Hopefully the pt be c/o to floor .\n Hypotension (not Shock)\n Assessment:\n Pt received on IV Levophed gtt infusing @ 0.02mcg/kg/min with team goal\n to keep SBP values > 90 which is the pts baseline SBP value. The pts\n cultures have been NGTD. Pt without obvious source of infection. AM\n lyte lab values WNL. AM Digoxin value of 0.7 noted.\n Action:\n IV Levophed gtt weaned down/off by 08:15. AM Vanco trough value of\n 23.3\n dose subsequently decreased. CVP values < 5 today. The pt has\n denied c/o dizziness, lightheadedness today. Digoxin dosing changed\n from Stat dosing to QD dosing.\n Response:\n Pt remains normotensive @ this time now off IV Levophed for over six\n hours @ this time.\n Plan:\n Cont to follow the pts SBP/VS values closely and adjust care\n accordingly.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt received/maintained on IV Insulin gtt currently infusing @ 6units/hr\n with last FS value of 194 @ 14:00. Pt has a 10 yr history of DM. FS\n values in the 106-212 range today. IV Steroid dosing for AI dose\n tapered down today.\n Action:\n Pt now being transisitioned off IV Insulin gtt according to recs\n which are now being entered into POE by HO. FS values followed hourly\n today/Insulin gtt rate adjusted accordingly.\n Response:\n Pt without significantly elevated FS values today and should be able to\n wean off IV Insulin gtt over the next 4-5 hours.\n Plan:\n Will cont to follow FS values, follow recs and adjust care\n accordingly today.\n Pain control (acute pain, chronic pain)\n Assessment:\n The pt has denied c/o pain now that he is OOB in chair.\n Action:\n Freq assessed pt for pain today.\n Response:\n No c/o pain by pt today.\n Plan:\n Cont to follow pain assessment and treat with IV Morphine accordingly.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407355, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407356, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407357, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,307 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Vanco level 31.1 Dig 0.7\n Lines / Tubes / Drains:\n A line D/C from the left wrist ,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407358, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted. He has a\n clot in blood bank for . His wife is at the bedside and supportive.\n Code Status: Full Code\n Hypotension (not Shock)\n Assessment:\n I received the patient with blood pressure in the one teens to one\n twenties via a line. He has remained off pressures since .\n Action:\n Left a line removed.\n Cuff placed\n Response:\n His blood pressure has remained 115 to 120\n Plan:\n Continue to monitor b/p\ns and hold home HTN meds.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Insulin GTT has remained off since . Last night he did\n receive Glargine 15Units.\n Action:\n Obtained blood sugars before meals.\n Response:\n His blood sugar before breakfast was 182. and the blood sugar\n before lunch was 314.\n He did receive sliding scale coverage.\n Plan:\n The glargine was increased up to 18Units. Please start tonight.\n Atrial fibrillation (Afib)\n Assessment:\n Patient has an ICD and is VPaced in the 70\ns. I have noted him is AF\n when he is on paced.\n Action:\n He is on dig and the level 0.7\n Response:\n PO dig given at 12 noon.\n Plan:\n Continue with current regime.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,307 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Vanco level 31.1 Dig 0.7\n Lines / Tubes / Drains:\n A line D/C from the left wrist ,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Pacemaker\n Additional history: Afib, cardiomyopahty with EF 15%, chronic kidney\n dx, obesity, gout, mild knee DJD, gallstone pancreatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:67\n Temperature:\n 95.8\n Arterial BP:\n S:113\n D:60\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,311 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:10 AM\n Potassium:\n 3.9 mEq/L\n 04:10 AM\n Chloride:\n 110 mEq/L\n 04:10 AM\n CO2:\n 17 mEq/L\n 04:10 AM\n BUN:\n 89 mg/dL\n 04:10 AM\n Creatinine:\n 1.7 mg/dL\n 04:10 AM\n Glucose:\n 215 mg/dL\n 04:10 AM\n Hematocrit:\n 27.8 %\n 04:10 AM\n Finger Stick Glucose:\n 314\n 12:00 PM\n Additional pertinent labs:\n Dig level 0.4, Vanco level 31.1\n Lines / Tubes / Drains:\n right TLC and right AC 22G.\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: Wife\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC7\n Date & time of Transfer: \n 13:36\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407353, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n .\n Of note, recent medication changes include uptitration of allopurinol\n to 250mg PO qday for gout after recent gout flare .\n .\n In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood\n pressures dropped to the 70s systolic and he was given 1L IVF, a CVL\n was placed and CVP was 13-16. A R IJ was placed and after dopamine was\n turned up to 20mcg/min, he was started on Levofed and dopamine was\n weaned down. He was given Vanc and Levofloxacin and nothing further\n due to allergy to Unasyn. He underwent non-contrast CT of the abdomen\n which was grossly normal. CXR was clear. A FAST scan in the ED did not\n show pericardial effusion, kidneys without hydronephrosis. Received 3L\n NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered\n but not given.\n .\n" }, { "category": "Nursing", "chartdate": "2179-05-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 407354, "text": "Mr. is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement,\n severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated\n LFTs, who presented to the ED with chest pain and L arm pain. By report\n of wife and patient he has had bad gout over the past several weeks to\n months. Principally this has been involving his right foot limiting\n his ability to walk. In the past few days had increasing right arm\n pain that patient thought was also his gout. Then starting about\n yesterday, patient had severe left arm pain at the shoulder and the\n elbow. This is ultimately what prompted him to come to the ED. ROS\n notable for +sharp midsternal chest pain with coughing, non-productive\n cough, sinus congestion for several weeks, chills. Patient denied back\n pain, neck pain, pain with chewing, changes to his urine output or\n other complaints beyond those noted.\n Update: The patient was weaned off the levo on , he was also\n weaned off the insulin gtt on . He is able to get out of the bed\n the recliner with one assist. He has a good appetite noted.\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 407359, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:15 AM\n - Patient off pressors morning of at ~8:00 AM\n - Dig and warfarin restarted\n - Hydrocortisone taper initiated at 50 mg PO Q8H but changed to\n prednisone 30mg daily later per pharm recs (although lacks mineralocort\n activity). Will plan for 10-day taper; recommend patient undergo\n re-stimulation later this admission once called out to floor. A-line\n left in while monitoring.\n - Insulin sliding scale adjusted recs; insulin gtt weaned\n off in late afternoon\n - Foley removed\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:28 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.4\n HR: 67 (63 - 92) bpm\n BP: 104/55(70) {90/47(61) - 136/94(97)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Height: 69 Inch\n CVP: 13 (2 - 18)mmHg\n Total In:\n 1,660 mL\n 129 mL\n PO:\n 720 mL\n TF:\n IVF:\n 940 mL\n 129 mL\n Blood products:\n Total out:\n 2,055 mL\n 900 mL\n Urine:\n 1,655 mL\n 900 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n -771 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Fingerstick: 185-250\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 157 K/uL\n 9.8 g/dL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n INR: 1.9 Dig: 0.7\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Micro: Coag negative staph, gram positive cocci pairs/clusters, stool\n studies pending\n Assessment and Plan\n Mr. is a 63yo M w/hx of severe systolic HF, EF 15-20%, afib on\n coumadin, who presents with hypotension\n .\n #. Hypotension: Likely due to adrenal insufficiency, given symptoms of\n fever, hypotension, diarrhea, high eosinophils, hyponatremia,\n hyperkalemia then low cortisol with failed ACTH stimulation. Initially,\n patient with marked fever, tachypnea, vasodilated on initial exam\n concerning for septic shock possibly from pulmonary source as possible\n pneumonia on CT scan (although normal lactate and normal WBC count).\n Septic arthritis considered given prominent joint complains and history\n of gout although joint tap negative. On vasopressors at admit, but\n weaned off over 48 hours. Normotensive with normal lactate.\n - Will follow UOP and re-start vasopressors as needed for MAP >60\n - CVP goal is likely much higher than typical given h/o CHF. Will\n be very difficult to interpret given h/o severe TR.\n .\n #. Infection/sepsis: Admission blood culture growing coag negative\n staph, likely contaminant. CT chest on admission with opacity\n atelectasis/pna. Patient has remained afebrile, normal white count.\n TTE w/ no evidence of vegetations on valves or hardware\n - discontinue vancomycin\n - appreciate rheumatology recs: consider repeat tap if clinically\n worsens and appropriate clinical scenario\n .\n # Adrenal insufficiency: Symptoms include hypotension, fever, diarrhea,\n elevated eosinophils. Low serum cortisol with failed ACTH stimulation\n test. Confounding factors that colchicine causes diarrhea, allupurinol\n induces hypereosinophilia. Abdominal CT with no evidence of adrenal\n pathology. Started on on oral prednisone with plan for taper.\n - prednisone 30mg daily with plan for 10 day taper\n - consider stim test when patient is on floor\n - consider MRI adrenal to r/o hemorrhage while on coumadin or infection\n pending improvement in renal function\n - f/ recs\n .\n #Hyperglycemia: poor glucose control in the setting of high dose\n steroids. Off insulin gtt overnight w/ adequate control on SSI.\n - increase glargine 15U to 18U with insulin sliding scale\n - diabetic diet\n - f/ consult recs\n .\n #. ARF: Likely pre-renal from poor-perfusion of kidneys, but must\n consider ATN given hypotension. Intrinsic renal disease from septic\n emboli would seem less likely. Trend improving with IVF's. - Urine\n bland. Normal renal U/S.\n - follow urine output closely and consider renal c/s if creatinine\n worsening\n - Renally dose all medications.\n - hold \n - Is likely to be torsemide dependent given severe CHF and renal\n failure so would consider dosing torsemide later but for now does not\n appear volume overloaded and is auto-diuresing\n .\n #. Elevated INR: likely elevated in the setting of coumadin use with\n other medical problems. Trending down after Vit K\n - continue Coumadin today (3.5 mg) at home dose\n - if signs of bleeding, consider vitamin K/FFP\n .\n #. Elevated T. Bili: has been chronically elevated in the past with\n other LFT elevations. CT unremarkable for obstructive etiology.\n Trending down\n .\n # CHF: Non-ischemic cardiomyopathy with severe TR.\n - Hold carvedilol given shock\n - Hold diovan given shock\n - Digoxin continued\n - Hold torsemide and dose as needed.\n - FYI to primary Cardiologist Dr. \n .\n # Atrial Fibrillation: h/o and returned to with dopamine on board.\n Wean dopamine, hold coumadin and other outpatient medications for now.\n - dose digoxin by level\n low at 0.7 today\n - continue Coumadin today (3.5 mg)\n .\n # Sinusitis: By history has had several months of sinus congestion.\n - fluticasone nasal spray\n - consider sinus CT\n .\n # Eosinophilia: Absolute count about 900. Has been noted in the past.\n Concerning for malignancy, occult parasitic infection, Churg-Strasuss\n (does have rhinitis but no h/o asthma and is older than typically\n seen). Improved with steroids.\n - Check ANCA\n - Trend eosinphils\n - Steroids prn as per rheumatology\n - Add on diff to AM labs\n - Rheum consult.\n F/U recs\n .\n # Gout: Renally dose allopurinol. No fluid to tap.\n - F/u rheum recs\n - hold colchicine/ibuprofen given renal failure.\n # AMS. Waxing and yesterday, refusing FS. Received haldol x 1\n with good effect.\n - Monitor MS\n - Chemical restraint as needed\n # FEN: IVF, replete/trend electrolytes, regular low sodium/heart\n healthy/diabetic diet\n # Prophylaxis: INR supratherapeutic, pneumoboots, discontinue\n famotidine\n # Access: peripherals, CVL, A-line (try to discontinue today)\n # Communication: Patient and wife who works in Radiology for \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2179-05-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 407360, "text": "Chief Complaint: Hypotension, adrenal insufficiency\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Off pressors since yest AM\n Doing well this AM --> no complaints\n 24 Hour Events:\n EKG - At 11:15 AM\n CALLED OUT\n History obtained from Medical records, icu team\n Allergies:\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n transaminitis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:25 AM\n Metronidazole - 07:51 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Gastrointestinal: No(t) Abdominal pain\n Musculoskeletal: No(t) Joint pain\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (60 - 98) bpm\n BP: 109/67(77) {87/55(63) - 116/67(77)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: A Paced\n Height: 69 Inch\n CVP: 11 (11 - 22)mmHg\n Total In:\n 1,660 mL\n 1,319 mL\n PO:\n 720 mL\n 840 mL\n TF:\n IVF:\n 940 mL\n 479 mL\n Blood products:\n Total out:\n 2,055 mL\n 1,300 mL\n Urine:\n 1,655 mL\n 1,300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -395 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 9.8 g/dL\n 157 K/uL\n 215 mg/dL\n 1.7 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 89 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.8 %\n 9.0 K/uL\n [image002.jpg]\n 08:14 AM\n 02:00 PM\n 04:15 PM\n 01:50 AM\n 09:29 AM\n 05:19 PM\n 03:51 AM\n 03:00 AM\n 04:10 AM\n WBC\n 8.1\n 5.7\n 5.8\n 9.1\n 9.0\n Hct\n 28.4\n 30.9\n 28.6\n 27.8\n 27.8\n Plt\n 137\n 128\n 129\n 151\n 157\n Cr\n 3.7\n 3.6\n 3.0\n 2.7\n 2.6\n 2.5\n 2.1\n 1.7\n TropT\n <0.01\n Glucose\n 178\n 198\n 187\n 227\n 15\n 215\n Other labs: PT / PTT / INR:20.3/32.1/1.9, CK / CKMB /\n Troponin-T:65//<0.01, ALT / AST:, Alk Phos / T Bili:70/2.3,\n Differential-Neuts:81.9 %, Band:0.0 %, Lymph:12.9 %, Mono:4.4 %,\n Eos:0.7 %, Lactic Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:158 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n DIABETES MELLITUS (DM), TYPE II\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 63 yo man with CHF (EF 15-20%), in MICU with hypotension/shock likely\n septic with contribution of adrenal insufficiency.\n Hypotension/Adrenal insufficiency: Off pressors and doing well. Now on\n pred 30mg daily. Would consider keeping him on an extended course\n given his symptomatic gout improvement along with necessity for BP for\n the time being. Will need repeat stim as an outpatient.\n GPC in blood cxs --> coag neg staph. Likely contaminant. Will d/c\n vanco. Did recieve extra dose this AM despite level > 30.\n Acute renal failure: Cr down to 1.7\n DM: Now on sq insulin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Arterial Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "RENAL U.S.", "row_id": 1130512, "text": " 9:54 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for abnormalities c/w ATN, pyelo or hydronep\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF, A. FIb, p/w likely septic shock and renal failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate for abnormalities c/w ATN, pyelo or hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old man with renal failure, evaluate for pyelo- or\n hydronephrosis.\n\n COMPARISON: Torso CT, .\n\n FINDINGS: The right kidney measures 10.5 cm and the left kidney measures 11.5\n cm. There is no hydronephrosis. No cysts or stone or solid mass seen in\n either kidney. No perinephric fluid collections are identified. A small\n splenule is identified in the splenic hilum measuring 1.3 cm. The urinary\n bladder could not be evaluated as a Foley catheter is in place.\n\n IMPRESSION: Normal renal ultrasound. No hydronephrosis and no perinephric\n fluid collection identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130442, "text": " 11:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hypotension, cardiomyopathy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hypotension. Clinical concern for congestive heart failure.\n\n COMPARISON: Multiple chest radiographs with the most recent from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Left-sided cardiac pacer is again noted\n with the tip of the electrode not visualized. Heart is enlarged. The aorta\n is mildly tortuous. There is no evidence of pneumonia, pleural effusion, or\n pneumothorax. There is no overt pulmonary edema.\n\n IMPRESSION: Cardiomegaly with no overt pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1130449, "text": " 12:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT ARM WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with c/o of L arm weakness, on coumadin, eval for ICH\n REASON FOR THIS EXAMINATION:\n ICH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:00 AM\n No ICH. If concerned for acute infarct MRI can be obtained.\n tiny air bubbles in the masticator space subq tissues, spinal canal and\n clinoid ar non-specisic. clinical correlation and follow-up ct in 6 hours can\n be helpful.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Left arm weakness, on Coumadin.\n\n COMPARISON: Head CT from .\n\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or\n -white matter differentiation abnormality. The ventricles and extra-axial\n spaces are appropriate for age. There is no osseous lesion to suggest\n malignancy or infection. A few gas bubbles within the masticator space around\n the mandible and inferior to the orbit within the subcutaneous tissues of the\n face, more on the right than left, are partially imaged and nonspecific. There\n is also a tiny focus of air in the spinal canal, likely extradural (2:1).\n There is also a tiny focus of air in the subcutaneous tissues of the forehead.\n Atherosclerotic calcifications of the intracranial carotid arteries are noted.\n Air in the left clinoid at the location of the carotid artery is also seen.\n\n IMPRESSION:\n 1. No acute intracranial abnormality. In case of clinical concern for acute\n infarction, an MRI can be obtained.\n\n 2. Gas within the spinal canal, masticator space, and left clinoid adjacent\n to the carotid artery. This is nonspecific and may potentially be secondary\n to recent line placement.\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1130458, "text": " 2:21 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PATHOLOGY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx CHF, fever with hypotension\n REASON FOR THIS EXAMINATION:\n eval obvious pathology\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 4:06 AM\n 1. no definite acute finding to explain pt sx's on this non- contrast CT.\n 2. Urinary bladder wall thickening likely under-distension\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: History of congestive heart failure, presents with fever and\n hypotension.\n\n COMPARISON: Multiple CTs of the abdomen and pelvis as well as chest\n radiographs with the most recent from earlier same date. Most recent CT\n abdomen and pelvis is from .\n\n TECHNIQUE: Multidetector CT images of the chest, abdomen and pelvis without\n administration of IV or oral contrast as per requested by ordering physician\n were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CHEST CT: Imaged thyroid gland is grossly unremarkable. There\n is a left-sided cardiac pacer with the lead terminating in the right\n ventricle. There is also a right internal jugular intravenous catheter with\n the tip at the mid-distal SVC. A few subcentimeter mediastinal lymph nodes\n with no evidence of lymphadenopathy are noted. There is no hilar or axillary\n lymphadenopathy on this non-contrast study. The aorta demonstrates\n atherosclerotic calcifications. Atherosclerotic calcifications of the\n coronary arteries are also seen. Heart is enlarged. There is no pericardial\n effusion. Bibasilar atelectatic changes and/or pneumonia, left more than\n right are noted. Mild emphysema is likely present. Calcified granulomas in\n the right lower lobe (2:46 and 2:30) are noted. There is no pneumothorax or\n pleural effusion.\n\n NON-CONTRAST ABDOMINAL CT: The unenhanced liver, spleen, pancreas, adrenals\n are unremarkable. Small pericholecystic fluid was also seen on prior study.\n Both kidneys are in normal anatomic location. A focal, somewhat band-like\n calcification in the interpolar region of the left kidney is stable since \n . There is a probable 2-mm nonobstructive stone in the inferior pole of\n the left kidney (2:74). There is no hydronephrosis. Abdominal aorta and\n iliac vessels demonstrate severe atherosclerotic calcifications with no\n aneurysmal dilatation. There is no retroperitoneal hematoma. Evaluation of\n the GI tract demonstrates no evidence of bowel obstruction or bowel wall\n thickening. Tubular blind ending structure in the right lower quadrant likely\n (Over)\n\n 2:21 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PATHOLOGY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n represents a normal appendix.\n\n NON-CONTRAST PELVIC CT: The urinary bladder is collapsed and contains a Foley\n catheter. Air within the urinary bladder is likely secondary to\n instrumentation. Bilateral small fat-containing inguinal hernias are seen.\n The rectum contains stool, otherwise unremarkable. Seminal vesicles are\n symmetric. The prostate gland measures about 5 cm in transverse diameter.\n The urinary bladder wall thickening may be secondary to underdistension. A\n few mildly prominent inguinal lymph nodes are noted. A hypoattenuating\n structure measuring 2.3 cm in the right lower abdomen to the right of the\n urinary bladder is stable.\n\n OSSEOUS STRUCTURES: There is no bony lesion to suggest malignancy or\n infection.\n\n IMPRESSION:\n 1. Left lower lobe atelectasis or pneumonia. Mild emphysema.\n 2. Small amount of pericholecystic fluid was also seen on prior study. Please\n clinically correlate.\n 2. Probable 2 mm nonobstructive left renal calculus.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1130460, "text": " 3:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval RIJ CVL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new CVL placed\n REASON FOR THIS EXAMINATION:\n eval RIJ CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: New central venous line placement.\n\n COMPARISON: Multiple chest radiographs, with the most recent from at 23:16 p.m.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There has been interval placement of a\n right internal jugular venous catheter with the tip at the mid superior vena\n cava. There is no congestive heart failure. Heart is enlarged. The aorta is\n mildly tortuous. There is no pneumothorax or pleural effusion.\n\n IMPRESSION: No pneumothorax. Cardiomegaly.\n\n" } ]

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Pt is a yo male with h/o PD, HTN, CAD who presented with a stable 6 mm left frontal SDH with SAH and small ICH after a mechanical fall. He was admitted to the neuro stepdown unit for close monitoring. We obtained further history to confirm that Mr did not lose consciousness or have another neurological event such as a seizure that may have prompted his fall. It appeared that it was solely a mechanical issue though. 1. C-spine clearance:He had flex/ex films of his C-spine that showed some mild spondylolisthesis, so a CT was recommended. This was obatined and essentially negative for fracture. An MRI was recommended to rulew out ligamentous injury, so this was also obtained. He had only mild ligamentous changes and no neck pain on exam, so his C-spine was cleared. 2. Neuro/SDH: The patient had a stable subdural hematoma after his fall. He had slight mass effect that was not causing symptoms during his admission. He hd a follow-up CT scan that showed no change in the bleed. He then had a follow-up MRI scan scan which showed stability of the bleeding. It also showed no evidence of stroke or other abnormality. Clinically, the patient displayed his baseline memory problems, but was otherwise pleasant and conversant throughout his stay on the floor. He had no complaints and no obvious neurological changes from his baseline. He did have a headache while he was here. Given the bleeding, we wanted to keep his BP well controlled and it stayed in a good range throughout. 3. Pulm:The patient had several episodes of wheezing while he was here. His respiratory rate and oxygen saturations remained normal throughout. A CXR was obtained and showed no obvious reason for these changes, but did show COPD. This may have been causing his wheezing. On speaking with his cregiver, he apparently has similar episodes at home. He was therefore sent home with a nebulizer machine and albuterol q6h prn. Albuterol wasn't used due to his heart condition. 4.CV:Pt was continued on his home antihypertensives and had no issues. He was also continued on his statin. 5.Parkinsonism:Pt was at his baseline neurologically from a Parkinsonism point of view. He was continued on Simemet and Celexa. He was seen by his outpatient neurologist. Also, the PT department taught his caregiver how to care for him better from a Parkinson's point of view. A hospital bed was sent to his house as well. His family wanted to take him home, so they arranged for more constant care for him and had their questions about home care answered by various staff members here. This was an acceptable arangement. They will watch closely to prevent further falls. He will follow up with Dr . He will see his PCP weeks. They can follow-up on his neurologic status, and discuss the need to get repeat CXRs to evaluate the nodule at the base of his left lung.

There is grade I retrolisthesis of C5 on C6 and slight anterior displacement of the anterior aspect of the spinous processes of C6 and C7 with mild narrowing of the spinal canal at these levels. IMPRESSION: Stable appearance of left-sided subdural hematoma, subarachnoid hemorrhage and intraventricular hemorrhage. CT HEAD WITHOUT IV CONTRAST: The left-sided hyperattenuating extraaxial collection consistent with a subdural hematoma is stable when compared to the previous exam. FS 124 ~ no regular insulin required.SKIN: hematoma l side of head. CT scan mild left to right shift, subdural/subarachnoid hematoma. There is a left frontal scalp hematoma. Incidental note is made of an ependymal cyst within the temporal of the right lateral ventricle. Chronic small vessel ischemic changes and an old, pontine infarct are again identified. NURSING NOTE 1900HRS-0400HRSADMIT WITH FALL CT SHOWED SLIGHT RT TO LFT SHUNT WITH SUDURAL/SUBARACHNOID HAEMATOMA....NEURO....BASELINE DEMENTIA WITH SHORT TERM MEMORY LOSS PLUS PARKINSONS...FAMILY HERE TO ESTABLISH BASELINE...IS ORIENTATAED TO PERSON/PLACE AWARE OF FAMILY MEMBERS AND NAMES OBJECTS...FIDIGITY AT BASELINE REQUIRING OBJECTS TO FIDDLE WITH...FULL POWER IN ALL 4 LIMBS AND PUPILS EQUAL/REACTIVE...REPAET HEAD CT LAST PM PLUS XR OF NECK [AWAITING REVIEW] UNABLE TO TAKE OF COLLAR AS OF YET AS PATIENT INCONSISTENT WHEN ASKED ABOUT PAIN...S/B NEURO @ 12MN TO HOLD OF MRI UNTIL THIS AM AS PATIENT STABLE...DENIES ANY PAIN/DISCOMFORT WHEN ASKEDCVS ...RECEIVED ON LABETELOL @ 0.5MGS /MIN TO MAINTAIN < 170...TITRATED DOWN AND SWITHCHED OF @ 12MN AS B/P CONSISTENTLY 140-160 HR @ 65-70BPM SINUS...AFEBRILE ..B/S STABLE...FLUIDS CONTINUE @ 85CC/HRRESP...LUNGS SOUND DIMINSHED BUT SATS MAINTAINED 92-98% RR SATISFACTORYGI...NO PO OVERNIGHT, ABDOMEN SOFT WITH BOWEL SOUNDS NO BOWEL MOTIONGU...VIA ILEOCONDUIT, SATISFACTORY AMOUNT, IV FLUIDS CONTINUESKIN...HAEMATOMA EVIDENT LEFT SIDE OF HEAD [ AREA DRY], NOW BRUISING EXTENDED DOWN TO LEFT EYE, BUT DOES NOT APPEAR TO BE AFFECTING EYE OPENING @ PRESENT...CONTINUE TO OBSERVELINES...X2 PERIPHERL PATENTSOCIAL..X2 DAUGHHTERS VISIST UPDATED LAST PMPLAN...OBSERVE NEURO STATUS, MRI TODAY ? CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is imaged from C1 through T3. Within the remainder of the cervical spine, there is marked multilevel degenerative change with loss of intervertebral disc space height and endplate sclerosis and osteophytosis, most prominent at C5-6 and C6-7. pt with repeat MRI of head (results pending) surgery cleared c-spine - neck collar removed. TECHNIQUE: Axial noncontrast MDCT images were obtained through the head. Hemorrhage is seen layering within the lateral ventricles bilaterally. no fracture of C-spine.PMH: bladder CA s/p vesicectomy and urostomy placement, Parkinson's Disease, HTN, Hyperlipidemia, CAD, CABG, dementia, short term memory loss, spinal stenosis, syncope.Allergies: ?percocet, strawberriesNEURO: pt w/ baseline dementia w/ short term memory loss, parkinsons, oriented to person only. The visualized outlines of the thecal sac appear slightly deformed at C5-6. The visualized portions of the mastoid air cells are normally pneumatized. The subarachnoid hemorrhage within the ambient cistern and layering over the left frontal and parietal lobes is also unchanged. Marked degenerative change with anterolisthesis of C2-3 and of C5-6. FINAL REPORT INDICATION: Head injury and large hematoma, assess for fracture. There is a focal area of sclerosis within the T4 vertebra on the left, a finding that is of uncertain significance and could possibly indicate a bone island. While these findings likely relate to degenerative change, if there is clinical symptomatology referable (Over) 1:43 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: assess for fracture FINAL REPORT (Cont) to these levels, MR of the cervical spine would be more useful for assessing for possible ligamentous injuries. Rotation of C1 upon C2 likely relates to patient head positioning. Marked multilevel degenerative change of the cervical spine with grade I anterolisthesis of C2 on C3 and of C5 on C6. TECHNIQUE: Axial MDCT images were obtained through the cervical spine without intravenous contrast. There is marked multilevel degenerative change of the cervical spine. The prevertebral soft tissues appear unremarkable. CT is limited in its ability to provide intrathecal detail. At C1-2, there is osteophytosis at the atlantoaxial articulation. There is grade I anterolisthesis of C2 on C3. 9:47 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: eval hemorrhage Admitting Diagnosis: HEAD BLEED MEDICAL CONDITION: year old man with SDH/SAH vs interparenchymal -- please schedule close to 22:00PM REASON FOR THIS EXAMINATION: eval hemorrhage No contraindications for IV contrast FINAL REPORT INDICATION: Subdural and subarachnoid hemorrhage. bp stable 148/56 HR 60's SR no vea.IVF D5NS w/ 20 meq kcl @ 85 cc/hrRESP: pt on RA O2 sats ~ 96% rr~20 lungs clear w/ decreased breath sounds @ bases.GI: was npo, on CV/heart healthy diet, grams NA, ground. Stable minimal rightward midline shift. Additional coronal and sagittal reformations are provided.

4

[ { "category": "Nursing/other", "chartdate": "2142-10-28 00:00:00.000", "description": "Report", "row_id": 1536614, "text": "NURSING NOTE 1900HRS-0400HRS\n\nADMIT WITH FALL CT SHOWED SLIGHT RT TO LFT SHUNT WITH SUDURAL/SUBARACHNOID HAEMATOMA....\n\n\n\nNEURO....BASELINE DEMENTIA WITH SHORT TERM MEMORY LOSS PLUS PARKINSONS...FAMILY HERE TO ESTABLISH BASELINE...IS ORIENTATAED TO PERSON/PLACE AWARE OF FAMILY MEMBERS AND NAMES OBJECTS...FIDIGITY AT BASELINE REQUIRING OBJECTS TO FIDDLE WITH...FULL POWER IN ALL 4 LIMBS AND PUPILS EQUAL/REACTIVE...REPAET HEAD CT LAST PM PLUS XR OF NECK [AWAITING REVIEW] UNABLE TO TAKE OF COLLAR AS OF YET AS PATIENT INCONSISTENT WHEN ASKED ABOUT PAIN...S/B NEURO @ 12MN TO HOLD OF MRI UNTIL THIS AM AS PATIENT STABLE...DENIES ANY PAIN/DISCOMFORT WHEN ASKED\n\n\nCVS ...RECEIVED ON LABETELOL @ 0.5MGS /MIN TO MAINTAIN < 170...TITRATED DOWN AND SWITHCHED OF @ 12MN AS B/P CONSISTENTLY 140-160 HR @ 65-70BPM SINUS...AFEBRILE ..B/S STABLE...FLUIDS CONTINUE @ 85CC/HR\n\n\n\nRESP...LUNGS SOUND DIMINSHED BUT SATS MAINTAINED 92-98% RR SATISFACTORY\n\n\nGI...NO PO OVERNIGHT, ABDOMEN SOFT WITH BOWEL SOUNDS NO BOWEL MOTION\n\n\nGU...VIA ILEOCONDUIT, SATISFACTORY AMOUNT, IV FLUIDS CONTINUE\n\n\nSKIN...HAEMATOMA EVIDENT LEFT SIDE OF HEAD [ AREA DRY], NOW BRUISING EXTENDED DOWN TO LEFT EYE, BUT DOES NOT APPEAR TO BE AFFECTING EYE OPENING @ PRESENT...CONTINUE TO OBSERVE\n\n\nLINES...X2 PERIPHERL PATENT\n\n\nSOCIAL..X2 DAUGHHTERS VISIST UPDATED LAST PM\n\n\nPLAN...OBSERVE NEURO STATUS, MRI TODAY ? D/C NECK COLLAR\n" }, { "category": "Nursing/other", "chartdate": "2142-10-28 00:00:00.000", "description": "Report", "row_id": 1536615, "text": "7A-7pm npn/ NSG TRANSFER NOTE\n y.o. male admitted to PMICU (on T-SICU team) s/p fall A home. CT scan mild left to right shift, subdural/subarachnoid hematoma. no fracture of C-spine.\n\nPMH: bladder CA s/p vesicectomy and urostomy placement, Parkinson's Disease, HTN, Hyperlipidemia, CAD, CABG, dementia, short term memory loss, spinal stenosis, syncope.\n\nAllergies: ?percocet, strawberries\n\nNEURO: pt w/ baseline dementia w/ short term memory loss, parkinsons, oriented to person only. MAE, asking for something to drink, HOB elevated 30 degrees, pupils 3mm equal and reactive to light. pt with repeat MRI of head (results pending) surgery cleared c-spine - neck collar removed. no seizure activity. dilantin d'cd. pt get oob w/ assistance. napping on/off. family in at bedside - helps pt stay in bed, pt fidgeting - SR up x4, bed alarm on\nPT/OT consult needed (ordered)\n\nCV/fluids: Labetolol gtt d'cd, pt restarted on 20 mg Lisinopril po qd, Atenolol 25 mg po qd. bp stable 148/56 HR 60's SR no vea.\nIVF D5NS w/ 20 meq kcl @ 85 cc/hr\n\nRESP: pt on RA O2 sats ~ 96% rr~20 lungs clear w/ decreased breath sounds @ bases.\n\nGI: was npo, on CV/heart healthy diet, grams NA, ground. taking sips of H20\nno stool, belly soft, on colace Pantoprazole 40 nmg IV q 24 hrs.\n\nGU: ileoconduit intact, draining clear, yellow urine 40-60 cc/hr\n\nENDO: FS q 6 hrs and cover w/ regular insulin. FS 124 ~ no regular insulin required.\n\nSKIN: hematoma l side of head. right eye w/ blood shot. no breakdown on coccyx. turned side to side.\nabrasion on left elbow and lower arm (from fall)\n\nLINES: 2 peripherals # 20/ #18\n\nSOCIAL: married, lives w/ wife, has a caretaker during the week from 8-5pm to help out. 2 daughters~very involved, full code\n \nWife \n\nA: s/p fall ~ subdural/subarachnoid hemorrhage of left fronto-parietal area\n\nP: continue neuro checks, PT/OT consults, oob to chair, hrt healthy diet, follow bp/hr/O2 sats, monitor hematoma, safety precautions.\n" }, { "category": "Radiology", "chartdate": "2142-10-27 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 881644, "text": " 1:43 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with head injury, and large hematoma\n REASON FOR THIS EXAMINATION:\n assess for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 3:07 PM\n No fracture.\n Marked degenerative change with anterolisthesis of C2-3 and of C5-6.\n These may relate to degenerative change although if evaluation for ligamentous\n injury is of clinical interest, MR is a more sensitive test.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head injury and large hematoma, assess for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\n intravenous contrast. Additional coronal and sagittal reformations are\n provided.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\n imaged from C1 through T3. No fracture is identified in the cervical spine.\n There is marked multilevel degenerative change of the cervical spine. At\n C1-2, there is osteophytosis at the atlantoaxial articulation. In addition,\n there is questionable lucency at the superior aspect of the dens, which could\n represent erosion versus a superiorly projecting curvilinear osteophyte.\n Rotation of C1 upon C2 likely relates to patient head positioning. There is\n grade I anterolisthesis of C2 on C3. Within the remainder of the cervical\n spine, there is marked multilevel degenerative change with loss of\n intervertebral disc space height and endplate sclerosis and osteophytosis,\n most prominent at C5-6 and C6-7. There is grade I retrolisthesis of C5 on C6\n and slight anterior displacement of the anterior aspect of the spinous\n processes of C6 and C7 with mild narrowing of the spinal canal at these\n levels. The visualized outlines of the thecal sac appear slightly deformed at\n C5-6. CT is limited in its ability to provide intrathecal detail. The\n prevertebral soft tissues appear unremarkable.\n\n The visualized portions of the mastoid air cells are normally pneumatized.\n Note is made of prominent vascular calcifications. The visualized portions of\n the lung apices demonstrate no pneumothorax. There is a focal area of\n sclerosis within the T4 vertebra on the left, a finding that is of uncertain\n significance and could possibly indicate a bone island.\n\n IMPRESSION:\n 1. No fracture of the cervical spine.\n 2. Marked multilevel degenerative change of the cervical spine with grade I\n anterolisthesis of C2 on C3 and of C5 on C6. While these findings likely\n relate to degenerative change, if there is clinical symptomatology referable\n (Over)\n\n 1:43 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fracture\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to these levels, MR of the cervical spine would be more useful for assessing\n for possible ligamentous injuries.\n 3. Sclerotic T4 vertebral body lesion may represent a bone island.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 881685, "text": " 9:47 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval hemorrhage\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with SDH/SAH vs interparenchymal -- please schedule close to\n 22:00PM\n REASON FOR THIS EXAMINATION:\n eval hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural and subarachnoid hemorrhage.\n\n COMPARISONS: Eight hours earlier.\n\n TECHNIQUE: Axial noncontrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: The left-sided hyperattenuating extraaxial\n collection consistent with a subdural hematoma is stable when compared to the\n previous exam. The subarachnoid hemorrhage within the ambient cistern and\n layering over the left frontal and parietal lobes is also unchanged. No new\n intracranial hemorrhage is identified. Hemorrhage is seen layering within the\n lateral ventricles bilaterally. There is a left frontal scalp hematoma. The\n minimal rightward midline shift is stable. The paranasal sinuses are well\n aerated. Chronic small vessel ischemic changes and an old, pontine infarct\n are again identified. Incidental note is made of an ependymal cyst within the\n temporal of the right lateral ventricle.\n\n IMPRESSION: Stable appearance of left-sided subdural hematoma, subarachnoid\n hemorrhage and intraventricular hemorrhage. Stable minimal rightward midline\n shift.\n\n" } ]

91,929

100,463

63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole 5 years ago admitted with acute change in mental status.

Endotracheal tube has been removed, as has the nasogastric tube. FINDINGS: There are postoperative changes seen in the right side from prior subdural hematoma evacuation. Consider prior anteroseptal myocardialinfarction. FINAL REPORT HISTORY: Altered mental status and intubation for airway protection. Bilateral low lung volumes are noted with crowding of bronchovascular markings. Interval extubation and removal of enteric catheter. Minimal poor definition of pulmonary vessels could reflect slight elevation of pulmonary venous pressure. Left hemidiaphragm is more sharply seen, consistent with some decrease in volume loss in the left lower lobe. Mild brain atrophy identified. Cardiac silhouette is accentuated by low lung volumes. pin projects over left tracheal margin. FINAL REPORT HISTORY: Possible right lower lobe consolidation. REASON FOR THIS EXAMINATION: RLL pneumonia? Blunting of costophrenic angles could reflect small effusions or pleural thickening. FINDINGS: In comparison with the study of , there again are lower lung volumes. pneumonia WET READ: EHAb MON 9:02 PM Right perihilar and left retrocardiac densities most likely represent atelectasis, but pneumonia cannot be excluded. ET tube is at the carina and should be repositioned. Poor R wave progression. Additionally, opacification at the left lung base and in the retrocardiac region appears concerning for either pleural effusion versus atelectasis, infectious process such as pneumonia cannot be completely excluded in the correct clinical setting. Non-specific lateral ST segment changes. WET READ VERSION #1 FINAL REPORT EXAM: CT head. CLINICAL INFORMATION: Patient with headache , recent confusion leading to fall and change in mental status and history of subdural hematoma. Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman s/p extubation with possible R LL consolidation. Cardiac silhouette is within upper limits of normal or slightly enlarged. 12:04 PM CHEST (PA & LAT) Clip # Reason: RLL pneumonia? Postoperative changes. No definite pneumonia is appreciated, though in the appropriate clinical setting a supervening consolidation would be difficult to exclude in lower zones. However, in the appropriate clinical setting, supervening pneumonia would have to be considered. 5:15 AM CHEST (PORTABLE AP) Clip # Reason: eval tube position MEDICAL CONDITION: History: 63F with intubated REASON FOR THIS EXAMINATION: eval tube position FINAL REPORT INDICATION: 63-year-old intubated, evaluate tube position. PORTABLE AP CHEST RADIOGRAPH: A feeding tube is noted with tip at the level of the gastric antrum. 6:56 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ? pain projects over the left tracheal margin. Sinus rhythm. 11:51 AM CT HEAD W/O CONTRAST Clip # Reason: r/o bleed or other acute pathology Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman with 9/10 HA since yesterday, recent confusion leading to a fall and change in mental status, with h/o subdural hematoma s/p craniotomy 5yrs ago REASON FOR THIS EXAMINATION: r/o bleed or other acute pathology No contraindications for IV contrast WET READ: AFSN WED 1:03 PM No acute abnormalities are seen. pneumonia Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: 63 year old woman admitted for altered mental status and intubated for airway protection now extubated REASON FOR THIS EXAMINATION: ? TECHNIQUE: Axial images of the head were obtained without contrast. FINDINGS: In comparison with the earlier study of this date, the lung volumes have improved. IMPRESSION: No acute intra- or extra-axial hemorrhage, mass effect, or hydrocephalus seen. No previous tracingavailable for comparison. No pneumothorax or pleural effusion detected on this single view. COMPARISON: NONE. There is no acute intra- or extra-axial hemorrhage, mass effect or midline shift seen. There are no prior similar examinations for comparison. Findings were discussed with Dr. at 6:11 a.m. on via telephone at the time of discovery of critical findings.

5

[ { "category": "Radiology", "chartdate": "2109-07-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1251452, "text": " 12:04 PM\n CHEST (PA & LAT) Clip # \n Reason: RLL pneumonia?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p extubation with possible R LL consolidation.\n REASON FOR THIS EXAMINATION:\n RLL pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible right lower lobe consolidation.\n\n FINDINGS: In comparison with the study of , there again are lower lung\n volumes. Cardiac silhouette is within upper limits of normal or slightly\n enlarged. Minimal poor definition of pulmonary vessels could reflect slight\n elevation of pulmonary venous pressure. Blunting of costophrenic angles could\n reflect small effusions or pleural thickening.\n\n No definite pneumonia is appreciated, though in the appropriate clinical\n setting a supervening consolidation would be difficult to exclude in lower\n zones.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-07-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1251563, "text": " 11:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed or other acute pathology\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with 9/10 HA since yesterday, recent confusion leading to a\n fall and change in mental status, with h/o subdural hematoma s/p craniotomy\n 5yrs ago\n REASON FOR THIS EXAMINATION:\n r/o bleed or other acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AFSN WED 1:03 PM\n No acute abnormalities are seen.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT head.\n\n CLINICAL INFORMATION: Patient with headache , recent confusion leading to\n fall and change in mental status and history of subdural hematoma.\n\n TECHNIQUE: Axial images of the head were obtained without contrast. There\n are no prior similar examinations for comparison.\n\n FINDINGS: There are postoperative changes seen in the right side from prior\n subdural hematoma evacuation. There is no acute intra- or extra-axial\n hemorrhage, mass effect or midline shift seen. Mild brain atrophy identified.\n\n IMPRESSION:\n No acute intra- or extra-axial hemorrhage, mass effect, or hydrocephalus seen.\n Postoperative changes.\n\n" }, { "category": "Radiology", "chartdate": "2109-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251277, "text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 63F with intubated\n REASON FOR THIS EXAMINATION:\n eval tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old intubated, evaluate tube position.\n\n COMPARISON: NONE.\n\n PORTABLE AP CHEST RADIOGRAPH:\n A feeding tube is noted with tip at the level of the gastric antrum. ET tube\n is at the carina and should be repositioned. Bilateral low lung volumes are\n noted with crowding of bronchovascular markings. Cardiac silhouette is\n accentuated by low lung volumes. Additionally, opacification at the left lung\n base and in the retrocardiac region appears concerning for either pleural\n effusion versus atelectasis, infectious process such as pneumonia cannot be\n completely excluded in the correct clinical setting. Findings were discussed\n with Dr. at 6:11 a.m. on via telephone at the time of\n discovery of critical findings.\n\n" }, { "category": "Radiology", "chartdate": "2109-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251364, "text": " 6:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman admitted for altered mental status and intubated for airway\n protection now extubated\n REASON FOR THIS EXAMINATION:\n ? pneumonia\n ______________________________________________________________________________\n WET READ: EHAb MON 9:02 PM\n Right perihilar and left retrocardiac densities most likely represent\n atelectasis, but pneumonia cannot be excluded. No pneumothorax or pleural\n effusion detected on this single view. Interval extubation and removal of\n enteric catheter. pin projects over left tracheal margin. Discussed with\n by phone at 9 p.m. on at the time of initial review\n of the study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status and intubation for airway protection.\n\n FINDINGS: In comparison with the earlier study of this date, the lung volumes\n have improved. Endotracheal tube has been removed, as has the nasogastric\n tube. Left hemidiaphragm is more sharply seen, consistent with some decrease\n in volume loss in the left lower lobe. However, in the appropriate clinical\n setting, supervening pneumonia would have to be considered.\n\n pain projects over the left tracheal margin.\n\n\n" }, { "category": "ECG", "chartdate": "2109-07-29 00:00:00.000", "description": "Report", "row_id": 306764, "text": "Sinus rhythm. Poor R wave progression. Consider prior anteroseptal myocardial\ninfarction. Non-specific lateral ST segment changes. No previous tracing\navailable for comparison.\n\n" } ]

899

188,576

71 year old male admitted from outside hospital with mitral valve endocarditis, R PCA infarcts, and ATN for preop evaluation. He underwent preoperative workup including cardiac catherization and infectious disease consult. Cardiac catherization mild single vessel coronary artery disease. He received hydration and creatinine was monitored closely. On he was brought to the operating room and underwent mitral valve replacement #27mm porcine valve. Please see operative report for further details. He was transferred to the cardiac surgery recovery unit requiring vasopressors and blood products. He returned to the operating room that evening due to bleeding and widened mediastinum. He returned to the CSRU and postoperative day 1 he was weaned from vasopressors and sedation. He awoke and responded to voice, weaned to pressure support. On postoperative day 2 he was extubated, chest tubes removed, and transferred to the floor. He continued to progress but on postoperative day 4 he was in atrial fibrillation with hypotension and returned to the CSRU for monitoring and vasopressors. He continued to be in and out of atrial fibrillation and sternal click noted with no drainage. Then on postoperative day 8 there was sternal drainage, erythema, and tenderness. He became asystolic, intubated, and returned to the operating room for reexploration . He returned to with open chest on Nimbex. Plastic surgery was consulted, VAC dressing was placed until he was ready for sternal closure. He was weaned off pressors and underwent flap closure . He required returns to the operating room for sternal exploration due to bleeding. He has continued to progress since sedation was weaned and he underwent a tracheostomy due to failure to wean from the ventilator.

Mild (1+) aortic regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Myxomatous mitral valve leaflets. The right ventricular cavity is mildly dilated.There is mild global right ventricular free wall hypokinesis. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Coccyx maserated with 1 small area of breakdown Dudoerm applied. Mild global RV free wallhypokinesis.AORTA: Mildly dilated ascending aorta. LSC(UNDER BINDER)GU/GI ADEQUATE HOURLY U/O.ABD SOFT. Trivial mitral regurgitation is seen. NIMBEX GTT LEFT AT CURRENT DOSE. replete lytes prn. Cont vasopressin gtt. Amio gtt off d/t HR/rhythm. cpt q2h. wean neo as tol. Dopperable pulses. CREAT STABLE, K+ REPLETED.SKIN: MOD AMT SEROUS DRNG WEEPING FROM UE'S. cdb q1h. FENTANYL AND ATIVAN GTT LEFT AT CURRENT DOSE. tolerating po liquids. ADDITIONAL AMIO IV BOLUS GIVEN AND HR CURRENTLY NSR 89, BP 113/61 AND WEANING NEO. nebs given by rt. pan cx done. Cont abx. Perrla. F/U w/hct, platelets & coags. SpO2 90s, MDIs given as ordered, tan secretions. R ln placed in , oozing slightly.A/P: continue to monitor cv, resp. +dopp pp bilat. k+ & ca low->lytes repleted. Pulses dopplerable. Minimal residual via Dob-hoff. Sputum sample sent.GI/GU: Abdomen soft, nondistended. og->lws w/billious drainage. Small amount of serosanguionous from vac drainage. VAP mouth care done. Resuscitated and take to OR for sternal debridement, laparoscopic mediastinoscopy. lytes repleted KCL, CA gluc. OGT DRG BILIUS SECRETIONS. 0935. remains intubated. shift update:s/p sternal wash & vac dsg applied. Respiratory Care Note: Vent settings unchanged t/o shift. TITRATE NEO PER BP PARAMETERS. Neosynephrine weaning. MDI PER RT. CONT TO HAVE GENERALIZED ANASARCA. requiring ^ doses of neo.+ Resp. Pulses confirmed by doppler. Administering Combivent MDI in line with vent Q4hrs. cr 1.2.endo: fs qid, cover per riss.plan: ? ADDENDUM: RT FEN AND LT CORDIS DC'D AND TIP SENT FOR CX. fluid resussitation as ordered. OR MON IF MORE STABLE PER DR. . START TFGU: UOP GOOD, FOLEY PATENT. PERRLA. Dopoff was coiled in throat, removed this am and new one placed. REPOSOTIONING.DIURESE. hypo bsp. PERRLA.CV: RSR->SB w/o ectopy. Drsg , /staples. extrs w/d. LOPRESSOR HELD AT .GENERALIZED ANASARCA. good diuresis w/lasix.endo: fs covered w/ssri per protocol.id: afebrile. ogt to lwsx for bilous dng. Cisatricurium weaned. 1x ivp lasix w/+diuresis. Has RIJ cath, drsg . Continues on Amiodarone. SCAN NEG. vanco d/c this am. GENERALIZED ANASARCA. Suctioned for mod amts tan sputum. Amiodarone gtt. Confirmed by CXR. Has RIJ cath. PERRLA. On PO amio & lopressor. Sternal drsg w/ old drng prox end. creatinine pnd. Sternal click palpated with NT suctioning and CDB, PA aware. sent am vanco dose. SQ Heparin for DVT prophylaxis. +anasarca, DP, PT by doppler. sent vanco level am. Dopplerable pulses bilat. Picc line to RAC, Multilumen to RIJ, R radial Aline.RESP: LS coarse with EXP whzs. gu: diuresis w lasix regimen. +hypoactive BS ABD soft. VAP care done.GI/GU: abd soft, distended with ecchy areas. gave po lopressor dose. treated wtih bicarb. +3 bilat UE/LE pitting edema. Nebs per RT.GU/GI: Foley to gravity. Occ wheeze noted after suct. Cont on triple abx.GI/GU: Abd softly dist. bs hypoactive. Wean sedation again in am. foley to gravity, low uo treated with volume with good effect.endo: fs qid, cover per riss.plan: s/p omental flap, jp x 3, wean sedation this am. UOP wnl, low last hr.Skin: See flowsheet. gave reglan. hypoactive bs. Neo weaned to off. Wean vasopressin as tolerated. K repleted.Resp: Pt remains intubated on cpap. Advance TF as tolerated. 7a-7pNeuro: Nimbex d/c'd this am. Check abg in am, ?wean vent accordingly as pt tolerates. Ecchymosis accross mid abd L>R. SQ Heparin for DVT prophylaxis. penile & scrotum edema noted. Vasopressin gtt cont. DP/PT diff. vac drsg . Metoprolol PO TID. paralytic and fent/ativan titrated up. +3 bilat LE pitting Edema. +peripheral edema. ON FENATNYL/PROPOFOL/NIMBEX GTTS. ALB/ATR nebs per RT. Occassional resp effort, cough noted. CXR done. Scrotal edema noted. Resp. PT/DP doppler. Dopplerable pulses bilat. pit added and neo weaned as . Wean neo gtt as . neg bowel sounds. Lytes repleted prn. DP/PT doppler.RESP: intubated. monitor sternal incis. SBP labile, see carevue, on and off neo. Pulses dopplerable. Pulses dopplerable. Sternal sutures cdi, covered w/ gauze and abd. Wean neo of tolerated. MDI's given. Generalized anasarca. Dophoff +placement. Monitor JP drng amt. MDI per RT. ETT repostioned and retaped. Nodding appropriatley. MDIs per RT. Hct stable s/p tx. ABD softly distended with +BS. PERLLA. Perrla. Wean neo as VS alow. See and Carevue for detailed documentationNeuro: Remains on ativan, fentanyl, nimbex. Afebrile. Afebrile. Afebrile. Afebrile. BS clear, diminished bliaterally in bases. The right internal jugular line terminates in mid SVC. There is marked suboptimal evaluation as the entire lateral aspect of the right hemithorax is excluded. Sinus tachycardia - Regular supraventricular rhythmPossible old inferior infarctGeneralized low QRS voltagesSince previous tracing, decreased voltages present The right internal jugular sheath terminates in the proximal SVC. d/c rt pleural tube. The patient is semierect. be sinus bradycardia with left atrial abnormality but consider also ectopicatrial rhythmLow QRS voltageProlonged Q-Tc intervalClinical correlation is suggestedSince previous tracing of , sinus tachycardia absent Decrease in pleural effusions is noted bilaterally. Decreased pleural effusions bilaterally. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is beam hardening artifact limiting evaluation. Left internal jugular sheath is present as before. There is a right pleural effusion with associated atelectasis. Bilateral pleural effusions are again noted. Again seen are bilateral pleural effusions, layering posteriorly. A Swan-Ganz catheter has been replaced. Right occipital lobe lesion as described above, of uncertain etiology. There are low attenuations within both kidneys, in the region of the prior described cyst. Near total resolution of the right pleural effusion after pleural catheter placement. Now status post right thoracentesis with catheter placement. Postoperative since with sternal revision and open chest. Position of previously described tracheotomy cannula, right subclavian central venous line unchanged. Resolving left cardiophrenic hematoma. Now status post right-sided thoracocentesis with catheter placement. Rule out hematoma. Bilateral layering pleural effusions are again noted. FINDINGS: Compared with 11/28, the right pleural catheter is no longer identified. FINDINGS: Supine portable abdominal radiograph reviewed.

233

[ { "category": "Echo", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 80459, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Dizziness. Shortness of breath. Source of embolism.\nHeight: (in) 65\nWeight (lb): 152\nBSA (m2): 1.76 m2\nBP (mm Hg): 127/73\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 09:03\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe echo findings were read in conjunction with DR/ .\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). [Intrinsic\nLV systolic function likely depressed given the severity of valvular\nregurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated ascending aorta. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Mild thickening of mitral\nvalve chordae. Torn mitral chordae. Moderate to severe (3+) MR. Eccentric MR\njet.\n\nTRICUSPID VALVE: TR present - cannot be quantified.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n\n1. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.] The left ventricular cavity size is normal.\n2.Moderate to severe (4+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric. The mitral valve leaflets are myxomatous. Torn\nmitral chordae are present. Flail anterior leaflet mitral valve.\n3. The left atrium is moderately dilated. No atrial septal defect is seen by\n2D or color Doppler.\n4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n5. Right ventricular chamber size and free wall motion are normal.\n6. Tricuspid regurgitation is present but cannot be quantified.\n7. Mild pulmonary insuficiency.\n8. The ascending aorta is moderately dilated. Mild simple atheroma in the\ndescending aorta.\n\n\nPOST-BYPASS:\n\n1. Preserved -ventricular systolic function.\n2. Bioprosthteic mitral valve is seated in good position without evidence of\nperivalvular leak. Trace mitral regurgitation. No evidence of mitral stenosis.\nMean gradient of 4 mm Hg.\n3. Rest of study is unchanged from pre-bypass.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-18 00:00:00.000", "description": "Report", "row_id": 80460, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. ?Mitral valve disease.\nHeight: (in) 65\nWeight (lb): 153\nBSA (m2): 1.77 m2\nBP (mm Hg): 83/50\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 08:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. [Intrinsic LV systolic\nfunction likely depressed given the severity of valvular regurgitation.] No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nModerately dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Large vegetation on mitral valve. Torn mitral chordae. Moderate\n(2+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. [Intrinsic left ventricular systolic function is likely\nmore depressed given the severity of valvular regurgitation.] Right\nventricular chamber size and free wall motion are normal. The aortic root and\nascending aorta are moderately dilated. The aortic valve leaflets (3) appear\nmildly thickened but without aortic stenosis. No discrete vegetation is seen\n(cannot be excluded). Mild-moderate (+) aortic regurgitation is seen. The\nmitral leaflets are moderately thickened. A highly mobile, 3.5cm long x 0.6cm\nwide echodensity is seen attached to the left atrial side of the anterior\nmitral leaflet and herniating through the mitral oriface during diastolie and\ninto the body of the left atrium in systole. A second ?8mm ovoid mobile\nechodensity is seen on the left atrial side of the posterior leaflet. These\nare most c/w vegetations. An eccentric jet of at least moderate (2+) mitral\nregurgitation is seen.The tricuspid valve leaflets are mildly thickened. Mild\nto moderate tricuspid regurgitation is seen. There is borderline pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Probable vegetations on the mitral valve with at least moderate\nmitral regurgitation. Mild-moderate aortic regurgitation. Dilated ascending\naorta. Preserved global and regional biventricular systolic function.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 80423, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Congenital heart disease. Endocarditis. Left ventricular function. Prosthetic valve function. Pulmonary embolus.\nStatus: Inpatient\nDate/Time: at 11:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nEmergency TEE study in the operating room following an episode of\ncardiopulmonary arrest.\nLEFT ATRIUM: Normal LA size. No thrombus/mass in the body of the LA. Good (>20\ncm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right\nshunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated ascending aorta. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Normal MVR leaflet\nmotion. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nPRE-BYPASS: The left atrium is normal in size. No thrombus/mass is seen in the\nbody of the left atrium. A patent foramen ovale is present. A left-to-right\nshunt across the interatrial septum is seen at rest. Left ventricular wall\nthicknesses and cavity size are normal. The remaining left ventricular\nsegments contract normally. The right ventricular cavity is mildly dilated.\nThere is mild global right ventricular free wall hypokinesis. The ascending\naorta is mildly dilated. There are simple atheroma in the descending thoracic\naorta. There are three aortic valve leaflets. The aortic valve leaflets are\nmildly thickened. Mild (1+) aortic regurgitation is seen. A bioprosthetic\nmitral valve prosthesis is present. The motion of the mitral valve prosthetic\nleaflets appears normal. Trivial mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is a small pericardial effusion\nwith no evidence of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2148-11-23 00:00:00.000", "description": "Report", "row_id": 80524, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Pericardial effusion.\nHeight: (in) 63\nWeight (lb): 154\nBSA (m2): 1.73 m2\nBP (mm Hg): 106/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:02\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). R. A bioprosthetic mitral valve prosthesis is present. There is a\nmoderate sized circumferential pericardial effusion. There are no\nechocardiographic signs of tamponade.\nIMPRESSION: Moderate-sized pericardial effusion without echocardiographic\nsigns of tamponade.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273386, "text": "Neuro: Pt moving upper extremities (lifting and holding) and moving lower extremities on bed. Will move toes and squeeze hands to command. Will also nod yes/no to questions. Pt given Tramodol X1 for incisional pain (pt motioned to chest when asked if in pain).\n\nCV: Pt in NSR entire shift with occasional PAC's. T max 98.4. Palpable pedal pulses. Received Lopressor 25 mg PO and Amio 200 mg PO.\n\nID: Pt receiving Ceftriaxone and Ampicillin. WBC increasing.\n\nResp: Pt on trach collar 15L, 50% FiO2. MDI's given. Inner cannula changed and trach care performed. Lung sounds coarse. Pt not able to mobilize secretions to mouth. Pt suctioned for moderate amt thick tan sputum q2-4 hrs. Passey muir trial performed by speech and swallow. Pt has weak voice-hard to hear.\n\nGI/GU: Pt has been NPO since midnight for US procedures. Started back on TF via Dobhoff @ 1700 (Nutren 2.0 full strength with beneprotein). Pt had speech and swallow exam. Specialist stated that pt would have to perform a video swallow in order to find if pt is not aspirating. Pt has 1 JP drain which drained 45cc serosanguinous draingage this shift. Pt voiding clear, yellow urine via Foley of SQ. Pt had 1 formed brown BM.\n\nProcedures: Pt had US of liver/gallbladder and sinuses.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Reddened area around coccyx-unbroken. Aloe vesta cream applied.\n\nA/P: Pulm toilet. Prepare for rehab. Pt scheduled for MRI.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-03 00:00:00.000", "description": "Report", "row_id": 1273387, "text": "NEURO: ALERT, NODDING/SHAKING HEAD TO QUESTIONS, ATTEMPTING TO MOUTH WORDS BUT NOT ABLE TO READ HIS LIPS. AT ONSET OF SHIFT PT PICKING AT NOSE AND PERIPHERAL IV, BITING AT BLUE CLAMP IN PERIPHERAL IV. SOFT LIMB RESTRAINTS TO BOTH WRISTS. TRAMDOL 50MG AT HS FOR GRIMACING WITH TURNING. ON MRI SCHEDULE.\n\nPULM: TRACH COLLAR ALL SHIFT, SATS 99-100%. LUNGS DIMINISHED BASES. STRONG COUGH, EXPECTORATED SMALL AMT GREEN TINGED THICK TAN SECRETIONS OUT TRACH. VAP PROTOCOL, HOB >30 DEGREES.\n\nCV: SR WITH OCC PAC'S. SBP DOWN LOW 80'S AFTER LOPRESSOR. PALPABLE PEDAL PULSES. D5W AT 100CC/HR DECREASED TO 50C/HR AT 0600, NA 145. WBC DOWN. AFEBRILE. ON AMPICILLIN AND CEFTRIAXONE.\n\nENDO: QID FSBS WITH SSRI COVERAGE.\n\nGI: ABDOMEN SOFT, + BS. + PLACEMENT OF DOBHOOF BY AUSCULTATION X 3. >100CC RESIDUAL AT 2400 FROM DOBHOOF, FEEDING HELD X 2H, RESUMED AT 0300.\n\nGU: FOLEY TO CD QS YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: MRI THIS AM. FOLLOW WBC AND TEMP, AWAIT BLD CX RESULTS, ADJUST ANTIBX AS NEEDED. DISCHARGE TO REHAB WHEN SURGICALLY CLEARED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273223, "text": "NURSING NOTE 1100-1900 EDT\nREVIEW CAREVUE FOR ALL OBJECTIVE DATA\n\nNEURO:LETHARGIC, AROUSABLE TO SPEECH, UNDERSTANDS HE IS IN THE HOSPITAL. HE FOLLOWS SIMPLE COMMANDS, ABLE TO LIFT AND HOLD UPPER EXTRIMITIES AND MOVES LL ON THE BED. ANSWERS YES/NO WHEN QUESTIANS ASKED.C/O PAIN INSICINAL SITE WHEN MOVING, NO MEDS NEEDED.\n\nCVS: HR 70-110, NO ECTOPY NOTED, SBP 90-100, CONTINUED ON NEO 0.5 MIC/KG/MIN. RECEIVED LASIX,PO METPROLOL 25 DOWN TO 12.5MG TID. K 3.7 REPLETED WITH 20MEQ.AMIADRONE D/CED IN AM.\n\nRESP:O2 50% ON FT, O2 SATS >95-98. UNPRODUCTIVE CONGESTED COUGH, NEEDS FREQUENT NASOTRACH SUCTION AND CPT, COPIOUS YELLOW THICK SECREATION. BILATERAL LS COARSE AND DIMINISHED AT THE BASE. ENCOURAGED DEEP BREATHING AND COUGH.\n\nGI/GU: POOR APPETITE, REFUSED TO EAT OR DRINK. ABD SOFT DISTENDED.URINE VIA FOLEY'S CATHETER, YELLOW CLEAR, LASIX IN AM WITH GOOD EFFECT.\n\nSKIN: STERNAL AND MEDIST DRESSING INTACT, RT HAND EDEMATOUS AND GENARALIZED EDEMA PRESENT. HEMATOMA NOTED ON ABD.\n\nID: AFEBRILE, CONTINUED ON VANCO, AMPICILLIN,AND ADDED CEFEPIME.\n\nPLAN: CONTINUE PUL TOILET, WEAN NEO AS TOLERATED, REPLETE LYTES AS NEEDED. ENCOURAGE D/COUGH, AND DIET.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273279, "text": "Respiratory Care\nPt intubated on ventilatory support. Vent settings unchanged this shift ABGs remain acceptable. planned for possible OR procedure today.\nNo vent weaning at this time.\u0013\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273280, "text": "7p-7a\n\nNeuro: Paralyzed on Cisatracurium .3-.33mcg/kg/hr. revealing eye twitches. Sedated on Ativan 1.25-1.5mg/hr. Pain control Fentanyl 70 mcg/hr. Tyradine self rotating bed.\n\nCV: SR-ST up to 115. Lopressor 2.5 mg iv, hr down to 80's. SBP 90-one teens. Presently MAP >100 with care. (increasing Ativan) To start po lopressor this am.\nGums cont to bleed. Also rt eye bloody. (Erythromycin ointment started for eye) Hct stable. PTT ^56.3 from 49.7 team aware.\nChest open, vac dsg to vac sxn. Plastic team in to see pt, no OR today as pressors were just stopped yest eve.\n\nResp: Lungs coarse. Suctioned by RT for green/yellow plugs. Sats 99% on SIMV 60%.\n\nGI/GU: Abd soft, distended with hard lumps from heparin injections. Sm mucousy brown stool this am. Large amts yellow urine out via foley. Nepro tf cont at 40/hr.\n\nSkin: Chest with vac dsg to sxn. Left arm pinhole bleed covered with dsg. Chest tube sites dsg changed- 2 sites open with sang drainage- dress with dsd only per . Duoderm to bottom .\n\nSocial: proxy called overnight, updated.\n\nPlan: Cont to monitor hemodynamics and resp status closely. Monitor chest. To OR for chest closure when Plastics feels pt is ready (off pressors for long enough). Monitor .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273281, "text": "resp care - Pt remains paralyzed and intubated on SIMV+PS 500/16/5/5 .60. RR was increased to 16, resulting in an ABG within normal limits. BS were clear, diminished in bases. MDIs given as ordered.\nContinued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273250, "text": "Neuro: pt paralyzed and sedated with Cisatracurium, Fentanyl and Ativan. Pt has 2 faint twitches on . no coughing noted when suctioned. Ativan decreased to 3mg 2nd to hypotension. No change in vitals noted with stimulation with decreased dose. Pupils equal in size but noreactive.\nResp: No vent changes made sats 98% suctioned for amounts.\nC/V: Pt in and out of afib and NSR most of night. WHen in afib BP would dip into the low 80's when back in NSR BP would be 90's to low100's. But SBP SBP slowly decrease through night even in NSR requiring more Neo presently on at 3mcg with SBP in the mid to high 80's. HO aware to discuss adding another pressor on rounds. Lytes treated as ordered.\nGI: Feeding tube placed by O and xray done to verify placement. Pt started on Tube feeds at 10cc/hr. Hypoactive Bowel sounds present.\nEndo: blood sugars well controlled No insulin required.\nGU: adequate urine outputs. 80-150cc/hr.\nSkin: pt leaking serous fluid from arms and legs. Coccyx maserated with 1 small area of breakdown Dudoerm applied. pt has red rash on his whole coccyx area. 2 small nickel sized skin tears on either hand oozing serous fluid. Vac dressing on chest intact.\nPlan: OR tomorrow am for chest closure if stable. Monitor labs treat as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273251, "text": "resp care\npt remained on imv 500x14 40% 5peep and 5psv with peak/plat 20/16. BS bil. Combivent given as ordered. RSBI held due to paralytics.Will cont to follow. Morning abg wnl.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273252, "text": "Respiratory Care\nPt remains on full ventilatory support as documented on Carevue. Taken to CT for scan of chest and abdomin without incident. Placed on rotating bed. With left side slightly up, pt's SAT decreasing. Suction for amount of pale white/clear secreations. MDI's given as ordered. Possible trip to MRI pending.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1273282, "text": "See and Carevue for detailed documentation\n\nNeuro: PERL. Rec'd on ativan , fentanyl and cisatricurium. Patient hypertensive, ativan increased with good result. BP stabilized. Patient later hypertensive with BP increased 160's with cares. Fentanyl increased, later decreased slightly. Cisatricurium dose increased with twitch at 10mA, increased resp, cough with stim and decreased BP. Patient now with stable VS on ativan 2mg/ hour, cisatricurium 0.35mg/kg/hour, fentanyl 85mcg/ hour.\n\nResp: Patient continues on vent. Increased PaCO2 tx with increase vent rate with good result. BS clear, diminished in bases. Continues with some resp effort despite paralytic. Suctioned for small amounts thick tan secretions with MDIs. Continues with large amounts bloody oral secretions. Mouthcare every 2-4 hours.\n\nCV: In NSR. HR 70-80 on lopressor. BP stable thru day with MAP >60.\nIncreased BP treated with sedation. Maintaining temp. Continues on antibiotics. Repeat vanco trough pending. Potassium repleted. Type and hold to blood bank.\n\nGI: On tube feeds, tolerated well with minimal residual. BM x2.\n\nEndo: RSSI per protocol. None required.\n\nGU: Foley to gravity with large amounts urine output. Negative fluid balance.\n\nPlan: Continue to monitor cardiopulmonary staus. Plan for OR in am. Titrate sedation per VS, Maintain BP without pressors.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273343, "text": "ROS:\n\nNeuro: Alert, makes eye contact and tracts. Nods head yes/no to questions asked. Denies pain when asked. Occasionally noted slight random movement in LE and LUE. PERRLA.\n\nCV: RSR w/o ectopy. VSS. Peripheral pulses palpable. Sternal wound w/staples. 3 jps fluid. Generalized edema. Right PICC line. P boots for DVT prophylaxis.\n\n\nResp: remains intubated and on vent, CPAP weaned to w/^ resp rate, denies dyspnea, MV ~ 12/L some abd breathing appears at times w/dyspnea but denies it. VS stable. Sats 98% or >.\n\nGI: Post pyloric pedi tube via right nare w/TF at goal. Abd soft w/active BS.\n\nGU: Foley patent clear yellow urine in QS. Lasix given.\n\nID: Remains on Fluconazole, ampicillin, and ceftriaxone. Vanco level 15.9 this AM, dose not given.\n\nEndo: FSG covered w/RSSI sq\n\nSocial: no contact from HCP\n\nPlan: Return PS back to 12 if appears to become tired or at HS. Mobilize. Pulmonary toileting. Monitor, tx, support, and comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273344, "text": "Remaining tachypnec rate 30-35, HR ^ to 95. PS ^ to 10 and then to 12 d/t continued tachypnea and HR > 90.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273345, "text": "Resp. Care note\nPt received intubated and vented on psv settings as charted on resp flowsheet. PSV level weaned from today. Pt appears labored at times with RR to 30's, psv increased back to 10 with pt settling to RR in mid 20's. Cont present settings and observe for signs of fatigue and need for PSV increase.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273310, "text": "NEURO-SEDATED ON ATIVAN WITH FENTANYL GTT FOR PAIN MANAGMENET.EYES OPEN WITH NO FOCUS,TRACKING OR STARTLE REFLEX. CLOSED MANUALLY BY NURSE AND RE-OPENED SHORTLY AFTERWARD.PERLA. NO MOVEMENT OF ANY TYPE SEEN.\n\nCV- NSR-> AFIB RATE CONTROLLED. CONTINUES ON AMIO GTT. NEO TITRATED TO KEEP SBP > 85.WBC=20.9.ON TRIPLE ABXS. S/P EXPLORATION HCT=30.9. AM HCT=26.6 & 28.2\nJP # 2&4 WITH MOD.AMT.SANG DRG. #1&3 WITH SMALL AMT SANG.DRG.TRANSPARENT DSG . CHEST BINDER ON. ANASARCA. PALP. PULSES.\n\nRESP- REMAINED ON AC VENT SETTINGS. SATS=98-100%. LSC(UNDER BINDER)\n\nGU/GI ADEQUATE HOURLY U/O.ABD SOFT. ABSENT BS.POST PYLORIC TUBE APPEARS TO BE OUT OF POSITION. ATTEMPT MADE TO FLUSH MEDS DOWN\nWITH RETURN OF YELLOW/TAN SECRETIONS ORALLY.\n\nLABS- NO LYTE REPLACEMENT NEEDED. ON INSULIN GTT. CXRU PROTOCOL FOLLOWED. GLUCOSE LO45. ->1 AMP D50.\n\nPLAN- CONTINUE TO TREAT BP AND HR. MONITOR LABS.JP DRG.LABS VALUES.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273311, "text": "Respiratory Care Note:\n Patient returned from OR last eve and placed on rate of 18 with FIO2 increased to 50%. ABGs WNL. BS=bilat, coarse, suctioned for thick yellowish sputum. ET tube resecured 22cm at lip. Patient continues with paradoxical pattern. RSBI=237.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273312, "text": "NEURO: PT. SEDATED ON 50MCG FENTANYL AND 0.5 MG ATIVAN. PT. OPENS EYES SPONTANEOUSLY, APPEARS TO TRACK MOVEMENT OF FINGER IN LEFT VISUAL FIELD ONLY (TO PERIPHERY), DOES NOT OBEY COMMANDS OR SPONTANEOUSLY MOVE ANY EXTREMITIES. PT. DOES NOT NOD HEAD TO ANY QUESTIONS, BUT DOES OPEN EYES WIDER TO SPEECH.\n\nCV: PT. NSR, IN AND OUT OF AFIB AND SINUS TACHYCARDIA THROUGHOUT THE AM, NP NOTIFIED OF RAF (HR 130'S)- 150MG AMIO BOLUS GIVEN. PO AMIO STARTED AND DRIP DC/D. 12.5 MG LOPRESSOR GIVEN AND TOLERATED. CURRENTLY NEO GTT TITRATED TO MAINTAIN MAP >60. ONE UNIT PRBCS GIVEN FOR FALLING HCT.PT. BLOOD PRESSURE INCREASES WITH TURNING, ORAL CARE, AND EYE CARE. HR CURRENTLY 80'S. MAG SULFATE IV GIVEN FOR FREQUENT PVC'S ONCE CONVERTED BACK INTO SINUS RHYTHM. PULSES DOPPLERABLE.\n\nRESP: LUNGS CLEAR IN UPPER FIELDS, DIMINISHED IN BASES. L UPPER FIELDS RHONCHI AT TIMES AND IMPROVED WITH SUCTIONING. PT. ETT SUCTIONED FOR TAN, THIN SECRETIONS, ORALLY SUCTIONED FOR BLOODY SPUTUM. J- DRAINS CONTINUE TO DRAIN DRAINAGE.\n\nGI/GU/ENDO: ABD SOFT-DISTENDED, HYPOACTIVE BOWEL SOUNDS, NEW DOBHOFF PLACED BY NP , PLACEMENT CONFIRMED BY CXR, TUBE FEEDS RESTARTED AT 1200 AND TOLERATING. PT. GIVEN DULCOLAX- ONE SMALL, SEMI-FORMED, GOLDEN STOOL PRODUCED. FOLEY CLEAR, YELLOW URINE- SOME IMPROPVEMENT IN OUTPUT WITH LASIX. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: FENTANYL GTT INCREASED FROM 25MCG TO 50MCG NP .\n\nPLAN: CONTINUE TO WEAN NEO, MONITOR HCT AND SIGNS OF BLEEDING, MONITOR NEURO STATUS, AND SKIN INTEGRITY (AND BREAKDOWN).\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273259, "text": "Nursing 7p-7a\nNeuro: Sedated on fent/ativan gtts. Paralyzed on nimbex gtt. eyelid twitches & +cough required increase in nimbex gtt to max dose. Pt cont w/ eyelid twitches & +cough, MD aware- no tx ordered at this time. No gag. Pupils 2mm, R sluggish, L brisk.\n\nC/V: Bradycardic & junctional in 40s. Hypothermic. EKG done to confirm junctional. Amio gtt off d/t HR/rhythm. Bed warmer & bair hugger applied. As temp increased pt HR increased, currently nsr 60s. Normothermic w/bair hugger (unable to wean off) & bed warmer. Rare pjcs/pacs. Lytes repleated. Dopperable pulses. Cap refil <3sec bilat. Cont vasopressin gtt. Titrated neo gtt to keep map >60. BP very labile. Received 1 prbcs for hct 24. F/U hct 26.6. Platelets decreased to 145. PTT 87. MD made aware of all lab values. No tx at this time.\n\nResp: SIMV, no vent changes. Suctioned yellow thick, changed to blood tinged overnight. MD aware. Lungs coarse throughout, LLL dim.\n\nGi: TF increased to goal 40cc/hr. Stool x2. Guiac neg. Absent BS. Abd soft. IV albumin.\nGu: Adequate HUO. Creat decreased to 2.0.\nEndo: RISS for blood sugars.\nID: IV vanco, ampicillin, fluconazole & ceftriaxone. WBC decreased to 16.6.\n\nSocial: HCP called, updated by RN.\nSkin: See carevue for impaired skin & wounds.\n\nPlan: Wean bair hugger as . Maintain normothermia, monitor hemodynamics. Wean neo if . F/U w/hct, platelets & coags. ?correcting coags. HIT to be collected & sent.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273260, "text": "NEURO: Paralyzed on Cisatracurium drip 0.3 mg, Ativan drip 2.5 mg for sedation, Fent drip 75 mcg for pain/sedation, PERRLA (2mm/brisk), Pt coughs when suctioned thru ETT, at 20mA, MD aware, no spontaneous respirations, movement, no gag reflex\n\nRESP: Intubated on SIMV 500/50%/; lung sounds clear at apices/dim at bases, CXR reveals pleural effusion, Sats >96%\n\nCV: NSR with rare PACs, on Neo 0.25, Pit 2.4, HR in 60s, MAP >60, cap refill < 3 sec, pulses present by Doppler, afebrile, anasarca, sternal VAC dressing with serosang drainage.\n\nGI/GU: Abd soft, distended with petechiae, on TF at 40cc/hr, hold TF starting at 0000 (Pt NPO for debridement), small BM in AM, C. DIff culture sent; Foley in place > 120cc/hr of yellow/clear urine, last K was 3.4, repleted with 40mEq KCl\n\nENDO: Pt on own SSRI, last BG was 148\n\nID: WBCs 14.7, afebrile, C. diff culture sent, Vanco level was 15.\n\nLABS: Last PTT was 76.3, PA notified, HIT screen sent , Plastic team ordered to hold heparin SC for debridement\n\nSOCIAL: No phone call or visit from family/relatives today.\n\nPLAN: NPO after midnight (hold TF), hold heparin, wean Neo as tolerated, f/u C. diff/HIT/MRI results, OR debridement tomorrow, monitor lytes, Hct, coags\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273220, "text": "Neuro: Pt is A&O X3. Pt stated he was seeing spiders on the wall. No pain reported during shift. Left sided weakness-only moves these extremities on bed. Able to lift and hold right-sided extremities. Obeys commands. PERRL.\n\nCV: Pt required 500 cc fluid bolus X2 for hypotension after lopressor given. Neo started for about 3 hours but is now off. Amio gtt started. Pt received PRBC X1 for Hct 27. Hct now 32. Palpable pedal pulses.\n\nResp: Pt now on 4L NC from 10L 40% face tent (pt continuously pulled face tent off). O2 Sats 92-95%. Lungs coarse at apexes, dim at bases. Weak cough.\n\nGI/GU: Pt swallowed pills without difficulty. Clear yellow urine of SQ. +BS, no BM.\n\nInteg: No skin issues at this time.\n\nEndo: RISS-pt has own protocol.\n\nA/P: Treat afib. Ativan? Monitor neuro status. Pulmonary toilet. Encourage activity and PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273221, "text": "shift update:\n\nneuro: a&o x1-2. initially agitated->pleasantly confused. denies pain. mae. turned q1-2hrs. sleeping in short naps this afternoon.\n\ncv/skin: afib initially->lytes repleted->nsr w/pac's & brief runs of afib. no vea. cont on amio gtt. neo restarted after po lopressor d/t sbp in 70's slowly weaning. multiple doses of iv kcl given see flowsheet. ca x2. +pp bilat.\n\nresp: lungs coarse but dim in bases. initially on 4l nc->abg's poor. 50% oft added abg's improved. nebs given by rt. cdb q1h. cpt q2h. nt suctioned for thick yellow. weak cough but expectorating small amts thick yellow this afternoon.\n\nid: afeb. ^wbc's. pan cx done. abx changed to vanco & iv levo.\n\ngi/gu: +bs. tolerating po liquids. poor appetite. foley leaking->changed. lg uop after foley changed.\n\nendo: no insulin per ss.\n\nsocial: minister friend into visit.\n\nplan: cont to monitor neuro status. cont amio. wean neo as tol. replete lytes prn. aggressive pulmonary toilet. ivabx. i&o.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273275, "text": "Nursing Progress Note\nNeuro: chemical paralytic cisatricurium at 0.3 mcg/kg/hy. twitches on r side of face with . Sedation with ativan gtt currently at 1.5 mg/hr. Pain control with fentanyl currently at 80 mcg/hr. No movement, no gag, rare cough with suction.\n\nCVS: HR 60's-70's nsr with increasing pacs. Vasopressin weaning maintain map > 60. Chest remains open covered with VAC dressing to VAC suction unit. Borders red, macerated. Abdomen ecchymotic, multiple skin tears. Skin is glossy r/t large edema in BL and Bues. RIJ multi lumen cath patent, CDI. A line with waveform and notch. Awaiting sternal closure by plastics, will not complete untill patient is off pressors per team. Multiposud boots for sore prevention. Tryadine self rotating bed.\n\nReso: LS dim throughout. Poor airation, suction ett for small thick brown. Sats > 95 on 0.5. MDI's by RT.\n\nEndo: FS BS not requiring ssri coverage at this time.\n\nGU: Foley cath draings conc clear urine.\n\nGI: Abdomen large round soft, bs pos. No wretchign, No bm. Remains on reglan 2 6 hours, IV.\n\nPlan: awaiting word from OR team, ? close today or tomorrow with plastics. wean vasopressin as tolerated.\n\nSee carevue flowsheet and for further details and values.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273276, "text": "Respiratory Care\nPt remains intubated on ventilatory support, no vent changes made this shift. ABGs with a slight respiratory acidosis, good oxygenation. RSBI not performed due to neuro-muscular blocking on board.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273346, "text": "Neuro: Pt nods yes/no to questions. Pt tracks with eyes and grimaces with care. Pt turns head side to side and also was also observed partially lifting left side of body off bed while feeling discomfort with care. Slight movement of left foot noted as well; no movement of right side. Tramadol given X 1 for pain (indicated by pt nodding).\n\nResp: Pt rested on CPAP and PS , 40% FiO2 overnight. Lungs coarse throughout. Pt suctioned for small to moderate amts thick, yellow secretions. RR upper 20's. Pt receiving MDI's.\n\nCV: NSR entire shift. MAP>60. HR 80's. T max 98.7. K repleted. Palpable pedal pulses. Pt has 3 JP drains sanguinous fluid.\n\nGI/GU: Pt receiving Nutren 2.0 with Beneprotein at goal rate (40cc/hr). TF residual 45cc at most. Banana flakes held for brown formed stool X1. Pt voiding clear, yellow urine of SQ via Foley.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Bruising on abdomen. General edema; especially arms and scrotal area.\n\nA/P: Wean vent as appropriate. Pulmonary toilet. Monitor movements of pt's extremities. Pain management as needed. Cont abx.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273347, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. PSV increased 10->12 to rest overnight. Pt continues to have episodes tachypnea to high 30's. BS's coarse, sxing thick yellow secretions. Administering Combivent MDI in line as ordered. RSBI=193. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273348, "text": "BS coarse crackles, occ rhonchi; no change with MDI's. Frequently agitated and tachypneic. PSV to 15. FiO2 to 80% and now weaned to 50%. Transfer to CSRUA.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273380, "text": "Neuro: alert and nodding head to questions correctly, mae-lifts and holds arms and moves legs on bed, oob to chair with , tramodol x 1 for pain.\n\nCardiac: nsr with frequent pac's, bp's wnl's, palpible pedial pulses, skin warm dry and , +1 edema in extremities, afebrile.\n\nResp: on trach mask for shift with good ra sats- team wants patient to go throughout the night on the mask as long as tolerates, lungs dim in bases, right side ct d/c'd today.\n\nSkin: chest with staples is cdi, right and left side old ct dsds are cdi, jp insertion site is cdi,coccyx is pink with no breakdown, compressive sleeves and multipodis boots on, is on air mattress.\n\nGi/Gu: npo-awaiting speech and swallow to come eval for passiur valve, abd soft round and nontender with huperactive bowel sounds, did have x 1 med formed bm today, started h2o flushes for high na, did cut back on lasix to , makes >30/hr of u/o.\n\nPlan: continue trach mask over pm, ?rehab in am, ? speech and swallow in am for eval prior to d/c.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273381, "text": "resp care\npt received on psv mode, placed on trach mask for duration of shift. rr mid 20-to high 30's. ambued with combivent mdi, lavaged and sxned for mostly brown, slightly bld tinged thick sputum. partially expectorates on own. vent is at bedside, hopefully will not need tonight.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273382, "text": "around 1845 patient went into raf in the 120 range-po lopressor given early-2 grms mag given-lytes sent bp sbp running around 98-100-np aware awaiting results of lab lytes-ultra sound in am patient to be npo at mdnight.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273383, "text": "NEURO: PT. ALERT, UNABLE TO ASSESS ORIENTATION, LIFTS AND HOLDS UPPER EXTREMITIES BILATERALLY, LOWER EXTREMITIES MOVE ON THE BED. PT. OBEYS COMMANDS AND NODS \"YES\" OR \"NO\" TO SIMPLE QUESTIONS.\n\nCV: PT. AFIB IN BEGINNING OF SHIFT, CONVERTED BACK TO NSR WITH OCCASIONAL PAC'S. HR 80'S AND SBP 95-110.\n\nRESP: PT. LUNGS CLEAR IN UPPER LEFT FIELD, SLIGHTLY COARSE IN RIGHT UPPER LOBE, DIMINISHED IN LOWER LOBES. PT. SUCTIONED FOR THICK, TAN AND BLOOD-TINGED SECRETIONS- IMPROVEMENT IN BREATH SOUNDS AFTER SUCTIONING. +COUGH, NO EXPECTORATION INDEPENDENTLY. PT. ON AEROSOL TRACH COLLAR THROUGHOUT THE NIGHT WITH OXYGENATION >95%. DRAIN MINIMAL SEROUS DRAINAGE.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TUBE FEEDS TURNED OFF AT MIDNIGHT FOR PROCEDURAL PURPOSES IN THE AM, ONE MEDIUM, BROWN, FORMED BM (GUAIAC NEGATIVE), FOLEY CLEAR, YELLOW URINE- GOOD U/O AFTER ADMINISTRATION OF LASIX. LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: TRAMADOL FOR PAIN GIVEN WITH RELIEF PER PATIENT.\n\nPLAN: POSSIBLE REHAB TOMORROW?, ULTRASOUND PROCEDURE, SPEECH AND SWALLOW.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273384, "text": "Resp: pt 50% T/C. Bs are clear with diminished bases. Suctioned for small amounts of tan thick secretions. Ambu/syringe @ hob. MDI's administered Q4 hr combivent/ . Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273319, "text": "Neuro: Pt has been off Ativan since 1800 last night. Pt winces with turns and will scrunch eyes with eye care. Does not track with his eyes. Eyes open spontaneously. . Pt receives erythromycin ointment to right eye and also artificial tears in both eyes. Movement of head seen as well. Pt on 50 mcg/hr Fentanyl.\n\nCV: Pt in NSR entire shift. Max HR=100. T max 99.9. INR 1.1. Hct 25.1. Neo titrated to keep MAP >60. Neo currently at 0.2 mcg/kg/min. K and Ca repleted. Pt has 4 JP drains. Drain #1 most serosanguinous drainage (50 cc this shift). Some oozing from JP site #4 with turns.\n\nResp: Pt on CMV, R=14, TV=400, FiO2=40%, 5 PEEP. Pt suctioned q4h for very small amt white, thick sputum X1. Lungs clear at apexes, dim at bases. Weak gag and cough.\n\nGI/GU: Pt receiving Nutren 2 with Beneprotein at 40cc/hr (goal). No TF residual. +BS, no BM. Buttocks area a bit red; aloe vesta cream applied. Pt voiding clear, yellow urine via Foley in large quantities.\n\nInteg: Pt oozing from arms (especially) and legs. Chucks under arms and legs changed. Pt also has massive scrotal and penile swelling. Groin area elevated.\n\nEndo: RISS per CSRU protocol.\n\nA/P: Monitor pt's resp status and Hct. Pulmonary toilet. Address skin issues.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273320, "text": "respiratory care\npt on the vent fairly well. changes made better with 2mg of mso4. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273321, "text": "UPDATE\nCV: NSR<-> AFIB MULT TIMES TODAY. SBP INITIALLY WNL W/ AFIB BUT DIPPED TO 70'S DURING A.M. EPISODE. MORPHINE ALSO JUST GIVEN AND POSS CONTRIBUTED TO HYPOTENSION. AMIO IV BOLUS GIVEN AND IV NEO RESTARTED BUT BP SLOW TO RECOVER. PT TO IR THIS AFTERNOON FOR PICC PLACEMENT R ANTECUB. PT IN NSR DURING PROCEDURE BUT BACK TO AFIB (AND BRIEFLY A-FLUTTER) THIS EVE, RATE 110-120, BP WNL. ADDITIONAL AMIO IV BOLUS GIVEN AND HR CURRENTLY NSR 89, BP 113/61 AND WEANING NEO. MORPHINE GIVEN AGAIN THIS EVE W/O EFFECT ON BP. CHEST DRAINS W/ SM AMTS DRNG. HCT STABLE.\n\nRESP: RR IN 30-40 RANGE THIS SHIFT W/ RETRACTION OF DIAPHRAGM NOTED. AFTER MULT ADJUSTMENTS BY R.T. AND MORPHINE, PT BREATHING EASIER. SPO2 ALWAYS WNL, BUT ABG CONT TO SHOW RESP ALKALOSIS. LUNG SOUNDS DIMINISHED @ BASES. SUX FOR MOD AMTS THICK, YELLOW SECRETIONS.\n\nNEURO: IV FENTANYL OFF THIS A.M., CHANGED TO INTERMITTENT MORPHINE DOSING PRN FOR COMFORT. EYES OPEN SPONTANEOUSLY BUT PT DOES NOT TRACK OR FOCUS NOR FOLLOW COMMANDS. NO SPONT MVMT OF EXTREMETIES NOTED. WINCES TO EYE CARE AND MOVES MOUTH W/ MOUTH CARE.\n\nG.I.: TF @ 40ML/HR., MINIMAL RESIDUALS. MED FORMED B.M. THIS A.M. AFTER DULCOLAX SUPP.\n\nG.U./RENAL: LG DIURESIS FROM LASIX. I&O CURRENTLY -1600ML. CREAT STABLE, K+ REPLETED.\n\nSKIN: MOD AMT SEROUS DRNG WEEPING FROM UE'S. COCCYX REDDENED. HAIR WASHED.\n\nI.D.: TMAX 101.1. WBC DOWN TO 16. CONT ON IV AMPICILLIN, FLUCONAZOLE, VANCO, CEFTRIAXONE. NEW PICC AS ABOVE.\n\nA/P: TACHYPNEA LESSENED BUT UNRESOLVED W/ MORPHINE AND VENT CHANGES. OXYGENATING WELL. UNSTABLE HR BUT MOSTLY WELL TOLERATED AND RESOLVED X2 AFTER REBOLUS W/ AMIO. R IJ ADV ACCESS TO BE REMOVED AND TIP SENT FOR CX. CONT ABX VIA PICC. CONT TO MONITOR LYTES CLOSELY W/ DIURESIS. HCT Q 12 HRS. LITTLE CHANGE IN NEURO STATUS OFF CONT SEDATION AND PAIN MED.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273277, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on SIMV/PSV w/ PIP/Pplat = 27/22. SpO2 90s, MDIs given as ordered, tan secretions. See resp flowsheet for specifics.\n\nPlan: maintain current support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273278, "text": "NEURO: PT. UNAROUSABLE, SEDATED AND PARALYZED, THIS AM (ON 20) REVEALED 3 TWITCHES, PT. NOT OVERBREATHING VENT, AND NO SPONTANEOUS MOVEMENT NOTED. NIMBEX GTT LEFT AT CURRENT DOSE. 0400 ASSESSMENT REVELAED ONE NP NOTIFIED. NIMBEX GTT LEFT UNCHANGED. FENTANYL AND ATIVAN GTT LEFT AT CURRENT DOSE. PUPILS 2MM AND BRISK.\n\nCV: PT. NSR, OCCASIONAL , PT. CONVERTED TO AFIB FOR A SHORT TIME (HR 100-110 WITH SBP 100, MAP >60, PITRESSIN TITRATED TO MAINTAIN MAP >60- CURRENTLY OFF. CURRENTLY HR 90'S, SBP 95-110, MAP >60. PULSES EASILY PALPABLE. WOUND VAC SANGUINOUS DRAINAGE.\n\nRESP: PT. COARSE THROUGHOUT, SUCTIONED FOR THIN, TAN SECRETIONS- SEE CAREVUE FOR ABGS. PT. ORALLY SUCTIONED FOR BLOOD TINGED SECRETIONS.\n\nGI/GU/ENDO: PT. ABD SOFT DISTENDED, HYPOACTIVE BOWEL SOUNDS, TUBE FEEDS AT 40CC/HR, FOLEY CLEAR, YELLOW URINE. LASIX GIVEN IN AM WITH GOOD EFFECT. LYTES REPLETED. PT. BLOOD SUGARS TREATED PER PATIENT'S PERSONAL RISS.\n\nINTEGUMENTARY: PT. ABDOMEN ECCHYMOTIC, HEMATOMAS PRESENT. PT. COCCYX PINK, DUODERM CHANGED AND IN PLACE. PT. ROTATING IN BED EVERY 10 MINUTES AT 15 DEGREES.\n\nPLAN: CONTINUE TO MONITOR SBP AND HR, CONTINUE TO MAINTAIN MAP >60, PULMMONARY HYGIENE (FREQUENT MOUTH CARE AND NECESSARY SUCTIONING), MONITOR WOUND VAC AND DRESSING, ?PLASTICS CONSULT?, ETC.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273338, "text": "7a-1500\nNeuro: eyes alert all shift, will track at times. squeezed left hand on command once. lt thigh muscle shaking at times but no mvmt of toes. no mvmt on rt side noted. Opens mouth for mouth care and blinks on command. Perrla. mod yellow drng from b/l eyes due to conjunctivits.\nCV: stable. HR 70-80's rare pac. amio decreased to once a day. palp pedal pulses. continues to be edematous\nresp: continues to be orally intubated on CPAP. PS weaned to 10 by 1300. Tolerating well and appears comforatable. MV . No ABG gotten per --following sats and rate. sx thick pale yellow, whitsh sputum\nGI: TF Nutren at 40cc/hr =goal. tolerating well. abd firm with ecchymosis from surgery. no residul. mod soft stool slightly blood streaked from hemmorhoids.\nGU: foley patent. clear yellow. good diuresis from lasix\nPLAN: wean ps as tolerated on vent. continue to assess neuro status. pulm toilet. advance as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273339, "text": "Resp Care\nPt remains intubated on PS. Weaned PS from 15 to 12 to 10 to 5.\nMDI's given. ABG results in normal range on . No other changes given.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273340, "text": " 4p-7p\nassessment unchanged from earlier except ps decreased to 5, pt tolerated well. abg post vent change wnl.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273242, "text": " PT WILL REMAIN INTUBATED/SEDATED/PARALYZED FOR FLAP CLOSURE OF OPEN CHEST AND STERNOTOMY ON . PROPOFOL @ 35MCGKGMIN & NIMBEX @ 0.12MGKGHR WITH NO SPONTANEOUS MOVEMENT. 4 TWITCHES OF LEFT EYE.PERLA @ 3MM/BRISK. 50MCG/HR FENTANYL.NO S/S PAIN.\n\nCV- SR-ST 85-115.IVP LOPRESSOR HELD D/T PRESSOR SUPPORT. LEVOPHED SWITCHED TO NEO FOR HEART RATE CONTROL AND BP.CO/CI 5.2/2.8 BY THERMODILUTION AND 8.5/4.6 BY FICK.SVR LOW.FILLING PRESSURES WNL.T-MAX=99.7 REQUIRING BAIR HUGGAR ON AT ALL TIMES OF WILL BECOME HYPOTHEMIC. WBC=19.4 (22.6 ON ) ON AMPICILLAN/VANCO ABX.NEW LEFT A-LINE PLACE.OLD TIP SENT FOR CX.PT , UP 20KILOS,SKIN WEEPING SEROUS FLUID FROM SCATTERED AREAS.AMIO GTT @ 0.5M/MIN. WITH NO ISSUES OF AFIB.\n\nRESP-REMAINED ON IMV 40% X500X14X . SATS=98%. LS CLEAR UPPERS VERY DIMINISHED LOWERS. SXD (BY RT) FOR THICK YELLOW SPUTUM.\n\nGI-ABD SOFT. ABSENT BS. OGT DRG BILIUS SECRETIONS. HAS NOT BEEN FED YET.?? NO BM ].\n\nGU- RECEIVES IVP LASIX WITH CONT'D DIURESES THROUGHOUT SHIFT.\n\nLABS- K+,CA+ REPLACED PRN.\n\nENDO- INSULIN GTT STARTED FOR REPEATED GLUCOSE LEVELS>120. GTT / GLUCOSE LEVELS BETWEEN 134->118.\n\nMISC.- NO CONTACT WITH FAMILY( NOT SURE IF HE HAS ANY) NO PHONE CALL FROM REVERAND OF HIS CHURCH.\n\nPLAN-CONTINUE WITH HEMODYNAMIC MONITORING,TITRATION OF PRESSORS,PARALYTRIC SUPPORT,GLUCOSE CONTROL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273243, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273244, "text": "Respiratory Care\nPt taken to the OR this shift for a brief period of time to irrigate his chest. return on Tuesday to close his chest. Remains on full ventilatory support. All settings documented in Carevue.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273255, "text": "Respiratory Care Note:\n Patient continues on SIMV/PSV mode of 500 by 14, 50% and 5PS,+5 PEEP. BS=bilat, slightly coarse. He remains paralyzed and sedated. Suctioned for med amounts of pale yellowish sputum. Plan for MRI today and possible closure of chest.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273256, "text": "Nursing Progress Note:\nNeuro: Pt sedated and paralyzed on fentanyl, cisat, and ativan gtts. Pupils 2-3mm sluggish. Severed redness noted to right eye. Team aware. Eye gtts and oinment started OU. 2-3/4 . No gag/cough reflex. No spontaneous respirations and movements noted. Head MRI done and results pending.\n\nCV: SB with pac's and intermittent afib. HR 50-60's. Amio at .25. MAP >60 on vasopressin and neo gtts. Sternum open with VAC drainage. Small amount of serosanguionous from vac drainage. Pulses dopplerable. Skin impaired with bruising to abdomen, duoderm to coccyx, and numerous open blisters to extremeties. Afebrile. Trauma and . Generalized +4 pitting and scrotal edema.\n\nResp: LCTA decreased at bases. Sats 96% on SIMV 14, 500, 50%, . Pt bronched for small amount of thick, yellow secretions. Sputum sample sent.\n\nGI/GU: Abdomen soft, nondistended. No BS noted. Minimal residual via Dob-hoff. Nepro at 30cc/hr. Small stool x1. Foley cath with good UO. Clear, yellow urine.\n\nEndoc: RISS\n\nPain: Fentanyl\n\nID: Started on Vanco qod, next dose tonight and recheck level Friday am. Ampicillin, fluconazole, and ceftriaxone for sepsis.\n\nPlan: To OR Friday for wash out and ?closing of sternum. Continue VAC drainage. Continue antibiotics. Monitor lytes, renal function, and CBC. Continue sedation and paralytics. Advance TF for goal of 40cc/hr if tolerating.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273257, "text": "resp care - Pt remains intubated on SIMV 500/14/5/5 50%. No changes made this shift. Pt went to MRI this PM. BS coarse t/o, clearing on sx of sm amt of secretions. Blood gas is within normal limits. Continued resp support planned.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273258, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. No changes made overnight. BS's diminished, sxing moderate amts yellow secretions. Administering Combivent MDI's in line with vent as ordered. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273341, "text": "Neuro: Pt will at times open eyes to command. Eyes also open spontaneously. Head turns spontaneously. No movement of extremities noted. Pt grimaces with eye care and mouth care. No pain otherwise noted.\n\nCV: NSR entire shift. SBP 90's to low 100's. T max 99.2. K and Ca repleted. Palpable pedal pulses.\n\nResp: Pt rested on CPAP and PS , FiO2 40% overnight. Lung sounds coarse. Pt suctioned for small amts thick, whitish secretions. MDI's given.\n\nGI/GU: Pt receiving Nutren 2.0 with Beneprotein @ 40cc/hr (goal rate). 15cc residual @ 0000. Pt voiding clear, yellow urine of SQ via Foley. +BS, no BM.\n\nEndo: RISS per CSRU protocol.\n\nInteg: Pt has bruising on abdomen and edema of extremities. Pt also has scrotal edema.\n\nA/P: Cont to wean vent as appropriate. Monitor movement of extremities/movement to command. Cont abx. Address skin issues as appropriate. Vanco level pending.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-24 00:00:00.000", "description": "Report", "row_id": 1273342, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Initially, pt on psv/cpap of , increased to to rest overnight. BS's diminished, but ess. clear. Sxing small amts brown plugs. RSBI=109 this am. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273230, "text": "Pt experienced asystolic arrest today. Resuscitated and take to OR for sternal debridement, laparoscopic mediastinoscopy. Chest left open. Pt has 7.5 ET, 22 @ lip. BS fine crackles, rhonchi; no change with MDI's.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273231, "text": "NEURO: this AM pt alert oriented x3 but calling out, moaning at times not answering questions. became unresponsive approx 0930 and CPR initiated. rhythm and pressure restored and transfered to OR. From OR on sedated on propofol and paralytic therapy-cisatracurium- initiated. TOF tested on L facial nerve with no twitches. per PA is goal. currently paralyzed and sedated.\nCV: This AM sinus with APC's with runs of Afib with RVR. amio bolus 150 mg admin. pt cardiac arrested approx. 0930 anesthesia MD and rhythm/blood pressure restored p approx 10 min CPR. no shocks delivered. no drugs admin. transfered to OR for sternal debriedment and returned with AFib rate 100's amio gtt initiated and pt converted to SR. PA catheter in place. MAP 60-70's, CO 3.7-4.2 and CI>2.0. neo titrated for MAP 60-90. skin cool and dry with palp. pedal pulses. warmed with bair hugger. sternum remains open. lytes repleted KCL, CA gluc. good response to lasix admin. in OR. +total body edema.\nRESP: this AM pt on cool nebs with neb trx for bialt wheezing. resp arrested and was intubated approx. 0935. remains intubated. ABG improving. lungs clear. VAP mouth care done. no overbreathing vent.\nGI/GU: abd soft distended with mult ecchy areas. no bowel sounds. OGT to LCWS with bilious drainage. foley has clear yellow urine.\nENDO: blood gluc treated with insulin gtt.\nID: on vanco, amp, cefipime\nSKIN: total body edema. chest open with transparent dressing and two JP tubing to LCWS. abd has hematoma and mult ecchy areas. +penis and scrotal edema. pressure points intact.\nSOCIAL: HCP for consent this AM. d/w MD and anesthesia.\nLINES/ACCESS: PICC line L AC, swan , , A line R rad. PIV R FA. R ln placed in , oozing slightly.\nA/P: continue to monitor cv, resp. maintian sedation and paralysis, blood gluc and lytes. can have HOB 30deg. but no turning in bed d/t open sternum PA. VAP care. skin care.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273232, "text": "Resp Care Note:\n\nPt cont intub OETT sedated and paralyzed on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-01 00:00:00.000", "description": "Report", "row_id": 1273245, "text": "shift update:\n\ns/p sternal wash & vac dsg applied. plan for or for chest closure.\n\nneuro: remains paralyzed &sedated on nimbix, fentanyl & propofol. left eye twitch remains on ma of 20 dispite increase to 0.25mcg/kg/hr. no spontaneous movements, no gag/cough reflex. pupils equal, non reactive. no visable signs of pain noted.\n\ncv/skin: nsr initially. rate controlled afib upon returning from the or. amio gtt cont. k+ & ca low->lytes repleted. currently in nsr. k+ repleted several times throught the day see flow sheet. neo cont at 2.0mcg/kg/min did have to increase to 2.5 breifly w/afib. weaning levo . goal sbp>90. vac dsg intact. +dopp pp bilat. generalized body edema w/weeping areas noted on arms.\n\nresp: lungs coarse to clear but diminished in bases. no vent changes. abg's acceptable. suctioned for thick yellowish green secreations.\n\ngi/gu: +hypo bs. og->lws w/billious drainage. tube feeding discussed at rounds, no ordered at this point. uop 100cc or greater/hr.\n\nendo: insulin gtt weaned to off. bs ranging 67-111. see flow sheet.\n\nsocial: hcp into visit update given & spoke with . minister into visit also.\n\nplan: continue current plan of care. wean levo goal sbp>90. watch lytes closely->replete prn. or tuesday for flap closure.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273301, "text": "Respiratory Care Note:\n Vent settings unchanged t/o shift. Patient appears comfortable on A/C of 500 by 14 (breathing 20) 50%, and 5 PEEP. BS=bilat with mild exp wheezing scattered t/o. Combivent MDI given app Q4. Suctioned for med amounts of thick yellow sputum. RSBI attempted and within 30 seconds his BP increased with a mean of >105 and RSBI attempt was aborted. Plan to maintain supportive care and monitoring. See Carevue flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273302, "text": "CHEST EXPLORATION\nCV: Afib with HR in 70-80s and rare PVCs noted on .5mg Amio, MAP >60 on 0.3 Neo, anasarca 2+ pitting edema, pedal pulses present, afebrile, Hct 24, given 2 PRBCs, Hct 30\n\nNEURO: Sedated on Ativan & Fent, PERRLA (4mm/brisk), eyelid movement noted but does not follow commands, gag impaired during suctioning\n\nRESP: Taken to OR for chest exploration, MD noted/ligated bleeding, JP drain #2 dark, sanguinous at >40cc/hr, intubated/continues on AC Sats 100%, lung sounds clear, suctioned for moderate blood-tinged secretions, Pt overbreathing vent, last ABG reveals resp. alkalosis\n\nGI/GU: TF at goal, < 5 residual, bowel sounds present, no BM today; Foley in place yellow/clear urine, given Lasix, last K was 3.8 given 20mEq KCl\n\nENDO: Continues on insulin drip at 4 units/hr\n\nSOCIAL: HCP notified of OR procedure, DNR status ordered\n\nPLAN: Monitor hemodynamics, resp, TF, LABS, JP drains for increased bleeding, UO, DNR status ordered today\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273303, "text": "Resp Care\nPt remains on CMV, no vent changes. Pt returned to OR for bleeding, was repaired. Plan to continue with current vent support and for trach in future.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273316, "text": "NEURO: PT. SEDATED ON FENTANYL AND ATIVAN, CURRENTLY RESPONDING TO PAINFUL STIMULI (FOR EX: PT. FLEXED AND WITHDREW SLIGHTLY WITH LEFT HAND WHILE ARTERIAL INSERTION SITE WAS CHLOROPREPED, AS WELL AS RIGHT ARM FLEXED AND WITHDREW SLIGHTLY WHEN PATIENT RECEIVED HEPARIN SUB-Q INJECTION IN R LOWER QUADRANT OF ABDOMEN.) PT. DOES NOT NOD HEAD TO SIMPLE QUESTIONS, DOES NOT MOVE LOWER EXTREMITIES SPONTANEOUSLY OR FOLLOWS COMMANDS. PERRLA.\n\nCV: PT. NORMAL SINUS RHYTHM WITH RARE PAC'S, HR 80'S, BLOOD PRESSURE LABILE AT TIMES- NEO ATTEMPTED TO BE WEANED, BUT MAINLY LEFT AT 1.0 MCG-1.5 MCG DUE TO FLUCTUATIONS IN BLOOD PRESSURE. GTT TITRATED TO MAINTAIN MAP >60. TORSO BINDER (FOR OMENTAL FLAP PROCEDURE STILL ).PULSES DOPPLERABLE- L DORSAL PEDAL PULSE MORE DIFFICULT TO DOPPLER. LABS: HCT STABLE- LEVELS EVERY 8 HRS DUE TO PLASTIC SURGERY ORDER.\n\nRESP: PT. LUNGS CLEAR IN UPPER AND DIMINISHED IN LOWER LOBES. PT. FOUND COARSE, BUT IMMEDIATE IMPROVEMENT WITH SUCTIONING. PT. ETT SUCTIONED FOR THICK, MODERATE TAN/BLOOD-TINGED SECRETIONS. ORALLY SUCTIONED FOR THIN, TAN SECRETIONS. FREQUENT MOUTH CARE- ORAL TISSUE . JP DRAINS DRAINAGE TO BULB SUCTION.\n\nGI/GU/ENDO: PT. ABD SOFT-DISTENDED, +BS, TUBE FEEDS AT GOAL (40CC/HR), ONE SMALL BROWN, SOFT BOWEL MOVEMENT. PT. FOLEY CLEAR, YELLOW URINE- GOOD U/O AND RESPONSE TO LASIX. LYTES REPLETED ACCORDINGLY. BLOOD SUGARS TREATED PER RISS- ?PATIENT'S OWN PERSONAL SLIDING SCALE?.\n\nID: CONTINUES ON 4 DIFFERENT ABX, WHITE CELL COUNT 18.9.\n\nINTEGUMENTARY: UPPER EXTREMITIES CONTINUE TO WEEP WITH EDEMA, PERIANAL AREA HAS SKIN BREAKDOWN AND AMT. OF BLOOD, R HEEL SLIGHTLY RED, BUT SKIN UNBROKEN.\n\nPLAN: CONTINUE TO MONITOR NEURO, WEAN NEO, MONITOR HCT AND SIGNS OF BLEEDING, PULMONARY STATUS, FLUID STATUS AND SKIN INTEGRITY.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273317, "text": "Respiratory Care\nBreath sounds clear, diminished, suctioned for moderate thick tan, WBC 18.9 suggesting ongoing bacterial infection, hemoglobin only 9.9, suggesting ongoing anemia, creatine 1.8, suggesting renal insufficiency, patient stayed into normal sinus rhythm whole day but was tachypneic at times RR ranged 22 to 38, still in acute respiratory alkalosis, ABGs at 1326 revealed an acute respiratory alkalosis with hyperoxemia, no significant progress noted neurologically, no vent changes made up to this point, patient has been treated with Combivent inhaler, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273318, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a respiratory alkalemia with good oxygenation on the current settings.\n\nRSBI = 139.9 on 0-PEEP and 0-PSV (FAILED RSBI).\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273215, "text": " 7p-7a\nneuro: alert, moves both arms to command and spontaneously, left hand grip stronger than right hand grip, moves left leg to command and spontaneously, no movement noted to right leg, able to hold head off bed x 5 seconds\ncv: sr 79-98 with occasional pvcs, sbp 99-125, ct output 0 while lying flat, 40-370 serosanguineous drainage with turns(np aware)\nresp: vent settings to this am (kept at 5/10 overnight for lethargy during day), lungs cta, diminished to bases, 02 sats > 95%\ngi: positive bowel sounds,insulin gtt d/ced at 2100, fingersticks remained wnl overnight\ngu: urine output adequate overnight, slowing this am\nlabs: stable, K+ 4.0 repleted with 20 meq kcl\npain: 1-2 tabs percocet q4hours overnight\nassess: stable\nplan: wean vent this am, extubate when able, to bed, tx to 2 this pm?\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273216, "text": "Resp. Care\nPt. remains on mech vent. Pt. had to be retaped due to cont. tongue movement and oral secr. Pt was on CPAP 10PSV/5peep and 50%.Pt. is being sx for mod amts of thick tan and B/S are scat rhonchi bilat.Pt. is currently on CPAP 5/5, and plan is to wean and extubate this A.M.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-22 00:00:00.000", "description": "Report", "row_id": 1273217, "text": "Respiratory Care\nPt was extubated today at 0815. Pt was able to talk, no cough effort, HR 91, RR 28 and non-labored, SpO2 95% of 60% OFM. No stridor was noted. Will continue to follow pt for post extubation care.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-23 00:00:00.000", "description": "Report", "row_id": 1273218, "text": "nursing progress note 1230-7p\nreadmitted from 2 for hypotension. bp on arrival 80/40's sr 90's. a-line placed by dr. . labs sent.\n\nneuro: a/ox3, answers questions but seeing kittens and talking on imaginary phone. increasingly agitated, wanting dentures but spits them out into face tent. follows commands but required multiple redirects to keep oxygen on. moans and grunts - baseline per report, also ? swallowing difficulty. left sided weakness from old cva. bilat legs very weak - transfer. perrla.\n\ncv: initially sr 90's. pac's ^ progressed to afib 110's, up to 130's at times. Dr. notified, 2gm mag sulfate. bp as above responded to ns 500cc and 2 units prbcs for hct 24.4 but dipped w/ afib now 100/60's. +3 distal pulses, 2+ general edema.\n\nresp: lungs on arrival clear uppers dim bases, sats 92-94% on 6l prongs. unable to clear secretions in back of throat but no acute distress. mouth breather. changed to humidified face tent 50% sats improved to 95%. orally sxn multiple times w/ yankower and tonsil tip for tenacious, blood-tinged secretions. gets very agitated. nt sxn x1 by RT w/ similar results. repeatedly removed o2 sats drop to 88%.\n\nendo: custom riss - see flowsheet.\n\ngi: kept npo d/t report of swallowing issues. +bos, no bm.\n\ngu: foley to gravity, clear yellow. adequate huo and brisk response to lasix. CRI, baseline 1.9\n\nplan: post transfusion hct. fluid resussitation as ordered. rate control. ? change meds to iv pending further swallow eval. redirection or distraction to keep o2 on. ? restraints if continues to remove. aggressive pulmonary hygiene and sxn prn.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-24 00:00:00.000", "description": "Report", "row_id": 1273219, "text": "Respiratory Care:\n Patient receiving albuterol/atrovent unit dose nebs Q6 for wheezy, congested chest. NT suctioned to attempt to clear without success. He tolerated tx fairly well. He remains on a 4lpm with SpO2>92%.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273233, "text": "NEURO: PARALYZED AND SEDATED ON PROPOFOL. FENT GTT ADDED FOR PAIN MANAGEMENT. TWITCHES ON NIMBEX--NOT WOKEN OR GTTS TITRATED PER DUE TO OPEN CHEST. BP INCREASES SLIGHTLY WITH STIMULI. PERRLA 3MM. NO MVMT OR OVERBREATHING NOTED\nCV: HR 80-90'S SR WITH PAC'S--PT INTO RAF WITH RATES UP TO 125-130 AT 0500--AMIO BOLUS GIVEN AND GTT UP TO 1MG/MIN. NEO TO MAINTAIN SBP>90 AND MAP>60. GENERALZIED ANARSARCA WITH WEEPING AREAS. CI>2. CHEST OPEN WITH IOBAN DSG INTACT, SLIGHT TENTING OF DSG WITH SMALL AMT BLOODY DRNG FROM JP SITES. IF PT NO GO TO OR WILL NEED WASHOUT. PAD 18-22, CVP 15. REQUIRED BAIR HUGGER OVERNIGHT TO MAINTAIN TEMP>36. RT GROIN SITE BLEEDING REQURING DSG CHNG X3 WITH SURGICEL. HCT INITALLY 23 UP TO 26 WITH NO TX ? DILUTIONAL.\nRESP: REMAINS ORALLY INTUBATED ON IMV OVERNIGHT. NO VENT CHANGES MADE EXCEPT WEAN FIO2 TO 50%. LUNGS CLEAR. MDI PER RT. ABG WNL. SATS>97%\nGI: OGT TO LCWS FOR BILIOUS DRNG. ABD OBESE BUT SOFT, NO BS. OGT PLACEMENT CONFIMRED BY AUSCULTATION. BLOODY ORAL SECRETIONS REQUIRING FREQUENT MOUTH CARE\nGU: UOP 30-140CC/HR, LIGHT YELLOW. FOLEY PATENT. SCROTUM EXTREMEMLY EDEMATOUS WITH MILKY EXUDATE FROM AROUND FOLEY. ABRASIONS ON SCROTUM WITH SEROUS DRNG OOZE\nSOCIAL: ANESTH DID PHONE CONSENT WITH HEALTH CARE PROXY FOR OR TODAY. PLASTICS ATTEMPTED BUT NO ANSWER. HCP EXPRESSED WISHES TO RETURN PT TO DNR? PT INSTRUCTED TO BRING SUBJECT UP WITH DR. OR PT PCP. STATED WOULD NOT TAKE ACTION UNTIL AFTER PT MADE THROUGH \"THIS NEXT SURGERY\"\nPLAN: REMAIN SEDATED AND PARALYZED UNTIL OR FOR FLAP CLOSURE. CONT ASSESS HEMODYNAMIC STATUS. TITRATE NEO PER BP PARAMETERS. CONT CURRENT PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273234, "text": "Respiratory Care\nPt remains on current ventilator settings as documented on Carevue as well as ABG results.\nPlan to return to OR this evening as an add-on.\nMDI's given as ordered. Breath sounds diminished throughout.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273292, "text": "7p-7a:\nneuro: sedated on ativan and fentanyl gtts. grimaces and opens eyes to painful stimuli. .\n\ncv: afib 100-120's, treated with amiodarone boluses and iv lopressor. electrolytes repleted. sbp 80's- 140's, map > 60. converted to nsr 80's with sbp > 90. easily palpable pedal pulses bilaterally. hct 21 this am, treated with 1 unit prbc's, ? bleeding from flap per pa , plastics following.\n\nresp: lungs coarse. o2sat > 97%. remains orally intubated, see carevue for vent settings. abg wnl. suctioned for thick white secretions.\n\ngi/gu: abd soft, nd. bs positive. dtube feeding at goal. foley to gravity, good huo. cr 1.2.\n\nendo: fs qid, cover per riss.\n\nplan: ? ct scan to evaluate bleeding, follow hct.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273293, "text": "RESPIRATORY CARE:\n\nPt remains orally intubated, fully vent supported on SIMV. No vent changes made overnight. BS's coarse. Sxing thick white secretions. Administering Combivent MDI in line with vent Q4hrs. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273294, "text": "Resp Care\nPt remains intubated, no vent changes. Pt traveled for chest ct without incident. Plan to continue with current tx.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273240, "text": "NET SEDATED ON FENT/PROP AND PARALYZED WITH NIMBEX. NIMBEX WEANED TO 4 TWITCHES BUT PT NOT MOVING SPONT. SLIGHT COUGH WITH SX. DR. DOES NOT WANT PT MOVING DUE TO RV BEING CLOSE TO BONE. PERRLA. BP DOES RISE WITH STIMULATION.\nCV: HR 80-90'S, NSR WITH PAC'S. AMIO GTT TO 0.5MG/MIN PER DR. . LEVO TITRATED TO MAINTAIN MAP>60 AND SBP>90. CVP 11-15, PAD 18-22. CI>3. PT HAD NEW / SWAN PLACED IN RT IJ, AWAITING CXR CONFIRMATION AND WILL D/C ALL REMAINING LINES DUE TO RISE IN WBC. LT PICC LINE DC'D BY IV. CONT TO HAVE GENERALIZED ANASARCA. DOPPLERABLE PEDAL PULSES. DR. UNABLE TO GET NEW , NEED NEW STICK.\nRESP: REMAINS ON SAME VENT SETTINGS, WEANED FIO2 TO 40% ? THEN WEAN PEEP (CURRENTLY ON 8) LUNGS CLEAR. SX FOR THICK TAN SM. AMTS. SATS>97%.\nGI: OGT TO LCWS. THICK BIKIOUS DRNG. ABD SOFT BUT LG. NO BS. ? START TF\nGU: UOP GOOD, FOLEY PATENT. LG SCROTAL EDEMA.\nENDO: INSULIN GTT STARTED FOR BS 180'S , RAPID BS DROP ---GTT NOW OFF. CONT TO ASSESS Q1HR DUE TO LABILITY.\nSOCIAL: NO CONTACT WITH FAMILY OR FRIENDS\nID: BC X2 SENT OFF OLD LINES, URINE CX SENT AS WELL. CONTINUE REQUIRE BAIR HUGGER TO MAINTAIN TEMP>36. NO CHANGE IN ANTBX. VANCO LEVEL >20 , CONTINUE TO HOLD. CHECK IN AM.\nPLAN: D/C OLD LINES WHEN CXR CONFIRMS PLACEMENT OF NEW LINE. CONT TITRATE LEVO PER ABOVE PAREMENTERS. CONT TO SEDATE AND REMAIN LIGHTLY PARALYZED PER TEAM. FOLLOW CX. ? START FEEDS. ? OR MON IF MORE STABLE PER DR. . CONT CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273241, "text": "ADDENDUM: RT FEN AND LT CORDIS DC'D AND TIP SENT FOR CX. STILL AWAITING CHANGE BY RESIDENT. LEVO REQUIRMENT INCREASING AGAIN SLIGHTLY. CONT REQUIRE BAIR HUGGER FOR TEMP AND CO RISING, CONT PRESENT SEPTIC PROFILE. CONT TO ASSESS AND CONT CURRENT PLAN\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273304, "text": "Update\nDr. from plastic surgery called to bedside to evaluate new swollen r chest. Chest firm to palpation, warm and skin slightly shiny. Possible sq air palpated r and l of sternum around nipple line.\n\nHct repeated and basically unchanged. Plan to recheck Hct @ 2130 and report to Dr. .\n\nMinimal to no drainage from JPs #1 & 3. Jp #2 continues w/significant dark bloody fluid (appears less serous that pre-op today). See flowsheet.\n\nLimb and facial edema appears to be less than pre-op today. Neosynephrine weaning.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273305, "text": "0640 Cartioverted per to SR w/ 150 J for sudden onset of Afib w/vent rate of 120-130 and SBP 70's. requiring ^ doses of neo.+\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273371, "text": "NEURO: Alert, awake, follows commands, PERRLA, currently off restraints, Hoyered from bed to chair and back; tolerated transfers well\n\nRESP: Trach collared and tolerated well with Sats >95%, plan to rest Pt on CPAP overnight, L pigtail minimal drainage serosanguinous, plan to insert R pleural pigtail tomorrow, respirations reg/unlabored\n\nCV: NSR with PACs earlier during the shift, HR in 80-90s, keep MAP between 60-90, pedal pulses present, afebrile. Max temp 99.9.\n\nGI/GU: Abd firm/distended, bowel sounds present, no BM, banana flakes held, continues on TF at goal with minimal residual; Foley yellow/clear urine. On recurring Lasix with good response\n\nENDO: Continues on SSRI\n\nSOCIAL: No phone/visit from family.\n\nPLAN: Monitor resp/hemodynamics/urine output, plan to rest Pt on CPAP overnight, ?discharge to rehab, plan to insert R pleural pigtail tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273372, "text": "Hyperglycemeia\nGlucose remains elevated. 32 units regular insulin given today in divided doses sc for glucose 133-185. need to evaluate for better glucose control. NSR w/PAC. Denies pain. Watching TV most of evening.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273373, "text": "Nursing Progress Note\nNeuro: Alert, attempts to follow commands consistently. Tracks nurse around room. Gag and cough . Moves arms, minimal movement of legs.\n\nCVS: hr 80's sr, occ pac. SBP > 90 no agents. afebrile. Pulses confirmed by doppler. Skin ruddy, . Anasarca trunk and peri area. Peri area excoriated, see carevue for further skin details. Multi boots and csl on/off overnight. Rac PICC 2 lumen patent.\n\nResp: resting on vent overnight, will trach collar again in am. Trach site pink, ties and cannula changed. Suction for small thick secretions. Lungs clear in uppers, dim at bases.\n\nGI: abd obese, tf at goal via dophoff. BS present.\n\nGU: Foley cath with brisk output post lasix dose at midnight. Clear yellow.\n\nPain: Ultram for grimacing with care.\n\nEndo: FS BS covered with ssri scale.\n\nPlan: trach collar again in am, continue monitoring per unit standards. Rehab screening.\n\nSee carevue flowsheets and mars for further details and values.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273374, "text": "Resp: pt on 50% T/C. Pt placed back on vent psv 10/5/50% to rest noc as md. Vt 450 Ve 13, 02 sats @ 99%. BS are coarse bilaterally which clear with suctioning. Suctioned for copious bloody thick secretions at beginning of shift that subsided towards morning. RBSI=75. Plan to continue with trach collar trials today.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-03 00:00:00.000", "description": "Report", "row_id": 1273388, "text": "7a-2p\n\nNeuro: Pt alert, nodding and shaking head no to questions.\nAdmits to discomfort, treated with Tramadol 50 mg po with effect.\n\nCV: SBP low 100's. SR 70's, occ pac's. 1+peripheral edema.\n\nResp: Lungs coarse, clear but dim bases after suctioned for thick green sputum. Sats 100% on 15L trach collar @50%. RR 28. Trach care done 10 am.\n\nGI/GU: Abd soft, +bs. Last bm moderate, soft, brown.\n*Video swallow this am, pt tolerated thin and thick liquids but had some back flow. ASPIRATION pt to sit up for 30 min after eating. Tolerated whole pill, swallowed with water. Pt to restart tube feeds to keep up nutrition as po intake with not be enough. Dopoff was coiled in throat, removed this am and new one placed. CXR revealed good placement at 1pm today.\n\nSkin: Chest staples dry and . Coccyx pink, no breakdown.\nJP to left chest mod amts ss fluid.\n\nEndo: covered with regular insulin sliding scale. BS at noon 127, covered with 4 units regular insulin.\n\nSocial: Proxy aware of transfer to NE , .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273270, "text": "ROS:\n\nNeuro: Sedated and paralyzed on ativan, fentanyl, and cisatracurium. Intermitent cough reflex noted. PERRLA.\n\nCV: RSR->SB w/o ectopy. Titrated vasopressin to 2.4 to keep MAP > 60. Open chest wound w/VAC drsg fluid. Has RIJ cath. Has left radial ABP line. Peripheral pulses palpable w/ease.\n\nResp: Remains orally intubated and on Vent, AC 60%. Lungs clear and diminished in bases. Sx thick yellow secreations at times. No resp distress noted, = rise and fall of chest. Sats 98% or >\n\nGI: Pedi tube via right nare w/TF infusing w/ minimal residual. Abd soft w/active BS throughout abd. Protonix for Gi prophylaxis.\n\nGU: Foley patent clear yellow urine in QS.\n\nEndo: No coverage RSSI\n\nLytes: K and mag repleted.\n\nSocial: No contact from family or friends this shift.\n\nPlan: Pulmonary toileting. Continue w/current tx reg. Monitor, tx, support and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273271, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on SIMV settings. No vent changes made during the night. Remains paralyzed. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273272, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on SIMV/PSV w/ PIP/Pplat = 23/20. No secretions suctioned, SpO2 mid 90s. MDIs given as ordered. ETT secure/patent. Alarms on/functioning. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1273273, "text": "See and Carevue for detailed documentation\n\nNeuro: PERL. Continues to be sedated and paralysed. No eye twitch noted. Cisatricurium weaned. Twitch noted at 20 .\n\nResp: Stable on vent , abg as noted. BS clearm diminsihed in bases. Initially no cough, no with cough with suction. Minimal secretions. Chest remains open\n\nCV: In NSR, BP stable on vasopressin. Initially pulses by doppler, now palpable. Potassium and calcium repleted thru shift.\n\nGI: Tube feeds advanced, tolerated well with residula < 100ml. No BM, no bowel sounds.\n\nGU: Foley to gravity with large amounts urine.\n\nEndo: RSSI per protocol, none required.\n\nPlan: Continue cardiopulmonary monitoring. Maintain BP with vasopressin. Repelte lytes as needed. ? plan for flap closure this week.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1273274, "text": "Nursing Progress Note\n0330 converted to a fib rate 120, with bursts to 145. Map at the time > 70. Lopressor 5 mg iv per pa, converted to sr 70;s with MAP > 60. Vasopressin now at 1.6, continue prior documented plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273333, "text": "NEURO- EYES OPEN,BLINKING,NO TRAKCING OR FOLLOWING ANY COMMANDS.NO BODY MOVEMENT.FACIAL GRIMACING WITH ALL STIMULI.\n\nCV-NSR. BP STABLE.STAYED OFF NEO ALL NOC.K+=3.4-> REPLETED PRN. GENERALIZED ANASARCA. RT UPPER ARM WEEPING LARGE AMOUNT SEROUS FLUID.\n\nRESP-CPAP/PS ALL NOC. SXD FOR THICK WHITE SPUTUM.LS COURSE-> CLEAR. SATS=100%.\n\nGI- ABD LARGE ROUND SOFT. PASSED 2 SMALL BLOOD STREAKED STOOL.JP'S MIN S/S FLUID. NEPRO@ GOAL RATE OF 40CC/HR.\n\nGU- DIURESING WELL FRIM LASIX.\n\nLABS- GLUCOSE AND K+ COVERED WITH SS. PRN\n\nPAIN- ULTRAM 50MG GIVEN X1 FOR FACIAL GRIMACING.\n\nPLAN- CONTINUE TO MONITOR HR/BP. RESP STATUS.TUBE FEED.LABS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273295, "text": "NEURO~RESPONDING TO STIMUI WITH GRIMACING. OPEN EYES INT. NOT FOLLOWING COMMANDS. CONT ON FENT AND ATIVAN GTTS. TIITRATING THROUGHOUT THE DAY.\n\nCARDIAC~SR/AFIB. 70'S-131. GIVEN AMIO BOLUS @ 1700. INEFFECTIVE CURRENTLY AFIB ^ 119-131. HO AWARE. HCT 25. RECIEVED 2 UNITS OF FFP THIS AM FOR ^COAGS. REPEAT COAGS WNL. EPISODES OF HYPOTENSION SBP 80'S TEAM AWARE, FOLLOWING MEANS. BILAT PEDAL PULSES BILAT W/ DOPPLER. TO CT SCAN THIS AM TO CHECK FOR HEMATOMA IN CHEST PER PLASTIC . SCAN NEG. D5W W/ NA+ HCO3- @ 85CC'S/HR X 6 HRS.\n\nRESP~CONT ON SIMV SEE FLOW SHEET FOR SETTINGS MAINTAINING SATS OF 100%. LUNGS COARSE THROUGHOUT. SX FOR AMTS OF THICK SEC.\n\nGI/GU~NPO SINCE 0700. ? RETURN TO OR. TO RESTART TF THIS EVENING.\nQD LASIX ~ HUGE DIURESIS. CALLED BY PLASTICS TO CHECK FOLEY PLACEMENT. CT~> CATHETER TIP IN URETHERA. PLACEMENT OK. HYPOACTIVE BS .\n\nENDO~ TX W SSRI PER CSRU PROTOCOL.\n\nA/P~HEMODYNAMICALLY UNSTABLE. AFIB ^ 119-131. W/ SBP~80'S TO BE GIVEN A CA++/ K+/ & AMIO BOLUS PER DR.. TO TRANSFUSE W/ 2 UNITS OF PRBC'S FOR HCT OF 25. CONT W/ ICU INTERVENTIONS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273359, "text": "neuro: pt alert @ shift change, slept mostly overnight; attempts to communicate by mouthing words & pointing w/left hand; follows commands, moves lle on bed, able to lift/hold lue; wiggles rt toes, rue lift/fall. +.\n\ncv: sr, no ectopy. k & calcium repleted; bp stable 90s-110s. palpable pulses. extrs w/d. compression sleeves on. afebrile. continues on ivab.\n\nresp: ls clr, o2sats 100%, on cpap .50 fio2 , resp rate 10s, vt 300s-400s~no distress. ? trach placement on days.\n\ngi/gu: npo overnight; doboff placed previous shift, unable to flush, MD made aware~doboff removed by Dr. ; unsuccessful attempt made to replace doboff, pt to have doboff placed on day shift per Dr. ; +bs, no bm, abd soft distended, nt. adequate huo-clr yellow.\n\nendo: bs monitored per csru ss protocol-rssi coverage required overnight.\n\nsocial: no phone calls from pt family/friends this shift.\n\nplan: continue monitoring cardioresp status; monitor labs, replete lytes; ? placement of trach & doboff on days. continue w/current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273360, "text": "RESPIRATORY CARE NOTE\\\n\nPatient continues to be intubated and ventilated on PS ventilation all through noc. No vent changes made. RSBI completed on PS 5=83. BLBS are coarse. Sxn for thick blood-tinged secretions this AM. Plan to wean PS as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273361, "text": "Respiratory Care\nBreath sounds bilaterally clear, suctioned for small amounts of thick tan secretions, patient was afebrile and stayed into normal sinus rhythm whole day, blood pressure stayed within range, RR 15 to 26 on PSV, sat 99 to 100, WBC 13.2 ? ongoing bacterial infection, hemoglobin only 9.1 ?anemia, patient was treated with Combivent and Flovent inhalers, ETT rotated and retaped 22 at lips, patient sat in a chair for about three hours, no ABGs nor vent changes made today, plan is for patient to have tracheostomy tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273298, "text": "POD#3 Omental/prepectoral flap\nAfebrile today. Frequent changes in BP with frequent runs of afib followed by NSR. No ectopics. Neosynephrine titrated to keep MBP >60. Continues on Amiodarone. Extremities warm. Anasarca noted. Extremities elevated on pillows.\n\nBreathsounds clear at apices but diminshed or absent at bases. CXR and CAT scan reported to show bilateral effusions. No plans for vent weaning today. Patient placed on control ventilation to minimize WOB. Minimal ett secretions. Continues on VAP protocol. Some old bloody secretions removed with subglottal suctioning.\n\nTubefeeds at goal via r nasal post-pyloric tube. Banana flakes to resume tid. Abd soft distended. Hypoactive bowel sounds. Incontinent large, pumpkin colored soft stool. FIB placed. Peri-rectal skin .\n\nGlucose elevated. Arms edematous. Red/purple bruising r upper arm (?site of prior blood pressure cuff readings). Insulin sc changed to CSRU glucose management protocol. See flowsheet.\n\nFoley yellow urine w/white sediment. Penis grossly edematous. Continues on lasix 20mg iv qd.\n\nNo gag, no cough noted. Spontaneous l hand movement, tongue movement and brief, limited eye opening. Ativan gtt decreased. Continues on Fentanyl. Blood remains present in OD sclera. Continues on eye gtts and erythromycin OD.\n\nDr. in and sternal dsg changed. DSD to upper sternal staple line only. Lower staple line to be left open to air. JP drains # 1, 2, 3 continue on bulb suction. #2 noted to be a significant amount of thin, bloody drainage.\n\nHct to ~24. 1 PRBC given, Hct to ~27. Cultures pending. Plan to monitor closely.\n\nPhone report to \"health care proxy\". He would like to be notified when Mr. is more awake.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273299, "text": "Resp Care\nPt remains intubated, was placed on CMV for increasing WOB. Plan to keep on CMV and trach in future.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-15 00:00:00.000", "description": "Report", "row_id": 1273300, "text": "ROS:\n\nNeuro: Sedated on Ativan gtt at 0.75 mg/hr. Fentanyl gtt at 30 mcg/hr. Appears comfortable. PERRLA.\n\nCV: Afib until ~ 0300 then RSR rate 80. Amiodarone gtt. Neo on at 0.5 mcg to maintain MAP > 60. Sternal drsg w/ old drng prox end. Drsg , /staples. Has RIJ cath, drsg . Peripheral pulses palpable w/ease. Generalized edema. SQ heparin for DVT prophylaxis.\n\nResp: Remains orally intubated and on vent. Lungs clear to coarse, sx thick yellow via ETT. Intermitent cough. No resp distress noted, = rise and fall of chest. Sats 97%. ABGs w/metobolic alcolosis. MDIs per RT.\n\nGI: ABD obese w/active BS x's all 4 quads of abd. Post pyloric pedi tube via right nare w/TF infusing at goal. Protonix for GI prophylaxis.\n\nGU: Foley patent clear yellow urine in QS.\n\nID: Afebrile. Remains on triple antibiotic coverage.\n\nLytes: K 3.4, repleted w/40 KCL. IC 1.1, repleted w/2 Gm ca+ gluc.\n\nEndo: Insulin gtt off when glucose down to 66.\n\nSocial: No contact from guardians\n\nPlan: Mobilize, pulmonary toileting, Monitor, tx, support, and comfort. Reassurance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273375, "text": "mr was placed on 50% T.M. for most of the day.mid afternoon he was placed back on while he was havinf a CT inserted on his right\nchest .1200 cc of bloody fluid was drained from his R pleura.\nBS:ronchoreous,suctionned bloddy secretion.he was then placed back on 50% T.M,spo2 95% and RR 26.MDI administerd as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273334, "text": "shift update:\n\nneuro: spontaneous eye opening. grimaces w/care. movement on bed noted in rue & bilat le. pt's minister into visit & pt appeared to be tracking conversation between nurse & minister. when asked if he was mad re his health he shrugged his shoulders. pearl.\n\ncv/skin: nsr w/rare->frequent pac's noted. lytes repleted. sbp stable high 80's->high 90's. am lopressor held d/t sbp<100. +pp.\n\nresp: lungs coarse. suctioned thick yellow secreations. attemped to wean ps->rr imediately increased>30.\n\ngi/gu: +bs. tf cont at 40cc/hr. inc lg soft formed stool. uop adequate. good diuresis w/lasix.\n\nendo: fs covered w/ssri per protocol.\n\nid: afebrile. cont on ivabx.\n\nsocial: minister into visit/pray w/pt.\n\nplan: cont current plan of care. attempt to wean ps if tolerates. ?trach & peg this week. replete labs prn.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273335, "text": "BS coarse crackles, rhonchi; no change with MDI's. Suctioned for moderate amount thick yellow secretions. Attempted again to lower PSV to 14 but rate > 40. Back on PSV 17. Continue to attempt to wean PSV. Probable trach/PEG this week.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273336, "text": "NEURO- AWAKE/ALERT/EYES OPEN. TRACKING VOICE AND RN POSITION AT TIMES. OPENED MOUTH TO COMMAND. PURPOSEFUL FACIAL GRIMACING AND TIGHTENING OF EYES/JAW WITH CARE. NO MOVEMENT OF EXTREMETIES.\n\nCV- AFEBRILE. WBC=16.1 HCT=27.0 NSR. BP STABLE. LOPRESSOR HELD AT .GENERALIZED ANASARCA. WEEPING SEROUS FLID FROM RT ARM.\n\nRESP- TOLERATING CPAP/ 17PS. WEANED PS DOWN TO 15 BUT PT BECAME MORE TACHPNEIC. LS COURSE-> CLEAR AFTER SXING THICK CLEAR SPUTUM.\n\n\nGI- NEPRO @ 40CC/HR VIA NASAL DOBHOFF.\n\nGU- ADEQ. U/O. DIURESING WELL FROM LASIX.\n\nPAIN- 50MG ULTRAM X1.\n\nPLAN- SLOW WEAN OF PS.SXING. REPOSOTIONING.DIURESE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-23 00:00:00.000", "description": "Report", "row_id": 1273337, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. PSw weaned to 15. well. Lungs sl coarse/sxd amt thick sputum. RSBI this am on 0 PEEP/5 PS was 96. Continue slow wean.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-28 00:00:00.000", "description": "Report", "row_id": 1273362, "text": "Nursing 7a-7p\nNeuro: Alert most of shift. Nodding yes/no appropriately to questions. Attempts to mouth words, this RN unable to interpret. PERRLA. + hand grasps, L>R. Moves bilat legs on bed. PO ultram for c/o pain. Apprehensive w/transfers & repositions, reassured frequently. OOB to chair x3hr. ROM done, bilat LE very stiff.\n\nC/V: NSR 60-80s. Rare- occasional pacs. Lytes repleated. On PO amio & lopressor. SBP 90-130. Skin W&D. Slightly hypothermic, bed warmer on- improved to normothermic. JP x2 to bulb sx w/min drainage.\n\nResp: CPAP 50% 10/5. No vent changes this shift. Sats >99%. Suctioned for mod amts tan sputum. VAP protocol.\n\nGi: Dophoff placed at bedside. Confirmed by CXR. TF resumed @ goal 40cc/hr. Banana flakes for loose bm in am.\nGu: HUO <30 x1. 1x ivp lasix w/+diuresis. Otherwise adequate HUO, on ivp lasix.\nEndo: RISS.\n\nSkin: See carevue for incisions/impaired skin.\nSocial: No call/visit from family friends.\nID: Mult iv antibiotics. Erythromycin oint for eyes.\n\nPlan: Add-on case for trach in OR tomorrow. TF to be shut off at midnight. Pulm toilet. Monitor lytes. Reorient & reassure frequently.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273235, "text": "csru update\nevents: remains w/ open chest. possible closure this afternoon.\n\nneuro: paralytic d/c this am. remains sedated on propofol and w/ fentanyl drip. pupils diff to assess. reactive to light.\n\ncv: vs/hemos as per flowsheet. pt w/ met acidosis on am abg w/ hct 26. 1 unit prbc transfused. bp drifting to low 80's though map remained > 60. 2nd U transfused. attempt not to tirate up neosynephrine r/t possible OR for chest closure w/ flap. 4+ anasarca, extrems warm. distal pulses by dopller. CO/CI wnl. afib / vent responce in 80's much of day. ? return to 1st avb this afternoon. amiodarone drip cont.\n\nresp: lungs coarse when no longer on paralytic. TV down to 500cc this am. abg as per flowsheet. met acidosis. o2 sats high 90's. chest open w/ drains to lwsx for serosang.\n\ngi/gu: abd soft. hypo bsp. ogt to lwsx for bilous dng. insulin gtt to off. no bm. reglan held. foley w/ uop 25-50cc/hr.\n\nskin: 4+ anasarca including lg amt scrotal swelling. weeping serous dng fluid. no turn r/t open chest.\n\nid: requiring bair hugger to maintain temp > 36. wbc 19 this am. chest open. vanco d/c this am. remains on ampicillin and cefipime,\n\nassess: met acidosis w/ drifting BP.\n\nplan: cont to monitor vs/hemos/labs closely. ? OR this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-29 00:00:00.000", "description": "Report", "row_id": 1273236, "text": "See and Carevue\n\nNeuro: Rec'd patient moving all in bed. No purposeful movement noted. Chewing at ETT with some blood noted a lip and in mouth. Making resp effort, slight ?cough intermittently. Patient restart on cisatricurium, no without movement. PERL. Minimal change in VS with stim.\n\nResp: Patient coarse thru out. Suctioned for sputum culture, small thick blood tinged pluggy secretions. Poor recovery. Decreased SAT, FiO2 increased to 60% with improvement. Metabolic acidosis treated with bicarb.\n\nCV: Patient in NSR-> NST. Afib resolved.On amio. Patient with increase in HR 80->110 with acidosis. Stable BP on neo. CO/CI unchanged. Calcium and potassium repleted. Bicarb for acidosis. Lactate stable at 1.2. Blood, sputum and urine cultures sent.\n\nEndo: Glucose stable off g insulin gtt.\n\nGI: OGT to LWS with large amount of output. Reglan given.\n\nPlan: Continue cardiopulmonary monitoring. Replete lytes as needed. Correct acidosis. Continue to evaluate for sepsis. Antibiotics as ordered.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273237, "text": "Resp Care Note:\n\nPt cont intub with OETT and on vent as per Carevue. Lung sounds coarse after suct sm th brn sput. MDI given as per order. ABGs stable on present vent settings. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273238, "text": "NEURO: paralyzed with cisatracurium and sedated on propofol and fentanyl gtts. TOF with zero twitches L facial on 20 MA. goal NP is <2 twitches. no motor or verbal response. no gag or cough.\nCV: at beginning of shift sinus with APC's converted in to Afib--> amio bolus admin and converted back to sinus. converted back to Afib 0530 on amio gtt. MAP goal 60-90. on neo at beginning of shift switched to levo. MAP 60's-70 on levo. CO 3.5-4.5 CI>2.0. PA pressures elevted systolid 40's. Sternum remains open. skin cool, +anasarca, +weeping serous fluid. pedal pulses by doppler. good response to lasix IV. bair hugger for goal body temp 36.0\nRESP: lungs coarse bilat. suctioned for tan secretions- thick. VAP care done and old blood and clots suctioned from mouth. intubated. at beginnng of shift O2 low, PEEP increased to 8 NP. stable on vent. acidotic later in shift. treated wtih bicarb. no overbreathing.\nGI/GU: abd soft distended with ecchy areas no bowel sounds. OGT with bilious drainage LCWS. Foley with clear yellow urine. penis/scrotum edema. + abrasion on scrotum with serous drainage.\nENDO: blood gluc rising pt place on insulin gtt.\nID: WBC rising. lactate 2.2 . ampicillin IV. ceftriaxone IV ordered awaiting ID approval.\nSKIN: sternum open covered with transparent dressing. abd with ecchy, skin weeping serous fluid. +anasarca.\nLINES/ACCESS: PA cath, R rad A line, R , L AC PICC- flushed, is sluggish but patent.\nSOCIAL: pt's minister visited pt this evening.\nA/P:maintain paralysis and sedation, monitor cv goal MAP 60-90, monitor resp, ABG acidocis, bair hugger normothermia, skin care as able (bath not done d/t inability to hold body temp off bair hugger). no turns in bed d/t open chest. lytes, blood gluc. plan to go to OR 0730 for sternum revision.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-30 00:00:00.000", "description": "Report", "row_id": 1273239, "text": "Respiratory Care\nPt remains on mechanical ventilation, supportive settings. Slowly weaning Fi02 as documented in Carevue.\nBilateral breath sounds diminished thoughout. MDI's given as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273367, "text": "neuro: pt more interactive. awake initial shift. slept most noc. nod head and non-verbal cues appro. cooperative to care. maex4. more strength L>R. minimum r leg and toes movement. perrla.\n\nid: wbc rising 17 today?? low grade temp. con't multi abx. sent am vanco dose. erythromycin ointment for OD - sclera red-but improving\n\ncv: sr w rare pacs. map >60. sbp mid 80s-100s. gave po lopressor dose. po amiodarone. bodily edema improved to 1pitting now. skin w/d. palpable pulses. pneumaboots on.\n\nresp: trach #8 portex - site sl drg. remain on cpap .50/10/5. vt 400s-500s, w db ^700s. sat >99%. ls cta, diminish both bases. sxn sm-scan amt blood-tinged. rr mid 10s-low 20s. no distress. trach care done. vap protocol.\n\ngi: tf at goal via dobhoff. no residual. gu: diuresis w lasix regimen. reglan scheduled. creatinine pnd. banana flakes. endo: treat bs per riss protocol\nwound: see careview. sternal/abd incisions healing. heels . JP x2 from sternal drain sm amt . multipodus boot\n\ncomfort: med w ultram prn for incis pain w relief. no relative call. update status to pt and provide support\n\na/p: s/p Trach in OR. no changed in Vent. uneventful noc.\nwean to trach collar today-pulm toilet. wound care. to chair. PT/OT consults. Rehab screening. f/u abx and ?elevated wbc. con't vap protocol\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273368, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 Portex DIC trach. BLBS are coarse. Sxn for thick yellow secretions. Tolerating PS 10/5. plan for future trach mask trial. RSBI completed on PS 5=91.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273369, "text": "NEURO: PLEASANT, MOUTHING WORDS. SEDATED BRIEFLY ON PROP FOR CT PLACEMENT\nCV: BP DOWN TO 79 AFTER PROPOFOL NOW CLIMBING BACK UP. HR 70'S WITH OCC PAC'S. PALP PEDAL PULSES\nRESP: LT PLEURAL PIGTAIL TUBE PLACED BY M. COURNTEY. DRAINED 700CC INITIALLY NOW NOTHING. DRNG. LUNGS DIM AT BASES. PLACED ON TRACH COLLAR 60% THIS AM RR 25-30, APPEARED COMFORTABLE, ABG WNL. BACK ON CPAP FOR PIGTAIL PLACEMENT WITH SEDATION.\nGI: AT GOAL ON TF AT 40CC/HR. NGT PLACEMENT CONFIRMED BY AUSCULTATION\nGU: FOLEY PATENT. DIURESING WELL FROM LASIX\nENDO: BS COVERED BY SSR, SEE FLOWSHEET\nPLAN; CONT TRACH COLLAR TRIALS. ? SPEECH SWALLOW IN AM IF TOLERATING WELL. CONT ASSESS CARDIO/RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-30 00:00:00.000", "description": "Report", "row_id": 1273370, "text": "Respiratory Care\n\n Pt received on PSV 10/5 placed on T-mask tolerating well B/S dim in bases. Sx'd small thick tan. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273212, "text": "Neuro: pt sedated overnight with propofol 30mcg and prn morphine x1 for pain. Pupils equal and reactive. Propofol weaned off this am pt has not woken yet, off for 1/2 hour.\nResp: Vent on SIMV with rate of 12 decreased from 14 MV of pt is not overbreathing the vent. O2 sats 95%. Suctioned for scant amounts.\nChest tubes patent draining serous sangunious drainage 20-40cc/hr no air leak detected.\nC/V: pt apaced most of night until this am underlying rhythm 88 sinus rhythm Pacer placed on back up mode of 60. pt required volum 1000 cc for low filing presse-ures low Blood pressure and decreased SVO2 along with a base excess on ABG of -5. pt also required small dose of neo for BP. Pulses palbable in feet.\nGI: OGT drainig scant amounts of green bilious fluid.\nEndo: Insulin drip weaned off for blood sugar of 69 and has not had to be restarted. blood sugars in the 70's to 90's.\nGU: excellent urine output most of night greater than 100 cc/hr.\nSkin: chest dsg intact no drainage noted. Pt has a large ecchymotic area in left lower abdonmin and groin area.\nPlan: wake and wean and possible extubate when ready. Neo for BP>\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273213, "text": "Respiratory Care\nPt remains intubated and on vent support. Vent changes were SIMV to PSV w/CPAP. Other changes were FiO2 from 0.40 to 0.50. Lung sounds were clear and diminished in the bases. Pt was suctioned for scant amounts of thinl clear secreretions. Last ABG showed a compensated mixed disorder with mild hypoxemia. Care plan is to continue to wean as tol with target volumes of >350 mL. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-27 00:00:00.000", "description": "Report", "row_id": 1273227, "text": "7P-7A\nNEURO: A/Ox3. Confused at times. Moves and lifts extremities. PERRLA. PO Percocet for ABD/INCS pain with good effect. Afebrile.\n\nCV: NSR 80's. Rare PAC's noted. Lytes repleted prn. PO Amio . NEO GTT weaned to off and restarted for MAP < 60 @ 0.5mcg/kg/min. Dopplerable pulses bilat. Sternal click palpated with NT suctioning and CDB, PA aware. No new drainage noted to sternal dsg. SQ Heparin for DVT prophylaxis. +3 bilat UE/LE pitting edema. Picc line to RAC, Multilumen to RIJ, R radial Aline.\n\nRESP: LS coarse with EXP whzs. NT suctioned for blood tinged thick sputum. Weak cough effort. IS to 500. O2Sat <94% on 60% face mask. Nebs per RT.\n\nGU/GI: Foley to gravity. HUO >30cc. BUN/CR 18, 1.6 Lasix PO BID. Scrotal edema noted. Abd pain per pt PA aware. +hypoactive BS ABD soft. Bruising noted secondary to SQ Heparin. PPI for GI prophylaxis.\n\nENDO: FSBS per ordered SS.\n\nID: Afebrile. IV Vanco check trough today. IV Ampicillian &IV CefePIME continue.\n\nPLAN: Continue aggressive pulmonary toileting!!!!! Wean Neo GTT to off. ? D/C Multilumen, culture cathether tip.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-27 00:00:00.000", "description": "Report", "row_id": 1273228, "text": "See carevue for objective data.\n\nAlert/oriented. Yelling out this AM \"go away! I want to die\". Support provided. Ultram/percs for pain with good effect. Much more appropriate affect this PM.\nShort period of AFIB which was self-limiting. Received 5 mg lopressor IV and po dose which was tolerated well. PAC's noted on monitor but no further AFIB. Neo currently off. Goal MAP>60.\nNon-compliant with pulmonary hygiene despite several attempts. NT sx X1 with poor results. Remains on face mask. Sats adequate.\nLasix dose increased to 40 mg po BID. Crackles auscultated right base. Total body edema remains.\nSternal dressing changed this AM and no staining noted. + sternal click. Team aware.\nTaking diet fair. Boost shakes/puddings tolerated well.\nNo BM. C/O some abd distention. Team aware.\nRIJ dc'd. Double lumen PIC patent.\n\nContinue current POC/support pt/pulmonary hygiene as tolerated/pain control.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-28 00:00:00.000", "description": "Report", "row_id": 1273229, "text": "S. I think I am going to die. It hurts all over.\nO. Neuro a/ox3 moaning and yelling out given oxycodone 2 x2 with good relief of discomfort. Pupils equal and reactive, mae, fc\nResp exertional I/E wheezes given neb tx x2 with some resolution of symptoms ABG on 100% 7.34/39/112/-. CPT and TCDB done pt with productive cough swallowing sputum\ncvs BP <70/ at 1900 started on neo and given 1liter of lr. Neo remained on all night on .6mcg/kg/min. Hct 31.3 Sternum staples in place oozing blood from mid staple site dsg saturated changed. HR 70-130 nsr to afib lopressor po held bp given amiodarone as ordered po. Lytes repleted. Skin anasarca weeping PP+\nGI coughing after swallowing abed snt BS+ stomach ecchymotic no stool\ngu u/o 35 for 3 hrs given 1l LR for low bp with improvement u/o also given lasix as ordered BUN 20 cr 1.6\nendocrine BS 64 tx\naccess lt picc, rt radial a line\na. s/p MVR blding from staple site\nhypotensive, afib, ? ability to swallow, exertional I/E wheezes\np. monitor blding from sternum, check hct, monitor bp , wean neo as tolerated, give lopressor when bp stable, vigorous pulm toliet, monitor swallowing ability have hob at 90% when taking po monitor\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273296, "text": "NEURO-ON FENTANYL & ATIVAN GTTS. NO PURPOSEFUL OR NON-PURPOSEFUL MOVEMENT SEEN. BP AND RR RESPONSIVE TO STIMULI,REQUIRING A COUPLE OF ATIVAN BOLUSES AND INCREASE IN DOSE.SPONTANEOUS ATTEMPTS TO OPEN EYES SLIGHLTY.\n\nCV- AFIB. RATE BETWEEN 115-125. AMIO BOLUS FOLLOWED BY AMIO GTT@ 0.5MG/HR. HYPOTENSIVE WITH SBP LOW=65.NEO GTT STARTED AND TITRATED TO KEEP MAP> 60.BECOMES HTN WITH STIMULI OR SPORADIC COUGHING EPISODES.AFEBRILE. WBC=17.1 ON VANCO,AMPICILLLAN,&CEFTRIAXONE.HCT=25.4->TRANSFUSED 2UPRBC WITH REPEAT HCT=28.1 SKIN W/D. SMALL AMT SANG. SEEPAGE THROUGH SUPERIOR EDGE OF STERNAL DSG. JP.S WITH OUTPUT.\n\nRESP- ASYNCHRONOUS BREATHING WITH INCREASED RR TO 29. SHORT,SHALLOW BREATHS AND \"BUCKING \" THE VENT. SATS MAINTAINED BETWEEN 98-100%. LS TIGHT. INH.GIVEN AND VENT SETTINGS CHANGED TO CMV TO REST PT .\nOCC. COUGHING EPISODE. SXD X1 WITH NO RETURN OF SECRETIONS.\n\nGI/GU- ABD SOFT,LARGE,ECCYHMOTIC WITH HYPOACTIVE BS.NEPRO RE-STARTD @20CC/HR AND ADVANCED TO 40CC/HR LATER IN SHIFT. NO STOOL. U/O LOW BUT ADEQUATE MOST OF SHIFT DECREAINIG TO 8 & 7CC/HR. MD NOTIFIED. BLOOD INFUSING. U/O INCREASED TO 45CC/HR.\n\nLABS- K+ REPLETED PRN.INSULIN GTT STARTED FOR GLUCOSE LEVELS > 130 X 2. CSRU PROTOCOL FOR SSCI IMPLEMENTED AND FOLLOWED.\n\nPAIN- FACIAL GRIMACING WITH TURNING &/OR MOUTH CARE.\n\nPLAN- PLACE BACK ON IMV VENT SETTINGS AND ATTEMPT TO WEAN MORE IF TOLETATED. TITRATE FENTANYLY &/OR ATIVAN GTTS IF POSSIBLE. CONTINU WITH ICU MONITORING.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-14 00:00:00.000", "description": "Report", "row_id": 1273297, "text": "resp care\npt initially on imv 500x14 50% 5peep but pt became increasingly out of phase with the vent. RR inc to > 30, tachy and hypertensive. Pt changed to a/c with improvement in WOB. Combivent given as ordered with some in cough.Suct for sput. Pt changed back to imv this am with inc in wob. RSBI attempted but >150. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273363, "text": "shift cover 2300-0700\n\nneuro: pt more awake at initial shift- watching tv. head appro to questions. grasp stronger l>r, move rle but minimumly. perl. slept most of noc\n\nid: low grade temp. wbc still ^- con't multi abx. sent vanco level am. erythromycin ointment to OD\n\ncv: sr. map 60-70. on po lopressor/amiodarone. skin w/d. con't bodily edema - more so both ues. palpable pulses. pneumatic boots.\n\nresp: cpap .50/10/5. sat>98%. breathing even. no distress. sxn sm-mod amt secretion.\n\ngi: tf at goal 40cc/hr. stopped at midnoc for OR tracheostomy in am.\nendo: treat bs w protocol dose d/t npo\ngu: bun and creat rising. huo adequate on lasix regimens\nwound: see careview\ncomfort: gave ultram x1 dose for discomfort w effect. no family/friend call . provide support and explain to pt status/icu enviroment\n\na/p: npo preop for OR trach in am.\npulm toilet. support\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273364, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on PS settings through noc. No vent setting changes. Plan for trach placement today. RSBI completed on PS 5=92. BLBS remain coarse. Sxn for thick yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273214, "text": "Neuro: Off propofol since 0500, slow to awake, follows command inconsistently, movement noted on LUE, weak grasps with R hand, unknown status on LE, no movement noted, hx of bilat knee replacement; PERRL 3mm; per friend stated to be wheel-chair dependent\n\nCV: Tachycardic high 90's-100's; off neo, MAP >65; K repleted in AM; increasing PAC's in PM, lytes rechecked; started on PO lopressor & IV lasix\n\nRESP: Intubated on pressure support & CPAP, 50% FiO2; improving ABG; lung sound clear, dim @ bases; CT draining minimal serrousang drainage\n\nInteg: Intact, redness noted on sacral area, skin protectant applied; old bruise noted on L lower abdomen; sternal drsg amount of serrousang drainage\n\nGI: NPO; OGT to low cont suction with small amount of billous drainage; carafate & protonix given\n\nGU: Foley draining yellow clear urine, minimal UO in PM, 20 mg IV lasix given with fair response\n\nEndo: Follow protocol\n\nSocial: Case manager and social worker contact regarding placement and spokeperson\n\nA/P: monitor hemodynamics; monitor labs; work on extubation; DC plan; ?DC CT in AM\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273266, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on SIMV settings. OR last noc for sternal washout. Chest remains open. Paralyzed. No vent changes made during the noc.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273267, "text": "NEURO: at beginning of shift moving mouth, coughing and SBP climbing. increased doses of cisat., fent and ativan with good response. now no vital sign change with interventions, twitches light coughing only with in line suction. pupils = NR.\nCV: sinus rhythm all noc. no ectopy noted K and mag repleted. neo weaned off and pitressin down to 1.2 labile bp over noc much titration required. +anasarca, DP, PT by doppler. chest remains open with VAC dressing.\nRESP: lungs clear at upper, dim. at bilat. bases. remains intubated, no vent changes over noc. ABG stable. VAP care done.\nGI/GU: abd soft, distended with ecchy areas. NG tube residual high >150. tubefeeds held. bowel sounds absent. foley with clear yellow urine.\nENDO: blood gluc covered with RISS\nID: remains on vanco, amp, fluconazole, ceftriax.\nSkin: open chest with vac, mediastinal DSD. abrasion to scrotum. + anasarca. buttocks with rash. multipodus boots on. triadyne bed rotating L only. bloody gums with oral care\nSOCIAL: no calls this shift.\nA/P: monitor cv, resp, maintain paralysis, sedation. keep intubated. wean presssors as . VAP mouthcare. lytes and blood gluc.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273287, "text": "7p-7a:\nneuro: sedated and paralyzed overnight. . fentanyl gtt for pain with good effects.\n\ncv: afib 100-120's, treated with amiodarone bolus with conversion to sr 80-90. no ectopy noted. electrolytes repleted as needed. neo gtt weaned to off, sbp 90-120's. remains on albumin qid. easily palpable pedal pulses bilaterally.\n\nresp: lungs coarse at times. remains orally intubated on full mechanical ventilation. see carevue for settings. hypoxic initially with po2 of 61, improved to 100 this am. suctioned for minimal secretions.\n\ngi/gu: abd soft, ecchymotic. bs hypoactive. dophoff tube clamped. foley to gravity, low uo treated with volume with good effect.\n\nendo: fs qid, cover per riss.\n\nplan: s/p omental flap, jp x 3, wean sedation this am.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273288, "text": "RESP CARE: pt recieved from OR s/p chest closure. Pt intubated/on SIMV, settings per carevue. PEEP increased to 8 following low Pa02 post-op. Oxygenation improved. Lungs dim/coarse bilat. Sxd small amount thick yellow sputum. MDIs given per /no sign improvement noted. No RSBI this am, pt recieving NMBA and FI02 .60/\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273289, "text": "Resp Care\n\nPt remains intubated and on simv/psv. MV is being maintained in the 7-8L range with an abg of 7.42/43/99/26. BS are diminished and suctioning small amts of tan yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 1273290, "text": "7a-7p\n\nNeuro: Nimbex d/c'd this am. Ativan decreased to 1mg/hr. Fentanyl decreased to 50mcg/hr. Pt responding to stimuli, moving mouth with care. Grimace to painful stimuli. PERL.\n\nCV: SBP 80-130 (Maps 60-90). SR 80-90's. 3JP's cont to drain dnge, output decreasing. Hct 26.1 this am (down from 29 last night) Next hct in am ok with Dr (plastics). +pedal pulses with doppler.\n\nResp: Pt remains intubated on full mechanical ventilation. ABG wnl. Sat 99-100%. Lungs clear, dim bases.\n\nGI/GU: Abd soft, no bs noted. Advancing TF Nepro, presently at 30cc/hr. Minimal to no residuals, due to advance to goal of 40cc/hr at 10pm. RISS, covered today. UOP wnl, low last hr.\n\nSkin: See flowsheet. Bleeds easily from pinhole sites one left arm, one rt forehead. aware. Bottom wnl.\n\nSocial: no calls today.\n\nPlan: Cont to monitor hemodynamics and resp status closely. Wean sedation again in am. Advance TF as tolerated. Monitor JP drains.\nMonitor chest site closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-13 00:00:00.000", "description": "Report", "row_id": 1273291, "text": "7p-7a:\nuo low throughout night, treated volume. hct 21 this am, 2 units prbc's given, cxr done. ? bleeding from flap site, awaiting plastics.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273365, "text": "Nursing 7a-7p\nResp: Pt traveled to OR for trach placement today. #8 Portex inserted without difficulty. Reversed in OR. Placed on cpap 50% 10ps/5 peep once in CSRU. Breathing unlabored. Lungs clear dim in bases. Suctioning sm amt blood tinged sputum. Trach site with min sanginous drainage.\n\nC/V: NSR 60-70s w/rare pacs. K+ repleated. SBP 80-120. Map >60, team accepting maps >60. +PP.\n\nNeuro: Awake & alert most of shift. More interactive today than yesterday. Mouthing words, this RN unable to interpret. No dexterity to write. PERRLA. MAE. Follows commands. PO ultram for c/o incisional pain.\nAct: Hoyered OOB to chair. Passive & active ROM done.\n\nGi: TF resumed @ goal 40cc/hr. Loose bm x1 in am, banana flakes resumed.\nGu: HUO <30x2 in afternoon. 1x ivp 20mg lasix MD . On schuled ivp lasix.\nEndo: RISS.\nSocial: friend called & stated would visit today.\nID: Afeb, mult iv antibiotics. Erythromycin oint OD.\nskin: See carevue.\n\nPlan: Pulm toilet. Increase act as . ?rehab screen. Monitor I/Os, lytes. Vanco trough to be drawn tonight.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-29 00:00:00.000", "description": "Report", "row_id": 1273366, "text": "Respiratory Care\nBreath sounds bilaterally coarse, suctioned for smlll thick white secretions, patient was afebrile, stayed into normal sinus rhythm whole day, RR 13 to 26, WBC 14.9 ?bacterial infection, hemoglobin only 9.2 ? anemia, patient went to OR this morning to have tracheostomy, cameback at 0900 am Portex size 8 with inner cannula inserted, cuff pressure 22cmh2o\nsince tracheostomy patient has been suctioned for small amounts of thick, blood-tinged secretions, has been treated with Combivent and Flovent inhalers, no vent changes made nor ABGs drawn up to this point.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273268, "text": "See and Carevue for detailed documentation\n\nNeuro: Rec'd on ativan, fentayl, cisatricurium. Attempt to decrease cis with spont resps noted and cough with reposition. Gtt increased. Otherwise remains paralysed, sedated. No change in VS with noxius stim.\n\nResp: Continues on vent. No changes made. BS clear, without wheeze. Suctioned for amounts secretions. Mouth care done with bloody secretions noted in mouth.\n\nCV: In NS brady with HR 50-60. BP stable. Pulses by doppler. Rec'd on vasopressin 1.2units. Patient with large output s/p lasix. BP with MAP <60. Vasopressin increased with good result, unable to wean and maintain BP>60. Potassium and calcium repleted. Afebrile, antibiotics continue.\nVAC dressing to open chest . Skin exam as noted in care view.\n\nGI: Restart feeds. Start residual 25ml. No bowel sounds noted.\n\nGU: Foley to gravity with large output s/p lasix. Negative balance.\n\nPlan: Continue cardiopulmonary montioring. Advance feeds if tolerated.\nRemain sedated, paralysed. Wean vasopressin as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 1273269, "text": "Respiratory care\nPt remains intubated on same simv setting no changes this shift. BS clear, suction small amts of secrections, pt remans paralyzed. Plan to continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273328, "text": "neuro- eyes open all shift. no tracking or startle reflex.blankly staring outward. no motor response or movement seen.\n\ncv- nsr->afib,hr>115. on p/o amiodarone .neo gtt @ 0.25mcgkgmin.md notified. no lopressor given.k+ repleted. afebrile. wbc=17.9 hct=28.4. bilateral upper extremities seeping large amounts serous fluid. left radial a-line site macerated,pink and maloderous.generalized anasarca.abdominal binder around chest to protect sternal flap and .\n\nresp-multiple vent changes made d/t tachypneia with \"guppy-like\" breathing.sats maintained >95%. lung sounds course. sxd. thick yellow/tan sputum.diuresing well with lasix.extra dose ivp lasix this shift.ett with positional air leak.\n\ngi- abd soft. hypoactive bs. no stool. nepro @ 40cc/hr. difficulty checking residuals with dobhoff.\n\ngu- diuresing well from ivp lasix.\n\nlabs- lytes/glucose covered with sliding scales.\n\nplan- continue to monitor resp.system,hemodynamics,skin care.labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273329, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support; however, patient was \"guppy-breathing.\" PSV increased to 17 cm, resulting in a more synchronous ventilatory pattern. No morning abg results at this time.\n\nRSBI = 154.1 on 0-PEEP and 5 cm PSV.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273330, "text": "BS coarse crackles, improving with suction; no change with MDI's. Suctioned for small amount thick yellow secretions. Attempted to wean PSV to 14 but pt became tachypneic and stressed. Will continue to attempt to wean as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273354, "text": "neuro:pt awake, perl. track. sleep most of noc. squeeze hands strength more rh vs. lh. move lle, no movement of rle. head appro to questions. fc consistently. occasional bodily shaky w stimulations, but resolve on own.\n\nid: low grade temp. on multi abx. sent am vanco random.\n\ncv: sr rare pacs. map >60. on po lopressor/amiod. bodily edemadous more so both ues, scrotum. skin w/d. palpable pulses. pneuma boots on.\n\nresp: remain on cpap .50/12/5. no weaning per team . sat 100%. no distress. breathing even. ls coarse, sxn sm-mod lt yellow. rr low 10s-mid 20s.\n\ngi: tf at goal, no residual. dobhoff was pulled out at 2300. npo after midnoc for tracheostomy procedure in am. dr. was informed->plan to place dobhoff in am.\nendo: no coverage for bs 116 d/t npo\ngu: inconnt smear amt soft bm. gave reglan. held colace/bananaflakes. diuresis w lasix\n\nwound: bodily edemadous w multiple skin abrasions throughout. dsd on rlarm cdi - llarm w sma areas of blacken skin. abd bruises w few areas of skin abrasions. buttock red/bruises - but and heels ->applied vesta cream. multi podus boots. sternal-abd wound w stables-cdi\n\ncomfort: pt denies pain. no family or relative call . orient pt to icu/status - provide suppport prn\naccess: picc line patent\n\na/p: long recovery from . plan for trach today. need dobhoff placement. pulm toilet. abx.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273355, "text": "addenum:\nJP x3 from sternal/. to bulb sxn -drain drg ->#2 has most amt.\n\nVAP protocol\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273356, "text": "Resp Care: Pt continues on PSV 12/5 50% 02. No changes overnight. LS coarse bilaterally. pt sxn'd for small-large amounts of thick yellow secretions. MDI's given as ordered. PLAN: continue to wean PS as pt tolerates, to OR for trach.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273357, "text": "Respiratory Care\nBreath sounds bilaterally clear and diminished, suctioned intermittently for small thick yellowish secretions, patient was afebrile, stayed into normal sinus rhythm whole day, RR 15 to 25, WBC 14.5 ? bacterial infection, treated with Combivent and Flovent inhalers, PS weaned down from 12 to 10, bedside tracheostomy postponed for specialist unavailability, Hemoglobin only 9.4 ?anemia, ETT rotated and retaped 22 at lips with nurse help,no ABGs done today, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-27 00:00:00.000", "description": "Report", "row_id": 1273358, "text": "See and carevue for detailed documentation\n\nNeuro: Patient alert thru day. Nodding appropriately to questions. Tramadol x1. Patient with increased strength in UE, reaching for tubes. UE now restrained.\n\nResp: Plan for trach today, not done to schedule conflict. Remains on vnet, In NAD. Suctioned for moderate secretions. Less secretions then in past. BS clear, slightly coarse. Continues on MDI.\n\nCV: In NSR, BP stable. Afebrile. Continues on antibiotics. Potassium repleted.\n\nEndo: RSSI per protocol.\n\nGU: FOley to gravity with good output s/p lasix.\n\nGI: Feeding tube placed. Small smear stool today.\n\nSocial: Health care proxy updated via phone.\n\nPlan: Continue cardiopulmonary monitoring. Restart feeds tonight. Reeval for trach in am.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273208, "text": "Respiratory Care\nPt was received from OR intubated. Pt placed onto vent vent changes were FiO2 from 1.0 to 0.50 per ABG. Lung sounds were noted to have crackles throughout. Pt was suctioned for scant amount of thin white secretions. Last ABG showed acute metabolic acidosis. Care plan is to continue therapy and when stable to start cardiac wean. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-21 00:00:00.000", "description": "Report", "row_id": 1273331, "text": "7a-7p\n\nNeuro: Eyes open, blinking but pt not responding to verbal stimuli. Responds to pain with grimace. Moving head at times but not extremities. PERL.\n\nCV: SBP 90's to low 100's. Neo weaned to off. BP presently 94/45.\nSR 90's with rare pac's. 3 JP's 20-30cc. K repleted.\n\nResp: Pt remains intubated on cpap. ABG this am wnl with peep 5, ps 17. Attempted to wean ps to 14 but pt rr ^35. PS back to 17, pt tolerating. Next abg in am. Sats 100%. Lungs coarse, sxn for small amt thick white sputum. Cont on triple abx.\n\nGI/GU: Abd softly dist. TF cont at 40cc/hr, minimal residuals. Mod size soft br bm today after dulculax supp. Foley yellow urine, ^amts.\n\nSkin: See careview.\n\nSocial: Proxy called in for update today.\n\nPlan: Cont to monitor hemodynamics/resp status. Check abg in am, ?wean vent accordingly as pt tolerates.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-22 00:00:00.000", "description": "Report", "row_id": 1273332, "text": "resp care\nPt remained on psv17/peep5 and 40% with volumes of 400-600cc and rr 20's to 30's. BS coarse rhonchi. Suct for thick creamy tan sput. Combivent mdi given as ordered. Occ wheeze noted after suct. RSBI done on 5psv/opeep=110. Will cont to follow with slow psv wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273224, "text": "Respiratory Care\nBreath sounds revealed bilateral coarse rhonchi, and diminished at the bases,nasotracheally suctioned intermittently for copious thick yellowish secretions, was afebrile , had few episodes of sinus tachycardia, but mostly stayed into normal sinus rhythm, HR ranged 77 to 111, has been treated around 1700 with Albuterol and atrovent via small nebulizer, sat ranged 94 to 98, patient is on 60% , continue to be monitored closely.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-26 00:00:00.000", "description": "Report", "row_id": 1273225, "text": "7P-7A\nNUERO: A/Ox3. Disoriented @ times. MAE. PERRLA. Tramadol PO for pain with good effect. Afebrile. Anxious at times.\n\nCV: ST @ beginning of shift. Converted to Afib 120's. 150mg AMIO bolus x1. Lytes repleted prn. Remains in Afib. NEO GTT to maintain MAP >60. SBP 90-100 on 0.6mcg/kg/min. Dopplerable pulses bilat. +3 bilat LE pitting Edema. SQ Heparin for DVT prophylaxis. Metoprolol PO TID. Double lumen to RIJ. R Radial Aline.\n\nRESP: LS coarse with whzs, dim @ bases. ALB/ATR nebs per RT. Weak cough effort, poor IS effort. NT suctioned with difficulty for thick bloody secretions. ABG adequate. 02 SAT 92-96% 60% Face tent.\n\nGU/GI: Foley to gravity with adequate HUO. Scrotal edema noted. Lasix PO BID. ABD snt +BS PPI for GI prophylaxis. Tolerating sips of H2O, swallows pills without difficulty.\n\nENDO: FSBS coverage per Ordered RISS.\n\nID: IV Ampicillin, IV Vancomycin and IV CefePIME.\n\nAM LABS PENDING AT TIME OF NOTE.\n\nPLAN: Aggressive Pulmonary tolieting!!!! Wean NEO GTT. Encourage PO intake/solids. Increase activity.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-26 00:00:00.000", "description": "Report", "row_id": 1273226, "text": "NEURO: alert, Ox3 to , , president. this evening stated he was in , easily re-oriented. , lifts and holds all extremities this AM weaker as day wore on. following commands.\nCV: sinus rhythm with APC's lytes repleted KCL. SBP 80's-100's MAP 60's-70 neo titrated to maintain MAP 60-90. skin warm, dry. +peripheral edema. DP/PT diff. to palp.\nRESP: lungs coarse throughout increasing o2 requirement on high flow mask. NT suctioned for small amt. thick yellow. coached and encouraged CDB, I/S and flutter valve use. pt with weak cough and poor I/S effort. sats 93-95%.\nGI/GU: +hypoactive bowel sounds abd soft distended. speech/swallow eval at bedside today went well until 10 min p eval dry heaving. medicated with anti emetic and meds and sips clears post. foley with clear yellow.\nENDO: blood gluc not requiring RISS\nSKIN: pressure points intact. abd LLQ hematoma. sternal dressing noted to be saturated with sang drainage post dry heaving dressing changed and pressure dressing applied. +sternal click noted by MD. will cont. monitor.\nPAIN/COMFORT: c/o incisional pain unrelieved with acetamin/tramadol. percocet admin PO 1 tab with good result--> pt napping.\nLINES/ACCESS: L AC PICC line placed in IR today. plan to d/c 3 lumen and culture tip.\nSOCIAL: no calls this shift.\nA/P: continue to monitor resp, cv. aggressive pulm toilet. neo for MAP 60-90. d/c 3 lumen and send tip for cx. borderline resp status with increasing o2 requirement. lytes, blood gluc., skin care. monitor sternal incis. for drainage.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273209, "text": "Nursing Admission Note: S/P MVR porcine\n\nArrived from OR @ 16pm. Intubated and sedated with prop 30. Pt very wet and oozy in OR-bled @ 1300-Given multiple blood products. Out on neo .3 2 MT CT's to sxn-no airleak-420cc sang dng on arrival-pleuravac changed r/t kicked over by MD. CO by TD 3.4-2.4 with CI 1.6-1.3. MVO2 sat-58 with much better CO/CI. CXR obtained and ET tube withdrawn 2cm.\n\nNeuro: Sedated with prop 30. PERRL. L foot drop.\nCV: Tachycardic 110's-103 ST without VEA, Hct 20.8 Transfused with 3u PRBC's. CO 3.4-2.4 TD with low CI 1.3. MVO2 sat sent 58 which gives CO 5.8/CI >3. CVP 20-22 with PAD 20-30. palp pedal pulses. K and Ca repleted.\nResp: Intubated on SIMV/12/550-weaned to 40%. ET pulled back 2cm. CXR done. 2 MT to sxn-minimal output very clotty/chunky. No airleak. ABG's met alk with -6 BE.\nID: On post op vanco as well as ampicillin 2gm q 8.\nGU: Foley to gd with uo>50cc/hr. CRI.\nGU: Abd obese,softly distended, no BS. Ecchymosis accross mid abd L>R. OGT placed.\nEndo: On insulin gtt per CTS protocol-see flowsheet.\nIncisions: Sternum and CT with DSD-D/I.\nComfort: MSO4 2mg IV X1 given.\nA/P: Fluid resucitation, watch hct, repeat CXR. Watch for s/s tamponade.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 1273210, "text": "cont. w rising & almost equal filling pressures,increased vea,hypotension to the 70's in t requiring increased neo & calcium chloride with worsening acidosis & dropping svo2. telephone update given to dr. ,no new orders given. dr. called immed. to bedside by me,cxr repeated which revealed mediastinal widening that had progressed from earlier.dr. notified & pt. transported to o.r. for re-exploration.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-21 00:00:00.000", "description": "Report", "row_id": 1273211, "text": "Resp. Care\nPt. did not do well Post Op. He was sedated and on mech vent but pt. failed to make any urine and no output from his chest tubes. The pt. became hypotensive. A CXR was taken that showed a widening of the mediastinam. The pt. was taken back to the OR where they evacuated a clot. He has been sedated all shift and at 0530, NSG is going to start to wean the sedation, and then to start to wean from vent.See carevue for ABGs and RSBI results.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-05 00:00:00.000", "description": "Report", "row_id": 1273261, "text": "Respiratory care\npt remains on simv settings without changes, Suctioning small amts of yellow secrections, MDI as ordered. Plan to return to oR tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273262, "text": "Resp: pt on simv 14/500/+5/50%. Ett 7.5 retaped and secured 20@ lip. Alarms on and functioning. Ambu/syringe @ hob. Bs are coarse bilaterally. Suctioned for copious amounts of bloody, clots secretions. MDI's administered Q4 with no adverse reactions. AM ABG 7.39/42/69/26. Fio2 increased to 60%. Plan trip today to OR for debridment.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273283, "text": "Respiratory Care:\nPatient remains on SIMV/PSV settings with no parametr changes made throughout the night. Still receiving paralytics. Latest abg results determined a fully compensated metabolic alkalemia with very good oxygenation.\n\nNo RSBI measured at this time. Plan is to go to OR this am for closure of chest.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273284, "text": "Neuro: pt sedated with Fentanyl and Stivan doses decreased some overnight. Cistracurium increased 2nd to 4 twitches and some coughing when ETT manipulated pt remained with4 twitches and cough and dose left at present rate.\nResp: No vent changes made, Suctioned for small ETT repositioned to right side of mouth.\nC/V: blood pressure dippinightly overnight after lopressor dose given total of 1 l NS with improvement in BP This am Bp 110-120/50's. Heart rate sinus rhythm in the 80's\nGI: tolerating tube feeds, stopped at midnight 2nd to npo for OR closure of chest today. Pt passing liquid stool this am to resume banana flakes when returned from OR. Stool quaiac neg\nEndo: blood sugars well controlled.\nGU: Adequate urine outputs 70-150cc/hr.\nSkin: pt remains with scrotal edema area has 1 small abrasion on backside of scotum elevated to help with swelling. Coccyx has old skin tear now healed Duoderm removed. Pt on Tridyne bed rotating 20 degrees every 10 minutes side to side and tolerating well.\nSocial: Reverend in to visit last evening , He will be out of town until the 12th and has left a number of another Reverend who will cover for him in case he is needed over next several days.\nPlan: return ot or for flap closure of chest today\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273285, "text": "resp care - Pt remains intubated on SIMV+PS 500/16/5/5/ 60%. ABG was within normal limits. BS clear, dim in bases. Sx amount of clear thin secretions. Meds given as ordered. Plan to go to OR @ 1800 for chest closure.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1273286, "text": "See and Carevue for detailed documentation\n\nNeuro: On cisatricurium with 4 eye twitch at 20mA. Occassional resp effort, cough noted. No gag. BP stable on ativan and fentanyl gtts.\nNo changs in sedation. PERL.\n\nResp: Continues on vent. BS clear, diminished in bases. Suctioned for small amounts thick white secretions. Large amounts bloody oral secretions. Chest open to VAC. To OR for flap closure.\n\nCV: In NSR, BP stable. Potassium and calcium repleted. Afebrile. Lopressor held.\n\nGI; NPG for OR.\n\nGU: Foley to gravity with large urine output s/p lasix.\n\nEndo: RSSI per protocol. None required this shift.\n\nPlan: Continue cardiopulmonary monitoring. Evaluate s/p OR for wakeup.\nContinue to support. Slow wean narcotic/ benzo eval for withdrawl.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-03 00:00:00.000", "description": "Report", "row_id": 1273253, "text": "NEURO: sedated, paralyzed. this AM coughing and sbp rising abruptly when in line suctioned. paralytic and fent/ativan titrated up. now 0-1 twitch on , no coughing, no overbreathing, no vital sign response to sitmulation. Pupils equal, fixed.\nCV: sinus rhythm with bouts of afib. lots of atrial ectopy. k repleted. MAP goal 60-90. labile today. pit added and neo weaned as . CI>2.0 today. continues on amio. +anasarca. remains with vac on sternum. DP/PT doppler.\nRESP: intubated. lungs diminished bilat. suctioned for yellow-->brown thick sputum. this afternoon desatting to 90% when turns on R side in triadyne bed. bronched this evening some plugs removed. will repeat ABG. pt traveled to CT chest/abd today.\nGI/GU: this AM dobhoff gastric changed by NP cxr confirmed post pyloric. tolerated readi-cat prep. tubefeeds held today for CT, bronch and MRI. abd soft, distended, ecchy. neg bowel sounds. foley with light yellow urine. lasix decreased to QD. +penis and scrotum edema with abrasion and peeling skin on scrotum.\nENDO: blood gluc covered with pt custom sliding scale.\nID: ceftriax/ampicillin/fluconazole\nSKIN: switched to triadyne bed. has rash on buttocks. duoderm to buttock intact. sternum with VAC dressing mediastinal DSD intact. MPboots on. skin weeping serous fluid +anasarca.\nLINES/ACCESS: RIJ trauma introducer. PA cath pulled for MRI. L rad a line.\nSOCIAL: HCP called for update.\nA/P: monitor cv, resp. follow ABG, wean neo as . triadyne bed ok to turn to 20 degrees not tolerating R side. plan MRI. resume tubefeeds p MRI. ?OR tomorrow. unlikely MD. follow lytes, blood gluc. maintain paralysis, sedation.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 1273254, "text": "neuro: pt remains I/S/P, on fentanyl/ativan/cisatracurium gtts; no left facial movements/twitching via , but rt facial twitching noted, and insp changes noted when sxn'd by RT~>paralytic titrated up; slight change in vitals in response to stimulation. pt tolerates triadyne rotational bed. pupils equal & nonreactive. ? travel to mri today.\n\ncv: pt in/out of rate controlled afib early in shift, then converted to sb~ aware, amio gtt continues @ 0.5. bp stable 100s-140s, sbp decreases marginally when in af but remains over 100. pitressin & neo gtts continue, but able to wean neo slightly; dp/pt by doppler. extrs w/d, +anasarca, scattered skin weeping serous fluid from both arms and rt leg. +4 edema all extrs. penile & scrotum edema noted. vac drsg . lytes repleted. afebrile. ? to OR today.\n\nresp: ls clr, dim @ bases. o2sats >94% on simv @ .50 w/rate of 14. sxn'd for sm amt thk tan sputum. abgs wnl. vap care done.\n\ngi/gu: tf nepro restarted @ 10cc/hr, 20cc resids adv as per order, absent bs, abd soft, slightly distended. adequate huo, clr yellow, creatinine 2.3.\n\nendo: bs monitored per ss; rssi coverage required this AM.\n\nsocial: pt's minister visited last night.\n\nplan: continue monitoring cardioresp status. monitor neuromuscular response, maintain sedation & paralysis. monitor labs. wean neo as tolerated. ? travel to mri & OR today. advance tf as tolerated. continue w/current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273246, "text": "NEURO-INTUBATED/SEDATED/PARALYZED. ON FENATNYL/PROPOFOL/NIMBEX GTTS. LEFT EYE TWITCHES.NO S/S PAIN.SPONTANEOUS COUGH X1. PERLA @ 3MM/BRISK.\n\nCV- T-MAX=99.5.IN/OUT OF NSR/AFIB-RATE CONTROLLED. ON AMIO GTT. NEO TIRATED UPWARD WITH AFIB.CO/CI/FILLING PRESSURES WNL.VAC DSG OCCLUSIVE OVER STERNUM. SCATTERED AREAS ON BILATERAL ARMS,RT LOWER LEG WEEPING SEROUS FLUID.\n\nRESP- REMIANED ON IMV/PS 40%X00/14/5.5. LS DIM IN UPPERS,VERY DIM (ALMOST ABSENT) IN BASES. ABG WNL. SATS=95-98%.\n\nGU/GI- ABD SOFT, ABSENT BS. OGT -> LCWSX WITH BILIOUS DRG. DIURESING AT LEAST 100CC/HR.\n\nLABS-K+ REPLETED Q2H. CA+ X1.\n\nPLAN- KEEP I/S/P/ UNTIL . TO HAVE FLAP REAPAIR DONE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273247, "text": "Respn Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent as per Carevue. Lung sounds ess clear after suct sm loose bld tinged sput. MDI given as per order. ABGs stable; no vent changes required . Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273248, "text": "Respiratory Care\nPt remains on full ventilatory support as documented on Carevue. Suction for small amounts of thick yellow secreations. MDI's given as ordered. Bilateral breath sounds diminished. No changes made this shift.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-02 00:00:00.000", "description": "Report", "row_id": 1273249, "text": "NEURO: Paralyzed and sedated on ativan/fentanyl. changed from propofol this AM. 3 lid twitches on . no cough/gag no overbreathing.\nCV: sinus rhythm with much A and V ectopy. KCL and MAG repleted. remains on amio gtt. neo titrated to maintain MAP 60-90. CO 3.8-4.0 CI >2.0 fick 3.30. PA elevated 40's/20. +anasarca, weeping fluid. sternum open with vac dressing. PT/DP doppler. remains on bair hugger to maintain body temp >36.0.\nRESP: intubated. lungs clear/diminished bases. suctioned for yellow secretions. no overbreathing. VAP care done. ABG stable no vent changes.\nGI/GU: abd soft skin ecchy. absent bowel sounds. tubefeed trial at 10/hour today did not tolerate. residual 50 cc at 5 hours. OGT to LCWS with bilious/tubefeed drainage. foley changed today. urine yellow, cloudy. penile and scrotal edema +serous drainage from skin.\nENDO: blood gluc covered with RISS. pt custom sliding scale.\nID: fungal blood cx sent today. on ceftriax./ampicillin. fluconazole IV started today.\nSKIN:HOB up to 30 degrees today. no turns. MP boots on. Sternal VAC dressing intact. mediast. DSD changed. +anasarca and weeping serous fluid from arms and legs.\nACCESS/LINES: L rad a line, RIJ trauma and PA cath.\nSOCIAL: Plastics spoke with HCP updated. friend called for update.\nA/P: continue to monitor cv, resp. blood culture results and abx. maintain MAP 60-90. maintain paralysis/sedation. no turns, can have HOB 30 degrees. lytes and blood gluc. bair hugger for body temp goal >36.0. plan to return to OR for sternal closure wed. .\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273263, "text": "Nursing 7p-7a\nNeuro: Sedated on fent/ativan gtts. Paralyzed on nimbex. & +cough w/ETT suction, team aware. PERRLA. Sluggish. R eye bloodshot & eyelid drooping, not new, team aware.\n\nC/V: NSR 60s. Intermittently SB 50s. Normothermic. Titrating neo gtt. Unable to titrate off. Vasopressin gtt cont. Dopperable pulses. Cap refil <3 sec. Copious amts serosang drainage from oral cavity. PTT 49. Platelets 150s. Hct 24, no tx at this time.\n\nResp: Fio2 increased for pa02 of 69. No other vent changes. Suctioned for copious amts blood tinged sputum. Lungs coarse throughout, dim in LLL.\n\nSkin: see carevue for impaired skin, incisions.\nID: Vanco trough sent today. On iv ampicillin, fluconazole, ceftriaxone and iv vanco.\nEndo: RISS.\nSocial: HCP called, updated by RN.\n\nPlan: Travel to OR for debridement & vac dsg change at 1600 per plastics. Wean neo gtt as . Pulm toilet. ROM as . Skin care.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273264, "text": "Nursing Progress Note:\nNeuro: Pt sedated and paralyzed via ativan, fentanyl, and cisat gtts. No spontaceous respirations or movements noted. + cough, - gag reflex. PERL 2mm sluggish. on max cisat. Team aware.\n\nCV: SR. HR 60's. BP 100/50's on vasopressin and low dose neo. Afebrile. Pulses dopplerable. Capi refill normal. Transfused 2u prbc's for hct 24.7. VAC dressing to sternum.\n\nResp: LCTA decreased at basses. Sats 97% on simv 14, 500, , 60% Minimal blood tinged secretions when ett suctioned.\n\nGI/GU: Abdomen soft, nondistended. NPO. Pedi tube clamped. Foley cath with good diurese from Lasix.\n\nEndoc: RISS\n\nID: Vanco, ampicillin, ceftriaxone, fluconazole\n\nPlan: To OR ~1600 for sternal debridement.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-06 00:00:00.000", "description": "Report", "row_id": 1273265, "text": "See and Carevue for detailed documentation\nNeuro: Remains on ativan, fentanyl, nimbex. No response/ change in VS with noxious stim. . PERL, sluggish. R eye hemorrhage.\n\nResp: Continues on vent. BS clear, diminished bliaterally in bases. Suction for white secretions.\n\nCV: BP stable on vasopressin, neo. In NSR 60. Afebrile. Hct stable s/p tx. Potassium repelted. Continues on albumin.\n\nSkin: Open chest with VAC dressing . See carevue for details re:incisions, exam.\n\nEndo: RSSI per protocol, none required.\n\nGI: NPO for OR.\n\nGU: Good urine output s/p early lasix dose.\n\nSocial: HCP by MD for OR.\n\nPlan: Continue cardiopulmonary monitoring. To OR tonight for debridement of chest. Wean neo of tolerated. Continue to assess for neuromuscular blockade. Replete lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-19 00:00:00.000", "description": "Report", "row_id": 1273322, "text": "Respiratory Care: Pt to IR for PICC line this afternoon. Remains on current vent settings, RR down to 10, for acidosis. No other changes this shift.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273323, "text": "7p-7a\nCorrection on neo 0.5mcg/kg/min at present time.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-25 00:00:00.000", "description": "Report", "row_id": 1273349, "text": "7A-7P\nNEURO: Alert. PERLLA. Tracking with eyes. Moving & LL extremities. Moving RUE, no movement to RLE. Follows commands. Nodding appropriatley. Tmax 99.3. Tramadol via feeding tube for pain with good effect. OOB to chair today with lift.\n\nCV: NSR no ectopy. SBP 100-110's. RUE ultrasound to evaluate swelling and discomfort. Compression sleeves for DVT prophylaxis. Palpable pulses bilat. JP bulb x3 S/S fluid.\n\nRESP: Remains orally intubated CPAP+PS 40-50%. 5PEEP 5-15PS. RR 20-30's. LS coarse diminished at bases. Suctioned for thick white/tan sputum. MDI per RT. When OOB to chair 02 sat 88-90%.\n\nGU/GI: Foley to gravity with adequate UO. IV Lasix started . ABD softly distended with +BS. PPI for GI prophylaxis. Tolerating nutren with beneprotein TF via peditube @ goal 40cc/hr. Max residual 10cc.\n\nID: Multiple IV Antibiotics. Vano level 11.4 dose given.\n\nENDO: FSBS coverage per RISS.\n\nPLAN: Monitor Resp Status. Pulmonary toliet. Assess/treat pain.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273350, "text": "Nursing Progress Note:\nNeuro: Opens eyes spontaneously. PERL 3mm brisk. Tracks. Follows commands by squeezing hands and moving toes. No movement to Rt leg. Weak cough. Gag reflex .\n\nREsp: Lungs coarse. Sats 100% on cpap 5/15/50% Suctioned for small amount of thick, yellow secretions. RR 20's\n\nCV: SR w/o ectopy. HR 80's. PICC . KVO. K repleted. Pulses palpable. Afebrile. Buttocks with redness noted.\n\nGI/GU: Abdomen soft, distended. BS present. BM x1. Nutren 2.0 w/ beneprotein at 40cc/hr. Foley cath. Good diurese with lasix.\n\nID: Vanco, ceftriaxone, ampicillin\n\nEndoc: RISS\n\nPlan: Wean PS. Continue antibiotics. Monitor and replete lytes. Pulmonary hygiene.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273351, "text": "RESP CARE: Pt continues on PSV 15/5 50%. Pt is tolerating well with no episodes of tachypnea overnight. LS: coarse and diminished bilaterally. Pt suctioned for moderate-large amounts of thick yellow secretions. Pt manually ventilated and suctioned for copious amounts of secretions due to occlusion of ETT. TX's given per . PLAN: wean PS as tolerated by patient.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273352, "text": "See and Carevue for detailed documentation\n\nNeuro: Alert, follows commands, nods yes/no. Became restless, tachypneic, diaphoretic OOB in chair. Calm with back to bed.\n\nResp: Continues on vent. PS 12, PEEP 5 50%. No further wean today. BS coarse, diminished in bases. Suctioed for moderate amounts thick yellow secretions.\n\nCV: NSR, no ectopy. BP stable. Afebrile. Strong peripheral pulses. JP with small-> moderate amount drainage. RUE skin abrasion with vaseline dressing. Other skin areas as noted. Continues on antibiotics.\n\nGI: Tolerating tube feeds. Small BM x2. Abd soft, distended.\n\nGU; Foley to gravity with good amounts urine s/p lasix.\n\nEndo: RSSI per protocol.\n\nPlan: Continue to monitor cardiopulmonary status. Wean vent as tolerated. Continue antibiotics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-26 00:00:00.000", "description": "Report", "row_id": 1273353, "text": "Resp Care\nPt remains intubated on PSV 12/5 50%. Pt suctioned for mod amt of thick tan sputum. Pt up in chair for part of the day. ETT repostioned and retaped. MDI's given. No current ABG results. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-17 00:00:00.000", "description": "Report", "row_id": 1273313, "text": "Respiratory Care\nBreath sounds mostly clear, left lung rhonchi, suctioned intermittently for small thick yellowish secretions, and moderate thick tan oral secretions, patient is on Amiodarone, Ativan, Fentanyl and Neosyneph,stayed mostly into sinus tachycardia, WBC 20.2 suggesting bacterial infection, hemoglobin 9.6 suggesting anemia. FiO2 decreased from 50% to 40%, Tidal Volume decreased from 500cc to 400cc to fight hyperventilation, ABGs at 1319 revealed a decrease in hyperventilation with hyperoxemia, patient will continue to receive mechanical ventilatory support and close monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273314, "text": "Nursing Progress Note:\nNeuro: Sedated on ativan and fentanyl gtts. Perl 3mm brisk. Opens eyes spontaneously but doesn't appear to track or focus. No spontaneous movements noted. No response to noxious stimuli. No gag noted. Coughs when suctioned.\n\nResp: LCTA decreased bases. Sats 98% on AC 14, 400, 40%, peep 5. Minimal secretions via ETT.\n\nCV: Converted to afib with HR 100-110. Pt converted to NSR on his own. Frequent PAC's. Pulses dopplerable. Anasarca. Afebrile. Received 1u rbc for hct 24.3. Repeat HCT 27. Pulses dopplerable. K repleted. Trauma and . JP X5 with minimal serosangunous drainage.\n\nGI/GU: Abdomen soft, distended. BS present. Nutren + beneprotein at 40cc/hr. No stool for shift. Foley cath. UO adequate. Diurese with Lasix.\n\nEndoc: RISS SC\n\nID: Vanco, ampicillin, ceftriaxone\n\nInteg: Abrasion to upper extremeties, moderate amount of serous drainage.\n\nPlan: RBC tag study to assess bleeding. Monitor rhythm and lytes. Pulmonary toilet. HCT Q6h. Continue current antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-18 00:00:00.000", "description": "Report", "row_id": 1273315, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a respiratory alkalemia with good oxygenation.\n\nRSBI = 150.2 on 0-PEEP and 0-PSV(Failed RSBI). SPO2 plummeted to 87% during measurement.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-02 00:00:00.000", "description": "Report", "row_id": 1273385, "text": "resp care\nfollowed for mdi's,airway management. tolerating 40% trach mask in no acute distress. sxning thick tan sputum. fair cough but not able to expectorate on own. pmv placed in conjunction with speech/swallow therapist. speech is audible , should be able to tolerate intervals of pmv with staff present.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273306, "text": "Code status reversed, Now a FULL CODE\n\nROS:\n\nNeuro: Sedated on ativan. Fentanyl gtt for pain mngt. Eyes open several times this shift, does not seem to focus or tract. PEARRLA.\n\nCV: RSR w/intermit Afib rate 80's -> 110. Neo titrated to keep MAP > 60. Peripheral pulses palpable. Has RIJ cath w/distal port transduce for CVP. Has left radial ABP. Sternal drsg w/ drng, mod amt, no ^ in amt from beginning of shift. Has 3 JPs w/large amt comming from JP #2. Amiodarone gtt on at 0.5 mg. SQ heparin and P boots for DVT prophylaxis.\n\nResp: Remains oraly intubated on vent. Lungs clear to coarse, sx small yellow via ETT. MDIs per RT. Right side of chest still firm and slightly swoolen (larger then left side). No change in swelling or firmness throughout shift. No resp distress note, = rise and fall of chest.\n\nGI: Abd swollen w/old ecchymosis. Active BS x's 4 quads of abd. Post pyloric pedi feeding tube via right nare w/TF at goal. Protonix for GI prophylaxis. Small mushy brown stool. Banana flakes TID. Peri anal area red, moisture barier cream applied. ? yeast\n\nGU: Foley patent clear yellow urine in QS.\n\nID: Remains on triple ABX coverage.\n\nEndo: insulin gtt titrated per FSG and CSRU protocol.\n\nLabs: Pending AM draw\n\nPlan: Pulmonary toileting. Mobilization. Obtain nystanin powder for bottom d/t ? yeast looking. Wean neo as VS alow. Monitor, tx, support, and comfort. Monitor JP drng amt. Monitor Hct. Tx, support, and comfort.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273307, "text": "Respiratory Care:\n Patient asynchronous with vent despite attempts to change mode. BS present bilat, suctioned for small amounts of thick yellow, receiving bronchodilators. Reccommend increase in sedation at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273308, "text": "Respiratory Care\nbreath sounds bilaterally diminished, suctioned for small, thick, pale yellow, treated with combivent inhaler, cardioverted at 0640 am, stayed mostly into A-fib, WBC 19.3 suggesting bacterial infection, hemoglobin, 6.8 suggesting anemia, often patient was asyncronic with ventilator, was mostly tachypneic, FiO2 dropped from 50% to 40%, will continue to be mechanically ventilated and closely monitored.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-16 00:00:00.000", "description": "Report", "row_id": 1273309, "text": "See and Carevue for detailed documnetation\n\nNeuro: Patient continues on ativan weaned 0.75->0.5. Fentanyl increased in am for cardioversion, weaned to 25mcg. Patient without command following. Opens eyes spontaneously, to verbal stim. PERL. Patient with chewing motions, +cough, no gag. Does not localize pain.\n\nResp: Continues on vent, tachypneic. Briefly decreased on settings. Patient with drop in BP, increased WOB. Suctioned for moderated amounts thin clear secretions.\n\nCV: In afib, HR 80-90. Increase in PVC, rec'd magnesium with improvment. Potassium and clacium repleted. Patient with neo requirement. Rec'd FFP x2 units. Repeat HCt 18. Rec;d 2units PRBC_> to OR for exploration. JP drainage 10-30ml per hour thru day. Dressing .\n\nEndo: Restart in insulin gtt per protocol.\n\nGI: Tolerated feeds thru day. NPO for OR. Loose watery BM x2\n\nGU: Foley to gravity with moderated amounts of urine.\n\nPlan: Continue cardiopulmonary monitoring. Continue to replece blood loss as needed. Continue sedation, plan for wena when stable. Repelte lytes as needed.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273324, "text": "7p-7a\nNeuro: Pt opens eyes, does not follow commands, does not RN in room, does not move any extremeties. Perrla. Morphine 2mg ivp given for pain shown by increase in BP.\n\nCV: HR 80-90s in and out of Afib. At present 80s SR no ectopy, lytes repleted prn. SBP labile, see carevue, on and off neo. At present time SBP 102, on 0.5mcg/kg/min. PICC to Right arm patent and . Left radial arm reddened. Dopplerable pedal pulses. Generalized anasarca. Bilat upper extremties oozy moderate amts of serous fluid. Sternal sutures cdi, covered w/ gauze and abd. binder to sternal area. Received 1 unit of PRBCs, no adverse reactions, repeat hct 28.\n\nResp: LS clear- coarse, diminished bases. Sats >98%. RR 25-35. Trial of CPAP RR increased to 40's. On CMV rate 10, FiO2 40% Peep 5, see carevue for abgs. Suctioned for small amts of thick yellow secretions via ett.\n\nGI/GU: Abd soft, round, hypoactive BS. TF residual at 0030 250cc, given back to pt, TF on hold, PA aware. Dophoff +placement. Foley adequate amts of clear yellow urine.\n\nSkin: Stg 2 2cm round to coccyx area, duoderm on and . See carevue for further details.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamcis. Monitor pulmonary status. Follow labs and treat as appropriate. Pain control. Monitor neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273325, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a respiratory alkalemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to the patient's elevated rr.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273326, "text": "Respiratory Care note.\nPt remains on settings as noted in careview. No secretions suctioned from tube. BS coarse bilaterally. No plans to extubate today. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-20 00:00:00.000", "description": "Report", "row_id": 1273327, "text": "NEURO: Spontaneously opens eyes, but does not track or follow commands, twitch noted on L hand otherwise no movement of any EXTs.\n\nRESP: Intubated with Sats 96%, LS clear to auscultation, Pt has strong cough and ETT suctioned for small, white, thick secretions\n\nCV: NSR with HRs in 80s, one episode of afib, given 2grams Magnesium Sulfate, back in sinus rhythm, keep MAP >60 and currently on 0.25mcg Neo, anasarca, pitting +3, upper EXTs has moderate drainage, pulses by Doppler\n\nGI/GU: TF stopped at 1600 for high residual >150mL, restarted at 1800 at goal 40mL/hr with TF residual at 120mL, bowel sounds hypoactive; Foley in place yellow,clear urine with good response to Lasix, K 4.0 repleted with 20mEq KCl IVPB\n\nENDO: Continues on SSRI\n\nWOUND: Duoderm changed for stage 2 ulcers, replaced bed with Kinair\n\nSOCIAL: No family call or visit today.\n\nPLAN: Monitor neuro, resp, hemodynamics, lytes, continue with ICU interventions\n" }, { "category": "Nursing/other", "chartdate": "2148-12-31 00:00:00.000", "description": "Report", "row_id": 1273376, "text": "R Pleural Chest Tube In\nNEURO: Alert, awake, follows command, Pt able to lift/hold L upper , moves on bed all other EXTs, PERRLA (3mm/brisk), Gag/Cough , Hoyered to chair/bed\n\nRESP: Trach collared with Sats >95% on 50%, plan to rest Pt on CPAP overnight, L pleural chest tube discontinued, R pleural pigtail drain inserted and drained about 1100 mL of serosanguinous fluid, lung sounds clear at apicals/coarse at bases, respirations reg/unlabored\n\nCV: NSR with occasional PACs, HRs in 80-90s, MAP >60, pedal pulses present.\n\nGI/GU: Abd soft, continues on TF at goal via Dobhoff, large/formed/ brown stool today; Foley yellow/clear urine at greater >70-80mL/hr\n\nENDO: Continues on SSRI\n\nID: Vanco level was 21.2, held Vanco.\n\nSOCIAL: No phone call/visit from visitors today\n\nPLAN: Continue to monitor resp/hemodynamics/neuro/urine output, ?discharge to rehab\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273377, "text": "neuro: pt alert overnight, follows commands, nods approp to questions. moves le's on bed, able to lift/hold both ue's. tramadol for nonverbal c/o pain w/good effect. +.\n\ncv: sr 80s, no ectopy. K repleted. bp stable 100s. palpable pulses. extrs w/d. compression sleeves on. hct stable, wbc 20.6, made aware. continues on ivab. afebrile.\n\nresp: ls clr, bases dim. o2sats >97% on cpap @ .50 fio2, vt 300s-500s. rr 20s-30s, briefly tachypneic, high 40s, sxn'd for sm thk bld tinged secretions, returned baseline within 2 minutes. rt pleural ct to lcs & rt jp to bulb sxn drained s/s this shift. trach care done.\n\ngi/gu: tf nutren w/beneprotein @ goal 40cc/hr. no resids; +bs. no bm. abd soft, nt, nd. adequate huo-clr yellow. bun 55, creatinine 1.6. NA 150, made aware.\n\nendo: bs monitored per ss protocol-required rssi coverage overnight.\n\nsocial: no phone calls from family/friends overnight.\n\nplan: continue monitoring cardioresp status; trach collar in AM, oob~>chair; ? d/c rt pleural tube. ? rehab screen.\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273378, "text": "ADDITIONAL NOTE:\n\nBLOOD, URINE & SPUTUM CULTURES SENT PER .\n" }, { "category": "Nursing/other", "chartdate": "2149-01-01 00:00:00.000", "description": "Report", "row_id": 1273379, "text": "Resp: pt on 50% t/c and placed back on vent psv 10/5/50% to rest noc. BS are coarse bilaterally. Suctioned for small to moderate amounts of tan/rusty secretions. Sample sent. No abg's this shift. Plan to continue with T/C trials this am.\n" }, { "category": "Nursing/other", "chartdate": "2148-11-25 00:00:00.000", "description": "Report", "row_id": 1273222, "text": "CSRU NPN\n\nS:\" SO WHAT DAY IS IT AGAIN?\"\n\nNEURO: A/O X2. NEEDS FREQ RE- ORIENTATION TO TIME. UNDERSTANDS HE IS IN THE HOSPITAL. YELLS OUT OCCASSIONALY FOR NO APPARENT REASON. STATES HE IS LONELY AND JUST WANTS SOMEONE IN THE ROOM. HE FOLLOWS SIMPLE COMMNADS. CAN LIFT AND HOLD UPPER . MOVES LOWERS ON BED. MUCH MORE QUIET AS EVE PROGESSED, LESS CONFUSED. ABG'S WNL\n\nCV: GIVEN LASIX AND LOPRESSOR AS ORDERED ,BUT IN STAGGERED DOSES. HR PRIOR TO LOPRESSOR 100 NSR W PAC'S OCCASSIONAL. SBP 110-120. GIVEN LASIX AS ORDERED 1 HR AFTER LOPRESSOR. HAD 400CC OUT. BP SLOWLY DRIFTING DOWNWARD AFTER LASIX GIVEN, SBP 85-90. NEO TITRATED TO 0.8 MCG/KG/MIN. SPOKE WITH DR AND UPDATED ON PT. LOPRESSOR AND LASIX NOW ON HOLD. REMAINS ON AMIO 0.5MG/MIN HR STABLE 70-80. ORDER GIVEN TO BOLUS PT W 500CC NS WHICH WAS COMPLETED. SLOW RISE IN SBP WITH FLUID AND ^ NEO.\n\nRESP: HAS NON PRODUCTIVE CONGESTED COUGH. PT NEEDS AGGRESSIVE PULM TOILETING. NASOTRACH SUCTIONED FOR THICK YELLOW SECRETIONS. BS COURSE AND DIMINISHED BILAT. FREQ CPT AND C/DB CURRENTLY ON 50% FT AND 4L NP. ABG'S WNL. NEBS Q6/HR. SATS 96-98%. RR BECOMES TACHYPNIC W ACTIVITY. RR-28-30 , BACK TO 20'S W REST.\n\nGI: POOR APPETITE FOR SOLIDS. TAKES MEDS W LIQ AND WELL. ABD SOFT NON TENDER. NO STOOL .\n\nGU: FOLEY DRAINING CL YELLOW LOS + 12600CC.\n\nSKIN: + BILAT EDEMA TO BILAT LEGS AND SCROTUM. R HAND EDEMATOUS AND BILAT UPPER ON PILLOWS. HAS SEVERAL BLISTERED AREAS ON LOWER CHEST ? D/T TAPE. STERNAL AND MEDIST. DSG CHG PER FLOW.\n\nID: AFEBRILE CON'T ON VANCO AND LEVO. + PNA\n\nLABS: PER FLOW. LYTES REPLETED X2. BS WNL.\n\nA/P: CON'T AGGRESSIVE PULM PLAN. HOLD LOPRESSOR AND LASIX TO BE D/CD BY TEAM. NEED ORDER. WEAN NEO IF BY PT. CON'T PER NSG JUDGEMENT\n" }, { "category": "ECG", "chartdate": "2148-12-04 00:00:00.000", "description": "Report", "row_id": 201914, "text": " be sinus bradycardia with left atrial abnormality but consider also ectopic\natrial rhythm\nLow QRS voltage\nProlonged Q-Tc interval\nClinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2148-11-20 00:00:00.000", "description": "Report", "row_id": 201915, "text": "Sinus tachycardia - Regular supraventricular rhythm\nPossible old inferior infarct\nGeneralized low QRS voltages\nSince previous tracing, decreased voltages present\n\n" }, { "category": "ECG", "chartdate": "2148-11-18 00:00:00.000", "description": "Report", "row_id": 201916, "text": "Sinus rhythm\nShort PR interval\nLeftward axis\nSince previous tracing, QRS changes in lead V2-V3 - ? lead placement\n\n" }, { "category": "Radiology", "chartdate": "2148-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932152, "text": " 7:43 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o collection vs tamponade\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n r/o collection vs tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for collection versus tamponade.\n\n COMPARISON: Comparison is made to study performed two hours earlier.\n\n PORTABLE CHEST: Again seen is endotracheal tube, Swan-Ganz catheter, median\n sternotomy wires, surgical clips overlying the midline, nasogastric tube,\n left-sided chest tube, and mediastinal drain. Cardiac silhouette appears\n larger compared to previous study. There has also been interval widening of\n the already widened mediastinum. No new focal consolidations are seen within\n the lungs.\n\n IMPRESSION: Interval increase in size of cardiac silhouette and widening of\n the mediastinum. While this may be partially due to patient's reverse\n Trendelenburg positioning, cardiac tamponade and mediastinal hematoma cannot\n be excluded. This was discussed with Dr. immediately following\n completion of the study, who reported clinical concern for tamponade and that\n patient would be returning to the OR.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932173, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion, tubesplacement,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n effusion, tubesplacement,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post mitral valve repair. Evaluate effusion, tube\n placement.\n\n Bedside AP chest radiograph dated compared to AP chest\n radiograph dated . In the interval, there has been interval\n decrease in the widening of the mediastinum. Patient has had a resternotomy.\n There are low lung volumes. There are bilateral pleural\n effusions and bibasilar consolidations, representing atelectasis and/or\n infiltrate. There is pulmonary vascular congestion. ET tube, Swan- Ganz\n catheter, mediastinal tubes, are in the standard positions. Nasogastric tube\n courses below the diaphragm, and is out of view.\n\n IMPRESSION: Pulmonary vascular congestion, bilateral pleural effusions,\n consistent with fluid overload/CHF. Interval decrease in the\n mediastinal widening\n\n\n\n\n\n\n\n\n\n\n\n\n\n .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932562, "text": " 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n eval for effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 11:46 A.M.\n\n HISTORY: Status post CABG and central line change with shortness of breath.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Per technologist report, the patient would not hold still for the\n radiograph. There is marked suboptimal evaluation as the entire lateral\n aspect of the right hemithorax is excluded. The patient is markedly rotated.\n This is a marginal diagnostic examination.\n\n There is opacity of the mid and lower left hemithorax as previously noted,\n which is likely due to multiple factors such as atelectasis and pleural\n effusion. A concomitant pneumonia cannot be excluded. Pulmonary vascular\n clarity is indistinct, although this may be in part an element of motion.\n Failure cannot be excluded.\n\n IMPRESSION: Nearly non-diagnostic radiograph secondary to patient compliance.\n Consider repeat study once the patient is appropriately sedated or can comply\n with technologist instructions.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932509, "text": " 2:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change\n\n REASON FOR THIS EXAMINATION:\n R/O infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 15:23 HOURS.\n\n HISTORY: Status post CABG and central line change.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are markedly diminished with resultant bronchovascular\n crowding. A right internal jugular approach central line remains stable in\n course and position. The mediastinum is widened, likely in part due to\n technique. The cardiac silhouette size is difficult to establish, but is\n grossly stable. There is poor opacification of the retrocardiac left lower\n lobe, possibly due to collapse. There are bilateral pleural effusions.\n Median sternotomy wires remain linearly alignment.\n\n IMPRESSION: Markedly diminished lung volumes. There is left lower lobe\n collapse with bilateral small pleural effusions. An element of superimposed\n mild edema cannot be entirely excluded given limitation as above.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 932419, "text": " 5:23 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check rt ij placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change\n REASON FOR THIS EXAMINATION:\n check rt ij placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 71-year-old man status post coronary artery bypass graft surgery\n and recent change to central venous catheter.\n\n CHEST, SUPINE PORTABLE VIEW: Comparison is made to an earlier radiograph of\n the same day. The patient is status post recent sternotomy with overlying\n staples and sternal wires in the midline. The cardiac and mediastinal\n contours are unchanged. The tip of a new right internal central jugular\n venous catheter terminates in the distal superior vena cava. There is\n persistent left lower lobe opacity, which may represent atelectasis. . There\n is also a left-sided pleural effusion, but no evidence of pneumothorax on this\n supine view.\n\n IMPRESSION: Tip of a new central venous catheter in superior vena cava.\n Otherwise, no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932137, "text": " 5:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, tamponade, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post mitral valve replacement.\n\n COMPARISON: .\n\n PORTABLE CHEST: Endotracheal tube seen with tip approximately 1 cm above the\n carina, pointing towards the right main stem bronchus. Right-sided Swan-Ganz\n catheter seen with tip overlying the proximal main pulmonary artery.\n Nasogastric tube is seen with tip overlying the stomach. Left-sided chest\n tube seen with tip overlying the left lower lung. Mediastinal drains seen\n with tip overlying the mid chest. Median sternotomy wires and surgical\n staples seen overlying the midline.\n\n Mediastinum appears widened, possibly representing post-surgical changes\n although this appearance is concerning for mediastinal hematoma. Cardiac\n silhouette appears enlarged. There is large left lower lobe opacity\n consistent with atelectasis, effusion, or consolidation. Patchy air space\n opacity seen in the right lung, likely representing mild pulmonary edema.\n\n IMPRESSION: Postoperative changes. Endotracheal tube with tip pointing\n towards the right main stem bronchus. Widened mediastinum possibly\n representing postoperative changes versus mediastinal hematoma. New left\n basilar opacification. Findings discussed with , PA, at 6:15\n p.m., .\n\n" }, { "category": "Radiology", "chartdate": "2148-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932642, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 A.M., \n\n HISTORY: Status post CABG and central line change, now short of breath.\n\n IMPRESSION: AP chest compared to :\n\n Left lower lobe is still collapsed accompanied by small-to-moderate pleural\n effusion. Small right pleural effusion stable. Postoperative widening of the\n cardiomediastinal silhouette is less pronounced suggesting remission and\n volume overload. Upper lungs clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 931816, "text": " 7:22 PM\n CHEST (PA & LAT) Clip # \n Reason: preop MVR\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with endocarditis\n REASON FOR THIS EXAMINATION:\n preop MVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with endocarditis.\n\n PA AND LATERAL CHEST RADIOGRAPH: The study is somewhat limited in this\n patient with cannot lift arm due to pain. The comparison was made with the\n prior study dated . Cardiac and mediastinal contours are\n unchanged compared to the prior study, and again note is made of tortuous and\n calcified thoracic aorta. Previously noted CHF is not seen on the present\n study. Again note is made of bibasilar atelectasis with bilateral pleural\n effusion, persistent since prior study, slightly decreased. There is no\n evidence of pneumothorax.\n\n IMPRESSION: Decreased bilateral pleural effusion with bibasilar atelectasis.\n No evidence of CHF. Tortuous aorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-26 00:00:00.000", "description": "PICC W/O PORT", "row_id": 932841, "text": " 11:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc, pt s/p MVR(endocarditis).Picc for antibx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n please place picc, pt s/p MVR(endocarditis).Picc for antibx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post mitral valve repair requiring IV\n access for antibiotics.\n\n RADIOLOGISTS: Doctors and . Dr. , the attending\n radiologist was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The patient was brought to the Radiology Suite and placed\n supine on the angiography table. Following a preprocedure timeout including\n the patient's name, and two patient identifiers, the left arm was sterilely\n prepped and draped. As no suitable veins were visible, ultrasound was used to\n identify the left brachial vein, which was patent and compressible.\n Approximately 3 cc of 1% lidocaine were administered for local anesthesia.\n Using ultrasound guidance, a 21 gauge needle was used to access the left\n brachial vein. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 inch guidewire was inserted\n through the needle and into the vein. Then the needle was exchanged for a 4\n French micropuncture sheath. The guidewire was advanced into the SVC and based\n on the markings on the wire, a PICC line was trimmed to a length of 42 cm. The\n PICC was then advanced over the wire and into the SVC under fluoroscopic\n guidance. The wire and peel-away sheath were removed. The catheter was\n flushed, capped and heplocked. Finally, the catheter was StatLocked into place\n and a sterile transparent dressing was applied. A final fluoroscopic image\n was taken demonstrating the tip of the PICC in the distal SVC.\n\n IMPRESSION: Successful placement of a 5 French double lumen 42 cm PICC by way\n of the left brachial vein with the tip in the distal SVC. The line is ready\n for use.\n\n\n\n\n\n\n\n\n\n (Over)\n\n 11:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc, pt s/p MVR(endocarditis).Picc for antibx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932795, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and central line change , now w/ SOB, poor ABG\n\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, now with shortness of breath.\n\n Bedside AP chest radiograph dated compared to AP portable\n chest radiograph dated .\n\n Since previous study, there has been no significant change in the radiographic\n appearance of the chest. There is persistent left lower lobe collapse, small\n right pleural effusion, moderate left pleural effusion. There is no\n pneumothorax. Right IJ terminates at the expected location of mid SVC. There\n is a stable enlargement of cardiomediastinal silhouette since most recent\n surgery.\n\n IMPRESSION: Persistent left lower lobe collapse, small right pleural\n effusion, moderate left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932379, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG and chest tube removal.\n\n AP view of the chest dated is compared to the prior from yesterday.\n The patient has been extubated and the Swan-Ganz catheter has been removed as\n well as the nasogastric tube. The right internal jugular sheath terminates in\n the proximal SVC. Median sternotomy clips and wires are in stable position.\n The aorta is tortuous. There is mild cardiomegaly. There is opacity at the\n left lung base which probably represents atelectasis and moderate left pleural\n effusion. There is a small right pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Status post CABG with left lung base atelectasis and effusion.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932959, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for sternal dehisence, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, now w/ sternal click\n REASON FOR THIS EXAMINATION:\n eval for sternal dehisence, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG with sternal click.\n\n Portable AP chest dated is compared to the prior from the yesterday.\n This film is poor quality secondary to patient positioning and patient large\n body habitus. The patient is semierect. The right internal jugular line\n terminates in mid SVC. Left subclavian central venous catheter terminates at\n the cavoatrial junction. The cardiac silhouette appears enlarged. There are\n large bilateral pleural effusions with bibasilar opacities, probably\n representing compressive atelectasis, however, consolidation within the left\n lower lobe cannot be excluded. There is no pulmonary vascular congestion or\n pneumothorax. The patient is status post median sternotomy and CABG, and\n mediastinal wires and clips are in stable position.\n\n IMPRESSION: Allowing for technical differences in the films, no significant\n short interval change. Large bilateral pleural effusions. No radiographic\n evidence of sternal dehiscence.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937565, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for tube position, other pathology\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n Assess for tube position, other pathology\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 10:24 A.M.\n\n HISTORY: Post-tracheostomy.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: There is moderate-to-severe pulmonary edema. Bilateral layering\n pleural effusions are evident and may have slightly increased in size since\n the prior examination. The patient has undergone tracheostomy, consistent\n with given history. The tube is in standard position. An enteric feeding\n tube is noted. The distal tip is seen but cannot be adequately assessed with\n the given radiograph. The previously noted drains remain stable in position.\n Likewise, a right upper extremity PICC line has not changed.\n\n IMPRESSION: Moderate-to-severe bilateral pulmonary edema with bilateral,\n possibly enlarging, pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 936295, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:14 A.M. \n\n HISTORY: Status post CABG. Sternal wound closed.\n\n IMPRESSION: AP chest compared to through 14:\n\n Large bilateral pleural effusion, increased mildly on the right and\n substantially on the left. Heart size normal. Mediastinal vascular\n engorgement noted. Lungs are obscured by large pleural effusions, but\n generally clear. ET tube, nasogastric feeding tube, right PIC or central\n venous line, and midline drains are in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 938097, "text": " 9:06 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: SP VALVE REPLACEMENT ,NOW RISING WBC ,EVAL FOR CHOLECYSTITIS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with valve replacement, now rising wbc\n REASON FOR THIS EXAMINATION:\n assess for cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man with aortic valve replacement now with rising white\n blood cell count. Evaluate for cholecystitis.\n\n PORTABLE RIGHT UPPER QUADRANT ULTRASOUND STUDY: The liver is of normal\n echogenicity. There are no focal or textural abnormalities. No liver masses\n are present. The main portal vein is patent and its flow is hepatopetal.\n There is no ascites. No intrahepatic or extrahepatic biliary ductal\n dilatation, and the common bile duct measures 4 mm in diameter. Images of the\n gallbladder demonstrates tumefactive sludge present. However, there is no\n gallbladder wall thickening, gallbladder wall edema, or pericholecystic fluid\n present.\n\n IMPRESSION: Sludge in the gallbladder without son signs of acute\n cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934933, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 8:52 A.M. :\n\n INDICATION: Status post CABG. Postop sternal revision. Evaluate for\n pneumonia.\n\n FINDINGS: Compared with , allowing for differences in technique and\n patient positioning, no obvious significant interval changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933919, "text": " 6:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man status post CABG, postop sternal revision and open\n chest.\n\n COMPARISON: at 10:47 a.m.\n\n SUPINE CHEST: Compared to the exam of eight hours earlier, there has been\n interval worsening and consolidation of both lungs, more prominent on the\n left. The large left pleural effusion has increased in size. The large right\n effusion appears relatively stable. The Swan-Ganz catheter has been removed.\n The appearance of the chest is otherwise stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933207, "text": " 3:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval sternal revision \n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval sternal revision \n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post bypass surgery performed to date. Sternal revision\n of open chest. Evaluate chest after sternal revision.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position. Comparison is made with a previous portable chest\n examination with patient in semi-erect position obtained eight hours earlier\n and apparently prior to the latest operation. During the interval, the\n patient has been again intubated. The ETT terminate in the trachea some 2 cm\n above the level of the carina. A left jugular vein approach central venous\n line is present carrying a Swan-Ganz catheter seen to terminate in the\n proximal PA. A new drainage tube from below enters the mediastinum. The\n previous multiple sternal wires have been removed and apparently the sternum\n has been divided with two longitudinally directed retainers indicating wound\n edges. There is no gross interval change in the mediastinal contours\n indicating significant cardiac enlargement. Related to the now supine\n position, the pleural effusions have layered more posteriorly resulting in a\n diffuse increased density bilaterally. No striking large new pulmonary\n infiltrates can be identified nor is there any conclusive evidence of\n significant pulmonary congestion. Also evaluation of the pulmonary\n vasculature is somewhat limited. The widening of the superior mediastinum is\n compatible with the patient's supine position.\n\n Further followup is recommended considering the presence of apparent size of\n the bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935082, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest,\n s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after sternum revision.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip, the feeding tube, the right internal jugular line is in\n unchanged standard positions. The two mediastinal drains has been inserted.\n The pulmonary edema _____ and bilateral large pleural effusions are grossly\n unchanged. The left lower lobe atelectasis is stable.\n\n IMPRESSION: Two new postsurgical drains inserted. Otherwise, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933122, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, now w/ sternal click, poor pulmonary toilet\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM \n\n HISTORY: Coronary artery disease status post CABG, now with sternal click and\n poor pulmonary toilet, rule out pneumonia.\n\n FINDINGS: An AP semi-upright portable chest radiograph shows bilateral\n pleural effusions with that on the right probably increased over the past\n several days. The patient's right internal jugular central venous catheter\n has been removed. PICC line tubing extending from the left ends at the level\n of distal SVC. Degree of cardiomegaly appears unchanged. The eight sternal\n wires and midline skin clips are intact. The lateral and inferiormost portion\n of the left chest is not included in the view of the film.\n\n CONCLUSION: Increase in right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2148-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933482, "text": " 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swann placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval swann placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Status post CABG with sternal revision.\n\n One portable view at 14:49. Comparison with . Bilateral pleural\n effusions persist. These partially obscure the inferior portions of both\n lungs. Post surgical changes again noted in the mediastinum. An endotracheal\n tube remains in place. A Swan-Ganz catheter has been replaced. The current\n Swan-Ganz catheter ends in the region of the pulmonary outflow tract. A left\n PICC line remains in place. Left internal jugular sheath is present as\n before. A nasogastric tube remains in place.\n\n IMPRESSION: Replacement of Swan-Ganz catheter. There is no other significant\n change. Bilateral pleural effusions persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 933877, "text": " 12:50 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infectious source\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with rising WBC, sepsis\n REASON FOR THIS EXAMINATION:\n r/o infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated white blood cell count, sepsis.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast axial images through the chest, abdomen and pelvis as\n requested by the referring service. Multiplanar reformats were performed.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The patient has a surgically open\n anterior chest wall. Air extends to the soft tissue around the clavicles.\n There is no pneumothorax. There are large bilateral pleural effusions as well\n as atelectasis of much of both lungs. There is a small amount of aerated left\n upper and right upper lobes. There are coronary artery calcifications as well\n as aortic calcifications. The endotracheal tube extends to the carina\n possibly entering the right main stem bronchus. No definite lymphadenopathy\n within the axilla, hila, or mediastinum. There is a small pericardial\n effusion.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is beam hardening artifact\n limiting evaluation. The liver, spleen, adrenal glands, pancreas appear\n unremarkable. The gallbladder is unremarkable, without visualization of the\n known stones. There are low attenuations within both kidneys, in the region\n of the prior described cyst. There is atherosclerotic calcification of the\n descending aorta. Large and small bowel are not dilated. There is no\n lymphadenopathy or free air. There is a small amount of free fluid in the\n lower abdomen in the pericolic gutters. Focal fluid collections. There is\n diffuse anasarca.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is no free fluid or\n lymphadenopathy. The bladder, sigmoid colon, and rectum are normal.\n\n BONE WINDOWS: No destructive lesions to indicate osteomyelitis.\n\n REFORMATTED IMAGES: Severe degenerative change within the spine, which is\n stable. Scoliosis.\n\n IMPRESSION:\n\n 1. Scan limited by severe beam-hardening artefact. No definite intrathoracic\n or intra-abdominal mabscess. Large bilateral pleural effusions, small\n (Over)\n\n 12:50 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infectious source\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pericardial effusion, and anasarca.\n\n 2. Small amount of ascites.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934445, "text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON .\n\n HISTORY: Postop sternal revision, open chest, question pneumonia.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube continues to be low, less than 2 cm above the\n carina. The right IJ catheter tip is at the junction of the internal jugular\n vein with subclavian vein. The oral tube is coiled in the stomach, pointed\n upwards. Again seen are bilateral pleural effusions, layering posteriorly.\n There is dense opacification of the right chest and left lower lobe, which may\n be due to effusion/infiltrate/volume loss. Compared to the prior film, there\n has been slight increase in the opacity in the right upper lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934008, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch, eval pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n s/p bronch, eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG, sternal revision.\n\n CHEST\n\n The tip of the endotracheal tube remains too low as on the prior chest x-ray\n and should be withdrawn to a better position. Bilateral pleural effusions are\n again noted. Consolidation and collapse in the left lower lobe is probably\n present.\n\n Since the prior chest x-ray, the Swan-Ganz catheter has been removed. The\n sheath remains. The position of the nasogastric tube is unchanged.\n\n IMPRESSION: Bilateral effusions, probable collapse, consolidation left lower\n lobe. Endotracheal tube too low. Dr. informed.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935242, "text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, sternal revision.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP SUPINE: The supine nature of the film causes the\n bilateral pleural effusions to layer posteriorly. This obscures the lung\n fields and evaluation for pulmonary edema is limited, although a component is\n likely present. Lines and tubes are in unchanged position. Surgical staples\n are seen over the mediastinum.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937704, "text": " 12:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx/assess effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n r/o ptx/assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG and sternal revision, tracheostomy.\n\n The left costophrenic region is not included on the film. Tracheostomy tube\n is 6 cm above carina. Right PICC line is in mid SVC. Feeding tube extends\n into duodenum but distal end is not included on this film. Bilateral chest\n wall drains. No pneumothorax. There is a right pleural effusion with\n associated atelectasis. There is atelectasis at the left base and probably a\n small left pleural effusion difficult to evaluate for reasons described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937299, "text": " 9:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the Dobbhoff tube.\n\n The Dobbhoff tube is coiled within the oropharynx and proximal esophagus with\n its tip still being in the distal portion of the esophagus. The right PICC\n line tip is in the mid SVC. The ET tube is partially obscured by the _____,\n but its tip terminates 3.2 cm above the carina. The mediastinal drains are\n again present. The bibasilar atelectasis and large bilateral pleural\n effusions are again noted with _____ improvement comparing to the previous\n chest radiograph. No evidence of congestive heart failure is present. These\n findings were communicated to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935409, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia/effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n eval for pneumonia/effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 71-year-old man status post CABG, sternal revision.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The tip of the endotracheal tube is more proximal since the previous study and\n is 3.3 cm from the carina. There is a Dobbhoff tube which is pointing\n cephalad near the gastroesophageal junction. There is a right IJ central\n venous line with a distal lead tip in the upper SVC. Bilateral drains are\n identified. There are bilateral pleural effusions, right greater than left.\n Only a small amount of aerated lung seen in the upper lung fields bilaterally.\n The cardiac silhouette is prominent. Overall, these findings remain stable.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938280, "text": " 12:55 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Assess for feeding tube placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Dobhoff placement\n REASON FOR THIS EXAMINATION:\n Assess for feeding tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n DOBBHOFF TUBE PLACEMENT\n\n A single AP view of the chest is obtained at approximately 13:05\n hours. The Dobbhoff tube has its tip remaining in the gastric fundus. There\n is more of the catheter within the stomach but it remains coiled. The\n remainder of the study is essentially unchanged since the prior examination\n with increased density in the left base consistent with atelectasis/airspaces\n disease. Right-sided PICC line and tracheostomy tube are unchanged. Patchy\n bibasilar atelectasis persists.\n\n IMPRESSION:\n\n No significant adverse interval change. Dobbhoff tube has more of the\n catheter within the stomach; however, the tip of the tube remains in the\n gastric fundus.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935808, "text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n check dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check Dobbhoff tube placement.\n\n COMPARISON: .\n\n TECHNIQUE AND FINDINGS: AP radiograph of the chest. Tip of the endotracheal\n tube is approximately 3.1 cm from the carina. The Dobhoff tube is again\n identified with the tip within the stomach and pointing cephalad to the left.\n Right internal jugular central venous is unchanged in position. Bilateral\n drains are again seen and unchanged. Decrease in pleural effusions is noted\n bilaterally. No pneumothorax is identified.\n\n IMPRESSION: Dobbhoff tube with tip within the stomach and pointing cephalad.\n Decreased pleural effusions bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-04 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 934018, "text": " 2:28 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o mycotic aneurysm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n r/o mycotic aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with sepsis, assess for mycotic aneurysm.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain without IV\n contrast including FLAIR, gradient-echo, and diffusion-weighted images. MR\n angiogram of the brain with 3D time-of-flight imaging and reformatted images.\n\n No prior studies for comparison.\n\n FINDINGS: There is moderate-to-severe generalized brain atrophy, with\n extensive increased signal in the white matter of both cerebral hemispheres\n and around both lateral ventricles, consistent with small vessel ischemic\n changes. Several small focal areas of susceptibility artifact are seen in\n both cerebral hemispheres, and the cerebellum. In the right occipital lobe,\n there is a 7-mm rounded lesion, which has increased signal on T2 and FLAIR\n sequences, restricted diffusion, and has a ring of decreased\n signal on gradient-echo and T2-weighted images. No other areas of abnormal\n restricted diffusion are identified. There is mild bilateral maxillary,\n sphenoid, and ethmoid sinus mucosal thickening. Mild opacification is also\n seen in both mastoid air cells, with a fluid level in the right mastoid\n sinus. A subgaleal soft tissue fluid collection is seen overlying the left\n temporal bone, measuring at least 3.8 x 0.7 cm in axial dimension.\n\n MR normal signal intensity in both vertebral, the\n basilar, both internal carotid, anterior, middle, and posterior cerebral\n arteries. There is very limited depiction of the distal vascular distribution\n of the middle cerebral arteries. No overt aneurysm or stenosis is identified.\n However, evaluation for mycotic aneurysm is not achieved, given the lack of\n visualization of the peripheral vasculature.\n\n IMPRESSION:\n\n 1. Right occipital lobe lesion as described above, of uncertain etiology. The\n intense restricted diffusion may suggest a small involving infarction with\n surrounding hemorrhage. Given the patient's history of sepsis, an abscess is\n also possible.\n\n 2. Areas of susceptibility artifact seen scattered throughout both cerebral\n hemispheres suggestive of amyloid angiopathy. Multiple cavernomoas is an\n alternative diagnosis.\n\n 3. Subgaleal fluid collection over the left temporal bone- etiology\n uncertain.\n (Over)\n\n 2:28 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o mycotic aneurysm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. MR no stenosis or aneurysm centrally. Evaluation\n for a mycotic aneurysm is unsatisfactory, as there is no clear visualization\n of the distal intracranial arterial vasculature, which is the usual locale for\n mycotic aneurysms.\n\n Findings were discussed with at approximately 5:20pm on .\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933852, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH FROM .\n\n HISTORY: Coronary artery disease status post CABG postop day 1. Sternal\n revision. Assess Dobbhoff feeding tube placement.\n\n FINDINGS: An AP portable supine chest radiograph shows Dobbhoff feeding tube\n coiled back upon itself in the stomach with the metallic tip directed upwards\n towards the GE junction. Swan-Ganz catheter placed via right IJ Cordis is in\n place with the tip at the level of the main pulmonary outflow tract directed\n towards the right main pulmonary artery. Endotracheal tube tip remains low,\n projected 2.5 cm above the carina. Penrose drains and sternal skin clips seen\n on yesterday's study are no longer present. Hazy obscuration of both\n hemidiaphragms with posteriorly layering pleural effusions are again noted\n though these appear slightly smaller, especially on the right.\n\n CONCLUSION: Dobbhoff feeding tube coiled back upon itself in the stomach.\n Unchanged but slightly low location of endotracheal tube tip.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 933774, "text": " 7:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: dobhoff position\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sepsis, s/p AVR, open chest\n REASON FOR THIS EXAMINATION:\n dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, status post Dobhoff tube placement.\n\n COMPARISON: None.\n\n FINDINGS: Supine portable abdominal radiograph reviewed. Tip of a Dobhoff\n nasogastric tube projects over the stomach cardia traversing the GE junction.\n Advancement is recommended for more optimal placement. Abdominal radiograph\n demonstrates a dense left lower lobe retrocardiac consolidation, and bilateral\n pleural effusions. No dilated bowel loops are identified. Significant\n degenerative changes in the lumbar spine including dextroscoliosis is noted.\n\n IMPRESSION: A Dobhoff tube at GE junction. Advancement for more optimum\n placement is recommended. Dr. and I discussed these findings.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937429, "text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check NG tube placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n Check NG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post sternal revision _____ NG tube placed.\n\n CHEST:\n\n The tip of the nasogastric tube lies within the region of the pylorus. No\n other changes are seen since the prior chest x-ray of , bilateral\n effusions, cardiomegaly and evidence of failure persist.\n\n IMPRESSION: Nasogastric tube in pyloric region.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937875, "text": " 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for fluid collections, pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n Assess for fluid collections, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post CABG with sternal revision, status\n post closure and right-sided thoracentesis.\n\n COMPARISON: .\n\n SEMI-UPRIGHT FRONTAL CHEST: Tracheostomy tube is 6.3 cm above the carina.\n The feeding tube tip is not visualized but is below the diaphragm. A right-\n sided PICC tip overlies the central superior vena cava. There is a new right-\n sided pleural catheter with its tip overlying the lung base. There has been\n near total resolution of the right pleural effusion. The cardiac and\n mediastinal contours are stable. There is continued opacification of the\n retrocardiac left lower lobe. Pulmonary vascularity appears within normal\n limits. No pneumothorax is seen. Vertically oriented midline skin staples\n are again identified.\n\n IMPRESSION:\n 1. Near total resolution of the right pleural effusion after pleural catheter\n placement. No pneumothorax.\n 2. Persistent left lower lobe retrocardiac opacity could be atelectasis or\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934779, "text": " 7:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:39 A.M., .\n\n HISTORY: Status post CABG and sternal revision.\n\n IMPRESSION: AP chest compared to through :\n\n Moderate left pleural effusion has decreased since . Severe left\n lower lobe atelectasis persists. Moderate enlargement of the cardiac\n silhouette is longstanding. Large right pleural effusion unchanged. ET tube,\n right jugular line, and a nasogastric feeding tube are in standard placements.\n Apparent widening of the superior mediastinum contiguous with adjacent pleural\n abnormality is due in part to vascular engorgement.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937946, "text": " 9:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 10:30 a.m., \n\n INDICATION: Multiple recent surgeries as above. Now status post right\n thoracentesis with catheter placement. Evaluate for pneumothorax.\n\n FINDINGS: Compared with 11/28, the right pleural catheter is no longer\n identified. No pneumothorax seen.\n\n No other dramatic interval changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937368, "text": " 4:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess dophoff placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open\n chest, s/p closure of open chest\n REASON FOR THIS EXAMINATION:\n assess dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sternal revision reopened status post closure of open chest.\n\n PORTABLE AP CHEST.\n\n Comparison done to the prior film done today at 9:53 a.m. In the interval,\n the Dobbhoff tube has been repositioned and now is seen beyond the projection\n of the film and probably beyond the stomach. The right-sided central venous\n catheter tip overlies the mid SVC. There is moderate cardiomegaly. Bilateral\n layering pleural effusions are again noted. Left retrocardiac atelectasis\n persists. Note that the left lateral chest wall is not included in the film.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "P SINUSES, COMPLETE MIN 3 VIEWS PORT", "row_id": 938111, "text": " 10:28 AM\n SINUSES, COMPLETE MIN 3 VIEWS PORT Clip # \n Reason: r/o sinusitis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n r/o sinusitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sinusitis.\n\n Two radiographs of the skull partially demonstrate the presence of a VP shunt.\n The visualized catheter tubing demonstrates no kinking or discontinuity. No\n previous radiographs are available for comparison. The paranasal sinuses are\n pneumatized and aerated. The mucosal thickening and mastoid air cell\n opacification seen on the MR examination of are not evident on\n today's radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-13 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 935282, "text": " 9:41 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for hematoma\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p AVR w/ sepsis, sternal dehisence s/p closure, with droping\n HCT\n REASON FOR THIS EXAMINATION:\n eval for hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post AVR and sepsis. The postoperative\n course was complicated by a mediastinitis and sternal dehiscence. The patient\n is status post omental flap.\n\n The patient presents with dropping hematocrit. Rule out hematoma.\n\n TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. 130 ml of\n nonionic contrast were administered. Nonionic IV contrast was used due to\n rapid bolus necessary for this study.\n\n CT CHEST: The patient is status post median sternotomy and near complete\n removal of the sternum. There is interval placement of an omental flap and\n closure of the skin. No evidence of new hematoma. A small fluid collection\n near the left cardiophrenic angle measuring 45 x 22 mm (2:38) appears to be\n slightly smaller than the previous study from , and also more\n hypodense. The findings are consistent with a resolving hematoma.\n\n The vessels supplying the flap are patent. Tiny pericardial effusion\n unchanged. Severe coronary artery calcifications and stents in the coronary\n arteries. Calcifications of the aorta. Large bilateral pleural effusions\n with associated atelectasis, similar to . ET tube is located\n 1-1.5 cm from the carina and could be withdrawn approximately 1 cm. A feeding\n tube with the tip in the stomach. Right IJ Cordis catheter within the upper\n right brachiocephalic vein.\n\n CT ABDOMEN: Small amount of free fluid in the abdomen with simple\n characteristics. No evidence of hematoma within the abdomen. The liver,\n spleen, and adrenal glands are within normal limits. The proximal portion of\n the pancreatic duct is slightly dilated measuring 8 mm, but the distal\n pancreatic duct is unremarkable. This is of unknown clinical significance.\n Multiple hypodense areas in the kidneys bilaterally, likely representing\n cysts. Some of the hypodense areas are too small to be characterized. No\n retroperitoneal lymphadenopathy. Multiple surgical clips in the regions of\n the harvesting of the omentum. Small periportal nodes do not meet CT criteria\n for pathology. Multiple nodules in the subcutaneous tissues in the anterior\n abdominal wall, likely from medication injection.\n\n CT PELVIS: There is malposition with the Foley catheter likely with the\n balloon in the urethra. (2:123.) The rectum, urinary bladder, distal\n (Over)\n\n 9:41 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for hematoma\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ureters, intrapelvic bowel loops are unremarkable. Small amount of simple\n free fluid in the pelvis.\n\n BONE WINDOWS: There are degenerative changes of the spine, but no suspicious\n lytic or blastic lesions. Healing fracture of the right twelfth rib.\n\n IMPRESSION:\n 1. No reason to explain dropping hematocrit.\n 2. Resolving left cardiophrenic hematoma.\n 3. Viable flap.\n 4. Large bilateral pleural effusions and associated atelectasis. The pleural\n effusions have simple characteristics and are unchanged since prior study.\n 5. Hypodense areas in the kidneys likely representing cysts, but some are too\n small to be characterized.\n 6. Mild dilatation of the central portion of the pancreatic duct measuring up\n to 8 mm of unclear significance. Correlate with history of simple ascites.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938166, "text": " 3:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dht placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision openchest, s/p\n closure of open chest, now s/p Right thoracentesis, catheter placement\n REASON FOR THIS EXAMINATION:\n dht placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Status post bypass surgery. Postoperative since with\n sternal revision and open chest. Now status post right-sided thoracocentesis\n with catheter placement.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n sitting semi-upright position and analysis is performed in direct comparison\n with a similar study dated . Position of previously\n described tracheotomy cannula, right subclavian central venous line unchanged.\n The Dobhoff NG tube has been withdrawn partially and is now terminating in the\n fundus of the stomach. No pneumothorax has developed. The left lower lobe\n diffuse density has cleared up slightly but still partial atelectasis remains.\n Also, the left lateral pleural sinus is obliterated.\n\n IMPRESSION: Stable chest findings with mild improvement of left-sided pleural\n densities and left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-19 00:00:00.000", "description": "PICC W/O PORT", "row_id": 936165, "text": " 10:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 71-year-old man status post MVR, needs IV\n access.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\n used to identify the right basilic vein, which was patent and compressible.\n The right arm of the patient was then prepped and draped in standard sterile\n fashion. After injection of 5 cc of 1% lidocaine, 21-gauge needle was\n advanced into the right basilic vein under ultrasonographic guidance. Hard\n copies of the images before and after the venipuncture were obtained. A 0.018\n guidewire was then advanced through the needle into the distal part of the SVC\n under fluoroscopic guidance. The needle was then exchanged for a 5 French\n micropuncture sheath. Based on the markers in the guidewire, it was decided\n that a length of 43 cm would be suitable. The line was then trimmed to this\n length and advanced over the wire into the distal part of the SVC. The wire\n and the peel-away sheath were then removed. The line was flushed, heplocked\n and statlocked. A dressing was applied, and final fluoroscopic image of the\n chest demonstrated tip of the catheter to be located in the distal part of the\n SVC. The patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of a 43 cm long double lumen line with the\n tip in the distal part of the SVC. The line is ready for use.\n\n\n\n\n\n\n\n (Over)\n\n 10:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2148-12-25 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 937123, "text": " 5:32 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: R/O DVT PT HAS LINE IN AND RT ARM SWELLING\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PICC in R and increased swelling.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC in right arm. Increased swelling. Rule out DVT.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, spectral, and color Doppler\n analysis of the right internal jugular vein, subclavian vein, axillary vein,\n brachial veins, cephalic vein, and basilic vein was performed. PICC catheter\n is seen in one of the brachial veins. There is normal flow, compressibility,\n augmentation, and waveforms in the right jugular vein, axillary vein, and\n brachial veins. No evidence of thrombus in the basilic or cephalic veins.\n\n IMPRESSION: No evidence of right upper extremity DVT.\n\n" }, { "category": "Radiology", "chartdate": "2149-01-03 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 938254, "text": " 10:15 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: R/O ASPIRATION, PT W/ ORAL DYSPHAGIA\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old, rule out aspiration.\n\n FINDINGS: Video oropharyngeal swallow study was performed in conjunction with\n the speech and swallow department. Various consistencies of barium were\n administered to the patient. NG tube is noted coiled within the nasopharynx.\n Please note the study was performed with tracheal cuff deflated. Note was\n made of mild-to-moderate impaired oral bolus handling. Unremarkable\n pharyngeal phase. There was trace penetration noted both with thin barium and\n with nectar. No more significant aspiration. Please see full speech and\n swallow report for more details and treatment recommendations.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934116, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p cabg, post op sternal revision open chest\n\n REASON FOR THIS EXAMINATION:\n eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pneumonia in a patient after sternal revision.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is still low, 1.7 cm above the carina, but the patient's neck\n is in flexion.\n\n The right internal jugular line catheter tip is at the junction of the\n internal jugular vein with the subclavian vein. The oral tube is coiled\n proximally but still most likely within the gastric fundus. The bilateral\n pleural effusion seems to be enlarged since the previous chest radiograph and\n underlying pulmonary congestion is likely.\n\n IMPRESSION:\n 1. Borderline position of the ET tube.\n 2. Massive bilateral pleural effusion, slightly increased with underlying\n pulmonary congestion.\n\n\n" } ]

70,884

171,528

As mentioned in the HPI, Mrs. underwent a cardiac cath on which demonstrated severe left main disease. Cardiac surgery was consulted and she was emergently taken to the operating room and underwent a coronary artery bypass graft x 2. Please see operative report for surgical details. In summary she had CABG x2 with: left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to obtuse marginal artery. her bypass time was 42 minutes and crossclamp time was 31 minutes. She tolerated the operation well and following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Later this day she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on beta-blockers and diuretics and gently diuresed towards her pre-op weight. On post-op day two her chest tubes were removed and she was transferred to the step-down unit for further recovery. Post-op she was in atrial fibrillation (has a history of chronic atrial fibrillation) and Coumadin was started. Once on the stepdown floor her hospital course was uneventful. She worked with the nursing and physical therapy staff to increase strength and endurance, her progress was slow. On post-op day three epicardial pacing wires were removed. On POD4 she was cleared for transfer to rehabilitation at either Rehab on the whichever the family chooses.

The ascending aorta is mildlydilated. There are simple atheroma inthe aortic arch. Mild mitral annularcalcification. Mildly dilated ascending aorta. Mildly dilated descending aorta. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Sinus bradycardia with slight P-R interval prolongation. Mild non-specific ST segmentflattening throughout. There is a small fibrinous echodensity in the left ventricularoutflow tract 1 cm below the right coronary cusp. There is mild regional leftventricular systolic dysfunction with mild hypokinesis of the distalanterolateral wall as well as the anterior wall and apex, The right ventricledisplays normal free wall contractility. The descending thoracic aorta is mildly dilated. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. SlightQ-T interval prolongation. Mildspontaneous echo contrast in the LAA. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Traceaortic regurgitation is seen. Mild regional LV systolicdysfunction.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. There appears to be one millimeter ofST segment elevation in lead aVL with downsloping ST segments and T waveinversions in leads III and aVF. QRS amplitudeis diminished in the limb leads. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Mild spontaneous echo contrast is present in the left atrialappendage. Ability to assess repolarization abnormalitiesis degraded by baseline artifact. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Baseline artifact has resolved.TRACING #1 Earlyanterior R wave transition persists. Valvular functionis unchanged. The thoracic aorta is intact after decannulation. Focal calcifications inaortic root. Sinus rhythm with P-R interval prolongation. Atrial fibrillation. Borderline leftventricular hypertrophy by voltage criteria. Hypertension. Left ventricular wallthicknesses and cavity size are normal. No atheroma in ascending aorta.Simple atheroma in aortic arch. The patient appears to be in sinusrhythm. Baseline artifact. Normal LV wall thickness and cavity size. The left atrial appendage emptying velocity is depressed (<0.2m/s).No atrial septal defect is seen by 2D or color Doppler. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. There arecomplex (>4mm) atheroma in the descending thoracic aorta. Compared to the previous tracing of , the rateis slightly slower, the computed P-R interval is slightly longer. Complex(>4mm) atheroma in the descending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Abnormal ECG. The patient was under general anesthesia throughout theprocedure. Early anteriorR wave transition. NewST segment elevation in lead aVL and ST segment depressions in the inferiorand right to mid-precordial leads are concerning for an acute ischemic process.Clinical correlation is suggested.TRACING #3 Compared to tracing #1 the rate is faster and no longerbradycardic. I certify I was present in compliance with HCFAregulations. No ASD by 2D or color Doppler.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. No AS. Coronary artery disease. No othersignificant changes from the pre-bypass exam. Intraoperative TEE for emergent CABGHeight: (in) 63Weight (lb): 147BSA (m2): 1.70 m2BP (mm Hg): 150/95HR (bpm): 50Status: InpatientDate/Time: at 15:41Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. Computed P-R and Q-T intervals are longer. A TEE was performed in thelocation listed above. Dr. was notified in person of the results in the operating room at the time ofthe study.POST BYPASS There is noemal biventricular systolic function. No TEE related complications. Chest pain. There is no pericardial effusion. Baseline artifact is significant. There are also downsloping ST segments likelyin lead II, as well as in leads V2 and V3 and possibly lead V4. Depressed LAA emptying velocity(<0.2m/s) All four pulmonary veins identified and enter the left atrium.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.

3

[ { "category": "Echo", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 100657, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Atrial fibrillation. Chest pain. Coronary artery disease. Hypertension. Intraoperative TEE for emergent CABG\nHeight: (in) 63\nWeight (lb): 147\nBSA (m2): 1.70 m2\nBP (mm Hg): 150/95\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 15:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA. Mild\nspontaneous echo contrast in the LAA. Depressed LAA emptying velocity\n(<0.2m/s) All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Mild regional LV systolic\ndysfunction.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. No atheroma in ascending aorta.\nSimple atheroma in aortic arch. Mildly dilated descending aorta. Complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was under general anesthesia throughout the\nprocedure. No TEE related complications. The patient appears to be in sinus\nrhythm. Results were personally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS: No spontaneous echo contrast is seen in the body of the left\natrium. Mild spontaneous echo contrast is present in the left atrial\nappendage. The left atrial appendage emptying velocity is depressed (<0.2m/s).\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. There is mild regional left\nventricular systolic dysfunction with mild hypokinesis of the distal\nanterolateral wall as well as the anterior wall and apex, The right ventricle\ndisplays normal free wall contractility. The ascending aorta is mildly\ndilated. There is a small fibrinous echodensity in the left ventricular\noutflow tract 1 cm below the right coronary cusp. There are simple atheroma in\nthe aortic arch. The descending thoracic aorta is mildly dilated. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr.\n was notified in person of the results in the operating room at the time of\nthe study.\n\nPOST BYPASS There is noemal biventricular systolic function. Valvular function\nis unchanged. The thoracic aorta is intact after decannulation. No other\nsignificant changes from the pre-bypass exam.\n\n\n" }, { "category": "ECG", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 303030, "text": "Sinus bradycardia with slight P-R interval prolongation. Borderline left\nventricular hypertrophy by voltage criteria. Mild non-specific ST segment\nflattening throughout. Compared to the previous tracing of , the rate\nis slightly slower, the computed P-R interval is slightly longer. Early\nanterior R wave transition persists. Baseline artifact has resolved.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-12-25 00:00:00.000", "description": "Report", "row_id": 303029, "text": "Baseline artifact. Sinus rhythm with P-R interval prolongation. Slight\nQ-T interval prolongation. Ability to assess repolarization abnormalities\nis degraded by baseline artifact. There appears to be one millimeter of\nST segment elevation in lead aVL with downsloping ST segments and T wave\ninversions in leads III and aVF. There are also downsloping ST segments likely\nin lead II, as well as in leads V2 and V3 and possibly lead V4. Early anterior\nR wave transition. Compared to tracing #1 the rate is faster and no longer\nbradycardic. Computed P-R and Q-T intervals are longer. QRS amplitude\nis diminished in the limb leads. Baseline artifact is significant. New\nST segment elevation in lead aVL and ST segment depressions in the inferior\nand right to mid-precordial leads are concerning for an acute ischemic process.\nClinical correlation is suggested.\nTRACING #3\n\n" } ]

17,546

194,805

79 yo m with ischemic cardiomyopathy (EF: 15-25%), s/p NSTEMI, hx of AFib, HTN recently admitted to for CHF exacerbation and treated with lasix was readmitted after 7 second pause while on COreg at rehab (digoxin was d/cd at this time). After decreasing the coreg to 6.25mg , he experienced RVR to 130s-140s. He received 10mg IV diltiazem with good rate control and was referred here for ICD placement. On admission, his troponin was up to 0.58 from 0.18 8 days PTA without EKG changes. On night of admission, patient was "Triggered" for increased HR and decreased urine output. His rate responded to metoprolol (4mg IV). He subsequently developed a 9 second pause on tele. Pacer pads were placed and patient was evaluated for the CCU and transferred for closer monitoring. EP was consulted and he was started on heparin for ACS.

IMPRESSION: Stable cardiomegaly and probable left pleural effusion. Unchanged cardiomegaly, failure, bilateral effusions, and opacity at the left lung base. Mild mitral annularcalcification. Moderate to severe (3+)mitral regurgitation is seen.7.The tricuspid valve leaflets are mildly thickened.IMPRESSION: No intracardiac thrombus. Left pleuraleffusion.Conclusions:1. Pulses d/d bilaterally post removal and dsd placed and maintained d/i. Regular narrow complex rhythm which may represent sinus tachycardia with aprolonged P-R interval. ]RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.AORTA: Simple atheroma in aortic arch. ]3.There is moderate global right ventricular free wall hypokinesis.4.There are simple atheroma in the aortic arch and the descending thoracicaorta.5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis isnot present. PORTABLE AP CHEST RADIOGRAPH: Again seen is stable cardiomegaly. Regular narrow complex tachycardia - mechanism uncertain - may be atrialflutter or atrial tachycardiaVentricular premature complexRight bundle branch blockLeft anterior fascicular blockConsider prior anterior myocardial infarctionST-T wave abnormalities - cannot exclude in part ischemiaSince previous tracing of , ventricular response now regular Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. co/ci/svr 3hrs off iabp 7.9/4.1/466 cont with ?septic numbers. Physiologic(normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. There is a retrocardiac opacity and a small left pleural effusion, which is unchanged. Unchanged left lower lobe atelectasis and bilateral effusions. Patient was made a . Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINDINGS: A right subclavian Swan-Ganz catheter ends in the mid right pulmonary artery. The rhythm appears to be atrial fibrillation. PATIENT/TEST INFORMATION:Indication: R/o intracardiac thrombusHeight: (in) 64Weight (lb): 165BSA (m2): 1.80 m2BP (mm Hg): 117/50HR (bpm): 123Status: InpatientDate/Time: at 13:33Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. Continued cardiomegaly with small bilateral pleural effusion. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There is a probable left pleural effusion. Atrial fibrillationRight bundle branch blockLeft anterior fascicular blockConsider prior anteroseptal myocardial infarctionProbable left ventricular hypertrophyST-T wave abnormalities - cannot exclude in part ischemia or left ventricularhypertrophySince previous tracing of , ventricular rate slower and ventricularectopic activity Dr pronounced patient. A single-lead pacemaker is identified with the lead in satisfactory position. Small left pleural effusion. There is severe globalhypokinesis, with relative preservation of the basal inferolateral wall. Left ventricular cavity isdilated, with severely depressed systolic function. Bilateral effusions (left greater than right) are unchanged. FINDINGS: Endotracheal tube ends in satisfactory position, 4 cm above the carina. Baseline artifactAtrial fibrillation with rapid ventricular responseVentricular premature complexesRight bundle branch blockLeft anterior fascicular blockConsider prior anterior myocardial infarctionProbable left ventricular hypertrophyST-T wave abnormalities - cannot exclude in part ischemia or left ventricularhypertrophySince previous tracing of , ventricular response now irregular andfaster, and ventricular ectopy present 2:58 PM CHEST (PORTABLE AP) Clip # Reason: eval for chf MEDICAL CONDITION: 79 M, CHF, now with sob REASON FOR THIS EXAMINATION: eval for chf FINAL REPORT INDICATION: History of shortness of breath, evaluate for CHF. Vasopressin 2.4u/hr added to regime. Ptt supratherapeutic at 131.6. ABG 7.46/31/130. Heparin gtt resumed for ? Remains on IABP 1:1 via r groin with variable unloading points. Pt remains +4.2L LOS.ID: Tmax 99.8 PR. Continues on IABP support at 1:1 via R femoral line. Repeat ABG7.44/39/122. Received vanco 1gm IV. Down to 3.7(8.4).Resp: LS clr in apexes. Heparin supratherapeutic. NGT via R nares. pt on Milrinone 0.28mcgs/kg/min and Levophed 0.4mcgs/kg/min. Bun/Cr 61/3.1. Milrinone weaned to off w/ addition of Neosynephrine - tolerating w/ MAP > 60. Cont on abx. Radial line placed and left fem multi lumen placed.Started Levo 0.1-.5mcg/kg/min after intubation. ?further iabp wean. Abd firm and distended but with BS x4. D-dimer >. Swan placed in R axillary site initially notable for slight ooze which has been resolving . am bun/creat-66/4.9. Pt received 2 gm Ca Gluconate w/ repeat Ion Ca 1.05. & RN @ BS. Mvenous 75-79. LS rales 3/4 up bilaterally.ID low grade temp 100.3 po with elevated WBC 18.8. Pt cont on Lisinopril/ASA/ Lipitor. Site remains CDI. stable #"s on iabp 1:2. rising bun/creat.p:contin presnt management. H/O GIB.Cont CO 7.20-7.9/CI 3.7-4.14/ 600-516. PA 63-53/20. Pt on Heparin 600u/hr with ptt 87. ,rrtpt. MgSO4 1.6. ?dc lasix gtt. HCT stable at 32.5. PTCA during this admission. CO/CI/SVR appear septic 9.2/4.82/583 at 12noon after Vasopressin initiated. cont iapb support. CRI at baseline 1.5-1.7. 0400 #'s w iabp 1:1-iabp mean 55, pad 25, & co/ci/svr 7.9/4.14/547 2hrs later after being on iabp 1:2-iabp mean 58, pad 29, & co/ci/svr 7.2/3.77/522. Fair augmentation w/ systolic unloading of points and diastolic unloading of points. BUN/creat 64/3.4 slightly up. Abd distended and firm. +BS x 4 quadrants. Anuric since admission. ccu nsg progress note.o:minimally to noxious stim-presently on prop gtt. BS are hypoactive. Electively intubated #8.0 22mm at the lip. Distal pulses dopplerable. Hold diuretics, Put on Flovent and Albuterol MDI PRN. transferred to CCU. CA 7.7 recd 2 amps ca gluc. UOP 10-18cc following Diuril/ 80 mg IV Lasix and 20 mg/hr Lasix gtt. Experienced tachy brady syndrome and impressive pauses requiring transfer to CCU. Bibase rales audible with upper coarse bs. Currently undergoing repletion w/ 2 gm Mag sulfate. ABP 90-108/40. had been on coreg and dig.on floor agitated 1mg ativan IV x2 change in MS . Sats cont 93-95% with most recent abg 7.47/35/72. BB held per HO. Pt extubated to RA per physician. Cont on IABP 1:1 and Levophed gtt to maintain goal MAP>65. 4pm, placement checked and 60cc bilious material aspirated. Impaired gag upon suctioning.GI - NGT clamped throughout day. TTE today to RO Thrombus.EP consult for cardioversion. VVI set at 60 bpm. Pt. Goal to diurese pt and maintain MAP's with IABP, inotropy with vasopressors.Continu CCU Nursing Progress Note 7am -7pmS/O: ID - Initially rec'd pt with core temp 96.6. Heparin restarted at 1530 at rate of 400u/hr - repeat PTT at 2130. Cont on iv abx Vancomycin which is dosed q48hrs and Aztreonam q8hrs.

29

[ { "category": "Echo", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 65904, "text": "PATIENT/TEST INFORMATION:\nIndication: R/o intracardiac thrombus\nHeight: (in) 64\nWeight (lb): 165\nBSA (m2): 1.80 m2\nBP (mm Hg): 117/50\nHR (bpm): 123\nStatus: Inpatient\nDate/Time: at 13:33\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely depressed LVEF. [Intrinsic\nLV systolic function depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications. The rhythm appears to be atrial fibrillation. Left pleural\neffusion.\n\nConclusions:\n1. The left atrium is dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler.\n2. Left ventricular wall thicknesses are normal. Left ventricular cavity is\ndilated, with severely depressed systolic function. There is severe global\nhypokinesis, with relative preservation of the basal inferolateral wall.\n[Intrinsic left ventricular systolic function may be more depressed given the\nseverity of valvular regurgitation.]\n3.There is moderate global right ventricular free wall hypokinesis.\n4.There are simple atheroma in the aortic arch and the descending thoracic\naorta.\n5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is\nnot present. Trace aortic regurgitation is seen.\n6.The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\nmitral regurgitation is seen.\n7.The tricuspid valve leaflets are mildly thickened.\n\nIMPRESSION: No intracardiac thrombus. Severely depressed left ventricular\nsystolic function. Moderately severe mitral regurgitation.\n\nCompared to the previous report of , the MR is more severe and the RV\nfunction appears worse.\n\n\n" }, { "category": "ECG", "chartdate": "2162-01-19 00:00:00.000", "description": "Report", "row_id": 140582, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nVentricular premature complexes\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of , ventricular response now irregular and\nfaster, and ventricular ectopy present\n\n" }, { "category": "ECG", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 140578, "text": "Regular narrow complex rhythm which may represent sinus tachycardia with a\nprolonged P-R interval. Left axis deviation. Right bundle-branch block. Prior\ninferior wall myocardial infarction. Possible prior anterior wall myocardial\ninfarction. Diffuse ST-T wave changes. Compared to the previous tracing the\nrate is faster.\n\n" }, { "category": "ECG", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 140579, "text": "Regular narrow complex tachycardia - mechanism uncertain - may be atrial\nflutter or atrial tachycardia\nVentricular premature complex\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nST-T wave abnormalities - cannot exclude in part ischemia\nSince previous tracing of , ventricular response now regular\n\n" }, { "category": "ECG", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 140580, "text": "Lead V6 absent\nAtrial fibrillation with rapid ventricular response\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anterior myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of the same date, ventricular rate increased\n\n" }, { "category": "ECG", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 140581, "text": "Atrial fibrillation\nRight bundle branch block\nLeft anterior fascicular block\nConsider prior anteroseptal myocardial infarction\nProbable left ventricular hypertrophy\nST-T wave abnormalities - cannot exclude in part ischemia or left ventricular\nhypertrophy\nSince previous tracing of , ventricular rate slower and ventricular\nectopic activity\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893859, "text": " 5:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm NGT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 M, CHF, sob, hyperkalemia, s/p NGT placement for kayexelate\n\n REASON FOR THIS EXAMINATION:\n confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 79-year-old male patient with CHF, shortness of breath,\n nasogastric tube placement.\n\n COMMENTS: Portable semierect AP radiograph of the chest is reviewed and\n compared with the previous study of yesterday.\n\n There is increased opacity in the left lower lobe indicating pneumonia or\n aspiration. There is slight increase in small bilateral pleural effusion.\n There is continued marked cardiomegaly. The previously identified mild\n congestive heart failure has been improving. There is continued tortuosity of\n the thoracic aorta with calcification.\n\n A nasogastric tube terminates in the gastric body.\n\n IMPRESSION:\n\n 1. Left lower lobe pneumonia versus aspiration.\n\n 2. Improving mild congestive heart failure. Continued cardiomegaly with\n small bilateral pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST FLUORO WITHOUT RADIOLOGIST", "row_id": 893950, "text": " 2:52 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: PACEMAKRE LINE PLACEMENT\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n Chest fluoro without radiologist present was performed in the CCU. Check\n pacer line placement. 42 seconds of fluoro time was used. No images were\n submitted.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 894030, "text": " 7:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chf ? PNA\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF. Intubation.\n\n FINDINGS: Endotracheal tube ends in satisfactory position, 4 cm above the\n carina. An NG tube passes beyond view into the distal stomach. A pacemaking\n device overlies the right chest with pacer electrodes in stable position\n compared to the previous day. An intraaortic balloon pump is positioned with\n its distal tip at the top of the aortic arch. Moderate cardiomegaly is\n unchanged. Mild failure is unchanged. Bilateral effusions (left greater than\n right) are unchanged. Left lower lobe atelectasis is also stable.\n\n IMPRESSION: The tip of an intraaortic balloon pump overlies the top of the\n aortic arch. Unchanged cardiomegaly, failure, bilateral effusions, and\n opacity at the left lung base.\n\n This was discussed with Dr. at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893920, "text": " 12:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate ET tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chf ? PNA\n\n REASON FOR THIS EXAMINATION:\n evaluate ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old with CHF, question pneumonia, evaluate endotracheal\n tube placement.\n\n COMPARISON: at 5:39.\n\n AP SUPINE CHEST RADIOGRAPH: Endotracheal tube is seen approximately 4 cm\n above the carina. Nasogastric tube is seen with tip within the stomach. An\n opacity in the left lower lobe indicates pneumonia or aspiration. There is a\n small left pleural effusion. There is continued marked cardiomegaly. There\n is mild CHF. Continued tortuosity of the thoracic aorta with calcification.\n The right lung base cannot be evaluated secondary to technical factors.\n\n IMPRESSION:\n\n 1. Left lower lobe pneumonia Vs. aspiration. Small left pleural effusion.\n\n 2. Mild congestive heart failure. Continued cardiomegaly.\n\n 3. Nasogastric tube.\n\n 4. Endotracheal tube in appropriate position.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893973, "text": " 7:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: rule out pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF now has a new VVI pacemaker and SG atheterchf ?\n\n REASON FOR THIS EXAMINATION:\n rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n INDICATION: 79-year-old man with CHF, new VVI pacemaker.\n\n CHEST PORTABLE: Comparison is made to a prior study from earlier the same\n day. There is cardiomegaly, which is unchanged. The pulmonary vasculature is\n prominent. There is a retrocardiac opacity and a small left pleural effusion,\n which is unchanged. The ET tube is unchanged in position. A single-lead\n pacemaker is identified with the lead in satisfactory position. A Swan-Ganz\n catheter is noted with its tip in the right hilum.\n\n IMPRESSION:\n 1. Status post pacemaker implantation with a single lead in satisfactory\n position.\n 2. Swan-Ganz catheter in appropriate position.\n 3. No change in the appearance of mild CHF and retrocardiac atelectasis and\n small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 893792, "text": " 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 M, CHF, now with sob\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of shortness of breath, evaluate for CHF.\n\n COMPARISON: .\n\n PORTABLE AP CHEST RADIOGRAPH: Again seen is stable cardiomegaly. Mediastinal\n contours are stable in appearance. There is minimal perihilar haziness,\n without any overt prominence of the pulmonary vasculature. There is a\n probable left pleural effusion. There is opacity in the left retrocardiac\n area which may represent atelectasis.\n\n IMPRESSION: Stable cardiomegaly and probable left pleural effusion. No\n definite CHF.\n\n" }, { "category": "Radiology", "chartdate": "2162-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 894185, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with sepsis, CHF now has a new VVI pacemaker and SG\n atheterchf ?\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, CHF. Swan-Ganz catheter placement.\n\n FINDINGS: A right subclavian Swan-Ganz catheter ends in the mid right\n pulmonary artery. An endotracheal tube ends in satisfactory position 4 cm\n above the carina. An NG tube passes beyond view into the stomach. A\n pacemaking device overlies the right chest with pacing electrodes in unchanged\n position compared to . An intra-aortic balloon pump ends 1 cm from\n the roof of the aortic arch. Moderate cardiomegaly is unchanged. CHF is\n slightly improved compared to the previous day. Left lower lobe atelectasis\n and small bilateral effusions (left greater than right) are unchanged. No\n pneumothorax is identified.\n\n IMPRESSION:\n 1. Improved CHF. Unchanged left lower lobe atelectasis and bilateral\n effusions.\n 2. The tip of an intra-aortic balloon pump ends 1 cm from the roof of the\n aortic arch as previously communicated to Dr on .\n\n" }, { "category": "Nursing/other", "chartdate": "2162-01-23 00:00:00.000", "description": "Report", "row_id": 1492209, "text": "Event Note\nReceived patient at 2300 with Heparin at 400u/hr..Levophed at .5 mcg/kg/min...Phenylephrine at 1 mcg/kg and vasopressin 2.4 u/hr. Heart rate 130 st .with SBP by aline 90 systolic. At 2200, patient dropped his HR to 70's..v-paced with multi focal pvc's..and profound drop in SBP to the 50's...Dr aware. Phenylephrine infusion titrated to max dose and a bolus of IVF one liter given ..Dopamine infusion begun. Family called and at bedside. After discussion with patient's wife and children. Patient was made a . A priest was called and last rites were given. All pressors were stopped and patient was extubated per family wishes. Dr pronounced patient. Family declined autopsy.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492205, "text": "CCU Nursing Progress Note 7am-3pm\nS: Orally intubated and sedated\n\nO: See careview for all objective data.\n\nID - t max 99.5 core. cont on abx, vanco q48hrs, Aztreonam and Flagyl started. Steriods started today. WBC 16.2\n\nCV - Pt on 1:3 and 1:3 iabp, unloading points attempting to maintain maps > 60 with Levophed 3.5 up to 5mcgs/kg/min and Milrinone maintained at 0.28mcgs/kg/min. Heparin off at10am and iabp placed on 1:1. IABP removed at 11:03 am without incident. Pulses d/d bilaterally post removal and dsd placed and maintained d/i. co/ci/svr 3hrs off iabp 7.9/4.1/466 cont with ?septic numbers. Pheneylephrine started at 3pm at 0.5mcgs/kg/min and will attempt to decrease milrinoe. HR remains st 130's with occ pvc's. Heparin will resume at 400u/hr at 3:30pm.\n\nResp - cont on AC 40%/450/13br/5 peep. pt will overbreath vent 3-10br/min. Sx for thick yellow/tan mucous plugs. bs are bronchial/coarse.\n\nGU - foley intact to cloudy urine. BUN/CREAt 66/4.0 today. Lasix cont 20mg/hr but u/o approx 30cc/hr.\n\nGI - NGT to lis draining dark bilious drainage. Bowel sounds are hypoactive this afternoon.\n\nSedation - Maintained on 50mcgs/kg propofol and pt is unarousable.\n\nSocial - Wife and daughters and spoke at lenght with DR. . Pt is now dnr. We will cont support and attempt to change milrinone in favor of neo, but no cpr/shock. Family asking questions about how pt will look when he dies. They wish him to be comfortable\n\nA/P: pt cont with septic looking co/ci. Attempt to start neo and d/c milrinone d/t possible sepsis. Heparin restart at 3:30pm. turn and position or sit up after 5pm (6hrs post iabp removal), cont support of family through this difficult time.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492206, "text": "resp therapist\npatient still on the vent doesn't improve stays on same settings.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492207, "text": "CCU Addendum: 1500-1900\n\nNursing staff and Dr. (CCU fellow) met w/ family to discuss plan of care and end of life issues. Pt.'s family verbalized concern that pt. be comfortable and not experience prolonged suffering. Decision made to continue current medication regimen (including antibiotic course) and re-evaluate/ meet w/ family each day to discuss goals of care. Family agreeable to this. Milrinone weaned to off w/ addition of Neosynephrine - tolerating w/ MAP > 60. Heparin restarted at 1530 at rate of 400u/hr - repeat PTT at 2130. PM labs pending. No vent adjustments - remains on AC/0.40/450/13/5 - maintaining O2 sat > 93% w/ adequate tidal volumes. Continue to monitor - provide emotional support and comfort to pt./family.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-23 00:00:00.000", "description": "Report", "row_id": 1492208, "text": "Resp Care\nPt removed from ventilator and extubated per Dr. . Pt extubated to RA per physician. & RN @ BS. Pt per family wishes.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492194, "text": "CCU NPN: please see flowsheet for objective data\n\n79 yo man with freq admissions for CHF,last time a week ago,at 6 second pause noted,tachy brady admitted to 6 for pacer placement. had been on coreg and dig.on floor agitated 1mg ativan IV x2 change in MS . in Afib 100-118 then increased to 130-140 while pushing 5mg lopressor BP 80/ only received 4mg. then had 9 second pause. ABG drawn 7.51/30/78 on 2l NP,lactate 6.5 and K noted to be 5.8,NGT placed given kaexalate,calcium,dextrose and insulin. transferred to CCU.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492195, "text": "CCU NPN addendum:\n\nResp: crackles 1/2 up rr 30-36. has exp wheezes,on 2l NP on 6 now on 40% face mask. sats 97 received 80mg lasix last evening at 10pm,no response.\n\nPain: has been complaining of left testicular pain.had rt inguinal hernia repair last month,steri-strips in place.\n\nSkin: tip of nose and lips bluish secondary to amiodorone,according to nurse who knows pt,color has improved.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492196, "text": "CCU Nursing Progress Note\nS-\"I can't breath too good.\"\nO-Neuro-lethargic but arousal to voice. Oriented to person only \"\". Calling out for - his wife. Asking to go to the bathroom and reminded about foley catheter. Moving all extremites, no need for restraints. Started Propofol gtt 50mcg/kg/min after intubation, with good sedative effect.\nCV-Intermittantly hypotensive early this am SBP 78-98 with RAF 110-130. Radial line placed and left fem multi lumen placed.\nStarted Levo 0.1-.5mcg/kg/min after intubation. Goal to maintain MAP >60. Pre cardioversion bedside TEE revealed no LV clot\nbut 4+MR <20%. After TEE pt HR decreased to 60-70 AF ECG obtained, no DCV planned until temp pacer in place. One 4.4 second pause noted on monitor. As pt was getting ready to be transferred to the EP lab, noted long pause > 5seconds then asystole. Transcutaneous pads in place, started to external pace pt rate 80 MA 60 with no pressure via aline. CPR started and pt received total 2mg atropine and 2mg epinephrine. Increased MA 100 with good capture and pressure 130. Emergent temporary pacer placed over wire left fem multi lumen with fluro for final placement and confirmation. Temp pacer rate set at 80 MA 20 with stim threshold 5, at full asych sensing. NO underlying rhythm noted. SBP 88 on levo at .5mcg/kg/min. Heparin transiently on this am at 1100u/hr but off since 0800.\nResp-rr 30 slightly SOB with minimal movement in bed. O2 sats dropping to 83% while HOB flat and on 100% face tent. Electively intubated #8.0 22mm at the lip. CXR pulmonary edema with pleural effusions. Vent settings at 100% 550x14AC PEEP 5 7.51/34/468/28, adjusted rr and FIO2 to new vent settings 60% 500x10AC PEEP 5, ABG 7.42/26/343. Minimal secretions white and thin sent for culture. LS rales 3/4 up bilaterally.\nID low grade temp 100.3 po with elevated WBC 18.8. Received vanco 1gm IV. Blood cultures sent x2 from new aline and multi lumen access.\nGU-BUN/Cr elevated 52/2.5 foley in place but no urine output noted until ~10cc at 1400.\nGI-NGT in place with some blood noted in right nare after placement.\nHCT stable 35.9(40) Elevated liver enezymes LDH 1753, AST 1571, ALT 1011. Abd firm and distended but with BS x4. No stool.\nEndo-blood sugars 130-150.\nSkin- please see careview for multiple open areas that are being treated with wet to dry.\nAccess- Attempted central access RIJ, but pt unable to lie flat without dropping sat. LEft radial aline placed, left multi lumen placed then changed over wire for emergent temp pacer. 2 PIV\nSocial-married with daughters, into visit and very upset over pt condition. MD/nursing staff keeping them informed of all procdures and evenets.\nA/P-CHF with known lo EF, now with tachy/brady syndrome, hypotension, no urine output and probable cardiogenic shock requring temp pacer, IABP and PA catheter for close hemdynamic monitoring.\nGoal MAP > 60 with PAD 18-20, following hemodynamic monitoring closely. Goal to diurese pt and maintain MAP's with IABP, inotropy with vasopressors.\nContinu\n" }, { "category": "Nursing/other", "chartdate": "2162-01-20 00:00:00.000", "description": "Report", "row_id": 1492197, "text": "CCU Nursing Progress Note\n(Continued)\ne to keep family aware of POC and any procedures as discussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492198, "text": ",rrt\npt. remained on ventilator, weaned fio2 down to 40%, rate down to 15, sx'ing scant secretions from pt.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492199, "text": "CCU NURSING PROGRESS NOTE 1900-0700\nS: Intubated and sedated.\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: Pt remains sedated on Propofol at 50 mcg/kg/min. PEARL. 2mm in size. Brisk to sluggish in response. No spontaneous movement noted. Wrist restraints remain off.\n\nCV: AFib/ rare Vpacing. VVI set at 60 bpm. HR initially 70-80s. But HR gradually trending up to 1-teens following Milrinone load and gtt which remains at 0.28 mcg/kg/min for inotropic support to improve poor UOP. Continues on IABP support at 1:1 via R femoral line. Site remains CDI. Waveform slightly improved following aggressive flushing. ? against wall or kinking. Fair augmentation w/ systolic unloading of points and diastolic unloading of points. ABP 90-108/40. Levophed gtt titrated from .25 mcg/kg-0.40 mcg/kg/min to maintain MAPs> 65. Swan placed in R axillary site initially notable for slight ooze which has been resolving . PA 63-53/20. CVP 16-10. PCWP 17-15. CO 7.20-7.9/CI 3.7-4.14/ 600-516. Mvenous 75-79. HCT stable at 32.5. Ion Calcium .95. Pt received 2 gm Ca Gluconate w/ repeat Ion Ca 1.05. MgSO4 1.6. Currently undergoing repletion w/ 2 gm Mag sulfate. Heparin gtt resumed for ? future cath in addition to anticoagulation for 6 wk hx of Afib. Ptt supratherapeutic at 131.6. Heparin gtt held x 1hr and then decreased by 450 units to 650 units/hr per sliding scale. INR 6.0. Pt was given 10 mg SC Vitamin K+. Repeat INR 5.8 this am. BB held per HO. Pt cont on Lisinopril/ASA/ Lipitor. Distal pulses dopplerable. Lactate improving . Down to 3.7(8.4).\n\nResp: LS clr in apexes. Crackles auscultated way up posteriorly. ABG 7.46/31/130. FIO2 and RR decreased. Repeat ABG7.44/39/122. Pt remains on AC 40%/ 15*500/ 5 peep.\n\nGI/GU: NPO. NGT via R nares. Abd distended and firm. +BS x 4 quadrants. No stool. H/o Crohns ds currently stable. Cont on abx. F/C to gravity. Anuric since admission. UOP 10-18cc following Diuril/ 80 mg IV Lasix and 20 mg/hr Lasix gtt. CRI at baseline 1.5-1.7. Bun/Cr 61/3.1. Pt remains +4.2L LOS.\n\nID: Tmax 99.8 PR. Sputum/BC sent on prior shift. U/A sent but ? contamination. Need to obtain additional U/A once urine becomes available.\n\nEndo: BS 98-111. No coverage indicated.\n\nSocial: No calls or visitors . Pt is married w/ 3 dtrs. HO spoke to family in great length on prior shift.\n\nSkin: Unchanged. Dsgs to preexisting ulcers stable. No new breakdown.\n\nA/P: 79 yo male w/ extensive h/o CAD, HTN, CHF of 30% and new onset Afib (6wk). Recently admitted from for increased incidence of pauses. Experienced tachy brady syndrome and impressive pauses requiring transfer to CCU. Temp wire/ PPM placed for 9 sec pause. IABP support for presumed cardiogenic shock and PCWP of 40. Pt not to diuretics alone requiring additional Inotropic support. Cont on IABP 1:1 and Levophed gtt to maintain goal MAP>65. PCWP goal 18-20. Heparin supratherapeutic. Held and decreased per sliding scale. Cont to monitor for s/s of bleeding. H/O GIB.\nCont\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492200, "text": "CCU NURSING PROGRESS NOTE 1900-0700\n(Continued)\nto aggressively diurese. Wean Levophed and IABP as tolerated. ? PTCA during this admission. Cont to follow hemodynamics. Repeat PTT at 12 noon. Cont supportive care. Keep family updated in POC.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492201, "text": "resp care\n79 years old male intubated on for pulmonary edema also has a left sided pleural effusion, was in a-fib, ?pacer for tachy/bradycardia,went to echo on ,where left atrium and left ventricle are deemed dilated. Patient was hypotensive, ?sepsis or ischemia. TTE today to RO Thrombus.EP consult for cardioversion. Hold diuretics, Put on Flovent and Albuterol MDI PRN.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-21 00:00:00.000", "description": "Report", "row_id": 1492202, "text": "CCU Nursing Progress Note 7am -7pm\nS/O: ID - Initially rec'd pt with core temp 96.6. Warmed with blankets and gradual warming to 98.6 core. Cont on iv abx Vancomycin which is dosed q48hrs and Aztreonam q8hrs. WBC 13.6 and 13 today\n\nResp - Cont orally intubated on AC 40%/500/15-13 br/5 peep. Sats cont 93-95% with most recent abg 7.47/35/72. Bibase rales audible with upper coarse bs. Sx q2-4 hrs for small-mod amts tannish secretions.\n\nNeuro - Cont on propofol 50mcgs/kg/min. Pupils and reactive. No response to painful stimuli. Impaired gag upon suctioning.\n\nGI - NGT clamped throughout day. 40cc bilious material returned early in shift. 4pm, placement checked and 60cc bilious material aspirated. LIS started and immediately 450cc bilious material drained. Aspirates currently bloody. BS are hypoactive. No stool noted today.\n\nCV - HR Initally Afib rate 110-120, and converted to ST rate 110-120 with rare apc's and occ pvc's. No paced complexes noted, as pt has temp screwed in pmr. Remains on IABP 1:1 via r groin with variable unloading points. Augmentation is good. pt on Milrinone 0.28mcgs/kg/min and Levophed 0.4mcgs/kg/min. Vasopressin 2.4u/hr added to regime. Able to slightly decrease Levophed to 0.35mcg/kg/min. CO/CI/SVR appear septic 9.2/4.82/583 at 12noon after Vasopressin initiated. At 6pm CO/CI 7.6/3.98/600/\nPAD's 23-25 throughout day with PCWP approx 10point lower than PAD. CVP 11-13. Pulses d/d bilat.\n\nGU - Foley cath patent small amts yellow urine which was sent for ua today, approx 30cc/hr. Cont on 20mg/hr IV lasix gtt.\n\nHeme/Chem- HCT 32.2. Pt on Heparin 600u/hr with ptt 87. Heparin decreased to 400u/hr (ptt due 10pm). INR 5.5. D-dimer >. BUN/creat 64/3.4 slightly up. LDH down this afternoon 4950 from >11,000. CA 7.7 recd 2 amps ca gluc. stim test performed.\n\nSocial - Family vss throughout day. Daughter spoke with Dr. this am and is aware of plan to cont full support of pt through tomorrow , then reassess plan. Wife and daughters spoke with Dr. and are aware of plan per multidisiciplinary rounds.\n\nA: 79yom s/p 9 sec pauses req ETT/DCV/pmr/iapb placement, cg shock and ?septic shock, responding poorly to pressors and inotropes.\n\nP: Cont support with current regime of levophed, pitressin and milrionone and attempt to levophed as tolerated. cont iapb support. PTT at 10pm. cont diuresis, Cont vent support as necessary with freq sx as needed, monitor GI status/GIB, monitor labs for change, keep family informed of plan/progress.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492203, "text": "ccu nsg progress note.\no:minimally to noxious stim-presently on prop gtt. attempted pressor wean-levophed, wo success (did not tolerate slightest decrease in dose). 0400 #'s w iabp 1:1-iabp mean 55, pad 25, & co/ci/svr 7.9/4.14/547 2hrs later after being on iabp 1:2-iabp mean 58, pad 29, & co/ci/svr 7.2/3.77/522. minimal uo. positive i&o. am bun/creat-66/4.9. elevated lft's. low grade t.\n\na:pressor dependent. stable #\"s on iabp 1:2. rising bun/creat.\n\np:contin presnt management. ?further iabp wean. ?dc lasix gtt. ?discussion w family re:overall prognosis & code status.\n" }, { "category": "Nursing/other", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 1492204, "text": "resp care\npt remained on a/c 450x13 40% 5peep with peak/plat 22/18. BS coarse bil. Sats 92-94. Flovent given as ordered. Will follow as needed.\n" } ]

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Patient was admitted on for acute onset dyspnea. Patient is a 61 yom with h.o. of severe systolic and diastolic function s/p AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam.

CAD s/p 5v CABG, CHF s/p AICD, systolic and diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea Dyspnea (Shortness of breath) Assessment: Pt adm this am via ED c/o SOB x3 d. denies throughout shift. I would emphasize and add the following points: 61M CAD (5v CABG, AICD for VT, EF 20%), hypothyroidism, AF, GIB on coumadin, PVD p/w several days progressive weakness - presented with AF c RVR to ED, developed hypotension following lopressor, CXR c ?CHF / pneumonia, abx / lasix given. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Action: Response: Plan: Impaired Physical Mobility Assessment: Action: Response: Plan: TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Pt with crackles in his lung bases bilaterally, upper lobes clear. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR. Depression: Will continue on home regimen of Citalopram and Bupropion. Depression: Will continue on home regimen of Citalopram and Bupropion. Depression: Will continue on home regimen of Citalopram and Bupropion. Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. TITLE: Chief Complaint: Dyspnea HPI: 61 y.o. Nutrition: Cardiac diet, replete lytes PRN Glycemic Control: Lines: Right IJ - discontinue Prophylaxis: DVT: Heparin SC TID Stress ulcer: VAP: Comments: Communication: Comments: Code status: FULL CODE Disposition: Pending resolution of symptoms ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:26 AM Multi Lumen - 06:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. Cholelithiasis, moderate ascites, new from cannot assess sign due to mental status CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural effusions, fluid along fissures cardiomegaly small amount of ascites, free pelvic fluid cholelithiasis. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate Dyspnea (Shortness of breath) Assessment: Pt with crackles in his lung bases bilaterally, upper lobes clear. Nutrition: Cardiac diet, replete lytes PRN Glycemic Control: Lines: Right IJ Prophylaxis: DVT: Heparin SC TID Stress ulcer: VAP: Comments: Communication: Comments: Code status: FULL CODE Disposition: Pending resolution of symptoms ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:26 AM Multi Lumen - 06:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Suspect CHF exacerbation; pt has severe systolic, diastolic dysfunction may have flashed during an episode of A. fib with RVR.

30

[ { "category": "ECG", "chartdate": "2159-08-24 00:00:00.000", "description": "Report", "row_id": 149477, "text": "Atrial fibrillation with rapid ventricular response. Since the previous tracing\nthe rate is slower. Early different morphology beats remain.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-08-24 00:00:00.000", "description": "Report", "row_id": 149478, "text": "Probable atrial fibrillation with rapid ventricular response with two wider\ncomplex beats, probably ventricular. Conducted complexes have intraventricular\nconduction delay of left bundle-branch block type. There are multiple\npseudofusion beats. Since the previous tracing of conducted complexes\nare now prevalent.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388362, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt with crackles in his lung bases bilaterally, upper lobes clear. SpO2\n 97-100% on 2L NC, pt states no SOB or DOE.\n Action:\n CXR took this morning, pt encouraged to cough and deep breath. Daily\n weight taken.\n Response:\n Venous PH 7.42, pt states being comfortable with breathing and shows no\n signs of distress. Pt\ns weight is 112kg.\n Plan:\n Titrate supplemental O2, encourage pt to deep breath, and encourage pt\n to use IS. Daily weights, pt is on a heart healthy low sodium diet \n to his Heart Failure.\n Impaired Physical Mobility\n Assessment:\n Pt at times with a flat affect and slow to manage ADL\ns on own.\n Action:\n Pt helped with turns however lower extremities unable to move them as\n well as upper extremities.\n Response:\n Pt is a min assist X 1 for turns/\n Plan:\n Pt could benefit from a PT and OT consult. Encourage pt to be OOB.\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388346, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 388341, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Unclear as to the exact etiology of the Lactate level. I\n suspect the lactate level may be from a nutrition poor hypoperfusive\n state at a cellular level given the hypoglycemia on chem panel as well\n as poor forward flow. Would expect mixed venous sat to be decreased\n however, this test was obtained on the floor after pt received\n Furosemide which would have improved forward flow. Other causes to\n consider include possible infection, however given the mild\n leukocytosis and lack of febrile history this is unlikely. Thiamine\n defiency could also cause the same issues, as well as cyanide toxicity.\n - will recheck Lactate level\n - will give Thiamine 200mg IV x 1\n - will f/u blood and urine cultures\n - will check daily cultures for surveillance\n - will continue to monitor SvO2\n .\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 61M CAD (5v CABG, AICD for VT, EF 20%),\n hypothyroidism, AF, GIB on coumadin, PVD p/w several days progressive\n weakness - presented with AF c RVR to ED, developed hypotension\n following lopressor, CXR c ?CHF / pneumonia, abx / lasix given. Labs\n notable for AG acidosis (>20) and lactate 13, glucose 42, elevated\n LFTs, ARF. Ab CT (I-) s clear pathology.\n Exam notable for Tm 96.8 BP 100/70 HR 81 / vpaced RR 19 with sat 98 on\n 2LNC CVO2 73%. Obese man, NAD. Coarse BS. RRRs1s2 2/6Sm. Soft +BS,\n non-tender, no rebound. 1+ edema. Labs notable for WBC 11K, HCT 38, K+\n 4.2, Cr 1.4, lactate 9, BNP 6K, Tn 0.05. CXR with cardiomegaly and B\n ASD, EKG AF vs VT.\n 61M DCM, AG acidosis with markedly elevated lactate, abnormal LFTs and\n ARF. Agree with plan to r/o infection (pancx, monitor off abx), run\n meds for interactions (no obvious culprits), and give IV thiamine. No\n compelling evidence for dead bowel, occult infection, compartment\n syndrome, malignancy, mitochondrial or glycogen storage disease though\n hypoglycemia may contribute - will check CO / CN levels as well as tox\n screen and osm gap, and will ask family about possible exposures.\n Suspect he is recovering from a low flow state d/t poor forward flow,\n possibly precipitated by episodic AF c RVR. For AF c RVR - consult EP\n re interrogation and continue sotalol, not an anticoag candidate; will\n also check TFTs. Will trend LFTs and consider HIDA - possibly passed\n stone? ARF somewhat better, not far off baseline, hold diuretics today,\n likely resume in AM, check sed for calcium oxalate crystals. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:01 PM ------\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388348, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388427, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Pt c/o with bed on CC7. Transfer held due repeat INR check, last INR\n was 4.7. If stable will be able to transfer.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388326, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea\n Dyspnea (Shortness of breath)\n Assessment:\n Pt adm this am via ED c/o SOB x3 d. denies throughout shift. Oriented,\n lethargic. Lungs dim, craclkes at bases this afternoon. O2 sats high\n 90\ns on 2 L n/c. abd large, soft, distended. Denies pain, nausea. NPO\n this am. LFT elevated and trending up. Presep cath in place and\n ranging 70\ns this am, now drifting to 50\ns. lactate elevated but\n improving. sbp 90\ns, V paced in 70\ns. cvp ~20. distal pulses by\n Doppler, left leg edematous w/ long standing wound left foot. Wifwe in\n this afternoon and updated.\n Action:\n Monitor labs as ordered\n Restarted home meds.\n Cardiac diet began\n EP consult, pacer interrogated\n Wound care consult\n Team aware of drifting pre CVo2 sat drifting to 50\n Response:\n Stable shift\n LFT not yet peaked\n Lactate improved 11-> 4\n Plan:\n Lasix 40mg iv after Kcl repletion\n Pulm hygiene\n Monitor CVo2\n Cont meds\n Am cxr\n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "ICU Attending Addendum", "row_id": 388410, "text": "MICU ATTENDING ADDENDUM\n 9:50a\n I saw and examined Mr. with the ICU team for the key portions\n of the services provided. I agree with the ICU team note from today,\n including the assessment and plan. I would emphasize and add the\n following points:\n 61 y/o man with complex cardiac disease presented with AFib with RVR\n complicated by hypotension and profound lactic acidosis. He reports\n feeling MARKEDLY improved, particularly with his dyspnea.\n 97.4 68 100/59 15 98% on nasal cannula. CVP 19. Distant\n heart. Course breath sounds. Looks chronically but not acutely ill.\n Abdomen is soft. Left TMA is dressed.\n Meds: SQH, H2B, bupropion, celexa, digoxin, levothyroxine, sotalol.\n CXR shows improved pulmonary edema.\n Labs show markedly decreased lactate; creatinine is slightly improved;\n bili and transaminases improved.\n A/P\n 61-year-old man with resolved/resolving global hypoperfusion state.\n Evaluation for other causes of lactic acidosis has been unrevealing\n (see Dr. \ns note from yesterday). Suspect this was related to AF\n with RVR rather than infectious trigger, though cultures still\n pending. Appreciate EPs help. Would aim to run about even today, then\n potentially resume home lasix tomorrow. Other issues as per ICU team\n note today. To floor today.\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388402, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 113 kg\n Daily weight:\n 112 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: Contact\n PMH: GI Bleed, Renal Failure\n CV-PMH: CAD, CHF, MI, Pacemaker\n Additional history: BiV ICD , osteomyelitis lt foot.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:66\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 1,320 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:34 AM\n Potassium:\n 3.4 mEq/L\n 03:34 AM\n Chloride:\n 99 mEq/L\n 03:34 AM\n CO2:\n 31 mEq/L\n 03:34 AM\n BUN:\n 29 mg/dL\n 03:34 AM\n Creatinine:\n 1.4 mg/dL\n 03:34 AM\n Glucose:\n 103 mg/dL\n 03:34 AM\n Hematocrit:\n 33.1 %\n 03:34 AM\n Finger Stick Glucose:\n 94\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC711\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388284, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388286, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.Pt admitted to MICU for further monitoring.\n Pt alert oriebted x3 but very lethargic.On 4lit NCO2.LS with fine\n crackles and diminished base.Pt mostly sleeping.Labs sent and\n monitoring cont Svo2.Svo2 72-80.\n Vitals stable.CVP 20-23.?needing more diuresis.Team to re-evaluate.\n" }, { "category": "Nursing", "chartdate": "2159-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388287, "text": "This is a 61 yo M with multiple health issues.Pt was brought into ED by\n his wife for increasing SOB.In pt tachycardic, tachpneic,\n desating.Was shortly on NRB which was weaned down to 4lit NCO2.\n Pt received 40 lasix and 5 of lopressor.Pt had CT /pelvis with\n pleural effusion, ascitis, free pelvic fluid but otherwise non\n significant.Pt had TLC inserted and received Vanc and levaquin.Blood\n and urine culture sent.Pt admitted to MICU for further monitoring.\n Pt alert oriebted x3 but very lethargic.On 4lit NCO2.LS with fine\n crackles and diminished base.Pt mostly sleeping.Labs sent and\n monitoring cont Svo2.Svo2 72-80.Lactate down to 11.2 from 13.7.\n Vitals stable.CVP 20-23.?needing more diuresis.Team to re-evaluate.\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388288, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that yesterday evening he noted sudden onset of shortness of\n breath. He denies any fevers, chills, nausea, vomiting, chest pain,\n melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n On the floor,\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Pt has been noted to be afebrile with no compliants of\n diarrhea, cough, skin lesions/infections. He also only shows mild\n leukocytosis which is suprising given the high lactate level. High\n lactate may be a combination of infection ?PNA given ground glass\n opacities on CT scan as well as poor cell perfusion secondary to poor\n forward flow and cardiac output.\n - will recheck Lactate level\n - will f/u blood and urine cultures\n - will continue on broad spectrum antibiotics with Zosyn/Vanc/Levo\n - will check daily cultures for surveillance\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388295, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Pt has been noted to be afebrile with no compliants of\n diarrhea, cough, skin lesions/infections. He also only shows mild\n leukocytosis which is suprising given the high lactate level. High\n lactate may be a combination of infection ?PNA given ground glass\n opacities on CT scan as well as poor cell perfusion secondary to poor\n forward flow and cardiac output.\n - will recheck Lactate level\n - will f/u blood and urine cultures\n - will continue on broad spectrum antibiotics with Zosyn/Vanc/Levo\n - will check daily cultures for surveillance\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388302, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that over the past 3 days he has noted progressive dyspnea on\n exertion. He states that prior to 3 days ago he was able to walk around\n his apartment, buy groceries and clean his apartment without difficulty\n breathing. He states that he noticed he would progressively become\n short of breath. He denies any fevers, chills, nausea, vomiting, chest\n pain, melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General: Chronically sick appearing Male, appears jaundices lying down\n in NARD.\n HEENT: Left Sclera icteric, EOMI, PERRL\n Neck: JVP noted at mandible\n Lungs: Crackles noted over right hemithorax and left base.\n CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops\n Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly, no murphys\n Ext: Lower extremities cool to touch, sensation intact, movement\n intact. Healing wound noted on LLE.\n Labs / Radiology\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Unclear as to the exact etiology of the Lactate level. I\n suspect the lactate level may be from a nutrition poor hypoperfusive\n state at a cellular level given the hypoglycemia on chem panel as well\n as poor forward flow. Would expect mixed venous sat to be decreased\n however, this test was obtained on the floor after pt received\n Furosemide which would have improved forward flow. Other causes to\n consider include possible infection, however given the mild\n leukocytosis and lack of febrile history this is unlikely. Thiamine\n defiency could also cause the same issues, as well as cyanide toxicity.\n - will recheck Lactate level\n - will give Thiamine 200mg IV x 1\n - will f/u blood and urine cultures\n - will check daily cultures for surveillance\n - will continue to monitor SvO2\n .\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt does have cholelithiasis\n although no mention is made of any CBD or prominence. Pt also fluid\n overloaded on examination, transaminitis may be due to congestive\n hepatopathy. Other differentials to consider include possible\n medications, infection.\n - will continue to trend LFTs daily\n - will consider HIDA scan to check for filling defects\n - will hold statin\n - will check hepatology serologies\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine. Do not suspect\n Methanol, Ethylene glycol , overdose given pt's history of\n exposures.\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Physician ", "chartdate": "2159-08-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 388283, "text": "TITLE:\n Chief Complaint: Dyspnea\n HPI:\n 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Pt states that yesterday evening he noted sudden onset of shortness of\n breath. He denies any fevers, chills, nausea, vomiting, chest pain,\n melena, hemetemesis, hematochezia, diarrhea, constipation.\n In the pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR\n 24, Sat 96%. His initial EKG was concerning for possible V tach however\n on further review it was noted to be A. fib with aberrancy, pt was\n given 5mg IV Lopressor which resulted in decrease of HR from 130s to\n the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed\n fluid overload and he was thus given Furosemide 40mg x 1. He was also\n given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs\n were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST\n were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was\n noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4,\n Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed\n edematous gallbladder wall but no cholecystitis, pt also had\n cholelithiasis. He also had a right IJ placed and underwent a CT\n abdomen/pelvis without contrast to eval for source of high lactate. CT\n scan was negative for bowel wall thickening, pneumotosis but did showed\n ground glass opacities in the lung. Prior to the CT scan he was given\n Levofloxacin and Zosyn given his acutely ill appearance and elevated\n lactate. Last set of vitals: HR 90-110, BP 96/74, RR 14, 98% on 2L\n On the floor,\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Bupropion 100 mg po bid\n Citalopram 10 mg daily\n Clonazepam 0.5 mg po bid\n Digoxin 125 mcg, 1 tab/2 tabs alterating\n Lasix 40 mg daily\n Levothyroxine 50 mcg daily\n Lorazepam 4 mg qhs\n Midodrine 1 mg po tid\n Simvastatin 40 mg daily\n Sotalol 120 mg po bid\n Spironolactone 12.5 mg daily\n Triamcinolone 0.1% ointment\n Zolpidem 10 mg qhs\n Past medical history:\n Family history:\n Social History:\n CAD s/p 5V CABG, anterior MI \n Ventricular tachycardia to \n Congestive heart failure s/p BiV AICD ( BiV ICD)\n PVD\n Hypothyroid\n Hyperlipidemia\n Atrial fibrillation, not currently anticoagulated\n Erectile dysfunction\n Anxiety\n h/o massive UGIB in gastritis NSAIDs and\n coumadin(intubated, c/b MRSA VAP, had tracheostomy)\n L hip arthritis\n Hyperlipidimia\n History of left foot osteomyelitis, currently treated with frequent\n debridement\n Father died of MI at age 52\n Married > 25 years. Has three adult children. Lives with his wife. Used\n to work in computers but on disability for health reasons. Denies\n tobacco, occasional etoh. No illicits.\n Review of systems:\n Flowsheet Data as of 04:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:13.7 mmol/L\n RUQ U/S [PRELIM READ]: Gallbladder partially decompressed, so difficult\n to assess for wall thickening, but GB wall appears edematous.\n Cholelithiasis, moderate ascites, new from cannot assess \n sign due to mental status\n CT Abdomen/Pelvis w/ limited contrast [PRELIM READ]: small b/l pleural\n effusions, fluid along fissures cardiomegaly small amount of ascites,\n free pelvic fluid cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from no secondary signs of bowel\n ischemia (no pneumatosis, free air, or dilation) pt received a 30mL\n prebolus of contrast.\n Assessment and Plan\n 61 y.o. Male with h.o. of severe systolic and diastolic function s/p\n AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea,\n elevated lactate, transaminitis and fluid overloaded on exam.\n ICU Care\n ##. Dyspnea: Pt presented to ED with complaint of SOB of sudden onset\n with no chest pain. On physical examination pt noted to have JVP,\n elevated elevated BNP and CXR which suggest fluid overload. Suspect CHF\n exacerbation; pt has severe systolic, diastolic dysfunction may have\n flashed during an episode of A. fib with RVR. Pt states he has been\n adherent to his medication, cardiac enzymes and EKG show no acute\n ischaemic event.\n - will cycle cardiac enzymes\n - will diurese with IV Furosemide\n - place foley\n - strict I/Os, daily bed weights\n .\n ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST,\n ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound\n which showed cholelithiasis with GB wall edema, per Radiology was not\n cholecystitis, as well as moderate ascites. Pt's transaminitis may be\n secondary to congestive hepatopathy.Unclear though as\n - will continue to trend LFTs\n .\n ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on\n admission. Given lack of fevers and only mild leukocytosis I suspect\n that his elevated lactate may be from poor cell perfusion secondary to\n poor forward flow and cardiac output. At this time though infection\n would also have to be considered given the appearance of ground glass\n opacities in the CT scan, it also difficulty to completely rule out\n infiltrate given the amount of fluid overload.\n - will recheck Lactate level\n .\n ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an\n AG of 26. Likely due to lactic acidosis given his lactate of 13.7.\n Other differentials to consider include possible ketoacidosis, which is\n less likely given pt only had 15 ketones in his urine, ASA toxicity. Do\n not suspect Methanol or Ethylene glycol posioning given pt's history of\n exposures.\n - will check ASA level\n - will recheck pt's electrolytes to determine whether gap has resolved\n - as mentioned above will also recheck lactate level\n .\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. h.o. VT w/ AICD: Pt has history of VT with a recent visit with Dr.\n notable for an ICD of shocks/ATP for VT within the\n past few months. Per his note, he recommended a restart of Sotalol\n medication. On review of pt's prior Echo in he was noted to\n have an Ef of 20%, although admittedly rare Sotalol may sometimes cause\n exacerbation of CHF with an EF <30%. Will touch base with Dr. \n given that pt's admission is likely due to CHF exacerbation.\n - will continue Sotalol 120mg \n - will notify Dr. of pt's admission\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue to monitor daily weights and maintain strict I/Os\n - will continue on digoxin\n - as mentioned above will discuss with Dr. regarding Sotalol\n in the setting of heart failure admission and EF <30%.\n .\n ##. Depression: Will continue on home regimen of Citalopram and\n Bupropion.\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388391, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388394, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388397, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate. Lactate now trending down.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n IV abx d/c\n Pt with HR 70, Vent paced 100% of time\n Bp 100\ns/ this am, 85-90\ns/ after receiving Sotalol this am\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Left foot with DSD in place, pulses dopplerable\n Lower leg pink from mid calf to foot\n Response:\n Plan:\n PT consult\n Daily dressing change, see wound care Rn note\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 113 kg\n Daily weight:\n 112 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: Contact\n PMH: GI Bleed, Renal Failure\n CV-PMH: CAD, CHF, MI, Pacemaker\n Additional history: BiV ICD , osteomyelitis lt foot.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:66\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 450 mL\n 24h total out:\n 1,320 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:34 AM\n Potassium:\n 3.4 mEq/L\n 03:34 AM\n Chloride:\n 99 mEq/L\n 03:34 AM\n CO2:\n 31 mEq/L\n 03:34 AM\n BUN:\n 29 mg/dL\n 03:34 AM\n Creatinine:\n 1.4 mg/dL\n 03:34 AM\n Glucose:\n 103 mg/dL\n 03:34 AM\n Hematocrit:\n 33.1 %\n 03:34 AM\n Finger Stick Glucose:\n 94\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC711\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388370, "text": "Chief Complaint: 61 yo male hx of CAD s/p CABG, CHF with AICD and EF of\n 20 %, hypothyroidism and afib admitted to the ICU with dyspnea, concern\n for run of V-tach and elevated lactate.\n 24 Hour Events:\n - lactic acidosis workup\n -osmolar gap = 1\n -lactic acid trending down = 13.7 -> 11.2 -> 9.0 -> 4.8\n -serum tox = negative\n -co-ox = 2\n -CN = pending\n - EP consult: pacer interrogation reveals no evidence of ventricular\n arrythmias, recommend switching to amiodarone from sotalol.\n - emailed Dr. re: use of Sotalol with EF of 20% - reports\n patient had reaction to amiodarone and recs continuing Sotalol until\n f/u with him next week\n - lactate trend: 13.7 -> 11.2 -> 9 -> 4.8 -> 3.4\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:07 AM\n Furosemide (Lasix) - 06:20 PM\n Heparin Sodium (Prophylaxis) - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (68 - 83) bpm\n BP: 100/59(69) {79/38(48) - 105/79(84)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 112 kg (admission): 113 kg\n Height: 72 Inch\n CVP: 19 (2 - 26)mmHg\n CO/CI (Fick): (10.1 L/min) / (4.3 L/min/m2)\n SvO2: 78%\n Total In:\n 340 mL\n PO:\n 240 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 2,008 mL\n 820 mL\n Urine:\n 1,758 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,668 mL\n -820 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.39/33/106/31/-3\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 130 K/uL\n 10.0 g/dL\n 103 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 29 mg/dL\n 99 mEq/L\n 136 mEq/L\n 33.1 %\n 8.5 K/uL\n [image002.jpg]\n 05:44 AM\n 07:23 AM\n 09:45 AM\n 12:49 PM\n 12:59 PM\n 07:31 PM\n 03:34 AM\n WBC\n 11.5\n 10.0\n 8.5\n Hct\n 38.0\n 32\n 34.4\n 33.1\n Plt\n 182\n 138\n 130\n Cr\n 1.4\n 1.3\n 1.4\n 1.4\n TropT\n 0.05\n TCO2\n 21\n Glucose\n 90\n 98\n 99\n 75\n 103\n Other labs: PT / PTT / INR:43.7/42.5/4.7, CK / CKMB /\n Troponin-T:90//0.05, ALT / AST:, Alk Phos / T Bili:192/3.3,\n Lactic Acid:3.4 mmol/L, Albumin:3.5 g/dL, LDH:986 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.8 mg/Dl\n Micro\n - Legionella \n negative\n - HCV \n pending\n - MRSA, Blood Urine \n pending\n Imaging\n - CXR -\n Assessment and Plan\n ##. Elevated Lactate: patient initially noted to have lactate to 13.7\n at admission with unclear etiology. Workup showed negative tox screen,\n normal carboxy hemoglobin, absence of osmolar gap and no signs or\n symptoms concerning for infection. Lactate rapidly trended down\n throughout day. SVO2 continued to drop suggesting adequate O2\n extraction by peripheral tissues making septic shock less likely.\n - continue to trend lactate\n rapid fall with transaminitis may suggest\n episode of SVT with aberrancy and poor forward flow\n - f/u initial blood and urine cultures in setting of possible infection\n .\n ##. Dyspnea: likely do to fluid overload associated with prolonged SVT\n with abberancy. Cardiac enzymes cycled and stable which are below his\n prior baseline. AICD interrogated by EP and found no ventricular\n arrhythmias and only evidence of SVT with aberrancy and patient\n subjectively improved after resolution of arrhythmia.\n - f/u CXR for interval improvement s/p diuresis\n - continued gentle diuresis for fluid overload\n ##. Transaminitis/hyperbilirubinemia: patient with initial\n transaminitis at presentation now resolving, likely suggest hepatic\n congestion vs. shock liver from prolonged hypoperfusion. Imaging\n showed no evidence of cholecystitis or hepatitis.\n - continue to trend LFTs\n resolving\n - consider HIDA scan if continued abnormalities to further evaluate GB\n in setting of edema but no\ntrue\n cholecystitis and setting of gall\n stones\n - holding statin\n - f/u hepatitis serologies\n .\n ##. Anion Gap Acidosis: AG closed to 6 in setting of falling lactate\n suggesting source as lactic acidosis. No osmolar gap and negative tox\n screen.\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin and defer to Dr. \n - continue sotalol per Dr. \n .\n ##. Hypothyroidism: continue on home regimen of Levothyroxine.\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue on digoxin per Dr. as patient had prior\n reaction to amiodarone\n .\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:26 AM\n Multi Lumen - 06:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 388392, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt denies SOB\n Action:\n Pt continues on NC 2l\n Denies SOB\n Foley cath remains in place, draining clear amber urine\n KCL and Phos repleted this am\n Response:\n Resolution of SOB\n Plan:\n Fluid goals to run pt even today\n Electrolyte repletion as ordered\n Impaired Physical Mobility\n Assessment:\n Pt remains on bedrest\n Action:\n Physical therapy consult ordered\n Ref to get oob this am\n States walks with cane at home\n Able to assist with turns in bed\n Response:\n Plan:\n PT consult\n" }, { "category": "General", "chartdate": "2159-08-25 00:00:00.000", "description": "Generic Note", "row_id": 388381, "text": "MICU ATTENDING ADDENDUM\n 9:50a\n I saw and examined Mr. with the ICU team for the key portions\n of the services provided. I agree with the ICU team note from today,\n including the assessment and plan. I would emphasize and add the\n following points:\n 61 y/o man with complex cardiac disease presented with AFib with RVR\n complicated by hypotension and profound lactic acidosis. He reports\n feeling MARKEDLY improved, particularly with his dyspnea.\n 97.4 68 100/59 15 98% on nasal cannula. CVP 19. Distant\n heart. Course breath sounds. Looks chronically but not acutely ill.\n Abdomen is soft. Left TMA is dressed.\n Meds: SQH, H2B, bupropion, celexa, digoxin, levothyroxine, sotalol.\n CXR shows improved pulmonary edema.\n Labs show markedly decreased lactate; creatinine is slightly improved;\n bili and transaminases improved.\n A/P\n 61-year-old man with resolved/resolving global hypo\n 61M DCM, AG acidosis with markedly elevated lactate, abnormal LFTs and\n ARF. Agree with plan to r/o infection (pancx, monitor off abx), run\n meds for interactions (no obvious culprits), and give IV thiamine. No\n compelling evidence for dead bowel, occult infection, compartment\n syndrome, malignancy, mitochondrial or glycogen storage disease though\n hypoglycemia may contribute - will check CO / CN levels as well as tox\n screen and osm gap, and will ask family about possible exposures.\n Suspect he is recovering from a low flow state d/t poor forward flow,\n possibly precipitated by episodic AF c RVR. For AF c RVR - consult EP\n re interrogation and continue sotalol, not an anticoag candidate; will\n also check TFTs. Will trend LFTs and consider HIDA - possibly passed\n stone? ARF somewhat better, not far off baseline, hold diuretics today,\n likely resume in AM, check sed for calcium oxalate crystals. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2159-08-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 388385, "text": "Chief Complaint: 61 yo male hx of CAD s/p CABG, CHF with AICD and EF of\n 20 %, hypothyroidism and afib admitted to the ICU with dyspnea, concern\n for run of V-tach and elevated lactate.\n 24 Hour Events:\n - lactic acidosis workup\n -osmolar gap = 1\n -lactic acid trending down = 13.7 -> 11.2 -> 9.0 -> 4.8\n -serum tox = negative\n -co-ox = 2\n -CN = pending\n - EP consult: pacer interrogation reveals no evidence of ventricular\n arrythmias, recommend switching to amiodarone from sotalol.\n - emailed Dr. re: use of Sotalol with EF of 20% - reports\n patient had reaction to amiodarone and recs continuing Sotalol until\n f/u with him next week\n - lactate trend: 13.7 -> 11.2 -> 9 -> 4.8 -> 3.4\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:07 AM\n Furosemide (Lasix) - 06:20 PM\n Heparin Sodium (Prophylaxis) - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.4\nC (95.8\n HR: 71 (68 - 83) bpm\n BP: 100/59(69) {79/38(48) - 105/79(84)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 112 kg (admission): 113 kg\n Height: 72 Inch\n CVP: 19 (2 - 26)mmHg\n CO/CI (Fick): (10.1 L/min) / (4.3 L/min/m2)\n SvO2: 78%\n Total In:\n 340 mL\n PO:\n 240 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 2,008 mL\n 820 mL\n Urine:\n 1,758 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,668 mL\n -820 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.39/33/106/31/-3\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 130 K/uL\n 10.0 g/dL\n 103 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 29 mg/dL\n 99 mEq/L\n 136 mEq/L\n 33.1 %\n 8.5 K/uL\n [image002.jpg]\n 05:44 AM\n 07:23 AM\n 09:45 AM\n 12:49 PM\n 12:59 PM\n 07:31 PM\n 03:34 AM\n WBC\n 11.5\n 10.0\n 8.5\n Hct\n 38.0\n 32\n 34.4\n 33.1\n Plt\n 182\n 138\n 130\n Cr\n 1.4\n 1.3\n 1.4\n 1.4\n TropT\n 0.05\n TCO2\n 21\n Glucose\n 90\n 98\n 99\n 75\n 103\n Other labs: PT / PTT / INR:43.7/42.5/4.7, CK / CKMB /\n Troponin-T:90//0.05, ALT / AST:, Alk Phos / T Bili:192/3.3,\n Lactic Acid:3.4 mmol/L, Albumin:3.5 g/dL, LDH:986 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.8 mg/Dl\n Micro\n - Legionella \n negative\n - HCV \n pending\n - MRSA, Blood Urine \n pending\n Imaging\n - CXR -\n Assessment and Plan\n ##. Elevated Lactate: patient initially noted to have lactate to 13.7\n at admission with unclear etiology. Workup showed negative tox screen,\n normal carboxy hemoglobin, absence of osmolar gap and no signs or\n symptoms concerning for infection. Lactate rapidly trended down\n throughout day. SVO2 continued to drop suggesting adequate O2\n extraction by peripheral tissues making septic shock less likely.\n - continue to trend lactate\n rapid fall with transaminitis may suggest\n episode of SVT with aberrancy and poor forward flow\n - f/u initial blood and urine cultures in setting of possible infection\n .\n ##. Dyspnea: likely do to fluid overload associated with prolonged SVT\n with abberancy. Cardiac enzymes cycled and stable which are below his\n prior baseline. AICD interrogated by EP and found no ventricular\n arrhythmias and only evidence of SVT with aberrancy and patient\n subjectively improved after resolution of arrhythmia.\n - f/u CXR for interval improvement s/p diuresis\n - hold off on lasix today and signout to floor team that I/O\ns must be\n strictly followed so that patient is negative\n ##. Transaminitis/hyperbilirubinemia: patient with initial\n transaminitis at presentation now resolving, likely suggest hepatic\n congestion vs. shock liver from prolonged hypoperfusion. Imaging\n showed no evidence of cholecystitis or hepatitis.\n - continue to trend LFTs\n resolving\n - consider HIDA scan if continued abnormalities to further evaluate GB\n in setting of edema but no\ntrue\n cholecystitis and setting of gall\n stones\n - holding statin\n - f/u hepatitis serologies\n .\n ##. Anion Gap Acidosis: AG closed to 6 in setting of falling lactate\n suggesting source as lactic acidosis. No osmolar gap and negative tox\n screen.\n ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED.\n Although he received 10 of IV Lopressor, no response noted. Pt has\n history of A. fib, not anticoagulated due to a prior GI bleed whilst on\n Coumadin.\n - will continue off Coumadin and defer to Dr. \n - continue sotalol per Dr. \n .\n ##. Hypothyroidism: continue on home regimen of Levothyroxine.\n .\n ##. systolic/diastolic dysfunction: Pt received an Echo in \n which was notable for an EF of 20% as well as Grade III/IV LV diastolic\n dysfunction.\n - will continue on digoxin per Dr. as patient had prior\n reaction to amiodarone\n .\n Nutrition: Cardiac diet, replete lytes PRN\n Glycemic Control:\n Lines: Right IJ - discontinue\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Pending resolution of symptoms\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:26 AM\n Multi Lumen - 06:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2159-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 388357, "text": "61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and\n diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.\n Over the past 3 days he has noted progressive dyspnea on exertion.\n Denies any fevers, chills, nausea, vomiting, chest pain, melena,\n hemetemesis, hematochezia, diarrhea, constipation.\n CXR which showed fluid overload in the ED and he was thus given\n Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to\n concern for possible PNA. His labs were notable for lactate of 13.7,\n mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos\n 257 with a TB of 5.1. He received a RUQ U/S which showed edematous\n gallbladder wall but no cholecystitis, pt also had cholelithiasis.\n Underwent a CT abdomen/pelvis without contrast to eval for source of\n high lactate. CT scan was negative for bowel wall thickening,\n pneumotosis but did showed ground glass opacities in the lung. Prior to\n the CT scan he was given Levofloxacin and Zosyn given his acutely ill\n appearance and elevated lactate\n Dyspnea (Shortness of breath)\n Assessment:\n Pt with crackles in his lung bases bilaterally, upper lobes clear. SpO2\n 97-100% on 2L NC, pt states no SOB or DOE.\n Action:\n CXR took this morning, pt encouraged to cough and deep breath. Daily\n weight taken.\n Response:\n Venous PH 7.42, pt states being comfortable with breathing and shows no\n signs of distress. Pt\ns weight is 112kg.\n Plan:\n Titrate supplemental O2, encourage pt to deep breath, and encourage pt\n to use IS. Daily weights, pt is on a heart healthy low sodium diet \n to his Heart Failure.\n Impaired Physical Mobility\n Assessment:\n Pt at times with a flat affect and slow to manage ADL\ns on own.\n Action:\n Pt helped with turns however lower extremities unable to move tem as\n well as upper extremities.\n Response:\n Pt is a min assist X 1 for turns/\n Plan:\n Pt could benefit from a PT and OT consult. Encourage pt to be OOB.\n" }, { "category": "Radiology", "chartdate": "2159-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099870, "text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated lactate, diastolic heart failure, shortness of\n breath\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diastolic heart failure. Evaluate for change.\n\n COMPARISON: .\n\n FINDINGS:\n\n AP radiograph of the chest demonstrates decreased pulmonary edema and\n decreased bilateral pleural fluid. There is no focal consolidation. The\n cardiomediastinal silhouette is stable, again noting mild cardiomegaly, median\n sternotomy wires, and ICD as well as a pacemaker. Right central venous\n catheter remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1099695, "text": " 1:26 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? CHOLECYSTITIS ELEVATED LFT'S\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CHF and elevated LFTs, jaundice\n REASON FOR THIS EXAMINATION:\n ?cholecystitis\n ______________________________________________________________________________\n WET READ: JXRl FRI 2:28 AM\n gallbladder partially decompressed, so difficult to assess for wall\n thickening, but GB wall appears edematous.\n cholelithiasis\n moderate ascites, new from \n cannot assess sign due to mental status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 61-year-old male with CHF, elevated LFTs and jaundice.\n\n COMPARISON: None.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic, without\n focal lesions identified. The right kidney is similarly echogenic. There is\n no intra- or extra- hepatic biliary ductal dilation. The common duct measures\n 3 mm. Flow through the portal vein is anterograde. There is a small amount of\n ascites. The gallbladder is contracted with multiple shadowing stones. The\n right kidney appears echogenic. The pancreas is suboptimally visualized,\n although is suboptimally visualized. Son sign cannot be\n assessed due to clincal status of the patient.\n\n IMPRESSION:\n 1. Ascites.\n\n 2. Cholelithiasis in a contracted gallbladder.\n\n 3. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n 4. Probable echogenic right kidney incidentally noted, which may suggest\n medical renal disease.\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099690, "text": " 12:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with VT\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with V-tach.\n\n COMPARISON: Multiple prior chest radiographs, most recently .\n Chest CTA . CT abdomen/pelvis .\n\n CHEST, UPRIGHT PORTABLE FRONTAL VIEW: Lung volumes are low. There is\n heterogeneous opacification of the right with effusion and dense left lower\n lobe consolidation. The heart is markedly enlarged, increased in size from\n portable chest radiograph .\n\n Radiographic findings correspond to unusual pleural fluid collections and mild\n pulmonary edema as demonstrated on subsequent CT abdomen/pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1099697, "text": " 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abdominal catastrophe\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 50 Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated LFTs and lactate 13.7\n REASON FOR THIS EXAMINATION:\n r/o abdominal catastrophe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl FRI 4:33 AM\n small b/l pleural effusions, fluid along fissures\n cardiomegaly\n small amount of ascites, free pelvic fluid\n cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from \n no secondary signs of bowel ischemia (no pneumatosis, free air, or dilation)\n\n pt received a 30mL prebolus of contrast\n WET READ VERSION #1 JXRl FRI 4:33 AM\n small b/l pleural effusions, fluid along fissures\n cardiomegaly\n small amount of ascites, free pelvic fluid\n cholelithiasis. GB shows wall edema, but decompressed\n L1 compression deformity new from \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with elevated LFTs and a lactate of 13.7.\n\n COMPARISON: Abdominal ultrasound, one hour prior and CT torso .\n Chest CTA .\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases through the\n pubic symphysis without administration of IV contrast. The study was\n protocoled as noncontrast. However, 50 ml prebolus of IV contrast was\n administered. Multiplanar reformatted images were generated.\n\n CT ABDOMEN: The pleura is thickened and hyperdense, which could reflect some\n enhancement in this patient who received a small amount of IV contrast, vs.\n precontrast hyperdensity. The appearance is similar to . There are\n small bilateral pleural effusions and bibasilar atelectasis. The heart is\n enlarged. There are dense mitral annular calcifications. Pacer/ICD wires are\n incompletely imaged. Calcifications of the cardiac apex likely represent\n calcified apical infarct.\n\n The relative lack of IV contrast limits evaluation of abdomen for focal\n lesions. There is a small amount of ascites. The liver is homogeneous. The\n gallbladder is decompressed, with numerous gallstones. The spleen is normal\n in size. The pancreas is unremarkable. The adrenals are unremarkable. There\n is a small amount of contrast in the renal collecting systems bilaterally.\n There are no enlarged mesenteric or retroperitoneal lymph nodes. The stomach,\n (Over)\n\n 2:08 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abdominal catastrophe\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 50 Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n duodenum, small bowel, and colon are nondilated. There is no pneumatosis and\n no free intraperitoneal air.\n\n The abdominal aorta is densely calcified, with a focal ulcerated plaque or\n small saccular aneurysm (2:57).\n\n CT PELVIS: The urinary bladder is decompressed with a Foley catheter in\n place. The rectum and sigmoid are within normal limits. The prostate and\n seminal vesicles are unremarkable. There is a small amount of free pelvic\n fluid.\n\n There are multilevel degenerative changes of the thoracic spine. Compression\n deformity of L1 is of age indeterminate, new from . Grade 2\n anterolisthesis of L5 on S1 with a large bridging anterior ostephyte and\n endplate sclerosis has progressed from . There are bilateral pars\n defects.\n\n IMPRESSION:\n 1. No secondary signs to suggest bowel ischemia. Vessel patency on this\n study cannot be evaluated due to lack of a full contrast bolus.\n 2. Thickened and hyperdense pleura bilaterally, similar to .\n Clinical correlation with history of possible prior infection or known\n pleural disease is recommended. This is incompletely imaged on this\n examination.\n 3. Small bilateral pleural effusions. Fluid tracks along the pleural\n fissures.\n 4. Calcified cardiac apex suggestive of chronic apical infarct.\n 5. Small amount of ascites.\n 6. Cholelithiasis.\n 7. Atherosclerotic vascular calcifications. Ulcerated plaque or small\n saccular aneurysm of the infrarenal abdominal aorta (2:57).\n 8. L1 compression deformity, new from the most recent prior study of .\n Severe L5-S1 degenerative changes. Bilateral L5 pars defects.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2159-08-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1099699, "text": " 3:24 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement r ij\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypotension, tachycardia, fever new line placement please\n confirm line placement\n REASON FOR THIS EXAMINATION:\n confirm line placement r ij\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:37 A.M. :\n\n HISTORY: Hypotension, tachycardia and new line in place.\n\n IMPRESSION: AP chest compared to at 12:16 a.m.:\n\n Tip of the new right jugular line is partially obscured, but beyond the upper\n SVC. No pneumothorax. A small right pleural effusion was present prior to\n line placement. Severe cardiomegaly is unchanged. In addition to right\n pleural effusion collected in fissures in the right lower lung, there is a\n suggestion of new consolidation, possibly pneumonia, since the upper lobes do\n not show progression of pulmonary edema. Transvenous right atrial and two\n transvenous right ventricular pacer defibrillator leads emanate from the right\n axillary pacemaker and one ventricular lead exiting from the left chest could\n be connected to an abdominal or temporary pacemaker. No pneumothorax.\n\n" } ]

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Patient was admitted for concern of meningitis, brainstem encephalitis to General Neurology Service. . 1. Neurology: Upon admission, patient had copius oral secretions, minimal alertness, worsening spasticity, and ophthalmoplegia with left 3rd nerve involvement and bilateral 6th cranial involvement. Lumbar puncture on admission showed WBC 150 wbc, 160 rbc with diff of 77%polys, 12% lymphs, 11% monos with TP 52, glucose 49; gram stain with 2+PMNs. He was kept in ICU for concern of poor handling of secretions and was stable for step-down unit the next day. MRI brain on admission showed new enhancement of the posterior pons and mid brain with new swelling of the left cerebral peduncle since scan. There was resolution of the prior enhancement of the lower pons, left inferior and middle cerebellar peduncles, and the left internal capsule/thalamus. MRI C-spine was normal. was making some mouthing movements that were concerning for seizure. However, a routine EEG showed occasional bursts of theta slowing in a random distribution, suggesting a mild encephalopathy. . Over the first week of his hospital course, his opthalmoplegia worsened and he developed facial diplegia. He had increased tone in all extremities and had extensor posturing to minimal stimulation. He had a hyperactive gag and jaw jerk indicative of pseudobulbar palsy. He was treated with 5 day course of Solumedrol without improvement. He was then started on 5 day course of IVIG and was noted to be more alert and improved extraocular movements by day 3 of this treatment. Patient started on Ampicillin, Ceftriaxone, Vancomycin, Acyclovir upon admission for concern of bacterial meningitis/HSV encephalitis. Acyclovir was discontinued once HSV PCR negative. Though CSF bacterial cultures were negative, he continued on course of ceftriaxone/vancomycin/ampicillin for 13 days. Patient had repeat lumbar puncture for further work-up of brainstem findings. . Work-up of his condition included 2 lumbar punctures, muscle/nerve biopsy by neurosurgery and small bowel biopsy by GI for concern of Whipple's disease. Differential diagnosis of etiology included 1. infection (though Serum Toxoplama IgM and IgG Ab Neg, Serum Cryptococcal Ag Neg, Serum Mycoplasma Ab IgM neg, IgG pos (1.7), Serum EBV Ab panel Neg, Serum Lyme Neg, RPR non-reactive and CSF EBV PCR negative, CSF Enterovirus PCR negative, CSF cx negative, CSF HHV6 negative, CSF Lyme negative, CSF VZV negative; CSF TB-PCR and GQ1B IgG Ab PENDING), 2. inflammatory, eg demyelinating disease ( Neg, ANCA Neg, Anticardiolipin IgG 17 (nl 0-15), Anticardiolipin IgA 8.2 (nl 0-12.5), ACE 15, ESR 20, CRP 37.8, CSF-PEP No oligoclonal banding, CSF IgG index and synthesis rate normal, CSF Whipple's PCR negative; work-up for Behcet's including ophthamological exam for uveitis and skin test with subcutaneous injection of saline negative) and 3. neoplastic (cytology sent, CT torse negative for adenopathy, scrotal US negative for mass). . A repeat lumbar puncture on showed 3 wbc, 0 rbc, TP 26, glucose 81; gram stain was negative. Cytology sent was sent and showed atypical lymphocytes but flow studies will have to be repeated at later date becuase poor sample. A MRS was done on and showed improvement in the enhancement seen within the posterior pons and mid brain on examination from . No new areas of abnormal enhancement were identified and there was normal MR spectrographic analysis of the midbrain and pons. Tissue samples of small bowel was within normal limits. Tissue of left gastrocnemius showed mild myopathy, chronic and active and no inflammatory findings on sural nerve pathology. Review of old medical records from of () indicated that midbrain was biopsied during a similar presentation of illness with T2 bright lesions in midbrain and pons. This biopsy revealed only gliotic changes in grey and white matter. No evidence of tumor or inflammatory changes. There were rare "rod cells" and lymphocytes associated with disorganized fragment of leptomeninges suggestive of encephalitis. A metabolic work-up had not been initiated at and patient had very long chain fatty acids (within normal limits), MMA (80 with normal range 87-318) sent on this admission. Further metabolic work-up may be considered in future. . Final results of muscle/nerve biopsy are pending. . On discharge, his bulbar function has improved, as has his strength. He is now, however, showing signs of pseudobulbar affect (mainly inappropriate laughter). He continues to have difficulty with speech and swallowing, as well as sitting up without support. . 2. CV/Resp: Patient was initially admitted to ICU for concern of poor handling of secretions. He developed an oxygen requirement several times during his hospitalization, which usually improved with suctioning. He was stable on room air at the time of discharge. . 3. FEN/GI: Mr. was fed via NG tube until he was more alert. During a speech and swallow evaluation on , it was determined that patient should remain NPO. A PEG tube was inserted. His AST/ALT were elevated on . GI was consulted and it was thought that his transaminitis was most likely drug-induced due to ceftriaxone. Labs were sent for possible infectious causes: HCV ab neg, HBsAg neg, HBsAb pos, HBcAb neg; HCV and CMV viral loads pending. A liver ultrasound was normal. On , his AST/ALT began to trend downwards. Patient was also noted to have constipation and was kept on an aggressive bowel regimen. . 4. Heme: Patient noted to have an anemia of chronic disease. Hct decreased from 36 to 29 on . DIC labs, coags, stool guaics were normal. . 5. ID: See Neuro. Patient had low grade fevers for which he was cultured on . BCX and UCX were negative. He had an episode of hematuria on with the Foley inserted. Blood cultures were negative. Foley was removed. . 6. Rehab: Patient worked with PT for concern of spasticity. . 7. Rheum: Rheum service consulted for concern of vasculitis who suggested angiogram in future. . 8. Ophthalmology: An ophthamologic exam was done to look for signs of uveitis which may be consistent with Behcet's disease. Exam was negative for uveitis but was found to have an increased cup-to-disc ratio and increased intraocular pressure. Follow-up was recommended in 6 mos to evaluate for glaucoma, especially given treatment with steroids.

Then after the uneventful intravenous administration of 130 cc of nonionic contrast, imaging was obtained through the chest, abdomen, and pelvis. Normal MR spectrographic analysis of the midbrain and pons. TECHNIQUE: Axial imaging was obtained of the abdomen without intravenous contrast. TECHNIQUE: Sagittal pre- and post-gadolinium T1; axial and post-gadolinium T1, T2, FLAIR, GRE, DWI, DTI; and coronal post-gadolinium T1-weighted images of the head were obtained. With the exception of a nasogastric tube placement, there has not been a substantial change in the appearance of the chest. Bowel is of normal caliber. The bowel is of normal contour. FINAL REPORT STUDY: MR of the head with and without contrast, including MR spectroscopy. Spectral analysis of the mid brain and pons reveal no abnormalities in the choline, creatine, and NAA peaks. UpdateSee careview for details...Neuro: Pt remains lethargic, follows simple commands at times, MAE, opens eyes to verbal, making some sounds but unable to understand themCV: VSS, afebrileResp: lungs coarse to clear, prod cough, sats 96-98%, mild sleep apnea noted, O2 3lncGI: abd soft, no BM, NPOGU: incont urine, adult diaper onSkin: dry and intact, LP site clean with band aid intactPlan: neuro assess There are no increased lactate or lipid levels in the area of original abnormality. FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable. FINDINGS FOR CT OF THE CHEST WITH IV CONTRAST: There is no mediastinal, hilar, or axillary lymphadenopathy. INDICATION: Nasogastric tube placement. FINDINGS FOR CT OF THE PELVIS: There is no ascites, lymphadenopathy, or free intraperitoneal gas. Pt put on 2Liters NC and sats have remained 94-98%.CV: Pt ST with HR 100-108, BP 110s-130s.GI/GU: Pt NPO, abdomen is large but soft with positive BS. No new areas of abnormal enhancement identified. The visualized orbits and major flow voids are normal. INDICATION: Patient with recurrent cranial nerve dysfunction and previously identified midbrain and pontine lesions. No new areas of abnormal enhancement are identified. There is no sizeable pleural effusion. 6:58 AM MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # MR SPECTROSCOPY Reason: Patient has midnrain and pontine lesions on T2. (Over) 6:58 AM MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # MR SPECTROSCOPY Reason: Patient has midnrain and pontine lesions on T2. A nasogastric tube is seen in place coursing throughout the esophagus. LS improved slightly after suctioning. Nasogastric tube terminates within the stomach. There is no shift identified of normally midline structures or hydrocephalus. present but minimal on today's examination. Portable AP chest radiograph compared to . MR spectroscopy was performed of the mid brain and pons. Patient post-steroid treatment with no clinical improvement. The paranasal sinuses are otherwise clear. (Over) 3:06 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for granulomatous disease, mass lesions Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) A large retention cyst is seen within the right maxillary sinus. There is no pleural or pericardial effusion. There is bilateral perihilar haziness which might represent volume overload or pulmonary edema. Needs MRS perfusion scans. The and white matter differentiation is maintained with no areas of slowed diffusion. Left pupil at 5mm and sluggishly reactive. Review of bone windows demonstrates no suspicious lytic or blastic lesions. NG tube tip is within the stomach. The distal tip of the nasogastric tube is seen within the body of the stomach. There is no pneumothorax. ?position REASON FOR THIS EXAMINATION: NGT placement FINAL REPORT REASON FOR EXAMINATION: Recurrent oxygen requirement. Received 5 d Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) There is bibasilar atelectasis. Nursing admit notePt arrived from 5 with assessment as follows:NEURO: Pt lethargic. There is no ascites, lymphadenopathy, or free intraperitoneal gas. 3:06 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: assess for granulomatous disease, mass lesions Admitting Diagnosis: R/O MENINGOENCEPHALITIS Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 21 year old man with recurrent brainstem lesions concerning for sarcoid vs. lymphoma REASON FOR THIS EXAMINATION: assess for granulomatous disease, mass lesions No contraindications for IV contrast FINAL REPORT CT TORSO WITH CONTRAST, COMPARISON: CT torso, . Pt follows commands and can MAE. There is no evidence of intracranial hemorrhage. No evidence of mass or lymphadenopathy within the chest, abdomen, or pelvis. Discussed with Dr. Bibasilar atelectasis. NGT shifted. IMPRESSION: 1. The tip of PICC line is not well demonstrated as overlying external monitoring leads limit assessment. LUE able to lift and hold, and other extremities with generalized weakness but an move on bed. Continue IV antibiotics as ordered.

6

[ { "category": "Radiology", "chartdate": "2199-01-25 00:00:00.000", "description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS", "row_id": 943761, "text": " 6:58 AM\n MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n MR SPECTROSCOPY\n Reason: Patient has midnrain and pontine lesions on T2. Received 5 d\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with recurrent cranial nerve dysfunction, ataxia and slurred\n speech, MRI abn\n REASON FOR THIS EXAMINATION:\n Patient has midnrain and pontine lesions on T2. Received 5 days steroids, no\n clinical improvement. Needs MRS perfusion scans. Discussed with Dr. \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MR of the head with and without contrast, including MR spectroscopy.\n\n INDICATION: Patient with recurrent cranial nerve dysfunction and previously\n identified midbrain and pontine lesions. Patient post-steroid treatment with\n no clinical improvement. Assess for progression of underlying lesions.\n\n COMPARISONS: MR from .\n\n TECHNIQUE: Sagittal pre- and post-gadolinium T1; axial and post-gadolinium\n T1, T2, FLAIR, GRE, DWI, DTI; and coronal post-gadolinium T1-weighted images\n of the head were obtained. MR spectroscopy was performed of the mid brain and\n pons.\n\n FINDINGS: The enhancement seen on the previous examination from within\n the pons and central mid brain is significantly improved, i.e. present but\n minimal on today's examination. No new areas of abnormal enhancement are\n identified.\n\n There is no evidence of intracranial hemorrhage. There is no shift identified\n of normally midline structures or hydrocephalus. The and white matter\n differentiation is maintained with no areas of slowed diffusion.\n\n Spectral analysis of the mid brain and pons reveal no abnormalities in the\n choline, creatine, and NAA peaks. There are no increased lactate or lipid\n levels in the area of original abnormality.\n\n The visualized orbits and major flow voids are normal. A large retention cyst\n is seen within the right maxillary sinus. The paranasal sinuses are otherwise\n clear.\n\n IMPRESSION: Significant improvement in the enhancement seen within the\n posterior pons and mid brain on examination from . No new areas of\n abnormal enhancement identified. Normal MR spectrographic analysis of the\n midbrain and pons.\n\n\n (Over)\n\n 6:58 AM\n MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n MR SPECTROSCOPY\n Reason: Patient has midnrain and pontine lesions on T2. Received 5 d\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2199-01-14 00:00:00.000", "description": "Report", "row_id": 1554269, "text": "Nursing admit note\nPt arrived from 5 with assessment as follows:\nNEURO: Pt lethargic. Pt follows commands and can MAE. LUE able to lift and hold, and other extremities with generalized weakness but an move on bed. Left pupil at 5mm and sluggishly reactive. Right pupil at 3mm and reactive to light. Pt intermittently attempts to verbalize although words are garbled.\nRESP: LS congested, pt suctioned for large amts of thick yellow secretions. LS improved slightly after suctioning. Pt put on 2Liters NC and sats have remained 94-98%.\nCV: Pt ST with HR 100-108, BP 110s-130s.\nGI/GU: Pt NPO, abdomen is large but soft with positive BS. Pt incontinent of urine in large amounts. Attends placed on pt.\nSOCIAL: Pt lives at in group home setting at baseline.\nID: Tmax 100.1, continue to monitor\nPLAN: Monitor neuro status closely. Pt to receive methylprednisone 1000mg X 5 days. Continue IV antibiotics as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2199-01-15 00:00:00.000", "description": "Report", "row_id": 1554270, "text": "Update\nSee careview for details...\n\nNeuro: Pt remains lethargic, follows simple commands at times, MAE, opens eyes to verbal, making some sounds but unable to understand them\n\nCV: VSS, afebrile\n\nResp: lungs coarse to clear, prod cough, sats 96-98%, mild sleep apnea noted, O2 3lnc\n\nGI: abd soft, no BM, NPO\n\nGU: incont urine, adult diaper on\n\nSkin: dry and intact, LP site clean with band aid intact\n\nPlan: neuro assess\n" }, { "category": "Radiology", "chartdate": "2199-01-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 943743, "text": " 10:04 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with mental status changes and recurrent oxygen\n requirement. NGT shifted. ?position\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Recurrent oxygen requirement.\n\n Portable AP chest radiograph compared to .\n\n NG tube tip is within the stomach. The heart size is enlarged with some\n dilation of the azygos vein. There is bilateral perihilar haziness which\n might represent volume overload or pulmonary edema. There is no sizeable\n pleural effusion. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-01-19 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 942999, "text": " 3:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with mental status changes\n\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: at 7:33.\n\n INDICATION: Nasogastric tube placement.\n\n Nasogastric tube terminates within the stomach. The tip of PICC line is not\n well demonstrated as overlying external monitoring leads limit assessment.\n With the exception of a nasogastric tube placement, there has not been a\n substantial change in the appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2199-01-17 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 942606, "text": " 3:06 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for granulomatous disease, mass lesions\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with recurrent brainstem lesions concerning for sarcoid vs.\n lymphoma\n REASON FOR THIS EXAMINATION:\n assess for granulomatous disease, mass lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH CONTRAST, \n\n COMPARISON: CT torso, .\n\n INDICATION: 21-year-old male with recurrent brainstem lesions concerning for\n sarcoid versus lymphoma, assess for granulomatous disease, mass lesions.\n\n TECHNIQUE: Axial imaging was obtained of the abdomen without intravenous\n contrast. Then after the uneventful intravenous administration of 130 cc of\n nonionic contrast, imaging was obtained through the chest, abdomen, and\n pelvis. Patient also received oral contrast.\n\n FINDINGS FOR CT OF THE CHEST WITH IV CONTRAST: There is no mediastinal,\n hilar, or axillary lymphadenopathy. There is no pleural or pericardial\n effusion. There is bibasilar atelectasis. A nasogastric tube is seen in\n place coursing throughout the esophagus.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The liver,\n gallbladder, spleen, pancreas, adrenal glands, and kidneys are unremarkable.\n The distal tip of the nasogastric tube is seen within the body of the stomach.\n There is no ascites, lymphadenopathy, or free intraperitoneal gas. The bowel\n is of normal contour.\n\n FINDINGS FOR CT OF THE PELVIS: There is no ascites, lymphadenopathy, or free\n intraperitoneal gas. There is a Foley with balloon inflated within the\n bladder. Bowel is of normal caliber. There is no evidence of mass.\n\n Review of bone windows demonstrates no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. No evidence of mass or lymphadenopathy within the chest, abdomen, or\n pelvis.\n 2. Bibasilar atelectasis.\n\n (Over)\n\n 3:06 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for granulomatous disease, mass lesions\n Admitting Diagnosis: R/O MENINGOENCEPHALITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

19,371

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77 year old female yo female h/o severe COPD (on 2L NC at home), T3 lung cancer s/p R pneumonectomy 4 years ago, admitted with COPD flare, found to have new liver, lung, and T6 lesions concerning for metastases. 1) COPD exacerbation: The patient received high dose steroids, bronchodilators, and 5 days of azithromycin. Her respiratory status gradually improved, and she was transferred from the ICU to the general medical floor . There, she was continued on a steroids, which will gradually taper until she follows up with Dr. next week, who will decide whether to continue steroids. At time of discharge, she was close to her baseline respiratory status and was on her home O2 requirement (2 liters). 2) Liver/lung/spine masses: A Chest CT revealed new left pulmonary and right hepatic masses, along with a new T6 sclerotic lesion (see result section). These findings are concerning for metastases, most likely lung CA, although pt also has h/o breast CA and a known cystic lesion near the duodenum (noted on a prior admission). The patient underwent an ultrasound-guided liver biopsy on , the results of which are pending at time of discharge. The patient will follow-up with Dr. and her PCP . to discuss the results and potential treatment. 3) Type II diabetes poorly controlled with complications: The patient was continued on Lantus with a Humalog sliding scale while in-house. As her prednisone dose was tapered, her glucose control improved and she was discharged on her home Lantus regimen (8 units). 4) Thyroid function test abnormalities: The patient's TSH was noted to be depressed at 0.1, although her free T4 was normal at 0.94. These should be repeated as an outpatient in 6 weeks. 5) Hypertension: The patient was continued on diltiazem. 6) Disposition: The patient was discharged home with VNA and PT to follow-up with her PCP and CT surgeon.

Recieved atrovent neb Tx q 6 hrs w/improvement in wheezes. Tmax 99.3po.Pain: Denies.Activity: Steady on feet. NS lock.A/P: exacerbation of COPD vs spread of lung CApossible bronch after Sx abatepossible call out today D/C'ed it. UA, C&S sent for c/o urgency & frequency. Felt better w/4 L NP @ that time for a few minutes. R side more diminished than L. Audibly wheezy when atrovent Tx due. Pt may have re-occurance in L lung now. Sinus rhythm with PACsPossible right atrial abnormalityPoor R wave progression - possible inferior myocardial infarctionLeft axis deviationSince previous tracing of , no significant change Induced for sputum for cytology & pneumocystis. Will try albuterol neb if needed. Atrovent nebs Q 6 hrs Tachypnea noted when patient got up to commode. Resp Care NotePt admitted within past 24 hrs. Wears 2 L O2 continuously. Able to move all limbs s difficulty & equally.CV: HR:80's SR no ectopy, cuff BP: 120's-170's/60's-80'sResp: Upper lungs clear. New R post forearm #20 started . Got up to commode several times w/assist of 1 person to help w/lines. Induced sputum sent for cytology and PCP. C/o that albuterol neb Tx gives a jittery feeling & nausea. Uses home O2 @ 2-3L NP.GI: LBM @ home. RR 22-38 O2sat 95-100% on 3L NP. She has hx COPD and lung ca R lung which resulted in pneumonectomy some years ago. Soft mildly distended abdomen. NPN 1900-Neuro: A&OX3. 4 NURSING PROGRESS NOTE 0700-1500FOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN "NURSING TRANSFER NOTE " SECTION OF CAREVIEW. THANK YOU. + bowel sounds.GU: Voids clear yellow urine. Lower lung fields diminished. Patient normally independent. Maintained O2 sat >90% even without increase in delivered O2. Has significant other who visits patient in her home, but just left to go to .Access: L ant forearm #20 () painful even w/blood return. is alert and oriented. Supportive family: stayed w/patient over last 3 weeks to help her w/ADL's. Tachypnea w/activity.Coping: Pleasant woman who enjoys talking.

4

[ { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517939, "text": " 4 NURSING PROGRESS NOTE 0700-1500\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE \" SECTION OF CAREVIEW. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517937, "text": "Resp Care Note\n\nPt admitted within past 24 hrs. She has hx COPD and lung ca R lung which resulted in pneumonectomy some years ago. Pt may have re-occurance in L lung now. Induced sputum sent for cytology and PCP. is alert and oriented. Wears 2 L O2 continuously. Atrovent nebs Q 6 hrs\n" }, { "category": "Nursing/other", "chartdate": "2196-05-18 00:00:00.000", "description": "Report", "row_id": 1517938, "text": "NPN 1900-\nNeuro: A&OX3. Able to move all limbs s difficulty & equally.\n\nCV: HR:80's SR no ectopy, cuff BP: 120's-170's/60's-80's\n\nResp: Upper lungs clear. Lower lung fields diminished. R side more diminished than L. Audibly wheezy when atrovent Tx due. RR 22-38 O2sat 95-100% on 3L NP. Tachypnea noted when patient got up to commode. Felt better w/4 L NP @ that time for a few minutes. Maintained O2 sat >90% even without increase in delivered O2. Recieved atrovent neb Tx q 6 hrs w/improvement in wheezes. Induced for sputum for cytology & pneumocystis. Coughing up nothing to clear secretions. C/o that albuterol neb Tx gives a jittery feeling & nausea. Will try albuterol neb if needed. Uses home O2 @ 2-3L NP.\n\nGI: LBM @ home. Soft mildly distended abdomen. + bowel sounds.\n\nGU: Voids clear yellow urine. UA, C&S sent for c/o urgency & frequency. Tmax 99.3po.\n\nPain: Denies.\n\nActivity: Steady on feet. Got up to commode several times w/assist of 1 person to help w/lines. Tachypnea w/activity.\n\nCoping: Pleasant woman who enjoys talking. Supportive family: stayed w/patient over last 3 weeks to help her w/ADL's. Patient normally independent. Has significant other who visits patient in her home, but just left to go to .\n\nAccess: L ant forearm #20 () painful even w/blood return. D/C'ed it. New R post forearm #20 started . NS lock.\n\nA/P: exacerbation of COPD vs spread of lung CA\npossible bronch after Sx abate\npossible call out today\n\n\n" }, { "category": "ECG", "chartdate": "2196-05-17 00:00:00.000", "description": "Report", "row_id": 298918, "text": "Sinus rhythm with PACs\nPossible right atrial abnormality\nPoor R wave progression - possible inferior myocardial infarction\nLeft axis deviation\nSince previous tracing of , no significant change\n\n" } ]

60,579

135,143

76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement who presented for total right hip revision with significant intra-operative bleeding and DIC requiring ICU transfer. ICU COURSE: # Hypotension: Shock most likely due to hypovolemia/hemorrhage given visible, significant bleeding in the OR. Patient was complicated by DIC and profuse bleeding (EBL 3000cc+) requiring 12L lactated ringers, 1.4L normal saline, 4 units pRBC, two units FFP and 2100cc of cell . Phenylephrine was started, but was weaned off within a day of the operation with stable BPs. Also on the differential were sepsis and cardiogenic process, both less likely. The patient has recent history of hip joint infection but presumably adequately treated; likewise, he had hemoptysis and cough in for which he was evaluated by pulmonary and treated with Z-pack. CXR currently possibly concerning for developing retrocardiac/right middle lobe infiltrate but not overwhelming. He was instrumented, though, today with new leukocytosis. Given empiric vancmycin, cefepime and ciprofloxacin, however changed to ciprofloxacin and cefazolin POD #2. Blood, urine and tissue cultures without growth. For cardiogenic processes, the patient has no known cardiac disease and good functional capacity previously. EKG also unchanged from prior. Coagulopathy management as below. Once stabilized, without further evidence of bleeding, patient was transferred to orthopedic surgery.

Status post right total hip long stem revision arthroplasty with constrained liner. INDICATION: Postoperative evaluation, status post revision right total hip arthroplasty. IMPRESSION: Expected postoperative change from right total hip long stem revision arthroplasty with constrained liner. Subcutaneous edema. Significantly since , gaseous distention of the stomach has resolved. Recently intubated. Low lung volumes with bilateral areas of atelectasis and borderline size of the cardiac silhouette. The endotracheal tube is in unchanged position. FINDINGS: As compared to the previous radiograph, the patient has undergone surgery. FINDINGS: Lateral skin staples. Getting significant amounts of fluid resuscitation, intubated. Sinus tachycardia. The patient is now intubated, the tip of the endotracheal tube projects 4.5 cm above the carina. FINDINGS: As compared to the previous radiograph, the image is unchanged. The lung volumes are low, there are bilateral areas of basal atelectasis. Degenerative changes of the knee. Borderline size of the cardiac silhouette without evidence of pulmonary edema. REASON FOR THIS EXAMINATION: s/p R THR revision FINAL REPORT HISTORY: THR revision. Surgical drain is present. Severe intraoperative bleeding. IMPRESSION: AP chest compared to and 5: Opacification at both lung bases is probably a combination of persistent atelectasis, moderate on the right and moderate to severe on the left. 7:45 PM FEMUR (AP & LAT) RIGHT Clip # Reason: post op eval **patient in . Compared to the previous tracing of the rate hasincreased. FINDINGS: In comparison with the study of , there is little overall change in the appearance of the long stem total hip replacement that appears to be well seated and without evidence of hardware-related complication. REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT AP CHEST, 6:04 A.M., HISTORY: Osteoarthritis. 9:44 PM CHEST (PORTABLE AP) Clip # Reason: acute cardiopulm processes Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with right hip revision today s/p significant blood loss in OR REASON FOR THIS EXAMINATION: acute cardiopulm processes FINAL REPORT CHEST RADIOGRAPH INDICATION: Hip revision, significant blood loss, rule out cardiopulmonary process. No newly appeared focal parenchymal opacities. 5:43 AM CHEST (PORTABLE AP) Clip # Reason: acute cardiopulm processes - patient remains intubated Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with osteoarthritis s/p total hip replacement complicated by salmonells joint infection now s/p total hip revision with significant intraoperative bleeding REASON FOR THIS EXAMINATION: acute cardiopulm processes - patient remains intubated FINAL REPORT CHEST RADIOGRAPH INDICATION: Osteoarthritis, status post total hip replacement, joint infection, rule out cardiopulmonary process. There also is minimal blunting of the left costophrenic sinus, so that the presence of a small left pleural effusion cannot be excluded. There is also at least a small and a moderate volume of left pleural fluid. PLEASE CAPTURE FROM KNEE TO Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man s/p revision R THA REASON FOR THIS EXAMINATION: post op eval **patient in . PLEASE CAPTURE FROM KNEE TO PELVIS (extra long revision prosthesis) FINAL REPORT STUDY: Two views of the right femur . No pulmonary edema. 5:07 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old male with past medical history of osteoarthritis s/p right total hip arthroplasty in complicated by Salmonella septic joint requiring multiple wash outs and antibiotic spacer placement who presented for total right hip revision with significant intra-operative bleeding. COMPARISON: . COMPARISON: . COMPARISON: . 10:02 AM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: s/p R THR revision Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA MEDICAL CONDITION: 76 year old man with Revision Right Hip Replacement.

6

[ { "category": "Radiology", "chartdate": "2188-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222408, "text": " 9:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulm processes\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right hip revision today s/p significant blood loss in OR\n REASON FOR THIS EXAMINATION:\n acute cardiopulm processes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hip revision, significant blood loss, rule out cardiopulmonary\n process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n surgery. The patient is now intubated, the tip of the endotracheal tube\n projects 4.5 cm above the carina.\n\n The lung volumes are low, there are bilateral areas of basal atelectasis.\n There also is minimal blunting of the left costophrenic sinus, so that the\n presence of a small left pleural effusion cannot be excluded. Borderline size\n of the cardiac silhouette without evidence of pulmonary edema. No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222449, "text": " 5:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulm processes - patient remains intubated\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with osteoarthritis s/p total hip replacement complicated by\n salmonells joint infection now s/p total hip revision with significant\n intraoperative bleeding\n REASON FOR THIS EXAMINATION:\n acute cardiopulm processes - patient remains intubated\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Osteoarthritis, status post total hip replacement, joint\n infection, rule out cardiopulmonary process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the image is unchanged.\n The endotracheal tube is in unchanged position. Low lung volumes with\n bilateral areas of atelectasis and borderline size of the cardiac silhouette.\n No newly appeared focal parenchymal opacities. No pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222591, "text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old male with past medical history of osteoarthritis s/p right total\n hip arthroplasty in complicated by Salmonella septic joint requiring\n multiple wash outs and antibiotic spacer placement who presented for\n total right hip revision with significant intra-operative bleeding. Getting\n significant amounts of fluid resuscitation, intubated.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:04 A.M., \n\n HISTORY: Osteoarthritis. Recently intubated. Severe intraoperative\n bleeding.\n\n IMPRESSION: AP chest compared to and 5:\n\n Opacification at both lung bases is probably a combination of persistent\n atelectasis, moderate on the right and moderate to severe on the left. There\n is also at least a small and a moderate volume of left pleural fluid.\n Significantly since , gaseous distention of the stomach has resolved.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-12-01 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1223015, "text": " 10:02 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: s/p R THR revision\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with Revision Right Hip Replacement.\n REASON FOR THIS EXAMINATION:\n s/p R THR revision\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: THR revision.\n\n FINDINGS: In comparison with the study of , there is little overall change\n in the appearance of the long stem total hip replacement that appears to be\n well seated and without evidence of hardware-related complication.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-11-26 00:00:00.000", "description": "R FEMUR (AP & LAT) RIGHT", "row_id": 1222399, "text": " 7:45 PM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: post op eval **patient in . PLEASE CAPTURE FROM KNEE TO\n Admitting Diagnosis: SEPTIC TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p revision R THA\n REASON FOR THIS EXAMINATION:\n post op eval **patient in . PLEASE CAPTURE FROM KNEE TO PELVIS (extra long\n revision prosthesis)\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Two views of the right femur .\n\n COMPARISON: .\n\n INDICATION: Postoperative evaluation, status post revision right total hip\n arthroplasty.\n\n FINDINGS: Lateral skin staples. Surgical drain is present. Subcutaneous\n edema. Status post right total hip long stem revision arthroplasty with\n constrained liner. The hardware appears intact. No evidence for\n peri-hardware lucency. No fracture or dislocation. Degenerative changes of\n the knee.\n\n IMPRESSION: Expected postoperative change from right total hip long stem\n revision arthroplasty with constrained liner.\n\n\n" }, { "category": "ECG", "chartdate": "2188-11-26 00:00:00.000", "description": "Report", "row_id": 128983, "text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n" } ]

88,523

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83-year-old female with hx of CAD s/p 5v CABG, COPD, ESRD on HD, chronic diastolic CHF (EF 45-50%), DM, and PVD presenting with dyspnea, productive cough and chills and found to have left mid/lower PNA. Hospital course complicated by hyperglycemia, CHF exacerbation, and elevated troponins suggestive of ?NSTEMI vs. demand ischemia. . #. Hypoxic Respiratory Distress: Respiratory distress likely multifactorial in nature, most influenced by PNA and acute on chronic CHF exacerbation. Patient also has history of COPD which was probably a less important factor in current status. CXR showed left mid/lower consolidation as well as rapidly evolving right sided consolidation. She was treated for Hospital Acquired Pneumonia given recent hospital admission and dialysis sessions with vancomycin and cefepime (day 1 = ); coverage was later broadened to include levofloxacin (day 1 = ). PICC was placed on for continued antibiotics at LTAC; plan was to complete a ten day course. She should get a CXR in weeks after completion of treatment to confirm resolution of her PNA. Pulmonary edema from acute on chronic CHF was also likely contributing to her respiratory distress. She was given 80mg iv lasix on the floor and 120mg IV lasix at ICU on day of admission. She had subsequent removal of fluid via HD on three consecutive days. In terms of her oxygen requirements, she had been on NC on the floor and then transitioned to NRB when she desated to the 70s at which point she was transferred to the ICU. At the ICU, she was kept for the majority of time on high flow face mask. She briefly required BiPAP and NRB at one point but was stable by the time of discharge to the floor. She was sating consistently in the 90s. She continued to breath well on room air on re-admission to the floor and was discharged to rehab saturating >93% on Room Air, having completed total antibiotic therapy for ten days. - Repeat CXR 4-6 weeks after discharge recommended to assess resolution of pna . #. Elevated troponins: Pt with ST depressions on V4-6 on EKG. Troponin at admission was at baseline of 0.04 but uptrended, peaking at 6. She was started on a heparin and nitroglycerin gtt. Cardiology consult was obtained. TTE showed preserved EF and without focal wall motion abnormalities. Per cardiology, elevated troponin was likely due to demand ischemia secondary to pneumonia and volume overload as well as metabolic derangements (hyperglycemia). Troponin subsequently downtrended to 5.8. She was continued on her aspirin, plavix, beta blocker, acei, and statin throughout hospital admission. . # Atrial Fibrillation: While in the MICU, she had an episode of tachycardia which was atrial fibrillation on EKG. After a one time dose of intravenous metoprolol she quickly reverted back into sinus. Her metoprolol was uptitrated to 50mg three times a day and she was in sinus rhythm with good rate control for the remainder of her stay. After discussion with Cardiology consult that a single episode of atrial fibrillation in the setting of hypoxic respiratory distress, CHF exacerbation, demand ischemia and pneumonia not indication for chronic anticoagulation as she was perisistently in sinus for duration of her hospital stay. If she has further episodes of tachycardia or is noted to be in atrial fibrillation, she should discuss with her PCP or cardiologist future anticoagulation. - Metoprolol 50mg TID . #. Hyperglycemia: Pt presented with critically high blood glucose levels while on the floor. Urinalysis showed glucose and trace ketones. Anion gap was elevated to 15. Hyperglycemia was believed to be secondary to infection (PNA) or steroids she had received in the ED for COPD. She was given IV fluid boluses while on the floor. She was given insulin boluses and BS was in 400s upon arrival to ICU. It downtrended to 100s with insulin sliding scale during her stay here. . #. ESRD: Patient had history of ESRD and was on HD three times a week. Cr 4.6 on admission. She received three consecutive days of dialysis to remove fluid as volume overload was contributing to her respiratory distress. She was continued on her sevelamer throughout hospital stay. . #. Acute on chronic diastolic CHF: TTE performed showed preserved EF of > 55% and grossly no focal abnormalities. BNP was elevated to 13K on admission and CXR was consistent with pulmonary edema. She was given 80mg lasix iv on the floor and 120mg lasix x 1 on admission to the ICU. She was continued on her cardiac medications, including metoprolol, acei, and nifedipine. Her metoprolol was titrated up to 50 mg tid, her nifedipine was titrated down to 30mg daily, and her lisinopril was increased to 40mg daily and her isosorbide was discontinued per recommendations of cardiology and renal. She was instructed to follow up with her PCP and cardiologist regarding these changes. - Nifedipine, metoprolol and lisinopril dose changes. - Isosorbide discontinued.

There is an anterior space which most likely represents a prominentfat pad.IMPRESSION: Mild-moderate mitral regurgitation. There is mild regional left ventricular systolicdysfunction with hypokinesis of the basal inferior wall. The estimated pulmonary artery systolic pressure isnormal. Trace aorticregurgitation is seen. ST-T wave abnormalities withprolonged QTc interval are non-specific but clinical correlation is suggested.Since the previous tracing of atrial fibrillation has been replaced bysinus rhythm, ventricular ectopy is seen, precordial lead QRS voltage is lessprominent, ST-T wave changes are less prominent and the QTc interval may belonger. Mild regional LVsystolic dysfunction. Since the previoustracing of atrial fibrillation has replaced sinus rhythm and furtherST-T wave changes are seen.TRACING #1 Normal PAsystolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. Left ventricular function. Considermyocardial ischemia. Sinus rhythm with ventricular premature beat. Non-specific inferior and lateral ST-T wave changes. Consider leftventricular hypertrophy. Sinus tachycardia. Very mild regional systolicdysfunction c/w CAD.Compared with the prior study (images reviewed) of , regional andglobal left ventricular systolic function is improved and the estimatedpulmonary artery systolic pressure is now lower.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Mild to moderate (+) mitralregurgitation is seen. Myocardial infarction. Inferolateral lead ST-T wave abnormalities suggestmyocardial ischemia. Since the previoustracing of same date sinus tachycardia and further ST-T wave changes are bothnow present. ST-T wave abnormalities. Mild [1+] TR. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg).Right ventricularchamber size and free wall motion are normal. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.MITRAL VALVE: Normal mitral valve leaflets. Sinus rhythm. Sinus rhythm. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3)are mildly thickened but aortic stenosis is not present. Right ventricular function.Height: (in) 62Weight (lb): 160BSA (m2): 1.74 m2BP (mm Hg): 125/44HR (bpm): 71Status: InpatientDate/Time: at 16:10Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness and cavity size. No resting LVOTgradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Clinical correlation is suggested. Clinical correlation is suggested. Since the previous tracing of the rate is slower. Probable atrial fibrillation with rapid ventricular response. Diffuse ST-T wave abnormalities may be due tomyocardial ischemia. Coronary artery disease. Compared to the previous tracing of the lateralST-T wave changes are similar to previous tracing. Congestive heart failure. Left ventricular wall thicknesses andcavity size are normal. Q-T interval is longer. No AS. PATIENT/TEST INFORMATION:Indication: Chronic lung disease. The mitral valve leaflets are structurally normal.There is no mitral valve prolapse. Clinical decisions regarding the needfor prophylaxis should be based on clinical and echocardiographic data. No MVP. TDI E/e' >15, suggesting PCWP>18mmHg.

6

[ { "category": "Echo", "chartdate": "2200-11-17 00:00:00.000", "description": "Report", "row_id": 102373, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Congestive heart failure. Coronary artery disease. Myocardial infarction. Left ventricular function. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 125/44\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 16:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferior wall. The remaining\nsegments contract normally (LVEF >55 %). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg).Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is an anterior space which most likely represents a prominent\nfat pad.\n\nIMPRESSION: Mild-moderate mitral regurgitation. Very mild regional systolic\ndysfunction c/w CAD.\nCompared with the prior study (images reviewed) of , regional and\nglobal left ventricular systolic function is improved and the estimated\npulmonary artery systolic pressure is now lower.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2200-11-19 00:00:00.000", "description": "Report", "row_id": 294804, "text": "Probable atrial fibrillation with rapid ventricular response. Consider left\nventricular hypertrophy. Diffuse ST-T wave abnormalities may be due to\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of atrial fibrillation has replaced sinus rhythm and further\nST-T wave changes are seen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2200-11-17 00:00:00.000", "description": "Report", "row_id": 294805, "text": "Sinus rhythm. ST-T wave abnormalities. Since the previous tracing of \nthe rate is slower. Q-T interval is longer.\n\n" }, { "category": "ECG", "chartdate": "2200-11-16 00:00:00.000", "description": "Report", "row_id": 294806, "text": "Sinus tachycardia. Inferolateral lead ST-T wave abnormalities suggest\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of same date sinus tachycardia and further ST-T wave changes are both\nnow present.\n\n" }, { "category": "ECG", "chartdate": "2200-11-16 00:00:00.000", "description": "Report", "row_id": 294807, "text": "Sinus rhythm. Non-specific inferior and lateral ST-T wave changes. Consider\nmyocardial ischemia. Compared to the previous tracing of the lateral\nST-T wave changes are similar to previous tracing.\n\n" }, { "category": "ECG", "chartdate": "2200-11-20 00:00:00.000", "description": "Report", "row_id": 294803, "text": "Sinus rhythm with ventricular premature beat. ST-T wave abnormalities with\nprolonged QTc interval are non-specific but clinical correlation is suggested.\nSince the previous tracing of atrial fibrillation has been replaced by\nsinus rhythm, ventricular ectopy is seen, precordial lead QRS voltage is less\nprominent, ST-T wave changes are less prominent and the QTc interval may be\nlonger.\n\n" } ]

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Pt was admitted and taken to the OR on for a left upper lobectomy via left thoracotomy complicated by an avulsion of the PA branch which was repaired. Trach was also changed intraoperatively. An epidural was placed for pain control. Pt was admitted to the ICU post-operatively d/t hypotension requiring neo gtt and IVF boluses. Cardiac enzymes were neg. Two left pleural chest tubes were to sxn and draining mod amt serosang fluid. POD#1 extubated and trach mask. hemodynamically stable off neo. chest tubes cont'd to sxn w/ persistant air leak. POD# 3 failed bedisde swallow exam -kept NPO. Persistant air leak. Epidural removed on PCA POD#4 chest tubes to water seal. POD#5 Chest tubes clamped. POD#6 purulent sputum on po levo. Breathing comfortably but did not clamping trial- back to water seal w/ perisistant air leak. POD# 7, 8 kept on water seal. progressing w/ post recovery. ambulating. reg diet and po pain med. one chest tube d/c'd. remaining chest tube w/ residual air leak. POD# persistant air leak on water seal. progressing w/post recovery. POD#12 chest tube clamping trial- tolerated trial and chset tube removed. post pull CXR unremarkable. POD#13 d/c'd to home .

IMPRESSION: New left effusion with air fluid level consistent with pneumothorax. Small apical pneumothorax on the left is again noted with unchanged amount of left subcutaneous emphysema. Stable left apical pneumothorax. 2nd to ..soc; family into visit and updated with pts current conditiona/p improved hemodynamics, off epidural. plan to wean ventilator when temperature increased.gi/gu: abd soft, obese. There is stable moderate left subcutaneous emphysema. pt turned and encouraged to cdb and chest pt done. For evaluation of the smali serial changes, a PA upright chest x-ray is recommended. Slight herniation of the right lung to the left. remains intubated via trach, see carevue for ventilator settings, abg wnl. The two left chest tubes are in place. 3p-7p:neuro: sedated on propofol gtt, light, opened eyes to stimuli. A tracheostomy tube is seen in a standard position. Elevation of left hemidiaphragm and atelectases in the left lower zone, unchanged. REASON FOR THIS EXAMINATION: evaluate lung field s/p h2o seal FINAL REPORT INDICATION: Left upper lobe lobectomy with low-grade fever. CHEST Comparison is made to the prior chest x-ray of . Moderate left lower lobe atelectasis. npn 0700-1900;events hypotension given fluid bolues with transient improvement. 11:30 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: eval any change in swallowing ability form exam Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA FINAL REPORT INDICATION: Status post supraglottic laryngectomy and chemotherapy and radiation therapy. done.skin; drsg to chest tubes due to around site, thoracotomy drsg and noted with marker.plan: transfer to floor for cont. Portable AP chest x-ray was compared to the previous film from . lytes wnlid: afebrile, post antib. REASON FOR THIS EXAMINATION: eval ptx FINAL REPORT REASON FOR EXAMINATION: Followup of a patient after left thoracotomy and left upper lobe lobectomy with low grade fever. npnvery pleasan woman admitted for lul thoracotomy r/t HX of to lung CA. There is a persistent small left apical pneumothorax. lopressor 5mg iv q 6 hours.resp: lungs clear. REASON FOR THIS EXAMINATION: evaluate lung field s/p chest tube removal r/o effusion /ptx FINAL REPORT CHEST TWO VIEWS, PA AND LATERAL. A small left apical pneumothorax is again demonstrated. INDICATION: Status post left upper lobectomy. FINDINGS: There has been interval removal of the left chest tube. CHEST: Left upper lobectomy has been performed. IMPRESSION: PA and lateral chest compared to and 12: Tiny left apical pneumothorax and minimal layering pleural effusion unchanged. Stable small left apical pneumothorax. A small apical pneumothorax on the left is again noted with unchanged. There is a persistent tiny left apical pneumothorax. IMPRESSION: Tiny left apical pneumothorax. IMPRESSION: Tiny left pneumothorax. IMPRESSION: Persistent tiny left apical pneumothorax. There is a tiny left apical pneumothorax. There is a small left apical pneumothorax. There is a small left apical and lateral pneumothorax which is similar in appearance to the film prior to chest tube removal earlier the same day. Herniation of the right lung to left, unchanged. FINDINGS: Compared with , the right upper lobe collapse has now resolved and the right lung appears well aerated. Tracheostomy tube in standard placement. Heart mildly enlarged and shifted to the left reflecting lung resection. Subcutaneous emphysema is again demonstrated in the left chest wall. Subcutaneous emphysema is noted. There is elevation of the left hemidiaphragm and atelectasis in the left mid and lower zones. AP ERECT CHEST: Leftward shift of mediastinal structures has decreased as well as moderate consolidation reflecting improving left lower lobe atelectasis. Chest tube is present in left upper hemithorax. The two left chest tubes appear unchanged, with a slight increase in the amount of soft tissue emphysema along the lateral left chest wall. The chest tubes are present in the left upper hemithorax. A small amount of left chest wall subcutaneous emphysema remains unchanged. A right upper mediastinal density is seen which is thought to represent a collapsed right upper lobe with elevation of the minor fissure. IMPRESSION: Mild pharyngeal dysphagia. ptx or recurrent collection Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA MEDICAL CONDITION: 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p chest tube d/c. Subcutaneous emphysema is present in the left chest wall and ill-defined opacities consistent with atelectasis in the left lower zone with slight elevation of the left hemidiaphragm. effusion FINAL REPORT TWO-VIEW CHEST X-RAY OF COMPARISON: . There is elevation of the left hemidiaphragm and atelectases in the left lower zone. There is right apical slightly nodular pleural thickening that is unchanged. Subcutaneous emphysema is present in the left chest wall. Subcutaneous emphysema is present in the left chest wall and left neck. IMPRESSION: Interval resolution of right upper lobe collapse. Swallow initiation, velar elevation, laryngeal valve closure and pharyngeal transit time were within normal limits.

24

[ { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343772, "text": "Resp Care\nPt was taken off the vent and currently on 50% trach collar, with good abgs, sats >97. Suctioned for mod. amount of thick blood tinged, pt is able to cough fairly well on her own through the trach.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343773, "text": "npn 0700-1900;\n\nevents hypotension given fluid bolues with transient improvement. epidurual off since 330 pm with bp 110-120.70. awaiting pain service for new orders .denied pain until 530 pm when c/o of severe pain in lt side more towarrds back. given 2 mgs morphine with min effect.\n\nneuro; aoox3 mae to command oob tochair with min assist. perla 3mm asking appropriate questions. lethargic at times voice quiet and difficult to understand occassionallly.\n\nresp; lungs coarse rhonchi upper diminished at bases. strong productive cough of thick yellow secretions pt removes plug from trach. and coughs with good strength. sometimes sound stridorous but settles without treatment. sats 93-97% on 4ln/c rr14-22.\n\ncvs; tmax 99.4 po nsr 65-90 iso pac.bp 64/19-120/70 with maps 52-70.given 750 mls ns in 250 ml increments with transient effect. bp improved with d.c epidural at 330 pm remained pain free until 530 pm given mso4 2mgs i.v repeated at 620 pm with some improvent in pain awaiting new mix of dilaudid for epidural.\n\ngu; poor urine output responding to fluid bolus remianed 15 mls/hr for last 3hours team aware and will treat if u/o remains below 20 mls/hr for next hour.following lytes.\n\ngi; hypoactive bs taking mod amounts fluids some vanilla pudding c/o of nausea with low bp improved when bp increased. bs wnl. toadvance diet to house.pt states takes normal food able to swallow. normally. burping no stool no flatus.\n\nct x2 lt pleural, both with h persistent airleak team aware. draining mod amounts serosanguinious drainage.dsd unchanged no further staining noted.\n\n fem aline and 3llremoved this am. pt with ecg and cardiac enzymes sent.troponins nml ck high ? 2nd to ..\n\nsoc; family into visit and updated with pts current condition\n\na/p improved hemodynamics, off epidural. low urine output, responds to fluid boluses.\n continue to obtain better pain control.continue with pulmnary toilet encourage use of is .offer emotional support to pt and family.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343774, "text": "C/O of surgical site pain, epidural off at start of shift waiting for new bag and changing solution to meperidine, notified Dr. , 2 mg MSO4 ordered and given with some effect, meperidine epidural started with good effect\n\nPlan: repeat labs, keep MAP >60 and UO > 15cc/hr per Dr. \n" }, { "category": "Nursing/other", "chartdate": "2121-05-28 00:00:00.000", "description": "Report", "row_id": 1343775, "text": "npn\nvery pleasan woman admitted for lul thoracotomy r/t HX of to lung CA. Has receive chemo and raditation in past,\n\nneuro: aox3, voice is very soft but easily makes needs known, follows commands, somewhat frustrated with stay but overall very pleasant, has been dozing off and on thru night. arousable\n\npain: see previous nursing note, at 12mn pt stating she was more comofrtable at a 3 raange,increase discomfort with activity but pt willing to help. demerol epidural remains at 6ml /hr with no additional boluses given. pain level seems acceptable at present time. pt resting comfortably\n\ncad hr 70-80's sr no ectopy noted, nbp 133/67 to 91/50 when sleeping.no issues\n\nresp rr teens remains on 4l nc, sats 97 to 100%, ls rhonchi RUl all other lobes dimished, chest tube 1 20 to 15cc/hr of ss output total of 140 since mn, ct 2 no output since mn. pt turned and encouraged to cdb and chest pt done. pt is able to handle her own secretions thru her trach.\n\ngi: obese , bs+ no bm this shift, pt had two small bites of jello and on second bite was choking, no difficulty with swallowing water noted,\n\ngu: uo 20 to 40 cc/hr, remainson d51/2 ns at 50cc/hr, creat 1.3 up from baseline of .8 on admission. overall negative 500cc since admission. lytes wnl\n\nid: afebrile, post antib. done.\n\nskin; drsg to chest tubes due to around site, thoracotomy drsg and noted with marker.\n\nplan: transfer to floor for cont. of care, continue to monitor uo, and pain issues, encourage cdb and use of IS\n" }, { "category": "Nursing/other", "chartdate": "2121-05-26 00:00:00.000", "description": "Report", "row_id": 1343770, "text": "3p-7p:\nneuro: sedated on propofol gtt, light, opened eyes to stimuli. temperature 94.5, bair hugger on. dilaudid and bupivicaine epidural at T3-T4 at 6 cc/hr. APS 20 concentration, to change to APS 10 concentration.\n\ncv: sb 50-sr 60, no ectopy. neo gtt on/off intermittently to maintain sbp >90. easily palpable pedal pulses bilaterally. lopressor 5mg iv q 6 hours.\n\nresp: lungs clear. remains intubated via trach, see carevue for ventilator settings, abg wnl. ct to 20 cm sxn, small airleak. team aware. moderate sanguinous drainage. plan to wean ventilator when temperature increased.\n\ngi/gu: abd soft, obese. bs hypoactive. foley to gravity, autodiuresing. cr wnl.\n\nendo: fs wnl.\n\nplan: monitor hemodynamics, pulmonary status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-27 00:00:00.000", "description": "Report", "row_id": 1343771, "text": "Neuro: weaned propofol to off, pt awoke angry amd upset because this writer was not able to read her lips as she attempted to speak, once extubated pt was able to write down her questions and needs, she is currently calm and cooperative with care, MAE's well\n\nCardiac: NSR, rare PVC, replaced calcium and magnesium as orderd with good results, neo weaned to off, goal to keep SBP > 90\n\nResp: see flow sheet for details, currently on FM at 50%, SPO2 >92%, CT's have an air , MD aware, minimal amount of bloody sputum pre extubation, zero sputum post extubation, pt has good cough and good lung volumes, pt has own trach and would like to know when she can have it put back in so she can talk again\n\nGI: sluggish BS, no flatus no BM, NPO\n\nGU: foley to gravity drainig clear yellow urine, quantity sufficient\n\nSocial: dtr called and updated, pt aware\n\nPlan: increase diet and activity as tolerated, follow labs and vitals and treat as orderd and as indicated\n" }, { "category": "Radiology", "chartdate": "2121-06-06 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 911652, "text": " 11:30 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval any change in swallowing ability form exam\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post supraglottic laryngectomy and chemotherapy and\n radiation therapy.\n\n VIDEO OROPHARYNGEAL FLUOROSCOPIC SWALLOWING EVALUATION:\n\n There has been no significant change in swallow since prior study. Trace\n aspiration is again noted of nearly all consistencies. Status post\n supraglottic laryngectomy and resection of epiglottis. For additional\n details, please refer to the swallow evaluation note in CareWeb from .\n\n" }, { "category": "Radiology", "chartdate": "2121-06-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911086, "text": " 1:16 PM\n CHEST (PA & LAT) Clip # \n Reason: chest tube clamped- plaese eval for PTX. OBTAIN CXR AT 1pm.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy\n\n REASON FOR THIS EXAMINATION:\n chest tube clamped- plaese eval for PTX. OBTAIN CXR AT 1pm.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left upper lobe lung cancer, status post left upper\n lobectomy.\n\n CHEST\n\n Comparison is made to the prior chest x-ray of . Pleural fluid is\n now present with an air fluid level which was not present on the prior chest\n x-ray. This indicates the presence of a pneumothorax. It does appear\n slightly smaller than on the prior chest x-ray.\n\n The right lung remains clear.\n\n IMPRESSION: New left effusion with air fluid level consistent with\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910936, "text": " 8:33 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: evaluate lung field s/p chest tube removal r/o effusion\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p chest tube removal r/o effusion /ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL.\n\n History of left upper lobectomy and fever.\n\n Chest tube is present in left upper hemithorax. There is a persistent small\n left apical pneumothorax. The second chest tube present on the prior study\n has been removed. There is subcutaneous emphysema in the left chest wall and\n neck. Elevation of left hemidiaphragm and atelectases in the left lower zone,\n unchanged. Slight herniation of the right lung to the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910753, "text": " 9:28 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate lung field s/p h2o seal\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p h2o seal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left upper lobe lobectomy with low-grade fever.\n\n COMPARISONS: Comparison is made to prior study of earlier the same day at\n 0553 hours.\n\n Small apical pneumothorax on the left is unchanged.\n\n A tracheostomy tube is seen in a standard position. Two left apical chest\n tubes remain unchanged in position. There is stable moderate left\n subcutaneous emphysema. Left retrocardiac opacification is unchanged. There\n is otherwise no significant change in the appearance of the chest from\n approximately 5 hours prior.\n\n IMPRESSION:\n 1. Stable left apical pneumothorax.\n 2. Moderate left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910595, "text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for atelectasis and pneumo hemo thorax\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n\n REASON FOR THIS EXAMINATION:\n Eval for atelectasis and pneumo hemo thorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for atelectasis and pneumothorax.\n\n Portable AP chest x-ray was compared to the previous film from .\n\n There is left lower lobe consolidation with prominent mediastinal shift to the\n left representing left lower lobe atelectasis which is new. The two left\n chest tubes are in place. Small apical pneumothorax on the left is again\n noted with unchanged amount of left subcutaneous emphysema.\n\n The right lung is clear. These findings were discussed with Dr. during\n reporting of this exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911629, "text": " 9:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after left thoracotomy and left\n upper lobe lobectomy with low grade fever.\n\n Portable AP chest radiograph compared to the previous film from done in\n upright position.\n\n FINDINGS: There is no sizable hydropneumothorax on the current chest x-ray\n which might be explained by difference in x-ray technique. The left-sided\n chest tube remain in place. The right lung remains clear. For evaluation of\n the smali serial changes, a PA upright chest x-ray is recommended. The\n mediastinal shift to the left is stable.\n\n" }, { "category": "Radiology", "chartdate": "2121-06-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911224, "text": " 10:35 AM\n CHEST (PA & LAT) Clip # \n Reason: ? effusion\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy\n\n REASON FOR THIS EXAMINATION:\n ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST X-RAY OF \n\n COMPARISON: .\n\n INDICATION: Status post left upper lobectomy. Evaluate effusion.\n\n A left-sided chest tube remains in place. A small left apical pneumothorax is\n again demonstrated. The previously reported loculated hydropneumothorax is no\n longer evident, but there remains a component of pneumothorax anteriorly on\n the lateral view in the retrosternal region in addition to the apical\n component. Subcutaneous emphysema is again demonstrated in the left chest\n wall. With the exception of resolution of the air-fluid level related to the\n loculated hydropneumothorax, there has not been a significant change from the\n recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910892, "text": " 10:52 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate lung field for effusion progression\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field for effusion progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of left upper lobectomy and fever.\n\n The chest tubes are present in the left upper hemithorax. There is a small\n left apical pneumothorax. There is elevation of the left hemidiaphragm and\n atelectasis in the left mid and lower zones. Subcutaneous emphysema is\n present in the left chest wall and left neck. The right lung remains clear.\n\n IMPRESSION: Tiny left pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910344, "text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Recent left upper lobectomy. Assess for pneumothorax/lung\n collapse.\n\n FINDINGS: Compared with , the right upper lobe collapse has now\n resolved and the right lung appears well aerated. The two left chest tubes\n appear unchanged, with a slight increase in the amount of soft tissue\n emphysema along the lateral left chest wall. No sizable left pneumothorax is\n identified. The residual left lung appears grossly clear. The position of\n the new tracheostomy tube appears unremarkable.\n\n IMPRESSION: Interval resolution of right upper lobe collapse.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910278, "text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PTX and chest tube placement\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy \n REASON FOR THIS EXAMINATION:\n Eval for PTX and chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left upper lobectomy.\n\n CHEST: Left upper lobectomy has been performed. Two chest tubes are present\n on the left side. No pneumothorax is seen. Subcutaneous emphysema is noted.\n\n Tracheostomy tube is present. A right upper mediastinal density is seen which\n is thought to represent a collapsed right upper lobe with elevation of the\n minor fissure.\n\n IMPRESSION: Probable collapse of right upper lobe. No left-sided\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910967, "text": " 9:13 AM\n CHEST (PA & LAT) Clip # \n Reason: evalaute lung field r/o ptx/effusion progression\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evalaute lung field r/o ptx/effusion progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of left upper lobectomy with fever.\n\n Chest tube is present in left upper hemithorax. There is a persistent tiny\n left apical pneumothorax. Subcutaneous emphysema is present in the left chest\n wall. There is elevation of the left hemidiaphragm and atelectases in the\n left lower zone. Surgical fracture, left sixth rib. Herniation of the right\n lung to left, unchanged.\n\n IMPRESSION: Persistent tiny left apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911772, "text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for ptx. Please do at Noon\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy with\n persistent air leak. CT to clamp. please do at Noon\n REASON FOR THIS EXAMINATION:\n Please eval for ptx. Please do at Noon\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: Squamous lung carcinoma, left upper lobectomy.\n\n IMPRESSION: PA and lateral chest compared to and 12:\n\n Tiny left apical pneumothorax and minimal layering pleural effusion unchanged.\n Heart mildly enlarged and shifted to the left reflecting lung resection.\n Right lung clear. Tracheostomy tube in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911841, "text": " 7:49 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval pneumo\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p\n d/c chest tube with sm pneumo\n REASON FOR THIS EXAMINATION:\n re-eval pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 07:41.\n\n INDICATION: LUL lobectomy - followup film after chest tube removal.\n\n COMPARISON: at 16:56.\n\n FINDINGS: Compared to the prior study, there is no significant interval\n change with a persistent small left apical pneumothorax and increased density\n projecting over the left lower lung field. Right lung remains clear.\n Pulmonary vascular markings are normal.\n\n IMPRESSION: Persistent left apical PTX and no interval change versus prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911800, "text": " 4:56 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx or recurrent collection\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy now s/p\n chest tube d/c. pelase do at 5pm\n REASON FOR THIS EXAMINATION:\n ? ptx or recurrent collection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS ON .\n\n HISTORY: Lung cancer status post left thoracotomy and left upper lobectomy\n with removal of chest tube.\n\n FINDINGS: There has been interval removal of the left chest tube. There is a\n small left apical and lateral pneumothorax which is similar in appearance to\n the film prior to chest tube removal earlier the same day. There continues to\n be scarring and patchy areas of volume loss in the left lung. The right lung\n is clear. There is right apical slightly nodular pleural thickening that is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-06-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911343, "text": " 9:28 AM\n CHEST (PA & LAT) Clip # \n Reason: eval interval change of L PTX.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68F c squamous cell lung cancer s/p left thoractomy, LUL lobectomy with\n persistent air leak. CT to water seal.\n REASON FOR THIS EXAMINATION:\n eval interval change of L PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old, squamous cell cancer and left upper lobectomy,\n assess pneumothorax.\n\n PA and lateral radiograph. Comparison is made to one day earlier.\n\n There is a persistent hydropneumothorax with new air-fluid levels seen\n posteriorly in lower lung. Left-sided chest tube remains in place. The right\n lung remains clear. The extent of hydropneumothorax is largely unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-29 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 910609, "text": " 9:12 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess swallowing capability\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with chronic trach, now with failed bedside swallow\n\n REASON FOR THIS EXAMINATION:\n assess swallowing capability\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old female with dysphagia.\n\n VIDEO ORAL AND PHARYNGEAL SWALLOW EXAMINATION:\n\n An oral and pharyngeal swallowing videofluoroscopy was performed today in\n collaboration with the Speech and Language Pathology Division. Various\n consistencies of barium including thin liquid, nectar thickened liquid, puree,\n and a cookie coated with barium were administered.\n\n The oral phase was within functional limits without significant residue or\n premature spillover. The pharyngeal phase was notable for mild-to-moderate\n pharyngeal residue. Swallow initiation, velar elevation, laryngeal valve\n closure and pharyngeal transit time were within normal limits. Vocal cord\n adduction and symmetric pharyngeal contraction were observed. There was mild\n penetration into the vestibule during the swallow with all consistencies due\n to anatomic changes, status post supraglottic laryngectomy. Mild aspiration\n occurred immediately after the swallow with nectar thick and puree due to\n spillover of penetrated material. Mild aspiration with thin liquids was also\n observed due to slightly reduced valve closure.\n\n IMPRESSION: Mild pharyngeal dysphagia. Mild aspiration.\n\n For greater detail and for treatment recommendations, please see the dedicated\n Speech and Language Pathology Division report of the same date.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910904, "text": " 1:13 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate lung field s/p clamping of chest tube\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field s/p clamping of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n History of left upper lobectomy and fever.\n\n Two chest tubes are present in the left upper hemithorax. There is a tiny\n left apical pneumothorax. Subcutaneous emphysema is present in the left chest\n wall and ill-defined opacities consistent with atelectasis in the left lower\n zone with slight elevation of the left hemidiaphragm.\n\n IMPRESSION: Tiny left apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910736, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate.\n Admitting Diagnosis: LEFT UPPER LOBE MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p L. thoracotomy, LUL lobectomy with low-grade fever.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow-up pneumothorax.\n\n COMPARISON: .\n\n AP ERECT CHEST: Leftward shift of mediastinal structures has decreased as\n well as moderate consolidation reflecting improving left lower lobe\n atelectasis. Two left chest tubes are unchanged in position. A small apical\n pneumothorax on the left is again noted with unchanged. A small amount of left\n chest wall subcutaneous emphysema remains unchanged. The right lung is\n grossly clear. No pleural effusion is present.\n\n IMPRESSION:\n 1. Stable small left apical pneumothorax.\n 2. Improving left lower lobe moderate atelectasis.\n\n" } ]

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Respiratory, the infant was admitted to the Newborn Intensive Care Unit with significant grunting, flaring and retracting, placed on nasal prong CPAP. Nasal prong CPAP was weaned within a few hours and infant weaned to room air with oxygen saturation greater then 95%, grunting, flaring and retracting quickly resolved. The infant has continued to be on room air for the remainder of her hospitalization. The patient has occasional bradycardic spells, no Methylxanthine have been required. Cardiovascular, the patient's blood pressure has been stable throughout her hospitalization. No saline boluses or pressor support has been required. A soft intermittent murmur has been noted during her hospitalization felt to be a PPS murmur. Fluids, electrolytes and nutrition, upon admission to the Newborn Intensive Care Unit, the patient was started on intravenous fluids of D10W at 80 cc per kg per day. D sticks have been within normal range throughout her hospitalization. Enteral feeds were initiated on day of life two and she quickly advanced to full volume feeds by day of life five. The patient is currently receiving feeds of premature Enfamil enriched to 26 calories with ProMod. Feeds are partially by bottle and partially by gavage. Last set of electrolytes on day of life four, sodium of 147, potassium of 5.3, chloride of 117 and a total carbon dioxide of 16. The patient is voiding and stooling without difficulty. The patient's weight at the time of transfer is gms (4 lbs 5.5 oz), length 45 cm, head circumference 32.5 cm. Gastrointestinal, peak bilirubin on day of life three was 8.2 with a direct bilirubin of 0.3. Phototherapy was started at that time. Phototherapy was discontinued on day of life six and rebound bilirubin on day of life seven was 5.2 with a direct bilirubin of 0.2. There have been no issues with feeding intolerance during her hospitalization. Hematology. The infant has not received any blood products during her hospitalization. Hematocrit at the time of admission was 43.5. Infectious Disease. A complete blood count and blood culture were drawn upon admission to the Newborn Intensive Care Unit. White blood cell count 10,000, platelet count of 284,000, hematocrit of 43.5 with 19% neutrophils and 2% bands. The patient received forty-eight hours of Ampicillin and Gentamicin. The blood culture drawn on admission was negative. Neurology, head ultrasound was not indicated for this 32 6/7 weeks infant. Sensory, a hearing screen was performed with automated, auditory brain stem responses. The patient passed in both ears. Ophthalmology, eye examination was not indicated for this 32 6/7 weeks. Psychosocial, a social worker has been involved with the family. The contact social worker can be reached at .

Minbenign asps. NPO for now with maintenance IVF. Passed hearing screen.Maturing breathing control. Currently on CPAP. abd soft,stable, voiding and passing very sm stool A: starting to pofeed P: continue present care.4. Baby stable, all VS WNL, see flow sheet for details. Infantoffered bottle x2 this shift. Serologies: A+, ab neg, RPR NR, hep BsAg neg, RNI. Offer bottle as interestedqof-qtf. Transfer isolette prepared with buld syrine, O2, monitor. Abd exam benign. Abd soft, bs +. of anterior anus.Impression:1. Med spitx1. P: Cont to supportand update. Will transfer to for futher level II care. 2 full po yest. Alt po/pg. visiting.A: Stable. A:AGA P:Cont to supportdev needs.#5: in this am, update given. Bottled entirevolume x's 1. UE=LE. +BS. A: AGA. Active, alert in an open cirb, AFOF, sutures opposed, good tone. Stooling (heme neg). Stool x2 trace. diddiscuss tranferring to Hosp. Both updated. Respiratory support as needed for RDS. +2 pulses noted. Sutures slightly seperated and mobile. Mucous membranes pink, moist.CV: HR 150's. On PE26 with Promod. Will f/u Blood cx results. Nospits or asp. Fontssoft/flat. Follow wt and exam. Both asking appropr. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. G3P0 now 2 mother. Ag stable. AG stable. Nostool thus far in shift. Passing heme negative stool. Alternating po/pg feeds. Alternating po/pg feeds. Dextrose level 63-104. AF flat, clear BS, soft murmur, abd soft, MAE. Bottling qof- took 29cc this am,with good coordination. Equal chest rise. RRR, without murmur, pulses 2+ and symmetrical. bely benign, abd soft, +, med spitx1. belly benign,voiding/stooling, abd soft, & +. Abd exam stable. Temp stable. A: Stable in RA P: Continue tomonitor#2 O: TF=140cc's/k/d of BM/PE 26 with promod. 1lg spit/minimal aspirates. BP stable. Temp stable.Active/alert w/ cares. A/G stable. A/G stable. Update given. Abdomen bneign.. AG stable. LS clear and =. Mild subcostal retractions. Gavaged TF at8a.m. Minimal aspirates. remains in RA. A: Toleratingfeeds. Cord care done. Voidingand stooling guiaic neg. Tempstable. Abdomen benign. Voiding/stooling, guiac neg. Passed hearing screen. Swaddled with boundaries in place. visual analfissure noted. Benign abdomen. Benign abdomen. Temp stable in off isollette.Wt 1665 up 10. On BM/PE 26 with Promod. asking appropriatequestions. Asking appropriatequestions. P: Continuew/ plan.4. Noretractions. A: , invested P: Continue to support andupdate Voiding/stooling, hem neg. Swaddled. AF , clear BS, no murmur, abd soft, MAE. A: Tol feeds, gaining wt. NPN 0700-1900#1 O: Infant remains in RA. NeonatologyDoing well. Abdomenbenign. Abdomenbenign. for4p.m. Active bowel sounds. Bellybenign. COmfortable appearing.No murmur.Last sepll on 24th. Stool x2. AG 23CM. for cares. Cont to monitor. Passed hearing test. Awake andalert with cares. Stools heme negative. A: Involved, P: Continue tosupport and update. P: supportfamily's needs. Neonatology-NNP Physical ExamInfant remains stable in RA. Stable girth. Gr murmur over ULSB, pulses +2, pink, CRT < 3 secs. Infant with nml pulses and brisk cap refill. one sm spit. VOIDING WELL; SMALL GREENSTOOL X1. cares. A: Involved, P: Continue tosupport and update Gavaged feed at8a.m. updatesgiven. Wean isolette as tolerated. helped with cares andfed pt. LS c+=. COnsolable with pacifier and bounderies. NPN Days#1 Pt received and cont in RA. P/ Cont. mild S/Cretrac. Neonatology attending note6 d.oresp: in RA, clear. Update given. In isolette, RA. Gaining wt. A: Tol feeds so far. Apgars . sounds clear with mild retractions.#2O: Wt. abd benign. Abd benign. Amp and gent as ordered. P: Consider d/cphototx. BBS =/clear. A/g stable. Nobrady's. Mild subcostal retractions. Mild retractions. Min. pt po qshift. Herbili was 4.9/0.3. LS clear. 1 sm. Br. NPN 7A-7P#1 Remains in RA w/o desat's or brady's. Resting well.BILI: Phx dc'd . Abd is benign,she is voiding and having trace stools, g-. asking approp ques. RR 40-60s, ls clear, nospells. sl jaund.eyeshields on. asp. Nursing Progress Note#1 RESPStable on RA with good sat. Remains in RA. P-Will cont to monitor FEN.#4 G&D- Temp stable nested in air mode isolette. Neonatology Attending remains in RA, isolette. of Pe20. A: Stable in RA. A: Stable in RA. F/n: O: Infant is on TF = 140cc/k/d, delivered mostly viagavage. Clear equal BS with mildretraction. Mottles with cares. P- Will obtain bili in am.See flowsheet for further details. Inital DS on arrival: 63/72. Rebound bili this am 5.2/0.2 from 4.9/0.3. P: Continue w/plan.4. AFOF. P- Will cont to monitor resp status.#2 FEN- TF= 140cc/kg/d of BM or PE22. ag- 24cm. PO's 1x shift; takes ~ of total volume po. max asp 4cc partially digestedformula, refed. LSclear/=, mild subC retractions present. Temps stable onwarmer/isolette. LSclear/=, mild IC retractions present. and ampi and gent d/c.#4O: In heated isolette with stable temp. Mild subcostal retractionsnoted. Single desat, self resolved.CV: Good HR, perfusion. Pt cont under singlephototherapy. nested insheepskin. Lytes andbili done, see flow sheet, d-s 61.#3O: Bld. Lungs clear, = bilat, mild SC retractions. helped with cares andheld pt. updatesgiven. able towean x2 for temps 98.8 and 99.1. alert and awake with cares.fontanelles soft and flat. lsc and equal. sounds clear and =.#2O: Wt. FunctionO: In RA, RR 30's-60's with mild SC retractions. Rebound bili to bedrawn in am. NEONATOLOGY ATTENDINGDay 2 for .RESP: RA, good sats. abd benign. in Resp. Transient soft bowel loops palpated. Neonatology - NP Physical ExamAwake and alert with cares, temp stable in air isolette. P- Willcont to monitor FEN.#4 G&D- Temp stable in air mode isolette. Sleeps well betwen cares.Tone is wnl- actions are appropriate for gestational age.FESO4 ordered. Voiding and stooling.4 DevTemp stable in air controlled isolette. mild scretractions noted. sounds clear with very mild retractions.#2O: Total fluids presently at 80cc/kg/d. Belly benign. Girth stable. Becoming independent with cares. cx neg. Lytes 145/5.2/112/19. thendiscarded. breath sounds clear and equla. BS +. NPN Days#1 Pt received in RA and cont in RA. cx. Belly soft, voiding and passingmec. Lytes and bili done, see flow sheet.#3O: Ambi and gent given, bld. RRR, without murmur, pulses 2+ and symmetrical. Advanced to 24 cals.

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[ { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725716, "text": "Progress Note: Nurse \n32 week infant now DOL 1. Admission wt 1740.\n\nSkin: Intact, no breakdown, no rashes, no lesions. Skin pink/slightly ruddy.\n\nHEENT: Moulding to head noted. Fontanels soft, flat. Sutures slightly seperated and mobile. Eyes free of reddness and drainage. Symmetrical facial features with grimace/cry when disturbed. No masses noted. Mucous membranes pink, moist.\n\nCV: HR 150's. S1S2. No murmur. +2 pulses noted. UE=LE. BP 64/36 (48).\n\nRespiratory: On room air. O2 saturations 99-100%. Breath sounds clear and equal. Equal chest rise. Mild subcostal retractions.\nRR 30-50.\n\nGI/GU: Abdomen soft, round, no loops. +BS. No masses noted.\n\nMetabolic: Skin slightly ruddy. Checking bilirubin level with 24hr labs.\n\nFEN: TF 80cc/kg/d. Starting feeds today PE20cal/oz- 20cc/kg. Dextrose level 63-104. Assessing 24hr electolytes.\n\nID: On Ampicillin and Gentamicin for 48hr rule out sepsis. Will f/u Blood cx results. Initial CBC benign.\n\nImpression: Premature infant doing well since self extubating from CPAP to room air. Continue close monitoring clinically in overall status, including respiratory, toleration to newly initiated feeds and pending blood cultures.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-17 00:00:00.000", "description": "Report", "row_id": 1725712, "text": "Neonatology Attending Admit Note\n\nInfant is a 32 week, 1740 gm, female twin I, who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 30 y.o. G3P0 now 2 mother. Serologies: A+, ab neg, RPR NR, hep BsAg neg, RNI. Pregnancy complicated by:\n1. PTL - cerclage placed at 12 weeks gestation\n2. admitted to for \"failing cerclage\", cervical changes, and bulging membranes\n3. borderline hypertension\n4. insulin-dependent gestational diabetes mellitus\n\nBetamethasone complete. Today with progressive spontaneous labor to vaginal delivery.\n\nIn DR - neonatology present. Apgars 7,8. Facial CPAP given.\n\nPhysical exam:\nWt 1740g = < 50%\nL 42.5 cm = 25-50%\nHC 31.5 cm = 50-75%\n\nVS per CareView. Complete exam documented on \"newborn summary form\". Notable for respiratory distress on CPAP, hypotonia, and ? of anterior anus.\n\nImpression:\n1. AGA, premature female, twin 1\n2. Respiratory distress syndrome - most likely RDS. Also consider TTN, neonatal pneumonia\n3. r/o sepsis - risks include prematurity, multiples, GBS unknown\n4. IDM\n5. hypotonia - c/w prematurity and current degree of illness. Expect to improve with time.\n\nPlan:\n1. Respiratory support as needed for RDS. Currently on CPAP. Will follow gases, if symptoms/support progresses will initiate additional evaluation including CXR and consider intubation with surfactant delivery.\n2. Monitor for development of apnea of prematurity.\n3. Monitor BP. Follow for development of PDA.\n4. NPO for now with maintenance IVF. Consider initiating enteral feedings once respiratory status stabilizes.\n5. IDM - hypoglycemia protocol.\n6. r/o sepsis - check CBC with blood cx. Initiate ampicillin, gentamicin pending lab results and clinical course.\n7. Monitor tone, neurological exam.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725713, "text": "1 Alt in resp status\n2 FEN\n3 Sepsis\n4 Alt in development\n5 Alt in parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in resp status; added\n Start date: \n 2 FEN; added\n Start date: \n 3 Sepsis; added\n Start date: \n 4 Alt in development; added\n Start date: \n 5 Alt in parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-03 00:00:00.000", "description": "Report", "row_id": 1725787, "text": "NPN 7a-7p\n\n\n#2: TF: 150cc/k/d. Conts on PE26 with Promod, tol feeds\nq4hrs gavaged over 1hr15mins. Few sm spits today. Min\nbenign asps. Abd soft, +, no loops. Voiding qs. No\nstool thus far in shift. Bottling qof- took 29cc this am,\nwith good coordination. Does tire toward end. A: tol feeds\nwell, conts to work on bottling skills P:Cont with current\nfeeding plan. Follow wt and exam. Monitor tol to feeds.\n\n#4: conts to maintain stable temps while swaddled in\nan open crib. Alert and active with cares. Not yet waking\non own for feeds. MAE. Fonts soft/flat. Brings hands to\nface. Enjoys sucking on pacifier. A:AGA P:Cont to support\ndev needs.\n\n#5: in this am, update given. did\ndiscuss tranferring to Hosp. did tour\nfacility this am and are agreeable to transfer. Aware that\ntenatively will happen tomorrow. Dad gave sponge bath to\ninfant. Did well, good positioning. Needed verbal\ninstruction and guaidance. Mom bottled infant. A: Involved\n, awaiting transfer. P:Cont to support and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725788, "text": "NPN 1900-0700\n\n\n2 FEN\nCurrent weight 1.970 kg, up 35 grams. TF remain at\n150cc/kg/day of PE 26 with pm. Alt po/pg. Bottled entire\nvolume x's 1. Tolerating feedings well. Abd soft, bs +. No\nspits or asp. Voiding and stooling.\n\n4 Dev\nTemp stable in open crib. Awake and active with cares.\nSleeps well between cares. Brings hands to face.\n\n5 Parenting\nSpoke to Mom at start of shift. Phone consent given for\ntransfer to . Mom will call in am for updated\nplan.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725789, "text": "Neonatology Attending\n\nDay 18\n\nRemains in RA. RR 30-60s. No bradycardia. Intermittent murmur. HR 130-160s. Weight gms (+35). On PE26 with Promod. Alternating po/pg feeds. No spits. Passing heme negative stool. Stable temperature in open crib. Passed hearing screen.\n\nImproving breathing control, feeding. Gaining weight on current nutritional regimen. Will transfer to for futher level II care. Primary pediatrician is Dr. Pediatrics.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-04 00:00:00.000", "description": "Report", "row_id": 1725790, "text": "Nursing Transfer Note\nBaby #1 to be transferred to Special Care Nursery. Report called to RN, Ambulance scheduled for 1030am. notified of transfer time, phone consent sheet shigned in chart. eager for transfer. Baby stable, all VS WNL, see flow sheet for details. ID Tags on. Transfer isolette prepared with buld syrine, O2, monitor. This RN will be accompanying baby on trip. Order for transfer obtained.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725781, "text": "2. TF 150cc/k/d of Bm/PE26 with promod, 47cc q4h. offering\npo when awake, took 52cc po well ~12n for Mom. abd soft,\nstable, voiding and passing very sm stool A: starting to po\nfeed P: continue present care.\n4. starting to wake for some feedings and take po, temps\nstable in open crib, active and alert with cares P: continue\nto support needs for growth and development.\n5. Mom here for 12/1230 feedings, has decided to stop\npumping, held and fed babies, planning to be here for next\ncares A: concerned and involved P: continue to inform and\nsupport.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725782, "text": "NPN NIGHTS\n\n\nFEN: Weight 1940gm up 50. TF 150cc/kg/day PE26 or BM26 with\npromod. Alternating po/pg feeds. No spits, max aspirate 4cc\npartially digested formula. Belly soft and round with active\nbowel sounds, no loops noted. Stool x1, heme negative. Will\ncontinue with current feeding plan.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares. Sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725775, "text": "NPN 0700-1900\n\n\n#2 O: TF= 150cc/kg/d. Infant taking 46cc's of BM/PE26 with\npromod q 4h via po/pg. Bottled 42cc's at 1200 for mom.\nAbdomen benign; voiding and stooling guaic neg x1. Med spit\nx1. Minimal aspirates. Feeding time increased to 1h 20\nminutes with no spit after. AG stable. A: Tolerating feeds.\nP: Cont to monitor.\n\n#4 O: Maintaining temp in oac. Awake and alert with cares;\nsleeping well between. Swaddled in blanket; brings hands to\nface for comfort. A: AGA. P: Cont to support development.\n\n#5 O: Both in to visit this afternoon. Mom feeding\nthis infant and very independent with cares. Grandparents in\nto visit as well. Asking appropriate questions. plan\nto come in for 1600 cares. A: Involved. P: Cont to support\nand update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725776, "text": "Neonatology Attending Progress Note\n\nNow day of life 14.\nCardiorespiratory status stable in RA.\nRR 40-50s.\nNo apnea and bradycardia.\nHR - 140-180s.\nBP 73/40 57\nWt. 1840gm up 40gm on 150cc/kg/d of MM or PE26 with Promod\nFeedings well tolerated by bottle or gavage.\nHas history of emesis.\n\nPO feedings are improving gradually.\n\nAssessment/plan:\n2 week old 32 week gestation infant with immaturity of feeding skills.\nWill continue with current management.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725783, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. In room air, BS clear and equal with symmetrical chest movement, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Hemangioma on right knee. Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725784, "text": "Neonatology Attending\n\nDOL 16 CGA 35 1/7 weeks\n\nStable in RA. No A/B.\n\nSoft murmur, intermittent. BP 67/33 mean 40.\n\nOn 150 cc/kg/d PE 26 with promod with feeds over 1 hr 15 min. 2 full po yest. Voiding. Stooling (heme neg). Wt grams (up 50).\n\nHemangioma on R knee.\n\n visiting.\n\nA: Stable. Minimal A/B. Tolerating feeds. Growing.\n\nP: Monitor\n Encourage pos as tolerated\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-02 00:00:00.000", "description": "Report", "row_id": 1725785, "text": "NPN 7a-7p\n\n\n#2: TF: 150cc/k/d, conts on PE26 with Promod. Infant\noffered bottle x2 this shift. Bottled 18-30cc tiring easily\nand slow to feed. Decent coordination using yellow nipple.\nSm spit noted. Abd exam benign. Ag stable. Voiding qs.\nStooled. A: tol feeds well, working on bottling skills.\nP:Cont to follow wt and exam. Offer bottle as interested\nqof-qtf. Monitor tol to feeds.\n\n#4: conts to maintain stable temps while swaddled in\nan open crib. Alert and active with cares. MAE. Fonts\nsoft/flat. Sucks on fingers and pacifier intermittently.\nDoes spend ~30mins of quiet awake time after feed. A: AGA\nP:Cont to support dev needs.\n\n#5: in for 12care. Both updated. Mom with\ntemp, diaper and bottling. Both asking appropr. questions.\nA: Involved P:Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-03 00:00:00.000", "description": "Report", "row_id": 1725786, "text": "Newborn Med Attending\n\nDOL#17. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. Wt= down 5. On 150 cc/kg PE26 with PM, mostly PG.\nA/P: Growing premie working up on PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725777, "text": "NNP Physical Exam\n\nPE: pale pink, AFOF, breath sounds clear/equal with easy wOB, soft high pitched murmur mid LSB, +2/= pulses, abd soft, non distended, nevus simplex right knee, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725778, "text": "NPN NIGHTS\n\n\nFEN: Weight 1890gm up 50. TF 150cc/kg/day BM26 or PE26 with\npromod. Took 50cc po x1 this shift. Attempting bottling\nevery other feed. No spits. Belly soft and round with active\nbowel sounds, no loops. Stool x2 trace. Will continue with\ncurrent feeding plan.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares, sleeps well between cares. Will continue\nto provide for developmental needs.\n\nAlt in Parenting: No contact so far this shift.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725779, "text": "Neonatology Attending\n\nDay 15\n\nRemains in RA. RR 40-50s. No bradycardia. Clear breath sounds. HR 140-150s. Soft, intermittent murmur. Pink. BP mean 52. Weight 1890 gms (+50). TF at 150 cc/kg of BM/PE 26 with Promod. Most feeds by gavage. Passing stool. Stable temperature in open crib. Passed hearing screen.\n\nMaturing breathing control. Monitoring cardio-respiratory status closely. Gaining weight well. Will continue to encourage po feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-06-01 00:00:00.000", "description": "Report", "row_id": 1725780, "text": "Neonatology-NNP Physical exam\n\nInfant remains stable in RA. Active, alert in an open cirb, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, CRT < 3 secs. Abdomen soft, non-distended with active bowel sounds, no HSM, hemangioma on right knee. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725769, "text": "1900-0700 NPN\n\n\n#2F/E/N\nO:TF AT 150CC/KG BM/PE26 45CC Q4HR GAVAGE OVER 1HR 10\".\nABDOMEN SOFT, FULL WITH GOOD B.S. NO SPITS AND MINIMAL\nASPIRATES. VOIDING AND STOOLING (SMALL AMTS) OVERNIGHT. WT\nUP 35GM\nA:TOLERATING FEEDS WELL; IMPROVED SPITTING\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR FOR SPITS\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES.\nBOTTLED 29CC TONIGHT--BABY ROOTING, LATCHED ON AND SUCKED\nVERY WELL TONIGHT. WELL COORDINATED S/S/B WITHOUT A/B'S OR\nDESATS DURING BOTTLING.FONTANEL SFOT AND FLAT; SUTURES\nSMOOTH\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT, OFFER BOTTLE QSHIFT AND\nADVANCE AS TOLERATED\n\n#5PARENTING\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TOD ATE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725770, "text": "Neonatology Attending\n\nDay 13\n\nRemains in RA. Oximeter discontinued. No bradycardia. RR 40-50s. Intermittent murmur. HR 140-160s. Pale, pink. Weight 1800 gms (+35). TF at 150 cc/kg/d. On BM/PE 26 with Promod. Receiving po/pg feeds. Offered po feed once per shift. Took one ounce with one feed overnight. Stable temperature in open crib.\n\nAdequate breathing control. Will continue to monitor closely. Gaining weight well. Encouraging po feeds.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725771, "text": "Clinical Nutrition:\nO:\n34 wks CGA, BG now on DOL #13\nWt: 1800g (+35g)-(10-25th%ile); gained an average of 14 g/kg/day over the last week.\nLN: 44cm (42.5)-(25-50th%ile)\nHC: 32cm (31.5)-(~50th%ile)\nLabs: none recent\nMeds: Iron (~4.0-4.1 mg/kg/day from feeds+suppl.)\nNutrition: BM/PE26 w/ promod @ 150 cc/kg/day\n3 day average intake: ~143 cc/kg= ~124 Kcals/kg & ~3.8-4.2 g/kg of protein\nGI: benign\n\nA/goals:\nTolerating feeds well, noted decrease number of spits. Alternates PO/PG, offered a bottle Qshift. Gavage feeds over 1hr 10min d/t h/o spits. Voiding & stooling. Wt gain slightly below goal range over the last week. Current feeds+supplements meeting recommendations to support cont'd growth. Due for nutrition labs. No changes to nutritional plan today, will cont. to follow w/team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725772, "text": "NPN 0700-1900\n\n\n#2 O: TF=150cc's/k/d of BM/PE 26 w/ promod. Gavaged feed at\n8a.m. and 4p.m. Bottle fed at 12p.m. Infant took 44 cc's. 1\nlg spit/minimal aspirates. Voiding/stooling, hem neg. AG=\n23cm. Abdomen benign. Active bowel sounds. A: Tolerating\nfeeds. P: Continue to monitor and encourage PO feeds.\n\n#4 O: Infant remains in OAC. Swaddled. Temp stable.\nActive/alert w/ cares. A: AGA P: Continue to support G&D.\n\n#5 O: Mom called this morning. She came at 3:30p.m. for\n4p.m. cares. A: , invested P: Continue to support and\nupdate\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-30 00:00:00.000", "description": "Report", "row_id": 1725773, "text": "Agree with above assessment and plan written by , coworker.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-31 00:00:00.000", "description": "Report", "row_id": 1725774, "text": "NPN NIGHTS\n\n\nFEN: Weight 1840gm up 40. TF 150cc/kg/day BM 26 with pm or\nPE26 with pm. Took 45cc po x1 so far this shift. Remainder\nof feeds gavaged over 1hr 10mins. No spits. Stool x2. Belly\nbenign. Will continue to offer bottle every other feed.\n\nAlt in Development: Temp stable in open crib. Awake and\nalert with cares. Swaddled with boundaries in place. Will\nsend PKU this am.\n\nAlt in Parenting: No contact so far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725764, "text": "1900-0700 NPN\n\n\n#2F/E/N\nO:TF AT 140CC/KG BM/PE 26 41CC Q4HR GAVAGE OVER 1HR 10\".\nABDOMEN SOFT, FULL WITH GOOD B.S. NO SPITS, MINIMAL\nASPIRATES AND NO LOOPS. AG 23CM. VOIDING WELL; SMALL GREEN\nSTOOL X1. WT UP 20GM. OFFERED BOTTLE WITH ABSOLUTELY NO\nINTEREST--UNABLE TO GET BABY TO ROOT TO, ON TO OR SUCK\nFROM NIPPLE\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANE TO FEEDS, ENCOURAGE PO/BF\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERTURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. SWADDLED AND NESTED ON SHEEPSKIN.\nFONTANEL SOFT AND FLAT; SUTURES SMOOTH. POOR PO'ER--UNABLE\nTO GET BABY TO ON, ROOT TO OR SUCK FROM BOTTLE\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nSEE SIBLINGS NOTE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725765, "text": "Neonatology-NNP Physical Exam\n\nInfant remains stable in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur over ULSB, pulses +2, pink, CRT < 3 secs. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, strawberry hemangioma near right knee. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725766, "text": "Neonatology Attending\n\nDay 12\n\nRemains in RA. RR 40-60s. Mild subcostal retractions. Soft murmur. Pale, pink. BP mean 45. Weight 1765 gms (+20). Tf at 140 cc/kg/d of PE 26 with Promod. Had one small spit yesterday. Poor bottling- offered once per shift. Minimal aspirates. Benign abdomen. Stable girth. Passing stool. Stable temperature in open crib.\n\nAdequate control of breathing. Will continue to monitor cardio-respiratory status closely. Gaining weight but will increase feeding volume to 150 cc/kg/d. Will continue to encourage po feeding. Eye exam next week.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725767, "text": "coworker \n\n\n#2 FEN: TF increased to 150cc/k/d of BM/PE 26 with promod\ngavaged over 1hr and 10 min. offerred bottle and took 5\ncc's. bottled with no interest. bely benign, abd soft, +\n, med spitx1. A/G stable. no asp. thus far on shift.\nA: tol feeds well P: monitor infant/encourage infant to PO\nfeeds.\n\n#4 DEVE: temp remains stable with infant swaddled in an open\ncrib. alert and active with cares. poor suck and on.\nMAE. fontanels are soft/flat. infant has strawberry\nhemangioma on inner right knee. eye exam scheduled for the\n. A: AGA P: continue to monitor and support the\ninfant.\n\n#5 PARENTING: Mom, mom's sister, and grandmother were in\nfor afternoon care. Mom ind with temp, diaper, dressing,\nand cord care. A: and caring family. P: support\nfamily's needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-29 00:00:00.000", "description": "Report", "row_id": 1725768, "text": "NPN 7a-7p\nAssessed infant and agree with co-worker noted.\n\nInfant conts to show little to no interest in bottling. Not really latching onto nipple. Abd exam stable. Voiding and stooling.\n\nSoft intermittent murmur noted. Infant with nml pulses and brisk cap refill. BP stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725758, "text": "Newborn Med Attending\n\nDOL#10. Cont in RA, no spells. AF , clear BS, no murmur, abd soft, MAE. WT=1715 up 50, TF=140 cc/kg/d. BM26 with PM mostly PG\nA/P: Growing premie working up on PO feeds. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725759, "text": "NPN 0700-1900\n\n\n\n\n#2 O: TF= 140cc's/k/d of PE/BM 26 with promod. Gavaged\nentire feed at 8a.m. and 12p.m. 2 large spits/minimal\naspirates. Will increase gavage time to 1h 10 min. for 4p.m.\nfeed. Voiding/stooling, guiac neg. AG= 23 cm. Abdomen\nbenign. A: Tolerating feeds P: Continue to monitor and\nencourage PO feeds.\n\n#4 O: Infant remains in OAC. Swaddled with hat on. Temp\nstable. Alert with cares. A: AGA P: Continue to support\ndevelopment.\n\n#5 O: will be in at 4p.m. for cares. They will\nattempt to bottle feed. A: Involved, P: Continue to\nsupport and update\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725760, "text": "2. F/n: O: Infant is on 140cc/k/d of 26cal BM/PE + promod,\ndelivered mostly via gavage q 4 hours over one hour and 10\nmin. Abd is benign, she is voiding and stooling g- stools,\neven though an anal fissure is visible. (A & D and vaseline\nointments applied.) No spits, Min asps. She gained 30g and\nis just above BW now. A: Tol feeds, gaining wt. P: Continue\nw/ plan.\n\n4. G/d: O: Temp is stable in the open crib and infant sucks\nwell on a binkie. She is alert and active w/ cares. A/P:\nContinue to support infant needs.\n\n5. : No contact from the family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725761, "text": "Neonatology Attending\n\nDay 11\n\nRemains in RA. RR 30-50s. Clear breath sounds. No bradycardia. Intermittent murmur not heard this morning. BP mean 44. HR 140-160s. Weight 1745 gms (+30). TF at 140 cc/kg/d on PE/BM 26 with Promod. Gavaged over 70 minutes. Stable abdominal girth. Benign abdomen. Stools heme negative. Small fissure. Passed hearing screen. Stable temperature. in currently.\n\nDoing well overall with adequate breathing control. Will continue to monitor closely. Gaining weight well. Will stay with this regimen for now.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725762, "text": "coworker p\n\n\n#2 FEN: TF remains at 140/cc/k/d of BM/PE 26 w/promod over\n1hour and 10 min. A/G stable. one sm spit. belly benign,\nvoiding/stooling, abd soft, & +. A: Tol feeds well P:\nmonitor infant.\n\n#4 DEVE: Temp remains stable with infant swaddled in open\ncrib. alert and active with cares. MAE. visual anal\nfissure noted. strawberry hemangioma also noted on inner rt\nknee. Passed hearing test. A: AGA P: Continue to support\ninfant.\n\n#5 PARENTING: were in for care. both are indep\nwith diaper, temp, and cord care. asking appropriate\nquestions. A: and caring family P continue to support\nthe family's needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-28 00:00:00.000", "description": "Report", "row_id": 1725763, "text": "NPN 7a-7p\nAssessed infant and agree with note by co-worker .\n\nInfant attempted to bottle x1 for Dad. Infant took 4cc and tired out. Anal fissure noted. No bleeding noted. Vaseline oint applied. Cont to monitor.\n\n in for visit. Update given.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725751, "text": "NPN 7A-7P\n\n\n#1 In RA, no brady's or desat's, maintaining sao2's >96%. LS\n= and clear, con't to have mild intercostal/subcostal\nretractions. Monitor.\n\n#2 TF at 140cc/k/d, cal's increased to 26 (2 more cal's via\nMCT oil). No interest in bottlng today though alert and\nactive. Had mod spit x 1 this AM but none further. Voiding\nand stooling guiaic neg. Cord care done. Monitor\nwt/tolerance.\n\n#4 Maintaining 98.0 temp in off isolette, no brady's,\ndisinterested bottler. Con't to monitor and assess for\nfeeding cues to PO.\n\n#5 visit daily, do cares with minimal assistance.\nCon't to update/teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725752, "text": "NPN\n\n\n#1-O: in RA sats 99-100, pink RR 40's-50's, comfortable, no\nissues.\n\n#2-O: TF at 140cc/k enteral feeds of BM26/PE26 41cc q 4 hrs\nover 1 hour PG, poor po attempts, one sm. spit. abd soft,\nbenign, voiding and stooling soft yellow. wt up 10gms today.\n\n#4-O: alert and active with cares, AFOF, no spells, wrapped\nin off isolette, temp stable this shift 98.6-98.3 ? trial in\ncrib.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725753, "text": "Neonatology\nDoing well. remains in RA. No spells. COmfortable appearing.\nNo murmur.Last sepll on 24th. Temp stable in off isollette.\n\nWt 1665 up 10. Tolerating feeds at 140 cc/k/d of 26 cal. Will add Promod today and monitor tolerance. Abdomen bneign.. Still requiring mainly gavage.\n\nSlightly jaundiced. Bili 5 several days ago.\n\nContinue current resp montioring and nutritional rx.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725754, "text": "NPN 0700-1900\n\n\n#1 O: Infant remains in RA. Resp rate 40's-50's. O2 sats\n100%, O2 sat monitor d/c at 1p.m. LS clear and =. No\nretractions. No spells. A: Stable in RA P: Continue to\nmonitor\n\n#2 O: TF=140cc's/k/d of BM/PE 26 with promod. Gavaged TF at\n8a.m. Dad attempted to bottle feed at 12p.m., infant took\n12cc's. No spits, minimal aspirates. AG stable. Abdomen\nbenign. voiding/stooling. A: Tolerating feeds P: Continue to\nmonitor and encourage PO feeds.\n\n#4 O: Infant was changed from Off-Isolette to OAC. Swaddled\nwith hat on. Temp stable. Awake/Alert during cares. Sucks on\npassifier. A: AGA P: Continue to monitor.\n\n#5 O: Mom and Dad came to visit from 11a.m.-2p.m.\nIndependent with temp and diapering. Each parent held\ninfant. Dad attempted to bottle infant. Asking appropriate\nquestions. A: Involved, P: Continue to\nsupport and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725755, "text": "NNP Physical Exam\n\nPE: pale pink, mottled, AFOF, sutures approximated, lungs clear/equal with easy wOB, no murmur, abd soft, non distended, bowel sounds active, \"birth mark\" right leg by knee, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-26 00:00:00.000", "description": "Report", "row_id": 1725756, "text": "Agree with above assessment and plan written by , Coworker. Infant passed hearing screen this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-27 00:00:00.000", "description": "Report", "row_id": 1725757, "text": "1. Resp: O: Infant is in RA w/ no spells so far tonight. She\nis on no resp meds. RR 30-50s, ls clear. She is no longer on\na pulse oxymeter. A: Stable in RA. P: D/c problem.\n\n2. F/N: O: Infant is on 140cc/k/d of 26cal PE/BM w/ promod,\ndelivered via gavage q 4 hours over one hour. Abd is benign,\nshe is voiding and having trace stools, g-. A/g stable. She\ngained 50g. A: Tol feeds so far. Gaining wt. P: Continue w/\nplan.\n\n4. G/d: O: Temp is stable in the open crib. Infant is active\nw/ cares and sucks on a binkie. She sleeps well otherwise.\nA/P: Continue to support infant needs.\n\n5. : No contact from the family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725714, "text": "NPN admission note\nInfant arrived to NICU from L&D. Apgars . BBO2 and facial CPAP in DR. MD note for further DR and OB hx.\n\nResp: Infant GFR on arrival. Placed on CPAP of 6 at 21%FiO2 x2hrs until Infant pulled out NP tube. Remains in RA. LS clear. RR 30-50's. Mild retractions. No increase WOB noted. O2 sats 99-100%. No spells. A/P: Continue to monitor resp status.\n\nCV: Pink, perfused. HR 130-160's. No murmur. BP means: 41-47. A/P: Continue to monitor.\n\nFEN: BW 1740. NPO. TF at 80cc/kg of D10W. Inital DS on arrival: 63/72. DS remain stable thru shift at 91/104. Large mec stool. Void x1. Abdomen soft with active bowel sounds. A/P: Continue to monitor. Start feedings today?\n\nID: CBC with diff benign. Blood culture pending. Amp and gent as ordered. VSS. A/P: Continue with plan, f/U with blood cx results.\n\nDEV: Temp stable on servo warmer. Nested with boundaries in place. Initially on admission, infant hypotonic. Infant more active, moving all extremities-hypertonic. Active with cares. AFOF. A/P: Continue to support dev. needs.\n\nPARENTING: Parents in to visit shortly after admission. Update given. Asking appropriate questions. Have named this baby . A/P: Continue to update daily and offer support.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725715, "text": "Neonatology attending note\nborn last night at 32 wks GA, brief episode of CPAP, now in RA.\nAFOF.\nmild retraction, clear lungs.\nAbdomen aoft no mass palpable.\nNO murmur.\nnormal tone.\nwt= 1740 gm, TF= 80 cc/kg/d.\nA: 32 wks GA, resolved initial transitional respiratory distress, sepsis evaluation.\nP: continue antibiotics, consider starting feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725738, "text": "NPN Days\n\n\n#1 Pt received and cont in RA. LS c+=. mild S/C\nretrac. no spells. P- Will cont to monitor resp status.\n#2 FEN- TF= 140cc/kg/d of BM or PE22. abd benign. voiding\nand stooling. no spits. max asp 4cc partially digested\nformula, refed. ag- 24cm. pt po qshift. Pt took 27cc po. P-\nWill cont to monitor FEN.\n#4 G&D- Temp stable nested in air mode isolette. alert and\nactive with cares. sucking on pacifier. putting hands to\nface. Mottles with cares. P- Will cont to monitor G&D.\n#5 Parenting- in this shift. helped with cares and\nfed pt. loving and caring. asking approp ques. updates\ngiven. P- Will cont to encourage parental visits and calls.\n#6 Pt cont under single phototherapy. sl jaund.\neyeshields on. P- Will obtain bili in am.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725739, "text": "1. Resp: O: Infant is in RA, no O2. RR 40-60s, ls clear, no\nspells. She is on no resp meds. A: Stable in RA. P: Monitor.\n\n\n2. F/n: O: Infant is on TF = 140cc/k/d, delivered mostly via\ngavage. She is on 22cal. Abd is benign, she is voiding and\nstooling g- stools. She took 15cc via the bottle w/ the\nyellow nipple, taking a few strong sucks. D/s was 104. She\nlost 5g. A: Mostly gavage fed, tol feeds, still losing wt.\nP: Monitor. Consider adding cals.\n\n4. G/D: O: Infant is weaning the heat in her isolette. She\nis under phototx. She is active w/ cares and sucks well on a\nbinkie. A/P: Continue to support infant needs.\n\n5. : O: Mom called for an update. A: Mom. P:\nContinue to support.\n\n6. Bili: O: Infant is under single phototx w/ her eyes\ncovered. She is jaundiced. She is also stooling well. Her\nbili was 4.9/0.3. A: Hx Hyperbilirubinemia. P: Consider d/c\nphototx.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725740, "text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy wOB, no murmur, abd soft, nondistended, bowel sounds active, no rashes, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725741, "text": "Neonatology attending note\n6 d.o\nresp: in RA, clear. no spells.\nno murmur.\nabdomen soft.\nwt= 1625 gm -25, 140 cc/kg/d with EBM 2, 1 bottle /shift, tolerated well.\njaundice, bili= 4.9\n\nA: 32 wks GA, jaundice, growing preemie.\nP: f/u bili, advance calorie to 24 cal/oz.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725742, "text": "Social Work\n\n\n of twins well known to me from mother's lengthy antepartum course on antepartum service.\n seen today, doing very well, mother tired, but coping with demands of hospitalization, and very invested and involved in infant cares.\n integrating well into nicu environment, adapting and learning about needs of preterm infant.\nWill follow as needed.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725736, "text": "Clinical Nutrition\nO:\n32 wk gestational age BG, AGA, now on DOL 5.\nBirth wt: 1740 g (~25th to 50th %ile); current wt: 1630 g (down ~6% from birth wt)\nHC at birth: 31.5 cm (~50th to 75th %ile)\nLN at birth: 42.5 cm (~25th to 50th %ile)\nLabs noted.\nNutrition: Started on EN on DOL 1. TF @ 140 cc/kg/d PE 20, increasing now to PE 22. PO's 1x shift; takes ~ of total volume po. Projected intake for next 24 hrs from EN ~103 kcal/kg/d, ~3.4 g pro/kg/d.\nGI: Infant had 11 cc aspirate last night; feeds not increased until this morning. Currently abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems except aspirate as noted above. Labs noted and within acceptable range. Initial goal for feeds is ~150 cc/kg/d PE 24, providing ~120 kcal/kg/d and ~3.6 g pro/kg/d. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~1 cm/wk for LN gain, and ~0.5 to 1.0 cm/wk for HC gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725737, "text": "Progress Note: Neonatal Nurse \n32 wkr now 6do. Wt 1630(- 30gm)\n\nSkin: Jaudiced, slightly mottled. Skin intact- no rash, no lesions, no breakdown noted.\n\nHEENT: Fontanels soft, flat. Sutures overlap slightly. Eyes free from drainage and reddness. Alert when bili mask removed and lights off. No masses noted. Facial symmetry noted with facial expressions. Mucous membranes pink, moist.\n\nCV: s1s2. No murmur noted. HR 120-150. +2 pulses- UE=LE.\n\nRespiratory: Room air. RR 30-60. Mild subcostal retractions. Breath sounds clear and equal. No apenic or bradycardic spells.\n\nGI/GU: Abdomen soft, round, no loops. No masses. Voiding and stooling.\n\nFEN: Tolerating feeds PE20cal/oz. TF 140cc/kg/day. Increasing calories to 22cal/oz today.\n\nMetabolic: Under phototherapy x1. Checking bilirubin level in am.\n\nSocial: Spoke with at bedside. Updated to status and plan of care. verbalize understanding of information. No questions verbalized when encouraged.\n\nImpression: Premature infant with issues of hyperbilirubinemia. Tolerating feeds but requires an increase in calories. Respiratory status stable at this time on room air and no spells. Plan as discussed by systems and with Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725745, "text": "NPN:\n\nRESP: Sats 98-99% in RA. RR=40-60 w/SC retraction. BBS =/clear. No A&Bs over past 24 h.\n\nCV: Soft murmur audible at LUSB, lt axilla. Color pink w/good perfusion.\n\nFEN: Wt=1640g (+ 15g). TF=140cc/kg/d; 41cc PE-24 q 4 h via NG/PO. Gavaged tonight; tolerated fdgs well. Abd benign. Voiding & stooling. FeS04 supp.\n\nG&D: CGA~34 wk. Temp stable in off isolette. Active w/cares; good tone. Beginning to bottle feed. Resting well.\n\nBILI: Phx dc'd . Rebound Bili 5.2/0.2/ 5.0 (up from 4.9).\n\nSOCIAL: Father in to visit. He took temp and changed diaper of twin #2; attempted to bottle feed her but she was uninterested. Handles babies well.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725746, "text": "Neonatology Attending\n is 7do, 33 wks corrected. In isolette, RA. No a/b. Wt up 15 to 1640 on TF140 MM/PE 24 pg>po. Rebound bili this am 5.2/0.2 from 4.9/0.3. Soft murmur noted L axilla/?LSB.\n\nMeds Fe\n\nImp/former 32wk twin doing well. Feeding & thermoreg immaturity appropriate for GA. physiologic hyperbilirubinemia resolving s/p phototherapy. Asymptomatic murmur most c/w PPS.\n\nPlan/ continue to monitor cvr status, feeding tolerance & abilities, growth. Wean isolette as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-24 00:00:00.000", "description": "Report", "row_id": 1725747, "text": "NPN 7A-7P\n\n\n#1 Remains in RA w/o desat's or brady's. LS = and clear,\ncon't to have intercostal retractions, but RR appear\nunlabored. Murmur audible x 1 this AM, is pink with quick\n refill. Monitor.\n\n#2 Bottled 15cc's well but got tired, remainder gavaged. No\nspits, voiding and stooling. On FIS. Con't to attempt PO\nfeeds.\n\n#4 Maintaining temp borderline in off isolette. Very alert\nand active for cares and resting comfortably b/t feeds. No\nbrady's. Working on bottling. Con't present interventions.\n\n#6 Bili this AM:5.2. No further checks ordered. Problem\nd/c'd.\n\n#5 in to hold x 2, do cares with minimal assistance.\nWill con't to update/support/teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725748, "text": "Nursing Progress Note\n\n\n#1 RESP\nStable on RA with good sat. Clear equal BS with mild\nretraction. No acute distress. No spells P/ Cont to assess\nCVR status\n#2 FEN\nWt 1.655 (up 15gm) On TF 140cc/k/d of BM24 or PE24cal.Due to\nmod spit feeding time increased, gavaged over 1 hour. Benign\nnon-tender abdomen.Girth stable at 23-24cm. NGT in place.\nVoiding and stooling heme neg stool. P/ Cont to assess\nfeeding intolerance.\n#4 G/D\nStable temp on unheated isolette. Alert and active with good\ntone. COnsolable with pacifier and bounderies. P/ Cont. to\nsupport G/D\n#5 Parenting\nNo contact with family this shift\n#6Problem of hyperbili resolved\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725749, "text": "6 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-25 00:00:00.000", "description": "Report", "row_id": 1725750, "text": "Neonatology Attending\n remains in RA, isolette. No a/b.\nWt up 15g to 1655 on TF140 MM/PE24 pg>po; occ spits.\nMeds Fe\n\nPE active, appropriate, pink; AFOF. lungs CTA, heart RRR s murmur, abd soft, extr well perfused.\n\nImp/ former 32+wk twin now 34 weeks corrected. immature feeding & thermoregulatory skills as expected for GA. Wt stabilizing but not yet back to Bwt.\n\nPlan/ continue to monitor cvr status, feeding tolerance, wt gain. Will increase to 26cal/oz feeds but keep TF at 140 given spits.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725729, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > 98% with no desats or\nbradys. Br. sounds clear with mild retractions.\n#2O: Wt. up 10 g on total fluids of 120cc/kg/d Feeds\nincreased to 100cc/kg, q 4 hrs. of Pe20. Belly soft, occ.\nsoft loops, voiding and stooling. Min. asp. 1 sm. spit. IV\nof D10W with lytes at 20cc/kg Lytes pnd., d-s 84.\n#4O: In heated isolette with stable temp. Active with\ncares.\n#5O: Mom called to check on the girls. Will visit later\ntoday.\n#6O: Under single phototherapy with eyes covered. Bili\nlevel done, see flow sheet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725730, "text": "Neonatology attending note\n4 d.o\nAFOF.\nin RA, no spell, clear.\nCV: no murmur.\nAbdomen soft.\nbili= 7.8\nwt= 1660 gm +10, TF= 120 cc/kg/d with feeding at 100 cc/kg/d with PE20.\nA: 32 wks GA, jaundice.\nP: observe for possible immaturity of breathing, f/u bili in 2 days, advance feeding.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725731, "text": "NNP Physical Exam\n\nPE: pink, mild jaundice, AFOF, sutures approximated, moveable, lungs clear/equal with comfortable WOB, no murmur, abd soft, non distended, bowel sounds present, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725732, "text": "NPN Days\nIV infiltrated, puffy DC'd. Pt to reach goal of 140cc/kg/d @MN.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-21 00:00:00.000", "description": "Report", "row_id": 1725733, "text": "NPN Days\n\n\n#1 Pt received in RA and cont in RA. mild S/C retrac.\nNo spells so far this shift. P- Will cont to monitor resp\nstatus.\n#2 FEN- TF=140cc/kg/d. Enteral feeds=120cc/kg/d of BM or\nPE20. abd benign. voiding and stooling. min asp no spits. po\n20cc x1. ag-23cm. IV fluids= 20cc/kg/d of D10W with 2NaCl\nand 1KCl. IV fluids to be DC this evening NNP. P- Will\ncont to monitor FEN.\n#4 G&D- Temp stable in air mode isolette. nested in\nsheepskin. alert and active with cares. PKU consent signed.\nP- Will cont to monitor G&D.\n#5 Parenting- in this shift. helped with cares and\nheld pt. asking approp ques. loving and caring. updates\ngiven. P- Will cont to encourage parental visits and calls.\n#6 Pt sl jaund. Pt cont under single\nphototherapy. eyeshields on. Bili to be drawn on wed am. P-\nWill cont to monitor hyperbili.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725734, "text": "NPN 1900-0700\n\n\n1 Resp\nSats remain 95-100% in RA. RR 40-60's. Lung sounds\nclear/=. Mild retractions, no increased work of breathing\nnoted.\n\n2 FEN\nCurrent weight 1.630 kg, down 30 grams. TF remain at\n140cc/kg/day. Enteral feedings currently at 120cc/kg/day,\ndue to advance to 140cc/kg/day at midnight but held d/t\nincreased asp. Abd soft, flat. Girth stable. BS +. No\nspits, 11cc asp x's 1. Voiding and stooling.\n\n4 Dev\nTemp stable in air controlled isolette. Awake and alert\nwith cares. Sleeps well between cares.\n\n5 Parenting\nNo contact thus far this shift.\n\n6 Bili\ncontinues under single phototherapy. Goggles in place.\nLevel to be checked .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-22 00:00:00.000", "description": "Report", "row_id": 1725735, "text": "Neonatology attending note\n5 d.o\nin RA, clear, mild IC retraction, no spell.\nno murmur\njaundice, under phototherapy\nAbdomen soft.\nwt =1630 -30, 140 cc/kg/d with feeding PE 20, some aspirate noted yesterday.\nA: 32 wks GA, jaundice.\nP: monitor for episodes, motnitor tolerance feeding and may consider advancing calorie density if tolerated, f/u bili.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725743, "text": "NPN 0700-1500\n\n\nRESP: Infant remains in room air with sats>95%. Breath\nsounds are clear and equal. Mild subcostal retractions\nnoted. RR 30-40's. No apnea or bradycardia noted.\nA/P: Stable- monitor for spells.\n\nF&N: Tf-140cc/kg/d. Advanced to 24 cals. Tolerating feeds\nwell. Abd is flat and soft with active bowel sounds.\n Voiding and stooling. Infant bottled well at noon for\nDad, taking 27/41cc.\nA/P: Learning to po feed- Bottling once/shift- advance as\ntolerated. Monitor weight.\n\nDEV: Temp is stable in an air-controlled isolette. Infant\nis alert and active with cares. Sleeps well betwen cares.\nTone is wnl- actions are appropriate for gestational age.\nFESO4 ordered.\n\n: Mom and Dad and grandmother in to visit. Dad did\ncares- very eager to participate. Dad also bottled \nand was very much in tune with her cues and responded\nappropriately.\nA/P: Involved/ - cont to teach and support\nthem.\n\nBILI: Single phototherapy d/c'd at noon for a bili of\n4.9/.3/4.6. Infant is ruddy/jaundiced. Rebound bili to be\ndrawn in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-23 00:00:00.000", "description": "Report", "row_id": 1725744, "text": "NPN 1500-2300\n\n#1 Alt. in Resp. Function\nO: In RA, RR 30's-60's with mild SC retractions. Breath sounds are clear. Sats 99-100. No spells.\nA: Doing well in RA\nP: Continue to monitor and observe. Document any spells.\n\n#2 Alt. in Nutrition\nO: TF=140cc/kg=41cc PE24 or BM24 Q 4 hrs. Abd. is round, soft with active BS, stable girth. Small aspirates, no spits. Voiding and passing green stool. Feeds given by gavage over 45 min.\nA: Tolerating feeds well at present, gaining wt.\nP: Continue with present feeding plan. Close observation for feeding tolerance and follow daily wts.\n\n#4 Alt. in Development\nO: Isolette turned off tonight and temp remains stable. Infant is swaddled, nested in sheepskin, positioned supine with boundaries in place. Not waking for feeds, but alert with cares. Sucks for short periods on pacifier. No spells.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs. Transfer to crib tomorrow if temp okay and no phototherapy needed.\n\n#5 Alt. in Parenting\nO: Mom in for 1600 feeding. Changed diaper and took temp. Held infant during gavage. Dad called later in shift. Plans to visit later tonight.\nA: Involved, \nP: Keep informed, support and teach.\n\n#6 Hyperbilirubinemia\nO: Color remains ruddy. Off phototherapy. Adequate hydration and passing stool.\nA: Resolving hyperbilirubinemia\nP: Check rebound bili in AM.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725726, "text": "Neonatology Attending\n\nDay 3\n\nRemains in RA. SA-O2 99-100%. Has had three bradycardic episodes- all mild- over last 24 hours. HR 120-130s. BP mean 55. Bilirubin 8.2/0.3. Weight 1650 gms (-55). TF at 120 cc/kg/d. Half volume is enteral. Bottle fed this morning. Increasing feeds by 20 cc/kg/ twice daily. Transient soft bowel loops palpated. Lytes 145/5.2/112/19. Stable temperature in air-controlled incubator.\n\nDoing well overall with mild apnea of prematurity. Will continue to monitor closely. Feeding well. Likely exaggerated physiologic hyperbilirubinemia. Will continue to treat with phototherapy and follow bilirubin. Continuing feeding advance. Metabolically fine. Family meeting held yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725727, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in air isolette. In room air, BS clear and equal with mild subcostal/intercostal retractions, color pink/jaundiced. RRR, without murmur, pulses 2+ and symmetrical. Slightly hypoactive bowel sounds, without loops, without HSM, tolerating advancing feeds well at present. Peripheral IV infusing well via left hand, without reddness or swelling at site.Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725728, "text": "0700- NPN\n\n6 Hyperbilirubinemia\n\nRESP: Infant is in RA with RR 30s-60s and sats 99-100%. LS\nclear/=, mild IC retractions present. Brady x1 without\ndesat, QSR. A: pot alt in resp r/t prematurity P: Cont to\nmonitor resp status.\n\nFEN: TF 120cc/k/d; IVFs D10w with 2NaCl+1KCl running at\n40cc/k/d via PIV, enteral feedings increased to 80cc/k/d\nPE20, po/pg. Infant bottled for the first time this a.m. and\ntook 15cc using yellow nipple. Good pacing and coordination\nnoted. No spits, min asp with small specs of brown, old\n present, NNP aware. Abd is soft and round with soft\ntransient loops present (NNP aware), active BS. Abd girth\n25cm, stable. Voiding and mec stooling (old also\npresent in stool). A: pot alt in feeding tolerance r/t\nprematurity P: Cont to monitor feeding tolerance, support\nand encourage po feedings.\n\nG&D: Temps stable in air iso, nested with sheepskin (under\nphotothx). MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping b'twn cares. Brings hands to midline,\nsucks on pacifier for comfort. A: AGA P: Cont to support\nG&D.\n\nPARENTING: in to visit today. Updated by RN, asking\nappropriate questions. Becoming independent with cares. Mom\nis being discharged today. A: loving and invested P: Cont to\nsupport and educate.\n\nBILI: Started on single photothx this a.m. for a bili of\n8.2-0.3-7.9. A: hyperbilirubinemia P: Recheck bili in a.m.\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725720, "text": "NEONATOLOGY ATTENDING\n\nDay 2 for .\n\nRESP: RA, good sats. RR 40-60. Mild retractions, no bradys. Single desat, self resolved.\n\nCV: Good HR, perfusion. MAP 39.\n\nBILI: Bili 5.2 last night. Repeat this AM pending.\n\nFEN: 1705 -35. 100/kg. 80/kg of D10 with lytes. 20/kg of HBM 20 gavage q4h. No spits, minimal aspirates. Belly benign. Urine 3.4/k/h. 145/5.1/113/21. Mec stools. Advance 20/kg .\n\nDVLP: Air-mode incubator.\n\nPARENTS: Parents happy.\n\nSee exam note below.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725721, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equla. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSm. active bowel sounds. ifnant alert and active.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725717, "text": "NPN 1430\n\n\n#1 Resp: remains in RA w/ O2sats 97-100%, no desats\nor bradys. Lungs clear, = bilat, mild SC retractions. Color\npink. A: Stable in RA. P: Cont to assess for change in resp.\nstatus.\n#2 F/N: Total fluids at 80cc/kg/d; feedings started at\n20cc/kg/d PE20 6cc q 4 hrs. PIV at 4.3cc/hr D10. Lytes and\nbili at 10pm tonight. Glucose= 114. Abd soft and flat w/ AG\n22.5cms, bowel snds present. Infant is voiding and stooling.\n#5 NG tube placed in the right nares to 17cms.\nA: Feedings initiated.\nP: Monitor for feeding intolerance.\n#3 ID: Remains on Ampi/Gent as ordered. Temps stable on\nwarmer/isolette. Behavior appropriate for age, moving\nall extremities. A: Stable on antibiotics. P: Cont as\nordered, monitor culture results.\n#4 Dev.: was moving to a 33.0C heated isolette this\nAM. Boundaries in place, sheepskin under baby. Baby is\nswaddled. Infant awake and alert w/ cares. A: AGA 33 wks.\nP: Cont dev. supports.\n#5 Parents: Mom and Dad up this AM. Held for a while.\nAsking appropriate questions. Mom is planning to attempt br.\nfeeding. Parents will try to locate a pediatrician in their\narea. A: Invested parents. P: Cont parent support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725722, "text": "0700- NPN\n\n\nRESP: Infant is in RA with RR 40s-60s and sats 99-100%. LS\nclear/=, mild subC retractions present. No bradys or desats\nat this time. A: stable in RA P: Cont to monitor resp\nstatus.\n\nFEN: TF 100cc/k/d; enteral feedings increased today to\n40cc/k/d BM20/PE20 pg, IVFs D10w with 2NaCl+1KCl running at\n60cc/k/d via PIV. No spits, min asp with small specs of\nbrown old- present, NNP aware. Abd soft, flat, no\nloops, active BS. Girth 22-22.5cm, stable. Voiding, no stool\nat this time. Dstick 73. A: tolerating feedings P: Cont to\nincrease enteral feedings 20cc/k/d as tolerated.\n\nSEPSIS: Cont on Amp and Gent x48hr r/o. VSS per flowsheet.\nA: no sx of sepsis at this time P: Cont to monitor.\n\nG&D: Temps stable in air control iso, dressed and swaddled.\nMAE, fontanels soft and flat. Alert and active with cares,\nsleeping b'twn cares. Brings hands to face, somewhat\ninterested in pacifier. A: AGA P: Cont to support G&D.\n\nPARENTING: Parents in to visit throughout the day, updated\nby RN. Both Mom and Dad taking temp and changing diaper with\nminimal assistance. A: loving and invested P: Cont to\nsupport and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725723, "text": "0700- ADDENDUM TO NPN\n\n\nInfant had a brady to 96 with desat to 78%, mild stim given.\nNo apnea noted.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725724, "text": "NNP On-Call/Family Meeting\nFamily meeting held with both , RN, myself, Dr. . All issues addressed per family meeting checklist. to chose primary pediatrician, are not interested in transfer to . All questions answered.\n" }, { "category": "Nursing/other", "chartdate": "2187-05-20 00:00:00.000", "description": "Report", "row_id": 1725725, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > than 98% with no desats or\nspells. Br. sounds clear and =.\n#2O: Wt. down 55g on total fluids of 100cc/kg. IV of D10W\nwith lytes presently at 40cc/kg. Feeds of Pe20 increased to\n60cc/kg, q 4 hrs. Belly soft, occ. soft loops and sm. asp.,\nno spits. Voiding qs, and passing mec stool. Lytes and\nbili done, see flow sheet, d-s 61.\n#3O: Bld. cx. neg. and ampi and gent d/c.\n#4O: In heated isolette with stable temp. Active and\nresponsive with cares, some mild sucking on pacifier.\n#5O: visited and updated. Mom will be d/c from the\nhospital later today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-18 00:00:00.000", "description": "Report", "row_id": 1725718, "text": "Nursing Note\n\n\n#1O: In room air with O2 sats > than 96% with no desats or\nspells. Br. sounds clear with very mild retractions.\n#2O: Total fluids presently at 80cc/kg/d. Will be\nincreased with new IV fluid. IV of D10W at 60cc/kg and\nenteral feeds at 20cc/kg. Belly soft, voiding and passing\nmec. stool. Had a partially digested asp. with flecks of\nblood at 20:00 feed. to NNP, and asp. then\ndiscarded. Lytes and bili done, see flow sheet.\n#3O: Ambi and gent given, bld. cx neg. to date.\n#4O: In heated isolette with temp weaned 2 degrees. Alert,\nvery mellow with cares.\n#5O: Parents up and shown how to take temp, change diaper\nand swaddle. Both parents pleased that daughters are doing\nwell.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-05-19 00:00:00.000", "description": "Report", "row_id": 1725719, "text": "nursing progress note 2400-0700\n\n\n#1 resp\no: pt in r/a with sats 99-100%. lsc and equal. mild sc\nretractions noted. rr40-60's. no spells. one drift to 84\nqsr. a: stable P: continue to monitor for changes and\nsupport as needed..\n#2 fen\no: tf 100cc/kg. ivf infusing via piv @ 80cc/kg. enteral\nfeeds of pe20 @ 20cc/kg. wt 1.705kg (-35gms). abd benign.\nmax aspir of 1.2cc brown in color, nnp aware. aspirate\ndisgarded and feed continued. ag stable 22.5-24.5cm. no\nspits. voiding 3cc/kg with trace mec stools. a: stable,\ntolerating feeds well. reported of infant swallowing large\namt of blood during delivery. p: continue to monitor for\nchanges and support as needed.\n#3 sepsis\nO: pt with stable temps in air controlled isolette. alert\nand awake with cares. remains on double abx til bc complete.\na: stable P: continue to monitor for changes and support as\nneeded.\n#4 g&d\nO; pt in air controlled isolette with stable temps. able to\nwean x2 for temps 98.8 and 99.1. alert and awake with cares.\nfontanelles soft and flat. sucking on pacifier. maew. a:\nstable P: continue to monitor for changes and support as\nneeded.\n#5 parenting\no: mom in for 12am cares. asking appropriate questions.\nconcerned. a; loving and caring mom P: continue to update\nwith new information when available and support as needed.\n\n\n" } ]

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82 yo WF w PMHx of Lung adeno ca sp lobectomy, HTN, GERD, Hx of cerberal aneurysm presents w septic shock cholangitis, needing ICU stay, fluids, pressors, brief intubation 1. Septic shock - cholangitis from choledocholithiasis w + bacteremia w Strep and Ecoli. Now resolved. SP on w removal of sludge/pus and stent placement. Repeat Blood Cx NGTD. Initially placed on Vanc/Zosyn, abx narrowed to Rocephin based on sensi. PICC placed for a total of 14 day course. Repeat in 4 weeks 2. Mild hypoxia - to fluid overload from aggressive fluid resuscitation. Repeat CXR shows improvement in fluid overload, continue to monitor. Incentive spirometer to avoid pna. 2liters Oxygen prn to keep sats >90% 3. Incidental finding of L adnexal cyst - pt and daughter informed that PCP will need to do an outpt FU w pelvic ultrasound 4. Recent episode of SVT vs afib - no such episodes on floor, tele discontinued 5. Anemia - mild anemia w stable HCT. PCP to follow up at discharge 5. GERD - continued on ppi 6. Hx of depression - continued on effexor 7. HTN - switched to outpatient meds which included atenolol, triamterene/hctz . FEN - regular diet . Code status - full . VTE prophylaxis - sq heparin . Disposition - Discharged to Epic of Nursing home

-supplementary O2 PRN -low index of suspicion to repeat ABG for mental status changes # Cholangitis: Vanco / Zosyn as above. Now she has had return to pressor requirement despite optimized volume status--this is in the absence of significant fever but with persistent bandemia. Response: Have been able to wean levophed gtt down to 0.03mcg/kg/hr. Will continue gentle diuresis and get OOB given volume overload in the setting of massive resuscitation. # Cholangitis: Vanco / Zosyn as above. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. Response: Pt remains on Levophed 0.01 mcg/kg/min. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. In the ED she was found to be febrile to 103, with HR 82, BP 146/77. - Pipercillin/tazobactam -Vancomycin for GPC - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. - Pipercillin/tazobactam -Vancomycin for GPC - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. - Vanc/Zosyn - Will d/c CVL after peripheral access established # Respiratory Failure: Patients ventilation and oxygenation are stable since extubation though she does have some persistent hypercapnea. -monitor serial abdominal exams # Hypertension: hold antihypertensives except BB for the moment until longer w/o hypotension # Lung Cancer: not active issue, outpatient follow up # Cerebral Aneurysm: low tolerance for hypertension # Depression: continue antidepressents # Hypercholesterolemia: hold statin for now, restart when LFTs trendign toward normal # Access: Right IJ, Aline, also 2 PIVs # FEN: NPO # PPx: PPI, heparin SQ # Dispo; ICU # CODE: FULL ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:50 PM Prophylaxis: DVT: Hep SC Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: COMPARISON: at 05:06 FINDINGS: The patient has been extubated and the NGT has been removed. HPI: 24 Hour Events: -Patient with PSV wean across yesterday to minimal settings--A/C required with decreased drive and sedatin lightened this mornign -Norepinephrine weaned to off History obtained from Medical records Allergies: Meperidine Unknown; Percocet (Oral) (Oxycodone Hcl/Acetaminophen) Lightheadedness Codeine Constipation; Last dose of Antibiotics: Piperacillin/Tazobactam (Zosyn) - 04:00 AM Vancomycin - 08:02 AM Infusions: Other ICU medications: Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Constitutional: No(t) Fever Respiratory: Tachypnea Gastrointestinal: No(t) Abdominal pain Genitourinary: Foley Flowsheet Data as of 09:27 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.9C (98.5 Tcurrent: 36.9C (98.5 HR: 69 (59 - 75) bpm BP: 171/67(107) {92/34(58) - 171/76(107)} mmHg RR: 21 (15 - 21) insp/min SpO2: 96% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch CVP: 13 (2 - 13)mmHg Total In: 1,524 mL 579 mL PO: TF: IVF: 1,479 mL 579 mL Blood products: Total out: 1,152 mL 580 mL Urine: 1,152 mL 580 mL NG: Stool: Drains: Balance: 372 mL -1 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: CPAP/PSV Vt (Set): 0 (0 - 500) mL Vt (Spontaneous): 471 (446 - 562) mL PS : 5 cmH2O RR (Set): 0 RR (Spontaneous): 21 PEEP: 5 cmH2O FiO2: 50% RSBI: 80 PIP: 16 cmH2O Plateau: 17 cmH2O Compliance: 42.7 cmH2O/mL SpO2: 96% ABG: 7.32/41/89.//-4 Ve: 8.9 L/min PaO2 / FiO2: 178 Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 9.8 g/dL 70 K/uL 79 mg/dL 1.1 mg/dL 19 mEq/L 4.4 mEq/L 15 mg/dL 119 mEq/L 140 mEq/L 30.9 % 4.1 K/uL [image002.jpg] 12:39 PM 01:04 PM 04:55 PM 09:25 PM 09:47 PM 04:10 AM 06:08 AM 12:28 PM 04:36 PM 08:25 AM WBC 5.9 3.1 4.1 Hct 33.8 27.9 30.9 Plt 72 53 70 Cr 1.0 1.1 1.1 TCO2 20 20 21 17 21 21 22 Glucose 86 81 79 Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos / T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %, Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:2.3 mg/dL Fluid analysis / Other labs: 7.32/41/89 Microbiology: GNR's with pan-sensitive Assessment and Plan 82 yo female admit with biliary obstruction and ascending cholangitis and now with excellent stability of blood pressure following Rx with decompression and drainage. There is a small amount of hypodensity adjacent to the shunt catheter which may represent adjacent edema, which is unchanged from the prior study. Also noted is a stable appearing hypodensity within the right internal capsule, which is likely attributed to chronic ischemic changes. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line placement via the right basilic venous approach. Limited evaluation of the lung bases is unchanged with basilar atelectasis and right pleural thickening noted. IMPRESSION: Endotracheal tube in satisfactory position. ETT placment PFI REPORT Endotracheal tube in satisfactory position. CT ABDOMEN: There is mild-to-moderate intra- and extra-hepatic biliary dilatation which is new compared to the prior study dated . FINDINGS: Again noted is a right posterior ventriculostomy shunt catheter with the tip terminating in the frontal of the left lateral ventricle. The visualized paranasal sinuses and mastoid air cells are normally aerated. Endotracheal tube in satisfactory position. Right PICC tip is in the SVC. IMPRESSION: Right central venous catheter with tip at the cavo-atrial junction. There is a stable appearing region of hypoattenuation within the right frontal periventricular white matter which may represent the sequelae of microvascular angiopathy. There is unchanged positioning of the endotracheal tube whose tip terminates approximately 4 cm from the carina. 10:57 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: PE?

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[ { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440839, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440909, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440989, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500. ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440990, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440994, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n back on CMV 500/18/50%/5 PEEP\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 440995, "text": "Chief Complaint: s/p ERCP, sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin - 07:56 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 59 (55 - 68) bpm\n BP: 114/54(76) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 65 Inch\n CVP: 10 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 712 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 667 mL\n Blood products:\n Total out:\n 2,707 mL\n 312 mL\n Urine:\n 2,707 mL\n 312 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 400 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, occasional)\n Abdominal: Soft, No(t) Bowel sounds present, Distended, Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2116-03-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440848, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440969, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym.\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440970, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains on vent settings,\n sedated with Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 440972, "text": "Chief Complaint: Sepsis\n Cholangitis\n respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n -2 liters overnight for hypotension and despite this Levophed\n restarted.\n History obtained from Medical records\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 07:56 AM\n Piperacillin/Tazobactam (Zosyn) - 10:03 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 60 (55 - 68) bpm\n BP: 94/50(68) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 9 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 897 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 852 mL\n Blood products:\n Total out:\n 2,707 mL\n 417 mL\n Urine:\n 2,707 mL\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 96%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n Diffuse\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 70 K/uL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Imaging: CVL, ETT, OGT in good position, persistent LLL opacity--no\n change\n Assessment and Plan\n 82 yo female admit with cholangitis and now s/p ERCP. She had\n significant sepsis and with stent relieving obstruction rapid wean of\n pressors was performed. Now she has had return to pressor requirement\n despite optimized volume status--this is in the absence of significant\n fever but with persistent bandemia.\n 1)Respiratory Failure\nPatient with intubationin the setting of sepsis\n and cholangitis. She has had substantial improvement in her\n oxygenation and ventilation with good preservation of aeration on CXR-\n -Will move to PSV today\n -Will trial RSBI and 1 hour SBT prior to extubation to consider\n possible successful extubation today\n -If mental status and CVP/fluid status favorable will move to\n extubation\n 2) SHOCK, SEPTIC\n -Vanco/Zosyn\n -Move to diuresis today as tolerated today\n ICU Care\n Nutrition: NPO given possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440978, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440979, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 10-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440984, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on CPAP 8/5, ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on CPAP 10/5 with a back-up rate of 10 and VT\n 500.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Remains\n on CPAP 10/5.\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 441053, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: RSBI-80. Pt placed on\n CPAP/PS @5am. Plan is to extubate today.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440906, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments\n" }, { "category": "Physician ", "chartdate": "2116-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 440964, "text": "Chief Complaint: s/p ERCP, sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 05:34 PM\n of f l aline and r triple lumen\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin - 07:56 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Morphine Sulfate - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 59 (55 - 68) bpm\n BP: 114/54(76) {90/38(57) - 131/72(89)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 65 Inch\n CVP: 10 (8 - 15)mmHg\n CO/CI (Fick): (9.2 L/min) / (4.9 L/min/m2)\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 6,390 mL\n 712 mL\n PO:\n TF:\n IVF:\n 6,180 mL\n 667 mL\n Blood products:\n Total out:\n 2,707 mL\n 312 mL\n Urine:\n 2,707 mL\n 312 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,683 mL\n 400 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.35/29/102/19/-7\n Ve: 8.5 L/min\n PaO2 / FiO2: 204\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, occasional)\n Abdominal: Soft, No(t) Bowel sounds present, Distended, Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 11:10 PM\n 03:22 AM\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n WBC\n 5.5\n 5.9\n 3.1\n 4.1\n Hct\n 34.9\n 33.8\n 27.9\n 30.9\n Plt\n 67\n 72\n 53\n 70\n Cr\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 19\n 21\n 20\n 20\n 21\n 17\n Glucose\n 89\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:126/43, Alk Phos /\n T Bili:318/5.2, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.1\n mmol/L, Albumin:2.4 g/dL, LDH:170 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Hopefully\n she will do well. Continues to demonstrate septic physiology with\n pressor requirment.\n - mixed venous 02\n - titrate CVP to 12 w/fluid bolus\n - wean levophed as tolerated with CVP ~12\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Interestingly, however, is her elevated\n bicarbonate which could be from a higher level at baseline or from a\n contraction alkalosis. Currently intubated on Assist control 500 x 14\n w/5 peep and oxygenating well on 60%.\n - wean Fi02 to 40%\n - check ABgs to see if pH treding toward normal. Would not\n overventilate as I suspect her pCO2 is somewhat elevated given her age\n and elevated bicarbonates in the past (~30). Maintain current minute\n ventilation and monitor PH. Woudl expect as sepsis resolves her pH\n trends towards normal.\n - If pH normal then could change to pressure support and begin weanign\n process. Do not expect her to be intuabed long as her lungs were ok\n prior to admission\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - plans per ERCP\n - NPO for now\n - stent removal in future\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Rihgt IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: famotidine, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 441284, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 82F cholangitis c/b GNR sepsis, respiratory\n failure, and AF vs AVNRT.\n Exam notable for Tm 99.9 BP 130/50 HR 72 RR 17 with sat 98 on FM. WD\n woman, mildly confused. Coarse BS bases. RRR s1s2. Soft +BS. 2+ edema.\n Labs notable for WBC 5K, HCT 31, Cr 0.8.\n Agree with plan to continue vanco/zosyn for cholangitis / GNR sepsis;\n recent cx are negative. Will continue gentle diuresis and get OOB given\n volume overload in the setting of massive resuscitation. AF/AVNR is\n likely mediated by fluid shifts and critical illness. Will continue\n metoprolol and d/c CVL as able, but will hold off on anticoagulation\n for now. Will need PICC for longterm abx. PT eval, wean oxygen for sat\n goal >92%, OOB today. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:29 ------\n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441194, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on\n po lopressor TID,\n CV\n Pt continues in rapid rhythm. Lopressor IV 5mg given x2 with good\n response. BP stable. Afebrile. After pt received vicadin for leg\n pain- pt converted to NSR and PAC\ns. Rate in the 60\ns-70\ns. At\n midnight\ns HR suddenly increased to 150 and then spont went into a\n very slow brady and then broke into a regularly irregular rhythm in the\n 60\ns. Pt did not seem to have any adverse affects from this and this\n rhthym has not been seen again.\n Resp\n At beginning of shift pt was very restless\n BS with insp and\n exp wheezes and requiring more FIO2. Given an atrovent treatment and\n the wheezes decreased and her resp became less labored. She is\n presently on Face tent at 70% and her sats have been stable all night.\n Neuro\n Pt was very restless the entire evening but was unable to\n verbalize why. Attempted mult repositions and even trazodone with min\n response. Continued to try to get legs over the side of the bed.\n Daughter called to check in on mother and stated that her mother has\n restless leg syndrome and does very well with vicadin. Med given x1\n with remarkable response\n pt able to sleep in long naps and much more\n coherant and cooperative. Continues to kick blankets off but is not\n attempting to get out of bed as much.\n GI\n pt had small stools x2.\n GU\n Pt did not receive any more lasix\n UO has been adequate at\n 50-80/hr.\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441277, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Vanc/Zosyn\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441278, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Social Work", "chartdate": "2116-03-23 00:00:00.000", "description": "Social Work Admission Note", "row_id": 441280, "text": "Family Information\n Next of : , (Daughter) (H) \n Health Care Proxy appointed: It appears to this writer that there is no\n HCP. In in Profile under HCP there is the following comment:\n does not yet have a proxy. Would prefer Dtr: .\n Family Spokesperson designated: Same\n Communication or visitation restriction: None known.\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: This admission is the\n seventh at for Ms. , with her first computer accessible\n admission date being .\n Past psychiatric history: Per pt's daughter, Ms. has a HX of\n depression.\n Past addictions history: None known\n Employment status: Retired\n Legal involvement: None known.\n Additional Information:\n Patient/Family HX: A doctor admitted this widowed 82 y/o woman with\n sepsis. This worker spoke with her daughter, ; there is a\n second younger daughter. of the interview focused on Ms. and\n her stress and concern. She has two adult children, a son and a\n daughter, who live in housing for people who are developmentally\n challenged.\n Assessment:\n Although there were reported concerns about pt\ns two daughters being\n extremely anxious when pt was in the ED and being admitted, that was\n not this worker\ns experience of Ms. , or her sister whom this\n worker met in later in the day. Ms. \ns concerns for her children\n and mother consume much of her time and emotional energy. She works as\n a dental hygienists, primarily with special needs children. There was\n little relevant HX re Ms. .\n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n 1. To be available to family for support while pt is in the .\n Page \n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441322, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on po lopressor TID,\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR throughout shift. Per report overnight pt had bursts of afib\n with HR up into 140\ns. Throughout shift, pt\ns HR remained in 60\n NSR. Received pt on Lopressor 50mg PO TID.\n Action:\n Lopressor dose lowered to 25mg TID as pt was normotensive and\n experienced no episodes of afib.\n Response:\n Pt remains in NSR with HR in 60\ns. Some PVC\n Plan:\n Continue to monitor for afib. Continue to give Lopressor as ordered.\n Pt started to become very agitated around 1800. Denied pain and was\n ripping O2 mask off. Given 0.5mg Haldol IV x 1 and soft limb\n restraints applied to wrists. Good effect with Haldol as pt is calm\n and resting in bed.\n" }, { "category": "Physician ", "chartdate": "2116-03-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 440693, "text": "TITLE:\n Chief Complaint: Lethargy\n HPI:\n 82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status. The history was\n obtained from review of the notes as the patient was intubated and\n sedated at the time of admission to the ICU.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72. She was taken to the .\n On arrival to the her blood pressure was in the 60s systolic. She\n was given further fluid resussication (4 liters, for 8 liters total)\n and started on levophed. She was then taken emergenctly to the ERCP\n suite where a stent was placed in the common bile duct and frank pus\n was expressed.\n She returned to the on AC 500 x 14, 100%Fi02 and 5peep. Her Fi02\n was weaned. She was continued on levophed.\n ROS was not able to be obtained as the patient was intubated and\n sedated.\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Propofol - 45 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n # Adenocarcinoma of the lung,\n nonmetastatic, status post resection, Grade T2N0M0. She is\n status post Carboplatin and Taxol on ,\n status post right upper lobectomy on .\n # Cerebral Aneursym, s/p coiling @ in \n # Hypertension.\n # Hypercholesterolemia.\n # Diverticulosis.\n # Hiatal hernia.\n # Gastroesophageal reflux disease.\n # Status post cholecystectomy, appendectomy, total abdominal\n hysterectomy with bilateral salpingo-oophorectomy.\n n/c\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient lives in . She has a positive tobacco\n history. She smokes two packs per day for 52 years; she quit ten years\n ago. 2 very involved daughters, and .\n Review of systems:\n Flowsheet Data as of 10:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 69 (66 - 81) bpm\n BP: 140/53(84) {113/51(78) - 185/68(110)} mmHg\n RR: 16 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 26 Inch\n CVP: 8 (8 - 22)mmHg\n Total In:\n 8,798 mL\n PO:\n TF:\n IVF:\n 4,598 mL\n Blood products:\n Total out:\n 0 mL\n 1,820 mL\n Urine:\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,978 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/44/219//-4\n Ve: 7.1 L/min\n PaO2 / FiO2: 365\n Physical Examination\n General Appearance: intubated and sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/5/ 09:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 23\n Other labs: Lactic Acid:1.4 mmol/L\n Imaging: CT TORSO:\n 1) No evidence of pulmonary embolism or aortic dissection.\n 2) Emphysema and left lower lobe air space disease which may represent\n aspiration versus pneumonia versus atelectasis. Clinical correlation is\n recommended.\n 3) New intra- and extra-hepatic biliary dilatation with a probable\n filling\n defect noted within the common bile duct, which could represent stones,\n sludge, or neoplastic process. An MRCP is recommended for further\n evaluation.\n 4) 2.8-cm left adnexal cyst which appears larger compared to the prior\n study.\n A pelvic ultrasound is recommended for further characterization given\n the\n patient's post-menopausal status.\n Assessment and Plan\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Hopefully\n she will do well. Continues to demonstrate septic physiology with\n pressor requirment.\n - mixed venous 02\n - titrate CVP to 12 w/fluid bolus\n - wean levophed as tolerated with CVP ~12\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Interestingly, however, is her elevated\n bicarbonate which could be from a higher level at baseline or from a\n contraction alkalosis. Currently intubated on Assist control 500 x 14\n w/5 peep and oxygenating well on 60%.\n - wean Fi02 to 40%\n - check ABgs to see if pH treding toward normal. Would not\n overventilate as I suspect her pCO2 is somewhat elevated given her age\n and elevated bicarbonates in the past (~30). Maintain current minute\n ventilation and monitor PH. Woudl expect as sepsis resolves her pH\n trends towards normal.\n - If pH normal then could change to pressure support and begin weanign\n process. Do not expect her to be intuabed long as her lungs were ok\n prior to admission\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - plans per ERCP\n - NPO for now\n - stent removal in future\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Rihgt IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: famotidine, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:54 PM\n 20 Gauge - 05:57 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440758, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440854, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n" }, { "category": "Nursing", "chartdate": "2116-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441057, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Resp\n Pt weaned from propofol slowly starting at 0400 and stopped at\n 0530. RSBI was 80 so changed to CPAP 10/5 at 0500.\n Tolerating this well. BS cl bilat and suctioned for scant amt\n secretions.\n Plan is to wean and extubated this morning.\n CV\n Able to wean levo off at 0300 and BP stable. HR has been in the\n 70\ns most of the night with no ectopy. Pt has been afebrile.\n GU\n foley cath draining adequate amt cl yellow urine.\n GI\n Pt had one very small brown soft stool. OGT clamped.\n Social\n Daughter in visiting last evening\n updated on plan of care\n and anxious to have mother make forward progress.\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441420, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night , HO obtained ABG\n this am at 0630\n Plan:\n Continue to monitor, f/u ABG results\n" }, { "category": "Physician ", "chartdate": "2116-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441423, "text": "Chief Complaint: 82 y/o woman with history of lung Ca and cerebral\n aneuysym admitted to the ICU with cholangitis, septic shock, and\n respiratory failure\n 24 Hour Events:\n \n -Quiet day, maintained on shovel mask O2 (nasal cannula 3L this a.m.)\n and mainly had concerns regarding some minor intermittent confusion,\n presumed post infectious\n -Attempted nurse and weren't able to place so ordered for\n IR placed\n -Blood Cx finally positive for two isolates of E. Coli (relatively\n sensitive) and one bottle with Strep angionosus (usually pen\n sensitive). Nothing positive since ED blood cx.\n -Agitation at night and received haldol w/ good effect.\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Haloperidol (Haldol) - 03:52 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 62 (60 - 75) bpm\n BP: 113/47(62) {90/44(59) - 154/74(86)} mmHg\n RR: 14 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 7 (7 - 9)mmHg\n Total In:\n 798 mL\n 185 mL\n PO:\n TF:\n IVF:\n 798 mL\n 185 mL\n Blood products:\n Total out:\n 2,570 mL\n 580 mL\n Urine:\n 2,570 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,772 mL\n -395 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.43/50/64/33/7\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 169 K/uL\n 10.2 g/dL\n 84 mg/dL\n 0.9 mg/dL\n 33 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 31.9 %\n 6.5 K/uL\n [image002.jpg]\n 08:33 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n 02:45 AM\n 06:48 AM\n WBC\n 5.6\n 7.1\n 5.8\n 6.5\n Hct\n 35.0\n 34.0\n 31.5\n 31.9\n Plt\n 89\n 113\n 126\n 169\n Cr\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 24\n 27\n 26\n 26\n 29\n 34\n Glucose\n 23\n 85\n 83\n 84\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:73.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:8.0 %, Eos:1.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.2 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 82 y/o woman with history of lung Ca and cerebral aneuysym admitted to\n the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: Patient admitted with hypotension and 2 GNR isolates\n as well as GPC\ns in blood cultures. The presumed source of this\n infection was her cholangitis and she is s/p ERCP and drainage of pus.\n Follow-up blood cultures remain negative and she has been successfully\n weaned off pressors.\n - Pipercillin/tazobactam\n -Vancomycin for GPC\n - Will d/c CVL after peripheral access established\n # Respiratory Failure: Patient\ns ventilation and oxygenation are stable\n since extubation though she does have some persistent hypercapnea. Her\n respiratory failure was presumed due to volume overload in the setting\n of aggressive fluid resuscitation. Currently this seems to be\n improved.\n -supplementary O2 PRN\n -low index of suspicion to repeat ABG for mental status changes\n # Cholangitis: Vanco / Zosyn as above. system has been decompressed but\n will need repeat ERCP after recovery to remove large stone.\n -stent removal in future\n -f/u ERCP reccs.\n -monitor serial abdominal exams\n # Hypertension: hold antihypertensives except BB for the moment until\n longer w/o hypotension\n # Lung Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: low tolerance for hypertension\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441141, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on\n po lopressor TID,\n Sepsis without organ dysfunction\n Assessment:\n Off pressors since 3am, extubated at 10am, CVP went from 10 up to high\n of 18, BP up to 160/80\ns I&O\ns show LOS +11 liters, rapid afib, 160\n BP ranged 90-120/60\ns ABGs done, blood culture x 1,\n Action:\n Atrovent nembs, lopressor 5mg x2 given, po started, cont to have short\n bursts of Afib during the day, lasix given 20mg , CVP down to 6-8 in\n the evening.\n Response:\n ABg slightly metabolic acidotic with improvement after lasix dose.\n Output 3.2 liters to lasix,\n Plan:\n Cont to follow ABG, closely monitor I&O\ns ?more lasix tonight,\n antibiotics as ordered. Awaiting culture results for isolation of\n bacteria, follow labs/electrolytes due to large output\n Social: son and two daughters in to visit updated by this RN and Dr.\n .\n" }, { "category": "General", "chartdate": "2116-03-19 00:00:00.000", "description": "ICU Event Note", "row_id": 440674, "text": "Clinician: Attending\n 83 yo female who has h/o HTN and is s/p lap ccy who presented with\n evidence of abdominal pain, fever and chills with associated N/V and\n now with evaluation had, in the ED-->\n -Pt with persistent lethargy patient had evolution of inability to\n maintain airway patency and patient intubated\n -Patient had elevation of T. Bili, CBD dilation and concern for\n obstruction on CT scan\n -Paitient to ICU for admission with CVL placed and 7 liters IVF given\n and Levophed started.\n Upon arrival-->\n Pt responsive to voice and follows commands\n BP-123/76 with levophed\n Bilateral Breath Sounds'\n Distant Heart sounds noted.\n 83 yo female with presentation consistent with cholangitis and bilary\n obstruction now with plans for acute ERCP to relieve obstruction. In\n the interim will-->\n -Place A-line for monitoring during procedure closely\n -Levophed to titrate to MAP >65\n -Will continue Antibiotics-Vanco/Zosyn\n -Continue with CMV support and FIO2=1.0 for now\n -Will continue evaluation following this initial stabilization\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2116-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441298, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Events : Extubated at 10am,\n Rapid afib responding to IV lopressor, now on po lopressor TID,\n Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR throughout shift. Per report overnight pt had bursts of afib\n with HR up into 140\ns. Throughout shift, pt\ns HR remained in 60\n NSR. Received pt on Lopressor 50mg PO TID.\n Action:\n Lopressor dose lowered to 25mg TID as pt was normotensive and\n experienced no episodes of afib.\n Response:\n Pt remains in NSR with HR in 60\ns. Some PVC\n Plan:\n Continue to monitor for afib. Continue to give Lopressor as ordered.\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440833, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440835, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis and is intubated\n and sedated with propofol gtt.\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440722, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Respiratory ", "chartdate": "2116-03-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440713, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 40.9 None\n Ideal tidal volume: 163.6 / 245.4 / 327.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440719, "text": "Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n BP: 102-139/33-55, obtained on levo 0.1 mcg/kg/min, intubated and\n sedated on prop gtt at 50mcg/kg, blood cultures pending, CVP 4-12, u/o\n >100cc/hr\n Action:\n Titrating levo throughout the shift, titrating prop gtt to pt comfort,\n antibiotics as ordered, trending ABGs, bolusing for 4L this shift\n Response:\n Pt unable to tolerate levo gtt to off currently on 0.03mcg/kg/min,\n tolerating slight decrease in sedation to 40 mcg/kg/min of prop gtt,\n ABGs with increasing acidosis most recent 7.27/43/116/21/-6\n Plan:\n f/u culture data, continue to titrate levo as tolerated, continue to\n monitor ABGs\n Sepsis without organ dysfunction\n Assessment:\n Pt with bile duct obstruction per ct on admission to MICU, tbili 6.3,\n febrile, lactate 3\n Action:\n ERCP in GI suite, stent placed no stone visualized, pt received one\n time dosings of zosyn\n Response:\n Lactate 1 after several fluid boluses as noted above\n Plan:\n Continue antibiotics as ordered, continue to monitor\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440940, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp in 90s-100s with map 57 at beginning of shift with cvp 11 then down\n to 8. lactate 1.1. pt remains intubated on ac with no vent changes:\n .5x500x18+8. hct down to 27.9 from 33.8, plt down to 53 from 72.\n continues with gm negative sepsis ( bld cx + for gm negative rods).\n The source of pt\ns septic shock is most likely r/t cholangitis. Pm k\n 3.1.\n Action:\n Given 1 liter ns with transient increase in map to low 60s and cvp to\n 12 but back down again to high 50s with cvp back down to 8. given\n another 1 liter ns bolus again with only transient increase of map to\n low 60s and cvp back up to . levophed restarted at .03mcg/kg/min\n and titrated down to .01 mcg/kg.min. mixed venous 02 sat 74%. Pt given\n iv zosyn and also ordered vanco iv qd, next due at 8am . repleted\n with 40 meq po kcl via ogt and an additional 40meq iv kcl.\n Response:\n Sbp in 100s with map in low to mid 60s, unable to wean levophed further\n d/t map down to high 50s with levophed off. Am k 4.4. am hct 30 from\n 27.\n Plan:\n Continue to wean levophed as tolerated with map goal >60, sbp >90, cvp\n >12. monitor lactate. Continue iv abx. replete lytes prn. f/u with am\n wbc, plt.\n Sepsis without organ dysfunction\n Assessment:\n Gm negative rods in blood cx bottles from . afebrile, wbc down\n to 5.6. sepsis most likely biliary source. s/p ercp and no stone was\n visualized. Source of infection still unknown.\n Action:\n Temp monitored. Surveillance bld cx drawn x2 with am labs.\n Response:\n Afebrile, still requiring minimal dose of levophed. Am abg with\n improved acidosis: 7,35.29/102.\n Plan:\n Continue to monitor temp, abx as ordered, , f/u with culture results.\n Change vent to psv now that his ph has normalized.\n" }, { "category": "Physician ", "chartdate": "2116-03-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 441100, "text": "Chief Complaint: Sepsis\n Respiratory Failiure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Patient with PSV wean across yesterday to minimal settings--A/C\n required with decreased drive and sedatin lightened this mornign\n -Norepinephrine weaned to off\n History obtained from Medical records\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 69 (59 - 75) bpm\n BP: 171/67(107) {92/34(58) - 171/76(107)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 13 (2 - 13)mmHg\n Total In:\n 1,524 mL\n 579 mL\n PO:\n TF:\n IVF:\n 1,479 mL\n 579 mL\n Blood products:\n Total out:\n 1,152 mL\n 580 mL\n Urine:\n 1,152 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 372 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 471 (446 - 562) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.32/41/89.//-4\n Ve: 8.9 L/min\n PaO2 / FiO2: 178\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 70 K/uL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n 12:28 PM\n 04:36 PM\n 08:25 AM\n WBC\n 5.9\n 3.1\n 4.1\n Hct\n 33.8\n 27.9\n 30.9\n Plt\n 72\n 53\n 70\n Cr\n 1.0\n 1.1\n 1.1\n TCO2\n 20\n 20\n 21\n 17\n 21\n 21\n 22\n Glucose\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos /\n T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0\n mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Fluid analysis / Other labs: 7.32/41/89\n Microbiology: GNR's with pan-sensitive\n Assessment and Plan\n 82 yo female admit with biliary obstruction and ascending cholangitis\n and now with excellent stability of blood pressure following Rx with\n decompression and drainage. She has been able to wean off pressors and\n maintained stable BP through to this morning. In addition, patient has\n had excellent tolerance of minimal ventilatory settings across the\n night and with sedation weaned to off patient with excellent mental\n status, able to follow commands and with minimal secretions.\n RESPIRATORY FAILURE\nPatient with initial intubation with altered mental\n status with sepsis and now has excellent alertness, sepsis (GNR\n improved, Ve requirement <10 and able to follow commands clearly and\n with CVP <10 has excellent control of volume status.\n -Extubation today given favorable RSBI, improvement in reasons for\n intubation\n -Check cuff leak prior to extubation\n -OOB to chair\n -Incentive spirometry\n SHOCK, SEPTIC\n -Vanco/Zosyn\n -IVF as needed\n -Continue to follow culture results\n ICU Care\n Nutrition: npo this morning\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "General", "chartdate": "2116-03-22 00:00:00.000", "description": "ICU Event Note", "row_id": 441110, "text": "Clinician: Attending\n Patient with extubation this am. She had favorable RSBI, excellent\n mental status but had evolution of paroxysms of tachycardia and\n significant pulmonary ocngestion and bronchospasm following extubation.\n She had excellent response to IV Lasix with 1.3 liters urine out.\n She has reasonable response to IV Lopressowith stabilization of HR to\n <90.\n She had some decrease in SB to 83 following diuresis whichi will limit\n capacity to prvide further diuresis.\n Patient exam shows substantial improvement in air movement and decrease\n in wheezing.\n Will need to-->\n Continue with rate control\n Lopressor po tid\n Hold on further diuresis\n No role for CPAP at this time as patient had significant diuresis and\n rate control will be primary mode for maintenance of extubated status.\n Plan described to housestaff/family and nursing.\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440929, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments No RSBI/no spont respiratory efforts at this time.\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441015, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n Shock, septic\n Assessment:\n SBP 90\ns-110\ns. Received pt on 0.01 mcg/kg/min Levophed. CVP 9-11,\n team aware. Remains on vent CMV 500/18 /50% fio2/12/5 PEEP. LS clear,\n o2 sats 96-99%. No sputum suctioned from ETT. HR 50\ns-60\ns in sinus\n rhythym. Source of pt\ns sepsis is most likely r/t cholangitis.\n Action:\n Blood cx\ns sent x 2 overnight RN report. Team aware that CVP is\n 10, decided not to bolus. Given Zosyn and Vancomycin as ordered. Pt\n placed on MMV , ABG 7.30/41/90/- on those settings. Minute\n volume 6. Pt placed on MMV with a back-up rate of 10 and VT 500.\n ABG 7.29/42/94/-.\n Response:\n Pt remains on Levophed 0.01 mcg/kg/min. SBP currently 90\ns. Placed\n back on CMV 500/18/50%/5 PEEP\n Plan:\n Monitor for further s/s of shock. Wean Levo off to maintain SBP > 90.\n Monitor CVP.\n Sepsis without organ dysfunction\n Assessment:\n WBC 4.1 this am. Pt remains afebrile.\n Action:\n Administered abx as ordered. Monitor temp and further s/s of\n infection.\n Response:\n Pt remains jaundiced. Abdomen non-tender with palpation from MD. Pt\n still requiring small dose of Levophed. Pt remains sedated with\n Propofol.\n Plan:\n Continue to wean Levo and monitor for s/s of infection. F/U with\n culture results. Wean vent as tolerated.\n" }, { "category": "Physician ", "chartdate": "2116-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441084, "text": "Chief Complaint: 82 y/o woman with history of breast Ca and cerebral\n aneuysym admitted to the ICU with cholangitis, septic shock, and\n respiratory failure\n 24 Hour Events:\n :\n - 2/2 blood cultures positive for GNR's (not yet speciated)\n - Norepinephrine weaned, off at about 17:00, received 1 L NS for\n hypotension (MAP of 50-60) in context of CVP decreased to 8, briefly\n responded but then required another liter bolus, considered tx but\n MVO2>70, persistently hypotensive with MAP's in 50's so restarted on\n norepinephrine\n - Surgery and GI recommended continuing supportive care\n ______________________________________________________\n \n - Trial of pt CO2 progressively rose and pH dropped with Minute\n Ventilation. ? if sedation interfering with resp drive. Expect to d/c\n sedation in am and retry PS for possible extubation tomorrow\n -Tried to wean levo but still requires between 0.01 and 0.02. Weaned\n off this a.m.\n - Blood cultures from growing pan-sensitive GNR.\n -d/c omeprazole- now on IV Famotidine only\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 07:56 AM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 75 (59 - 75) bpm\n BP: 111/62(83) {92/34(58) - 119/76(91)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (2 - 10)mmHg\n Total In:\n 1,524 mL\n 349 mL\n PO:\n TF:\n IVF:\n 1,479 mL\n 349 mL\n Blood products:\n Total out:\n 1,152 mL\n 320 mL\n Urine:\n 1,152 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 372 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 446 (446 - 562) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 80\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 95%\n ABG: 7.29/42/94.//-5\n Ve: 8.5 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 70 K/uL\n 9.8 g/dL\n 79 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 15 mg/dL\n 119 mEq/L\n 140 mEq/L\n 30.9 %\n 4.1 K/uL\n [image002.jpg]\n 04:12 AM\n 12:39 PM\n 01:04 PM\n 04:55 PM\n 09:25 PM\n 09:47 PM\n 04:10 AM\n 06:08 AM\n 12:28 PM\n 04:36 PM\n WBC\n 5.9\n 3.1\n 4.1\n Hct\n 33.8\n 27.9\n 30.9\n Plt\n 72\n 53\n 70\n Cr\n 1.0\n 1.1\n 1.1\n TCO2\n 21\n 20\n 20\n 21\n 17\n 21\n 21\n Glucose\n 86\n 81\n 79\n Other labs: PT / PTT / INR:16.8/26.8/1.5, ALT / AST:107/30, Alk Phos /\n T Bili:344/4.7, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:1.0\n mmol/L, Albumin:2.3 g/dL, LDH:144 IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.3 mg/dL\n Assessment and Plan\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ, pneumoboots\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:53 PM\n Arterial Line - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2116-03-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 440777, "text": "Chief Complaint: Sepsis\n Cholangitis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with abdominal pain and fever and to ED with those complaints\n and was found to have bile duct obstruction and dilitation which when\n combined with fever and abdominal pain was felt to be consistent with\n cholangitis.\n Upon arrival in ICU patient given 4 liters IVF and started on NE gtt.\n ERCP was performed last evening with stent to CBD with drainage of\n purulent fluid noted but no stone visualized. Stent was placed.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Lung Cancer-_Stage I--s/p resection\n Cerebral Aneurysm\n S/p CCY\n S/P APPY\n Occupation: Lives in \n Drugs: None\n Tobacco: 100 py hx\n Alcohol: None\n Other:\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 35.6\nC (96\n HR: 63 (57 - 81) bpm\n BP: 131/52(81) {84/33(51) - 185/68(110)} mmHg\n RR: 19 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 26 Inch\n CVP: 9 (4 - 22)mmHg\n Mixed Venous O2% Sat: 74 - 74\n Total In:\n 9,879 mL\n 2,676 mL\n PO:\n TF:\n IVF:\n 5,679 mL\n 2,676 mL\n Blood products:\n Total out:\n 2,200 mL\n 1,650 mL\n Urine:\n 1,200 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,679 mL\n 1,026 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 232 (232 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 51\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.27/43/116/20/-6\n Ve: 8.7 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 34.9 %\n 10.9 g/dL\n 89 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 20 mEq/L\n 120 mEq/L\n 3.6 mEq/L\n 142 mEq/L\n 5.5 K/uL\n [image002.jpg]\n 08:55 PM\n 09:20 PM\n 11:10 PM\n 03:22 AM\n 04:12 AM\n WBC\n 5.5\n Hct\n 34.9\n Plt\n 67\n Cr\n 1.1\n 1.1\n TC02\n 23\n 19\n 21\n Glucose\n 99\n 89\n Other labs: PT / PTT / INR:17.7/28.9/1.6, ALT / AST:169/76, Alk Phos /\n T Bili:352/6.2, Differential-Neuts:64.0 %, Band:21.0 %, Lymph:9.0 %,\n Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.4 g/dL,\n LDH:186 IU/L, Ca++:7.1 mg/dL, Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR--OGT, ETT, CVL in good position. MIld per-hilar fullness\n noted but no frank pulmonary edema.\n Microbiology: BC--GNR's in blood cultures\n Assessment and Plan\n 82 yo female admitted with sepsis and with severe compromise and\n significant bandemia consistent with septic shock.\n 1)Sepsis\nClearly most likely biliary source. She is now s/p ERCP but\n without stone seen raising the question of what the source of\n obstruction was. This may be stone not visualized or narrowing at the\n level of the ampullla\nfor now stent has provided decompression.\n Abdomen with mild tenderness. Of note CVP is 7, HCT is >30. Will\n -Utilize Fluid bolus as needed\n -Will continue with Levophed and wean as possible today\n -Vanco/Zosyn to continue\n -Will consider addition of Vasopressin if unable to wean Levophed\n rather than additional fluid if CVP remains elevated\n 2)Cholangitis-_Will follow up ERCP results with team\n -Continue ABX\n -NPO today\n -Stent in place\n 3)Respiratory Failure-Patient with persistent and significant elevation\n in required FIO2 in the setting of sepsis and fluid resuscitation\n dose have excellent compliance\nwith Pplat=18 in the setting of\n PEEP=8 and Vt=500. This is reassuring that if once we have PEEP\n optimized we shuld be able to decrease FIO2.\n -Wean FIO2-0.5 today\n -Up-titrate PEEP to 10 if decrease in PaO2 seen\n 4)Thrombocytopenia-\n -Will check DIC labs ongoing\n -Would consider likely related to Sepsis\n -Is decreased from baseline quite rapidly\n 5)Metabolic Acidosis\nNon gap and likely related to saline and volume\n expansion required.\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition: NPO today\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 05:50 PM\n 18 Gauge - 05:54 PM\n 20 Gauge - 05:57 PM\n Arterial Line - 06:20 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2116-03-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 440795, "text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 81.2 kg\n ~4kg in ~6 mths\n 30\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 144\n 63\n 77.7kg \n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 03:22 AM\n BUN\n 15 mg/dL\n 03:22 AM\n Creatinine\n 1.1 mg/dL\n 03:22 AM\n Sodium\n 142 mEq/L\n 03:22 AM\n Potassium\n 3.6 mEq/L\n 03:22 AM\n Chloride\n 120 mEq/L\n 03:22 AM\n TCO2\n 20 mEq/L\n 03:22 AM\n PO2 (arterial)\n 116 mm Hg\n 04:12 AM\n PCO2 (arterial)\n 43 mm Hg\n 04:12 AM\n pH (arterial)\n 7.27 units\n 04:12 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 04:12 AM\n Albumin\n 2.4 g/dL\n 03:22 AM\n Calcium non-ionized\n 7.1 mg/dL\n 03:22 AM\n Phosphorus\n 2.8 mg/dL\n 03:22 AM\n Magnesium\n 1.8 mg/dL\n 03:22 AM\n ALT\n 169 IU/L\n 03:22 AM\n Alkaline Phosphate\n 352 IU/L\n 03:22 AM\n AST\n 76 IU/L\n 03:22 AM\n Total Bilirubin\n 6.2 mg/dL\n 03:22 AM\n WBC\n 5.5 K/uL\n 03:22 AM\n Hgb\n 10.9 g/dL\n 03:22 AM\n Hematocrit\n 34.9 %\n 03:22 AM\n Diagnosis: Sepsis\n PMH : Lung CA s/p RUL rxn with adjuvant chemo, cerebral aneurysm s/p\n coiling ', HTN, >chol, diverticulosis, hiatal hernia, GERD, s/\n ccy/appy, TAH.\n Food allergies and intolerances: none noted.\n Pertinent medications: norepinephrine, propofol.\n Current diet order / nutrition support: NPO.\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: dx, hx of CA, age\n Estimated Nutritional Needs\n Calories: 1386 - 1764 (BEE x or / 22 - 28 cal/kg)\n Protein: 70 - (1.1 - 1.488 g/kg)\n Fluid: per team.\n Specifics:\n 82 YO female p/w abdominal pain, N/V/D & found to have sepsis,\n cholangitis & respiratory failure & currently intubated. s/p ERCP on\n with stent to CBD w/ drain but stone not visualized. Per team NPO\n for today. Recommend nutrition support if remains intubated or NPO in\n the next 24-48hrs. TPN vs TF. If TF: FS Fibersource HN at goal 55mL/hr,\n providing 1584kcals & 70g protein. If TPN\nwill need central access &\n start with Day /Starter TPN & adjust lytes per labs. Goal TPN would\n be 60kg 3-in-1 STD solution: 1500mL(255g Dex/90g AA/30g Fat), providing\n 1500kcals.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If remains NPO or intubated in the next 24-48hrs: Consider TF:\n Fibersource HN; start at 10mL/hr, advance by 10-15mL/hr to goal 55mL/hr\n via OGT/NGT\n 2. Check residuals Q 4hrs & hold TF X1hr if >150mL\n 3. If TPN; obtain central access & start Day /starter & adjust\n lytes per labs\n 4. Check Triglycerides\n 5. start RISS; check FSBG Q 6hrs\n 6. Check chem. 10 daily\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 441463, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3. Sleeping this morning. Very restless even while asleep.\n Recived small dose of Haldol 0.5mg IV x1 overnight.\n Action:\n Family in to visit and Pt. more calm. Cont. on Effexor.\n Response:\n Sleeping this morning after Pt.\ns daughter left. redirected.\n Plan:\n More family to visit later today. OOB to chair.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. in NSR now and has for at least past 24 hrs.\n Action:\n Lopressop PO as ordered.\n Response:\n HR 60\ns NSR with no ectopy. BP 100\ns systolic and stable.\n Plan:\n Cont. with PO Lopressor. Monitor VS.\n Pt. with R IJ TLC. Ordered for PICC in IR today. Will go down shortly.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 81.8 kg\n Daily weight:\n Allergies/Reactions:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: hypercholesteremia,diverticulosis, hiatal hernia\n gerd, s/p cholecystectomy, appendectomy, total abd hysterectomy,bil\n salpingo oopherectomy, cerebral artery aneurysm rupture\n Surgery / Procedure and date: cholecystectomy, appendectomy, total abd\n hystorectomy with bilat salpingo-oophectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:108\n D:47\n Temperature:\n 98.3\n Arterial BP:\n S:133\n D:72\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 505 mL\n 24h total out:\n 790 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:45 AM\n Potassium:\n 3.3 mEq/L\n 02:45 AM\n Chloride:\n 101 mEq/L\n 02:45 AM\n CO2:\n 33 mEq/L\n 02:45 AM\n BUN:\n 13 mg/dL\n 02:45 AM\n Creatinine:\n 0.9 mg/dL\n 02:45 AM\n Glucose:\n 84 mg/dL\n 02:45 AM\n Hematocrit:\n 31.9 %\n 02:45 AM\n Finger Stick Glucose:\n 120\n 12:00 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley cath,\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 402\n Transferred to: 1181\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2116-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440871, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp 89-122 with hr in the 50-60\ns. still requiring levophed gtt for\n support of bp but have been able to wean it off some in the setting of\n gm negative sepsis. Pt with nongap metabolic acidosis most likely\n related to and volume rescusitation. Pt is intubated and sedated\n with propofol gtt. The source of pt\ns septic shock most likely related\n to cholangitis,ercp with drainage of pus.\n Action:\n Weaned levophed gtt to keep map> 60 and sbp> 90. hemodynamics including\n cvp monitored throughout the shift as well as hourly uo. Pt given 1\n 500cc bolus of iv ns for cvp of 9 and medicated with vancomycin and\n zosn for antibiotic coverage as ordered.\n Response:\n Have been able to wean levophed gtt down to 0.03mcg/kg/hr. pt\n maintaining adequate hourly uo though her fluid balance for this shift\n is pos 1.6 liters and for los pos 9.6 liters. Wbc ==5.5 and max\n temp=96. 8orally.\n Plan:\n Continue to follow hemodynamics and cvp closely to keep map>90,cvp> 12\n and map>60. if cvp drops below 12 and uo drops off might consider\n additional boluses if iv fluid.administer antibiotics as ordered\n Sepsis without organ dysfunction\n Assessment:\n Gm neg rods in blood culture bottles from . afebril and wbc\n down to 5.6.sepsis most likely biliary source. s/p ercp and no stone\n was visualized so the question is what was the source of obstruction.\n Action:\n Fever curve followed. Following culture data as final results return.\n Iv fluids give as needed in the setting of sepsis. Levophed gtt being\n weaned presently as she tolerates it hemodynamically. Pt give ndoses of\n zosyn and vancomycin as ordered.\n Response:\n Afebrile and tolerating weaning of pressors.\n Plan:\n Conintue to follow fever curve. Administer antibiotics as ordered.\n Await all final culture data and adjust antibiotics accordingly.\n Continue to check abg\ns to follow acid/base balance.\n Resp: pt orally itnubated with vent settings: 60%/500/ac 18 and 8 peep\n with last abg=7.33/36/119/-. lung sound clear to upper lobes bil\n with diminished bs at the bases.reps failure most likely secondaru to\n metabolic acidosis. Once ph normalizes then can change vent to\n pressure support and begin weaning process.\n ------ Protected Section ------\n Levophed gtt off and will continue to follow pt\ns hemodynamics. Fio2 on\n vent dropped to 50% and abg on these settings=7.31/38/95/-. will\n maintain these vent settings over noc and if Hemodynamically stable\n tonoc will wean vent as pt tolerates and hoperfulle extubate.\n Surveillance blood cultures sent off to microbiology.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:43 ------\n" }, { "category": "Nursing", "chartdate": "2116-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440918, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICU from the emergency department where\n she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. She had some improvement yesterday,\n but was barely arousable today and was brought in for evaluation.\n In the ED she was found to be febrile to 103, with HR 82, BP 146/77.\n She had elevated transaminases, a lactate that peaked at 4.7, and a CT\n torso showed dialted common bile duct. She had a central venous line\n placed, and was given 4L of NS and was intubated due to increased\n lethargy. She was not hypotensive in the emergency department. A blood\n gas obtained after intubation was 7.29/51/72.\n Sig Events: pt to GI suite for ERCP, stent placed no stone visualized,\n puss extracted, pt tolerated procedure well, returned to with\n stable VS remained on same dose of Levo throughout the procedure\n Shock, septic\n Assessment:\n Sbp in 90s-100s with map 57 at beginning of shift with cvp 11 then down\n to 8. lactate 1.1. pt remains intubated on ac with no vent changes:\n .5x500x18+8. hct down to 27.9 from 33.8, plt down to 53 from 72.\n continues with gm negative sepsis ( bld cx + for gm negative rods).\n The source of pt\ns septic shock is most likely r/t cholangitis. Pm k\n 3.1.\n Action:\n Given 1 liter ns with transient increase in map to low 60s and cvp to\n 12 but back down again to high 50s with cvp back down to 8. given\n another 1 liter ns bolus again with only transient increase of map to\n low 60s and cvp back up to . levophed restarted at .03mcg/kg/min\n and titrated down to .01 mcg/kg.min. mixed venous 02 sat 74%. Pt given\n iv zosyn and also ordered vanco iv qd, next due at 8am . repleted\n with 40 meq po kcl via ogt and an additional 40meq iv kcl.\n Response:\n Sbp in 100s with map in low to mid 60s, unable to wean levophed further\n d/t map down to high 50s with levophed off.\n Plan:\n Continue to wean levophed as tolerated with map goal >60, sbp >90, cvp\n >12. monitor lactate. Continue iv abx. f/u with am kcl results and\n replete prn. Monitor am wbc, hgb, hct.\n Sepsis without organ dysfunction\n Assessment:\n Gm negative rods in blood cx bottles from . afebrile, wbc down\n to 5.6. sepsis most likely biliary source. s/p ercp and no stone was\n visualized. Source of infection still unknown.\n Action:\n Temp monitored. Surveillance bld cx drawn x2 with am labs.\n Response:\n Afebrile, still requiring minimal dose of levophed.\n Plan:\n Continue to monitor temp, abx as ordered, f/u with abg results, f/u\n with culture results. Change vent to psv once his ph normalizes.\n" }, { "category": "Physician ", "chartdate": "2116-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 441235, "text": "Chief Complaint: Cholangitis/sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 AM\n INVASIVE VENTILATION - STOP 09:30 AM\n ARTERIAL LINE - STOP 10:52 AM\n EKG - At 11:00 AM\n -Extubated and did well. Had some hypercapnia (worst ABG 7.28/50/94)\n but did well afterward with improvement in pH to 7.34/46/83 by 7pm.\n -Did not get PICC b/c waiting for blood cx to be neg x 72hrs\n -Had runs of narrow complex tach, rhythm was re-entrant vs\n a.fib/flutter. Also had runs of bradycardia with a few 2 second pauses\n around 1 a.m. Started on po metoprolol for tachyarryhthmia but\n continued without improvement so needed metoprolol 5mg iv three\n seperate times.\n -Vanc d/c'd in a.m. but had GPC in chains in bcx so restarted\n overnight\n Allergies:\n Meperidine\n Unknown;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Lightheadedness\n Codeine\n Constipation;\n Last dose of Antibiotics:\n Vancomycin - 08:02 AM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:15 AM\n Metoprolol - 10:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.4\n HR: 73 (66 - 134) bpm\n BP: 124/62(79) {96/31(31) - 153/6,461(104)} mmHg\n RR: 19 (15 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (3 - 20)mmHg\n Total In:\n 875 mL\n 128 mL\n PO:\n TF:\n IVF:\n 875 mL\n 128 mL\n Blood products:\n Total out:\n 4,535 mL\n 530 mL\n Urine:\n 4,535 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,660 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (471 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 55\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.34/51/175/27/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : )\n Abdominal: Soft, Bowel sounds present, Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 83 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 107 mEq/L\n 143 mEq/L\n 31.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:28 PM\n 04:36 PM\n 08:25 AM\n 11:15 AM\n 11:39 AM\n 02:42 PM\n 06:01 PM\n 06:11 PM\n 04:40 AM\n 07:20 AM\n WBC\n 7.1\n 5.8\n Hct\n 34.0\n 31.5\n Plt\n 113\n 126\n Cr\n 1.0\n 0.9\n TCO2\n 21\n 21\n 22\n 24\n 27\n 26\n 26\n 29\n Glucose\n 85\n 83\n Other labs: PT / PTT / INR:15.2/24.5/1.3, ALT / AST:75/27, Alk Phos / T\n Bili:350/3.0, Amylase / Lipase:17/12, Differential-Neuts:67.0 %,\n Band:13.0 %, Lymph:10.0 %, Mono:7.0 %, Eos:3.0 %, Lactic Acid:0.9\n mmol/L, Albumin:2.7 g/dL, LDH:158 IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n SHOCK, SEPTIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 82 y/o woman with history of breast Ca and cerebral aneuysym admitted\n to the ICU with cholangitis, septic shock, and respiratory failure\n # Septic Shock: source cholangitis, ERCP with pus drainage. Continues\n to demonstrate septic physiology with pressor requirment. Levo weaned\n overnight but had to be increased again this afternoon. CVP\n consistently ~10 today and pt looks edematous. Think has enough fluid\n on board at this time.\n - wean levophed as tolerated to MAP >65\n - Vanc/Zosyn\n - Aline, CVL\n # Respiratory Failure: likely secondary to metabolic acidosis and\n inability to compensate. Originally, Bicarb was elevated but has since\n declined to 19. Pt needs to hyperventilate approx 10% to compensate for\n this. While trying to wean to PS today, pt unable to do this, unable to\n maintain 7.5L minute ventilation as ABGs showed pH dropped and pt was\n put back on a/c\n - rest on a/c overnight. Trial of PS again tomorrow while monitoring\n ABG to check if pt able to maintain nl pH by adequate respiratory\n alkalosis in compensation for metabolic acidosis.\n # Cholangitis: Vanco / Zosyn as above. No large stones seen.\n - NPO for now\n - stent removal in future\n -f/u ERCP recs.\n # Hypertension: hold antihypertensives\n # Breast Cancer: not active issue, outpatient follow up\n # Cerebral Aneurysm: care with pressors, keep MAP ~60, 65 not higher\n # Depression: continue antidepressents\n # Hypercholesterolemia: hold statin for now, restart when LFTs trendign\n toward normal\n # Access: Right IJ, Aline, also 2 PIVs\n # FEN: NPO\n # PPx: PPI, heparin SQ\n # Dispo; ICU\n # CODE: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441364, "text": "82 y/o woman with a history of lung cancer s/p lobectomy and adjuvant\n chemotherapy admitted to the ICUon from the emergency department\n where she presented with fever and altered mental status.\n Per reports, she had several days of diarrhea, abdominal pain, nausea,\n vomitting and increased lethergy. In the ED she was found to be febrile\n to 103, with HR 82, BP 146/77. She had elevated transaminases, a\n lactate that peaked at 4.7, and a CT torso showed dialted common bile\n duct. She had a central venous line placed, and was given 4L of NS and\n was intubated due to increased lethargy. She was not hypotensive in the\n emergency department. A blood gas obtained after intubation was\n 7.29/51/72.\n Sig Events: - pt to GI suite for ERCP, stent placed no stone\n visualized, puss extracted, pt tolerated procedure well, returned to\n with stable VS remained on same dose of Levo throughout the\n procedure\n : Extubated at 10am\n overnight: Rapid afib responding to IV lopressor, now on po\n lopressor no episodes of afib noted since\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night\n Plan:\n Continue to monitor, ?ABG if confusion persists, pt reporting hx of\n sundowning f/u with family\n" }, { "category": "Respiratory ", "chartdate": "2116-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 440998, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2116-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 441148, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: pt extubated\n" }, { "category": "Nursing", "chartdate": "2116-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441362, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3, though hallucinating at times, removing O2 on several\n occasions, obtained pt on FM 70% high flow, when removes O2 pt desating\n to 80%\n Action:\n Given haldol 0.5mg x1, transitioning pt\ns supplemental O2 from FM to\n NC, reorienting throughout the shift\n Response:\n Maintaining sats well on NC 3L ~94%, continues with confusion\n throughout the night though easily redirectable, responds well to\n haldol dosing, largely resting throughout the night\n Plan:\n Continue to monitor, ?ABG if confusion persists, pt reporting hx of\n sundowning f/u with family\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1061153, "text": " 8:41 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yo F with RUQ, increased LFTs, and dilated CBD. Cholangitis. Rule out\n choledocholithiasis.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated LFTs and dilated CBD. Evaluate for choledocholithiasis.\n ERCP.\n\n COMPARISON: CT torso from .\n\n FINDINGS: Twelve spot fluoroscopic radiographs were obtained during ERCP are\n provided for review. Scout images demonstrate surgical clips in the patient's\n right upper quadrant, likely related to prior cholecystectomy. A nasogastric\n tube appears positioned near the duodenum. Multiple additional tubing\n catheters overlie the patient. Injection of contrast into the biliary system\n demonstrates a dilated common bile duct with luminal filling defect. There is\n mild dilatation of the intrahepatic biliary ducts. Per the patient's ERCP\n report, a single 10-mm stone was present. A plastic stent catheter was\n positioned in the common bile duct. For full details, please refer to the\n patient's ERCP note from the same day.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061526, "text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for volume overload vs infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p ercp, s/p extubation now with wheezing\n and tachycardia\n REASON FOR THIS EXAMINATION:\n eval for volume overload vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 12:22\n\n INDICATION: Abnormal breath sounds.\n\n COMPARISON: at 05:06\n\n FINDINGS: The patient has been extubated and the NGT has been removed. The\n right CVL remains in place. Compared to the prior study, there is no\n significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-24 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1061935, "text": " 11:39 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with need for IV abx for cholangitis and failed attempt by IV\n nursing.\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for ABx.\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. , the\n Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right baslic vein\n was punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a PICC line measuring 41 cm in length was then placed through\n the peel-away sheath with its tip positioned in the SVC under fluoroscopic\n guidance. Position of the catheter was confirmed by a fluoroscopic spot film\n of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line\n placement via the right basilic venous approach. Final internal length is\n 41cm, with the tip positioned in SVC. The line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061350, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placment\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis, bacteremia, resp failure\n REASON FOR THIS EXAMINATION:\n ? ETT placment\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb SAT 9:11 AM\n Endotracheal tube in satisfactory position. No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n INDICATION: 82-year-old woman with cholangitis and bacteremia. Respiratory\n failure. Question endotracheal tube placement.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube is in satisfactory position, approximately 3 cm\n above the carina. Remainder of the support lines and tubes are in stable\n position. There is no significant interval change in the appearance of the\n left base opacity, possibly representing atelectasis or consolidation. There\n is no pneumothorax. Heart and mediastinal contours are unchanged.\n\n IMPRESSION: Endotracheal tube in satisfactory position. No significant\n interval change in the appearance of the lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061351, "text": ", S. MED 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placment\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis, bacteremia, resp failure\n REASON FOR THIS EXAMINATION:\n ? ETT placment\n ______________________________________________________________________________\n PFI REPORT\n Endotracheal tube in satisfactory position. No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1060974, "text": " 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hx of aneurysm w/ lobectomy and vp shunt w/ vomiting and\n altered ms.\n FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:14 AM\n No acute hemorrhage. rt ventriculostomy shunt catheter terminating in left\n ventricle. No change in ventricular size. No change from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD\n\n COMPARISON: .\n\n HISTORY: 82-year-old female with history of aneurysm with lobectomy and VP\n shunt now with vomiting and altered mental status.\n\n TECHNIQUE: Contiguous helical acquisition through the head was performed\n without intravenous contrast.\n\n FINDINGS: Again noted is a right posterior ventriculostomy shunt catheter with\n the tip terminating in the frontal of the left lateral ventricle. The\n ventricles are stable in size compared to the prior study. There is no\n evidence of intraparenchymal hemorrhage or mass effect identified. There is a\n small amount of hypodensity adjacent to the shunt catheter which may represent\n adjacent edema, which is unchanged from the prior study. There is a stable\n appearing region of hypoattenuation within the right frontal periventricular\n white matter which may represent the sequelae of microvascular angiopathy.\n Also noted is a stable appearing hypodensity within the right internal\n capsule, which is likely attributed to chronic ischemic changes. Aneurysm\n clips are noted at the skull base. Evaluation of the skull base is limited\n secondary to streak artifact from the clips. The calvarium is stable in\n appearance. The visualized paranasal sinuses and mastoid air cells are\n normally aerated.\n\n IMPRESSION:\n\n No evidence of acute abnormality or change compared to the prior study.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1060977, "text": " 10:57 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: PE? pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hx of aneurysm w/ lobectomy and vp shunt w/ vomiting and\n altered ms. hypoxic on RA.\n REASON FOR THIS EXAMINATION:\n PE? pna?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:04 PM\n NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE REPRESENT ASPIRATION VS\n PNEUMONIA VS ATELECTASIS.\n .\n CT abd/pelvis: mild to moderate biliary dilitation with probable soft tissue\n defect in CBD. CHD measures 17 mm. rec MRCP for further eval.\n\n left adnexal cyst, larger than prior. rec US for further eval.\n WET READ VERSION #1 11:54 AM\n NO PE OR DISSECTION. LEFT BASILAR AIRSPACE DISEASE REPRESENT ASPIRATION VS\n PNEUMONIA VS ATELECTASIS.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO, \n\n COMPARISON: .\n\n HISTORY: 82-year-old female with history of aneurysm and lobectomy and VP\n shunt with vomiting and altered mental status.\n\n FINDINGS: Contiguous helical acquisition through the chest, abdomen and\n pelvis was performed with intravenous contrast.\n\n CT CHEST: The heart is normal in size. There is atherosclerotic disease of\n the coronary arteries and aorta. The pulmonary artery and branch vessel\n opacifies normally with no evidence of intraluminal thrombus. The aorta\n opacifies normally with no evidence of aortic dissection. There is no\n mediastinal or hilar lymphadenopathy identified. There is left basilar air\n space disease identified. The right lung is clear. A surgical clip is noted\n at the right lung base. Post-surgical changes within the lungs are noted\n status post right upper lobectomy. There are diffuse emphysematous changes\n identified. There are old right-sided rib fractures noted. The osseous\n structures are otherwise intact. There are degenerative changes of the\n bilateral shoulders and spine.\n\n CT ABDOMEN: There is mild-to-moderate intra- and extra-hepatic biliary\n dilatation which is new compared to the prior study dated . Also noted is\n a probable soft tissue-density filling defect within the mid/distal common\n bile duct. The common hepatic bile duct measures 17 mm in diameter. The\n patient is status post cholecystectomy. The pancreas is normal in appearance\n with no evidence of pancreatic ductal dilatation. The spleen, adrenal glands,\n (Over)\n\n 10:57 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: PE? pna?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and bowel are normal in appearance. There are multiple low-density lesions\n noted within the kidneys bilaterally which are too small to characterize but\n likely represent renal cysts. There is no free air or free fluid identified.\n There is atherosclerotic disease of the descending aorta. There is a\n ventriculostomy shunt catheter identified.\n\n CT PELVIS: There is a left adnexal cyst which appears somewhat larger\n compared to the prior study and currently measures 2.8 cm. There is\n diverticulosis of the sigmoid and descending colon without evidence of\n diverticulitis. No pelvic masses or lymphadenopathy is identified. The\n osseous structures are intact with degenerative changes noted within the\n lumbar spine.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary embolism or aortic dissection.\n\n 2) Emphysema and left lower lobe air space disease which may represent\n aspiration versus pneumonia versus atelectasis. Clinical correlation is\n recommended.\n\n 3) New intra- and extra-hepatic biliary dilatation with a probable filling\n defect noted within the common bile duct, which could represent stones,\n sludge, or neoplastic process. An MRCP is recommended for further evaluation.\n\n 4) 2.8-cm left adnexal cyst which appears larger compared to the prior study.\n A pelvic ultrasound is recommended for further characterization given the\n patient's post-menopausal status.\n\n\n DFDdp\n\n" }, { "category": "ECG", "chartdate": "2116-03-22 00:00:00.000", "description": "Report", "row_id": 196795, "text": "Sinus rhythm with atrial premature complexes\nLeft axis deviation\nIV conduction defect\nLateral T wave changes are nonspecific\nSince previous tracing of , atrial premature complexes are new,\ndecreased QRS voltages\n\n\n" }, { "category": "ECG", "chartdate": "2116-03-19 00:00:00.000", "description": "Report", "row_id": 196796, "text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. Left ventricular hypertrophy. Non-specific\nST-T wave changes. Compared to the previous tracing right bundle-branch block\nis new.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061009, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess et tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with\n REASON FOR THIS EXAMINATION:\n assess et tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess endotracheal tube.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The tip of the endotracheal tube terminates 3 cm from the carina.\n Nasogastric tube courses through the esophagus into the stomach and off the\n field of view of the radiograph. A VP shunt catheter courses along the right\n hemithorax and off the field of view of the radiograph. The cardiac\n silhouette is enlarged which may be reflective of cardiomegaly. There is\n slight prominence of the pulmonary vasculature which may be representative of\n pulmonary congestion in comparison to the prior examination. Lung volumes are\n low and there is bibasilar atelectasis. No areas of consolidation are seen.\n Surgical clips projecting over the patient's right upper quadrant are likely\n related to prior cholecystectomy. Thickening of the right pleura and old\n mulitple right sided rib fractures.\n\n IMPRESSION:\n 1. Endotracheal tube 3 cm from the carina.\n 2. Low lung volumes with mild prominence of pulmonary vasculature.\n 3. Nasogastric tube and VP shunt catheter as described.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1062122, "text": ", V. MED 11R 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent septic shock w aggressive fluid resuscitation,\n eval for interval change in pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Bilateral pleural effusions are small, greater on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "P PORTABLE ABDOMEN PORT", "row_id": 1061095, "text": " 10:11 PM\n PORTABLE ABDOMEN PORT Clip # \n Reason: pls assess position of OGT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p OGT.\n REASON FOR THIS EXAMINATION:\n pls assess position of OGT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb FRI 3:11 PM\n Satisfactory OG tube position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with cholangitis, status post OG tube placement.\n\n COMPARISON: CXR .\n\n FINDINGS: A radiograph positioned at the thoracoabdominal junction was\n obtained for evaluation of orogastric tube placement, which terminates in the\n expected region of the gastric pylorus. A biliary catheter and scattered\n abdominal surgical clips are noted. Limited evaluation of the lung bases is\n unchanged with basilar atelectasis and right pleural thickening noted.\n\n IMPRESSION: OG tube tip near gastric pylorus.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061123, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pna, position of ET tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p intubation.\n REASON FOR THIS EXAMINATION:\n assess for pna, position of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M. \n\n HISTORY: Cholangitis after intubation. Assess for pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Worsening opacification in left lower lobe, probably due to progressive\n atelectasis. Right lung and left upper lung clear. ET tube in standard\n placement. Nasogastric tube ends in the stomach. Right jugular line tip in\n the region of the superior cavoatrial junction. Shunt catheter traverses the\n right neck, chest and upper abdomen. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1062121, "text": " 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent septic shock w aggressive fluid resuscitation,\n eval for interval change in pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 10:34 AM\n Bilateral pleural effusions are small, greater on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Recent septic shock with fluid resuscitation.\n\n Comparison is made with prior study, .\n\n The small bilateral pleural effusions are largely on the right side. Bibasilar\n atelectasis have improved. They are greater on the left side. There is mild\n fluid overload. Mild cardiomegaly is stable. Right PICC tip is in the SVC.\n There is no pneumothorax. A thin catheter projects over the right hemithorax\n medially and right neck.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061025, "text": " 2:14 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with intubation and central line placement. Please confirm\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation and central line placement. Confirm line position.\n\n PORTABLE AP CHEST RADIOGRAPH\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: Since the study from approximately one hour prior, there has been\n placement of a right-sided central venous catheter whose tip terminates\n slightly above the cavoatrial junction. There is unchanged positioning of the\n endotracheal tube whose tip terminates approximately 4 cm from the carina. The\n nasogastric tube and VP shunt catheter are unchanged. There is slight\n prominence of the pulmonary vasculature; however, this is likely due to low\n lung volumes. There is minimal pleural thickening along the right lateral\n pleura, and there is minimal left basilar atelectasis. Otherwise, the lungs\n are clear. The cardiomediastinal silhouette appears unchanged. There are old\n multiple right-sided rib fractures which are chronic.\n\n IMPRESSION: Right central venous catheter with tip at the cavo-atrial\n junction. Low lung volumes with left basilar atelectasis. Endotracheal tube\n in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2116-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061836, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis and known pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n slightly better inspiration. Indistinctness of pulmonary vessels is again\n consistent with elevated pulmonary venous pressure. Increased opacification\n at the left base is consistent with atelectasis and effusion, though\n supervening pneumonia cannot be excluded in the absence of a lateral view.\n There may well be some pleural fluid and atelectasis at the right base as\n well.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-03-19 00:00:00.000", "description": "P PORTABLE ABDOMEN PORT", "row_id": 1061096, "text": ", F. MED 10:11 PM\n PORTABLE ABDOMEN PORT Clip # \n Reason: pls assess position of OGT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cholangitis s/p OGT.\n REASON FOR THIS EXAMINATION:\n pls assess position of OGT\n ______________________________________________________________________________\n PFI REPORT\n Satisfactory OG tube position.\n\n" } ]